The New Public Health: Beyond Genetics and Social Inequalities


Cancer is a growing global problem and is increasing in the proportion of the burden among low income and middle-income countries. While the pattern can be blamed on demographic change and to transition in risk factors, it can be prevented by present knowledge of modifiable risk factors and continued research on cancer genetic landscape. Pancreatic cancer (PC) has the lowest 5-year relative survival rate, and treatment for metastatic pancreatic cancer are minimally effective. In early 2000, incidence rates of PC have been approximately stable in many European countries. Ma, Siegel, & Jemal (2013) noted that the complex patterns of PC death rate trends remain unexplained by known risk factors. Given that there are only 20% of patients diagnosed with the disease are eligible for surgical resection (Spanknebel & Conlon, 2000); it is paramount to rationalize the importance of the development of public health policies designed in lowering the economic burden of the disease. Money saved from reducing the overall economic burden of the disease could open up resources and funding allocation to pursue other public health projects for the better good of the many. A synergy begets by outcomes research and epidemiology can provide unique and compelling insights on the significance of interventions designed to improve the quality and effectiveness of care in populations. Recent developments in non-communicable diseases (NCDs) epidemiology highlight the increasing worldwide burden of NCDs as the result of complicated interactions between several demographic, economic and social structural changes (Suhrcke et al., 2006), considered to be strongly associated with the globalization of unhealthy lifestyles (Ferretti, 2015). Between 1997 and 2002, unhealthy behavior index (UBI)  tends to increase along with the level of human development. In the USA and Japan, mortality has been declining since the previous decades, including Argentina, Colombia, Puerto Rico and Hong Kong, with a reversal of trends over the most recent years (Bosetti et al., 2012). Trends were also declining in countries of central/eastern Europe with highest rates, such as the Czech Republic, Croatia, and Hungary, but mortality rates reached 8.5/100,000 men in 2006 in Russia. Ferretti (2015) found that Belarus and Russian Federation are the two countries with the unhealthiest NCD-related lifestyle. Tobacco use, and in particular cigarette smoking, is the single largest preventable cause of cancer in the European Union (EU), including second-hand smoke (SHS), that is still common in indoor, indoor public places, and more so in the homes of smokers (Leon et al., 2015). Secondhand smoke, referred to as ETS, contains many of the same carcinogenic compounds as the mainstream smoke inhaled by active smokers (World Health Organization, International Agency for Research on Cancer, 2004; Bao et al., 2009).

In early 2000, incidence rates of PC have been approximately stable in many European countries, Japan, Australia and the US. Overall trends are likely to improve in the next future with more favorable recent trends in young adults from 30 to 49 years old (Bosetti et al., 2012). PC has the global ranking of 13 as the most common cause of cancer and represents the 7th most frequent cause of cancer death, and accounts for about 3% of all cancers in the US with cancer mortality of 7% (American Cancer Society, Inc., 2016).  PC ranked fourth among all cancers in the U.S. (Jamal et al., 2003), the mortality rate of the disease in China ranks sixth (Ding et al., 2015). There are more than 278,000 new diagnoses of pancreatic ductal adenocarcinoma (PDAC) annually worldwide, accounting for 10% of all digestive system cancers (Ferlay, et al., 2010). The 5-year survival rate makes the prognosis of this disease dismal and the twelfth most common cancer in the world with 338,000 new cases diagnosed in 2012. Czech Republic had the highest rate of pancreatic cancer with a 9.7 age-standardized rate per 100,000 (World), followed by Slovakia and Armenia. (World Cancer Research Fund International, 2015). The highest incidence of PC is found in the Czech Republic, ranking second in men (11.9 per 100,000) and first in women (7.9 per 100,000). The key PC statistics according to the American Cancer Society are lifetime risk of 1.5% (1 in 65) for both men and women; 27,670 men and 25,400 women will be diagnosed; 21,450 men and 20,330 women will die of the disease. Using data from nine registries of the Surveillance, Epidemiology and End Results (SEER) program, Shaib, Davila and El‐Serag (2006) examined temporal changes in the incidence and survival of patients with pancreatic adenocarcinoma. The study identified 58,655 cases of pancreatic cancer. Age-adjusted and age-specific was calculated grouped in 5 yearly intervals: 1977–1981, 1982–1986, 1987–1991, 1992–1996 and 1997–2001. The average age-adjusted yearly incidence of PC was 11.3 per 100 000 in 1977–1981 and 10.9 per 100 000 in 1997–2001. Overall incidence rates were also calculated for different subgroups based on gender (men, women) and race (White, Black, others) and geographic location as defined by SEER registries. Men had approximately 30% higher incidence rates than women with an overall average age-adjusted yearly incidence rate of 13.0 per 100 000 (95% CI: 12.9–13.2) among men and 9.8 per 100 000 (95% CI: 9.7–9.9) among women. Among different racial groups, Blacks were approximately 50% more affected when compared with Whites and people of other races. The overall average age-adjusted yearly incidence rates were 16.4 per 100 000 (95% CI: 16.0–16.9) for Blacks, 10.8 per 100 000 (95% CI: 10.7–10.9) for Whites and 9.8 per 100 000 (95% CI: 9.4–10.1) for people of other races. The overall average age-adjusted yearly incidence rates were 16.4 per 100 000 (95% CI: 16.0–16.9) for Blacks, 10.8 per 100 000 (95% CI: 10.7–10.9) for Whites and 9.8 per 100 000 (95% CI: 9.4–10.1) for people of other races.

Primary prevention must be prioritized as an integral part of global cancer control. According to Vineis et al., (2014), primary prevention has several advantages: the effectiveness could have benefits for people other than those directly targeted, avoidance of exposure to carcinogenic agents is likely to prevent other non-communicable diseases, and the cause could be removed or reduced in the long term through regulatory measures against occupational or environmental exposures such as environmental tobacco smoke (ETS). Improving the future of individuals diagnosed with PC through the concerted efforts of policymakers, public health professionals, clinicians and scientists, the Recalcitrant Cancer Research Act of 2012 lays the foundation for a heightened focused on further development and use of prevention, screening and therapeutic strategy (Rahib et al., 2014).   Introduced initially as the Pancreatic Cancer Research and Education Act, the Recalcitrant Cancer Research Act was signed into law as part of the National Defense Authorization Act on January 2, 2013, through broad bi-partisan and bi-cameral support (The Pancreatic Cancer Action Network, 2013). The genuine progress against PC as a  recalcitrant cancer warrants strategic direction and guidance on the continued understanding, development of efficient early detection strategy and identifying therapeutic targets that could stem the tide of its growing economic burden.

Methods: Pancreatic Cancer and Environmental Tobacco Smoke (ETS)

PubMed, Google Scholar, and JSTOR were searched from 1990 to present. Scholarly materials considered in this systematic literature review are epidemiologic research of environmental tobacco smoke (ETS) and assess its relationship to pancreatic cancer, as well as other demographics related to the disease. Peer-reviewed literature is identified using Thoreau Multi-Database. I identified a total of 25 studies, 15 articles met the final inclusion criteria.

Results of the Systematic Literature Review

After the completion of the Human Genome Project (HGP) in 2003, the theory used in the studies in this systematic scholarly literature review is the Genome Theory of Cancer Evolution. Moreover, building on the premise of one of the variants of sociopolitical epidemiologic theory, the fundamental cause approach in the 2014 study of Rubin et al. stated that while the variant’s hypothesis predicts the increased prevention of lung cancer with the development and dissemination of knowledge of the causal link of tobacco use to the disease. There has been no change in the mortality of pancreatic cancer because of lack of major prevention or treatment innovations. The data analyzed in this study supported the fundamental cause hypothesis and asserted the impact of access to resources amplified by the availability of preventive knowledge. The study highlighted the role of public health interventions and policies in facilitating more equitable distribution of new health-enhancing knowledge and the faster uptake and utilization among lower socioeconomic status (SES) group. On the contrary, the argument of integrating the individual-biologic and population levels of analysis that embody the premise of ecosocial framework put public health in the conundrum of the proximal-distal divide. The interlinking of the traditional epidemiologic level of intervention (upstream or distal) and the modern epidemiologic level of intervention (downstream or proximal) embraced by both biomedical and social determinist frameworks are proposed to be replaced with explicit language about levels, pathways, and power (Krieger, 2008). Parallel to the argument of integrating the individual-biologic and population levels of analysis (Chen et al., 2015), utilizing a 2 × 2 factorial design, patients were randomized to either observation, 5-FU based chemotherapy, 5-FU based chemoradiation, or both after undergoing curative resection, Neoptolemos et al. (2004) investigated the efficacy of both chemotherapy and chemoradiation in patients undergoing surgical resection (p. 15565). In this 2004 study of Neoptolemos et al., a significant survival benefit was found in patients who received systemic 5-FU based chemotherapy, leading to a European standard of care that does not include radiation therapy in the multimodal treatment of the disease. On the other hand, because of the randomization scheme, the relatively low-dose of radiation administered and the lack of quality control of the radiotherapy administered, the negative prognostic effect of chemoradiotherapy was not accepted within the United States. Overall, after a review of clinically relevant biomarkers in PC, while the neoadjuvant approach is presently the best available strategy, both epigenetic profiling and the identification of various oncologic microRNA molecules, contributes to the field of PC treatment (Neoptolemos et al., 2004). While the predictive and prognostic abilities, of molecular biomarkers, have gained popularity, surgical resection in combination with chemotherapy and/or chemoradiation have the best opportunity for long-term survival.

In the discussions on the impact of environmental exposures on human health, Peters, Hoek and Katsouyanni (2012) emphasized on the significance of environmental epidemiology in providing robust evidence to assist timely and sufficient protection of vulnerable subgroups of populations from environmental hazards. While the researchers discussed some limitations of the exposome in biological samples, the study noted individual’s exposure that begins before birth and over his or her lifetime. The notion of considering the vulnerable periods and assessment of environmental exposures in a life-course fashion is a precious concept embedded in the exposome paradigm argued in this study as a missing feature in environmental epidemiology. Another missing feature is the combined analyses of studies from different life phases that need conceptual and statistical methodological developments along with integrative exposures assessment combined with traditional and novel approaches. Peters et al. acknowledged the significance of emerging wealth of methods and data, as well as asserted the necessity to integrate environmental questions into research on disease mechanisms that is overturning paradigms based on technical innovations (p. 104). ETS is an example of environmental exposure that has been associated with an array of adverse effects on health. Secondhand smoke, referred to as ETS, contains many of the same carcinogenic compounds as the mainstream smoke inhaled by active smokers (World Health Organization, International Agency for Research on Cancer, 2004; Bao et al., 2009). Given that the role of passive smoking in pancreatic carcinogenesis remains unclear, Bao et al. (2009) examined the association of ETS with PC risk. In this prospective study, 86,673 women in the Nurses’ Health Study was considered, and ETS exposure was assessed through questionnaires. Using Cox proportional hazards models, relative risks (RR) and 95% confidence intervals (CI) were estimated. Bao et al. (2009) found that maternal smoking significantly increased the risk of PC (RR, 1.42; 95% CI, 1.07–1.89). Conceding the fact that the risk associated with maternal smoking remained elevated, no association was found for adult passive exposure at work or home. Paternal smoking was not related to the risk (RR, 0.97; 95% CI, 0.77–1.21). In addition to self-reported indicators of exposure through questionnaires or interviews that was used by the Bao et al. in their 2009 study, there are other ways to measure ETS: measuring tobacco smoke components in the air to which subjects are exposed (environmental measurements), and the use of biomarkers to measure concentrations of components of smoke in the body of exposed individuals. While environmental measures are considered suboptimal and may not reflect the dose of ETS that reaches the body; self-reports and biomarkers have been more commonly used in epidemiologic studies. Questionnaires are not only inexpensive to administer to large numbers of subjects; this measurement tool has been successfully used in many smoking cessation studies (Fergusson et al., 1998; World Health Organization, 2001; Brooks et al., 2004). A meta-analysis of studies that validated self-reported smoking behavior with biochemical measurements, Patrick et al. (1994) concluded that self-reports of smoking status are accurate in most studies. However, using questionnaire data alone makes analysis and quantification of ETS exposure challenging and need more objective and reliable methods.  Hatsukami et al. (2003) proposed several potential biomarkers that measure ETS exposure and include carboxyhemoglobin, thiocyanate, carbon monoxide (CO), DNA adducts, protein adducts, nicotine, and cotinine (p. 11). Both self-reports and biomarkers help in producing evidence-based studies needed in the development of smoke-free air policies. Without reliable ETS exposure measurements, there will be no scientific evidence that will support the significance of smoke-free policy adoption. On the other hand, environment measurements could play a major role in evaluating policies that have been implemented. In the Netherlands Cohort Study, Heinen et al. (2010) examined the role of active cigarette smoking, smoking cessation, and passive smoking as determinants consisted of 120,852 men and women who completed a baseline in a 1986 questionnaire. Using a case-cohort approach, person-years of follow-up of a random subcohort (n = 5,000) was chosen. Multivariable-adjusted hazard rate ratio (HR) of 1.34; 95% confidence interval (CI), 1.02-1.75 and HR, 1.82; 95% CI, 1.40-2.38 after comparison with never cigarette smokers. While there are no association was observed between passive smoking exposure and PC risk in women; Heinen et al. observed an increased risk per increment of 10 years of smoking (HR, 1.15; 95% CI, 1.08-1.22) and an HR of 1.08 per increment of 10 cigarettes/d (95% CI, 0.98-1.19). There are 520 PC incident cases was observed after 16.3 years of follow-up. The study confirmed that cigarette smoking is an important risk factor for the disease, and quitting smoking benefits the burden on incidence level.

While smoking has been established as a PC risk factor, passive smoking remains to confirm as an environmental factor. According to Simard, Rosner and Michels (2008), recent studies argue that passive smoking put fetuses to have a higher risk of illnesses later in life. Ding et al. (2015) explored the relationship between PC and passive smoking. In this study, a Hospital-based case-control study on PC was conducted from the inpatient of five hospitals from Oct. 1991 to Sep. 2014.  History of exposure to ETS was quantified using Cox proportional hazards models to estimate relative risks (RR) and 95% confidence intervals (CI). From 1991 to 2014, 686 men and 390 women were diagnosed with PC, and compared to paternal smoking (RR, 0.97; 95% CI, 0.77-1.21; P = 0.084), maternal smoking significantly increased the risk of pancreatic cancer (R, 1.56; 95% CI, 1.13-1.98; P = 0.018). In this study, the risk associated with maternal smoking remained elevated compared to the never smokers (RR, 1.49; 95% CI, 1.072.27). The results of this study are suggestive of the positive association between maternal smoking and the potential role of early exposure to environmental tobacco smoke in pancreatic carcinogenesis. Ding et al. confirmed the significant overall risk of PC maternal smokers, but not among paternal smokers. The researchers suggested that the only way to reduce the burden of the disease is maternal smoking inhibition. Canada like the U.S., PC is the fourth leading cause of cancer mortality. While obesity and diet have been identified as modifiable risk factors associated with the etiology of this disease (Hanley, Johnson, Villeneuve & Mao, 2001; Michaud et al., 2001), it  has been estimated that both active and passive smoking is 27-33% attributable to all PC cases (Silverman et al., 1994; Siemiatycki, Krewski, Franco & Kaiserman, 1995), containing numerous carcinogenic constituents. ETS contains 43 known carcinogens with smaller particle sizes (vapor phase constituents rather than particulate phase) making it unclear which cancer sites may be affected by ETS exposure. In 2004 of Villeneuve, Johnson, Mao, and Hanley, the relationship between PC incidence and ETS was explored using data collected from a Canadian population-based case-control study that was conducted in 8 provinces between 1994 and 1997. The researchers examined the same subjects of their 2000 study who formed the basis of risk assessment to evaluate the associations between PC, coffee consumption, alcohol, and measures of tobacco use among smokers, and using methods developed previously to assess the relationship between ETS and other type of cancers within is a large-scale Canadian research initiative called as the National Enhanced Cancer Surveillance System (NECSS). Mailed questionnaires, with telephone follow-up if necessary to clarify the lifetime history of potential exposure at home and work to passive smoking. Multivariate models were adjusted for the effects of other known or suspected risk factors of PC, and risk assessment was performed for males, females and both. An odds ratio of 1.21 (95% CI=0.60-2.44) among never smokers, those who were exposed to ETS both as a child and as an adult relative to those with no exposure. Villeneuve et al. (2004) found that risk increases were more pronounced among active smoker with an increased number of years of smoking, cigarette pack-years, years since quit smoking, and an average number of cigarettes smoked daily, compared to those who are never smokers and had not been regularly exposed to ETS (p. 34). While the results of this study are suggestive of a weak association between PC and ETS, the results show the probable confounding role of ETS smoking in the association of active smoking with PC.

In the study on pathological changes in the pancreas of smokers, Tomioka et al. (1990) examined histopathologically 73 pancreases obtained by autopsy from 42 heavy cigarette smokers and 31 non-smoker patients. One invasive adenocarcinoma measuring 2 cm in diameter and three small carcinomas (2-5 mm in diameter) were found in smokers and one small carcinoma in a non-smoker patient. The pathological difference between smokers and non-smokers in this study was statistically not significant, albeit the incidence of PC in smokers was higher than in non-smokers. The type and the incidence of ductal alterations, two had lung cancer, one skin cancer, one colon cancer and one was free of any malignancies. Ductal changes, including mucinous or squamous cell metaplasia and papillary hyperplasia) were found with equal frequencies in both smokers and non-smokers. Exclusion of other relevant variables (diet, diabetes, alcohol) weakens the strength of this study. Considering that the results of this study are subjective to age-related incidence rather than smoking history, the researchers should have included risk factors such as family history of PC, high-risk inherited syndromes such as among Ashkenazi Jews, and other environmental tobacco exposures such as cigar, and pipe smoking. Using these approach, the researchers could have the chance to compare tumor size differences between smokers and non-smokers that could be associated with these demographics including race, and high fat/high cholesterol diet., obesity, chronic pancreatitis, and diabetes mellitus. Results of such research design could have a more meaningful outcome and amplify the significance of the result especially in correlating the study shared exposure of subjects to ETS. It is important to acknowledge the need for continued research to establish a meaningful risk prediction models that could be practically applied in clinical settings to raise the accuracy of predicting the potential for PC. Given that surgical resection procedure is the only treatment approach that could improve survival rate, establishing a high-risk prediction model using novel early identification protocol of pre-malignant lesions and molecular profiling is paramount, as part of a personalized therapeutic approach and standardized methods of early detection, and prevention.

PC involves both genetic and environmental factors, and like any other human diseases, PC is complex and multifactorial that has the greatest burden on society.  According to Bookman et al. (2011), the development of high-density genotyping platforms has allowed investigators to screen hundreds of thousands of genetic variants to test for associations with disease (p.2). Hindorff et al. (2011) asserted that to date, Genome Wide Association Studies (GWAS) have identified over 900 statistically significant findings in various diseases and conditions. Parallel to this argument, Yeo et al. (2009) characterized one of the largest national registries of familial PC and sporadic PC, focusing on demographics, survival status, clinical factors, self-reported environmental and occupational lifetime exposures. In this retrospective cross-sectional study, the data was aggregated from the Johns Hopkins National Familial Pancreas Tumor Registry (NFPTR) enrolled between 1994 and 2005. While the study did not perform a comparative histopathological assessment, Yeo et al. conducted a case-only analysis that includes cases of 569 FPC (n=569) and 689 SPC. In addition to the reported risk factors such high-risk inherited syndromes, family history of PC, exposure to occupational and environmental carcinogens, cigarette, pipe smoking, and cigar, other demographics included in this study are age, race, chronic pancreatitis, diabetes mellitus, high fat/high cholesterol diet and obesity. The results show that exposure to tobacco carcinogens and environmental tobacco smoke (ETS) could lead to the earlier occurrence of PC. Yeo et al. (2009) concluded that the findings provided a risk prediction model that support the benefit of early identification of pre-malignant lesions and molecular profiling, as methods of early detection, prevention, and personalized therapy for high-risk individuals.  While Yeo et al. was the first to generate the findings that occupational and environmental exposures may act synergistically with inherited or acquired genetic polymorphisms; Gallicchio et al. (2006) examined the association of household passive smoke exposure and active cigarette smoking in the development of PC using a prospective cohort design from the Washington County Cancer Registry. Current active smokers were found to have a two-fold increased risk of PC using Poisson regression analysis in both cohorts, the 1963 cohort to 1978 (n = 45,749) and 1975 cohort from 1975–1994 (n = 48,172). While household passive smoke exposure was not associated with an increased risk of PC among never-smokers in each cohort that could be explained by wide confidence limits due to a small number of cases, Gallicchio et al. further documents the approximate doubling of PC risk in current active smokers. Vrieling et al. (2010) examined the association between ETS exposure and tobacco use with PC risk within the European Prospective Investigation into Cancer and Nutrition (EPIC). Data analysis was based on 465,910 participants, including 524 first incident PC cases diagnosed after a median follow-up of 8.9 years. In this study, using Cox proportional hazard models, an increased risk of PC was found among current cigarette smokers with greater intensity and pack-years compared with never smokers (HR = 1.71, 95% CI = 1.36–2.15). Among never smokers with daily ETS exposure during childhood, increased PC risk was found with HR = 2.61, 95% CI = 0.96–7.10 and HR = 1.54, 95% CI = 1.00–2.39 among those who are exposed to ETS at home and/or work. The results of this study show that while PC risk is reduced to levels of never smokers within five years of quitting, increased risk of the disease is associated with both active cigarette smoking and ETS exposure. Studies of passive smoking or the use of noncigarette tobacco products often are limited by the small number of exposed individuals among never smokers, albeit the high prevalence of cigarette smoking among PC patients. Hassan et al. (2007) assessed the associations between the risk of pancreatic cancer and passive smoking and the use of other tobacco products using a large-scale case-control study from 2000 to 2006. In this hospital-based study of 808 patients with pancreatic adenocarcinoma with a control group of 808 healthy individuals, analysis of data includes the relation between PC and smoking cigarettes, cigars, and pipes; the use of smokeless tobacco products; and passive smoking after controlling for the effects of other confounders and major risk factors for this disease (p. 2). All participants were enrolled prospectively at The University of Texas M. D. Anderson Cancer Center and controls were selected from M. D. Anderson healthy visitors who accompanied cancer patients.  All controls have no cancer history and are not genetically related family members (spouses) of patients with cancers.  The patients and controls were frequency-matched by age (±5 years), race/ethnicity, and sex (Hassan et al., 2007). Stata software (Stata Corporation, College Station, TX) was used for data management and statistical analysis.  Univariate and multivariate analyses, unconditional logistic regression was performed to compare the demographic characteristics and proportions of potential risk factors among patients and controls. Previously reported association between active smoking and increased risk for PC was confirmed in this study with adjusted odds ratio (AOR) of 1.7 (95% CI, 1.4-2.2) for regular smokers, 1.8 (95% CI, 1.4-2.4) for long-term smokers, and 3.1 (95% CI, 2.2-4.3) for former smokers. While  passive smoking has an AOR of 1.3; 95% CI, 0.9-1.7 and never smokers (AOR, 1.1; 95% CI, 0.8-1.6), suggesting to nonsignificantly elevated risk for PC in the entire study population (AOR, 1.3; 95% CI, 0.9-1.7), Hassan et al. found the association of ever smokers with the disease (AOR, 1.7; 95% CI, 1.03-2.6) but was absent among never smokers (AOR, 1.1; 95% CI, 0.8-1.6). Chewing tobacco, snuff, and pipes also showed a non-significant risk elevation for PC after controlling for the confounding effects of demographics and other known risk factors. Hassan et al. noted that neither intensity nor duration of passive smoking modified the risk of PC among never smokers, but the use of cigars in never smokers showed a borderline significant increase in risk for the disease with an AOR, 2.2; 95% CI, 1.0-4.7; P =.05. It was concluded in this study that results are not enough to support the role of passive smoking or the use of noncigarette tobacco products in the PC etiology. Hassan et al. asserted the need to confirm the association between cigar use and the disease in other study populations.


Going back to the concept of gene-environment (G x E) interaction by Fisher (1958) and Hogben (1968) emphasized the need to consider the fundamental, philosophical differences between a variation partitioning approach and a mechanism-elucidation approach that provides the initial understanding of some aspects of genetics in association to smoking in cancer causation. The reason why the results of risk factor research for PC appears to be generic could be explained by the failure of the researchers to focus on a multi-level approach, failing to connect the gap between individual, macroenvironmental and biologic level. While the failure to appreciate the importance of the biological pathways is a more serious problem, Rutter (2015) noted that failure to pay proper attention to the methodological checks needed to highlight G X E in cancer causation results in some poor research that lead to disputable outcomes.

Bao et al. (2009) and Heinen et al. (2010) shared the same argument of the positive association between maternal smoking and the development of PC. In this study, it was found that early exposure to ETS and maternal smoking could lead the potential in utero to a lifetime risk of this lethal disease. An earlier study of  Villeneuve et al. (2004) also recognized the role of ETS as a risk factor for PC and noted the probable confounding role of active cigarette smoke. Gallicchio et al. (2006) confirmed the approximate doubling of pancreatic cancer risk in current active smokers. While Hassan et al. (2007) observed significant associations between passive smoking, the use of noncigarette tobacco products and risk of pancreatic cancer, Hassan et al. highlighted the need for future assessment of the role of passive tobacco use in population-based studies. The synergistic interaction of occupational and environmental exposures and its role in the early occurrence of PC was explored in the 2009 study by Yeo, Hruban, Brody, Brune, Fitzgerald, and Yeo, C. J., aligning to the intent of the 2010 study of Vrieling et al. to examine the association between cigarette smoking and exposure to ETS with PC risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). The overall findings of these studies support the obligation of environmental epidemiology and the importance of inter-disciplinary collaboration to provide robust evidence on the positive role of active and passive smoking, ETS-related carcinogens to protect vulnerable population subgroups. Identification of pre-malignant lesions and molecular profiling is paramount, as methods of early detection, prevention, and personalized therapy for high-risk individuals. While the study of Yeo et al. considered the causality of predictors at an individual and biologic level; including etiologic agents at macroenvironment-level could have given a more citable outcome. Given that the study has access to one of the largest national registries of familial PC, the researchers did not utilize the extensive data available and assessed the data within hierarchical levels. Integrating individual and biologic level to macroenvironment-level into a multilevel framework will allow the interdisciplinary exchange of knowledge, optimizing the value of multilevel studies for both clinical and public health activities. Lynch et al. (2013) proposed a multilevel approach to bridge the gap between individual, macroenvironmental and biologic level called  “Multi-level Biological And Social Integrative Construct” (MBASIC). The primary goal of the MBASIC is to guide researchers to consistently, and systematically incorporate biological mechanisms generate significant statistical or epidemiological model better to understand the complex nature a lethal disease like PC. Lynch et al. highlighted the significance of MBASIC in expanding the utility of the multilevel approach by including levels of etiology and carcinogenesis with levels of intervention and implementation/evaluation. The interaction of these levels could provide a resource-efficient approach to early PC screening and detection.

The exposure to rare chemicals may pose a large individual risk if a child is exposed, justifying the need to consider the impact of maternal smoking during pregnancy and postnatal environmental tobacco smoke (ETS) exposure. ETS exposure and other exposures to common substances in the perspective of public health equates a relative risk that could have a progressive/cumulative effect to the public. Röösli (2011) argued that children differ from adults in many aspects which are relevant when assessing health risks from chemicals; therefore future research warrants a working framework that addresses the potential for non-cancer effects resulting from continuous short-duration and intermittent exposures to chemicals. A good example is the framework of Haber et al. (2016) presents an integrated, tiered approach that could be adopted in assessing the acceptability of toxicity reference values (TRVs) in relation to short-duration or intermittent exposure scenarios. Environmental tobacco smoke (ETS) is an example of environmental exposure that has been associated with an array of adverse effects on health. Secondhand smoke, referred to as ETS, contains many of the same carcinogenic compounds as the mainstream smoke inhaled by active smokers (World Health Organization, International Agency for Research on Cancer, 2004; Bao et al., 2009). Under the lens of public health, quitting smoking could decrease the incidence of PC, by protecting vulnerable members of the population. The rapid uptake and use of new health information among groups with lower SES and access to health-enhancing treatment and technologies will be dependent upon the development and implementation of public health policies that include equal allocation of resources to every enclave of the community. While the past and current research could help continue the improvement of the accuracy of passive smoking measurement, it is critical for the continuance of applying the exposome concept to environmental health problems. Research outcomes that help the drafting of amendments to policies and approaches, built on existing policies such as cigarette labeling acts, smoking bans, and distribution of cessation tools will not only improve mortality level of the disease, but population health as a whole. Overall, the results of articles reviewed between 1990 to present suggest the potential role of early exposure to environmental tobacco smoke in pancreatic carcinogenesis. While maternal smoking cessation is the only way to reduce the burden of PC to both the baby, the mother and others who shared the exposure, future research needs to confirm the positive association of PC with maternal smoking and ETS. Continued research on the association between passive smoking exposure and the disease, as well as early shared exposure of these predictors, are critical to better understand its association to lifetime risk. The focus on obtaining a larger number of endpoints, it is paramount for future research to combine more cohorts to have a stronger and standardized sampling that yields a statistically significant assessment of predictors associated with pancreatic cancer.


The argument on the gene-environment interaction paradigm to genome-wide studies in relation to the development of a public issue was discussed in the 2014 study of Boardman et al., highlighting  the importance of integrating social and genetic perspectives in enhancing findings for both biologically and socially focused research such as the causality of active and passive smoke exposure to lifetime risk of a fetus to develop a lethal disease like PC. For decades, behavior geneticists have been working to disentangle the genomic component of family risk from the social and behavioral component. According to Boardman et al. (2104), understanding the genomic component in combination with specific environmental contexts could provide the pertinent information about an individual’s likelihood of exhibiting a particular behavior at a given time, critical not only to social and genetic epidemiologists, but to the understanding of the association of modifiable behavioral risk and adjustable predictors in the development of the disease. New evidence for genetic influences on most health behaviors, new statistical methods, and new genetic data sources could help confirm the impact of environmental influences on individual’s genetic composition that could be contingent on the social environment in which one resides, works, and plays. The findings of the literature reviewed in this paper will not only add to the wealth of information needed in the development of a standard PC risk model but also highlight the significance of the early screening and molecular profiling, as a prudent approach to the prevention of PC. Parallel to the intent of my dissertation on “Pathopoiesis Mechanism of Smoking and Family Cancer History in Pancreatic Cancer,” findings discussed in this paper emphasize the need for novel therapeutic strategies that will improve survival level and quality of life for late-stage PC patients.


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“In our fight against cancer—we must be unwilling to postpone—for the loved ones we’ve lost and the ones we can save.”

Violent Radicalization: An Impending Public Health Issue

Empathy Gap

Violent Radicalization An Impending Public Health Issue

Labilles, U., Noboa, C., Riddle, J., & Beckles, W.


Over the past 15 years, the incidence of violent extremism has increased worldwide. Adapa et al. (2016) noted a sharp increase in the number of attacks and deaths since 2012 based on data from the National Consortium for the Study of Terrorism and Responses to Terrorism (NCSTRT), while the Global Terrorism Index (2014), showed that there was an increase of 41% in the number of violent attacks between 2012 and 2013, and an increase in deaths by 61% reaching around 18,000. Moreover, terrorist/violent attacks rose 81% globally in 2014, causing 3.2-4.4% increase in fatalities with more than 5,000 attacks against private citizens and property (NCSTRT, 2015). Violence related statistics had already increased if the 2015 Paris and San Bernardino California attacks are included; and the recent attacks in Turkey, Orlando, Dallas and Nice, France are quantified.

Jerkins (2010) examined the extent to which radicalization has occurred within the United States (U.S.). For example,  between December 2009 and September 2011, there were 46 cases involving domestic radicalization and recruitment into jihadist terrorist groups, and 125 out of 46 cases were identified. There are 3 million Muslims in the U.S., and the incidence of radicalization among this population is 1 in 30,000 (Jerkins, 2010). The NCSTRT (2015) stated that from 2001 to 2014, the number of deaths related to terrorist attacks was 3,066, while 2,961 occurred in the U.S. were 2,902 took place during the September 11, 2001, attacks. The Institute for Economics and Peace (2014) showed that 82% of deaths (killed) globally occurred in five countries: Iraq, Afghanistan, Pakistan, Nigeria, and Syria. Moreover, as compared to homicide, there were 437,000 homicides which are 40 times greater than compared to deaths related terrorism (Institute for Economics and Peace, 2014).  Radicalization rates were found higher in regions of  South Asia and Sub-Saharan Africa (2006-2012). Furthermore, the typical profile of a radicalized individual was younger than average, less educated than average, unemployed and struggling to meet ends, less religious than average, and willing to sacrifice his/her for (Kiendrebeogo & Ianchovichina, 2015). Despite radicalization prevention, it has been estimated that 20,000 individuals from around the world, including 500 from the United Kingdom, and 3,000 from Europe could be considered under the spectrum of violent radicalization (Bhui, 2015). Channel (anti-radicalization scheme) a study conducted by the United Kingdom (U.K.) police, found that 44% of 500 are vulnerable as it relates to mental health or psychological difficulties, while 15% found to have possible vulnerabilities, but requires further assessment (Dodd, 2016).  A survey conducted by the Department for Communities and Local Government, U.K. (2010) focused on attitudes towards extremism in England and Wales, 85% of participants stated that it was ‘always wrong’ to use violent extremism to protest against things that are unfair or unjust; 95% indicated that it was ‘always wrong’ to use violent extremism in the name of religion to achieve a goal; 92% stated that it was ‘always wrong’ for political campaigners to distribute leaflets that encourage violence towards other ethnic groups, and 81% indicated that it was ‘always wrong’ for animal protesters to use violence to protect animals.

Prevailing Theories and Conceptual Frameworks

Empathy gap and social movement theory.  A Facebook live feed of Philando Castile dying next to his fiancé with a 4-year old girl in the back seat could have convinced Micah Johnson to drop his bigger plan, and commit a tragic event that killed five Dallas police officers on the street, one through a second-floor window. What is the role that empathy plays in establishing individual or group identity? Failures of empathy are especially likely if the sufferer is socially distant, for example, the perceived social injustice among black Americans for being unfairly treated by the police authority. Emile Bruneau, a cognitive neuroscientist at the Massachusetts Institute of Technology, has spent the past eight years studying intractable conflicts around the world. Bruneau’s theory on “empathy gap” states that while empathy signals might be great at improving prosocial behavior among individuals, boosting a person’s empathy could also increase hostility toward the enemy (Interlandi, 2016). Therefore, it is paramount to explore the significance of “empathy gap” parallel to social movement theory’s potential social, cultural, and political consequences that empower social mobilization.

Criminal justice system approach. Bhui et al. (2012a) suggested a criminal justice model to understand violent radicalization. This theory is focused on comprehending the motivation and pathway that leads to radicalization and eventual terrorism, and it assumes that it is capable of handling crimes regardless of their origins and context, and terrorism can be prevented through intelligence and specifically geared justice system versus theories and practice. Bhui et al. (2012a) go on to argue that an epidemiological approach, along with psychology, sociology and other behavioral sciences.

Situational action theory (SAT). Based on a theory of offending, aimed at providing fundamental insights into the causal processes leading to acts of crime, or more generally, moral rule breaking (Wikstrom et al., 2012). This theory serves to understand the violent extremism and consequently conceptualize acts of violent extremism as the result of the interaction between an individual and the environment (Schils & Pauwels, 2014). There are some assumptions related to this theory including; 1) the individual propensity to violent extremism and exposure to violent extremist settings can be seen as direct causes of political violence, and 2) the impact of exposure to violent extremist settings is contingent on the level of individual violent extremist propensity (Schils & Pauwels, 2014). Bouhana and Wikstrom (2008) mentioned that the likelihood that a person will commit political violence depends on his/her propensity towards violent extremism and its interplay with exposure to violent extremist settings.

Psychoanalytic theories. Psychoanalytic theorists applied their knowledge to the reasons behind sociopolitical conflicts, the origins of violent terrorist activity, and the psychodynamics of organizations (Reid & Yakeley, 2014). This theory suggested that terrorism is meaningful communication expressed as violence (Reid & Yakeley, 2014). Psychic determinism, the notion that unconscious forces control the conscious thoughts, actions, behaviors, and symptoms describe how violence may represent communication from conscious and unconscious fantasies, wishes, memories, and defenses (Reid & Yakeley, 2014). Furthermore, terrorism is influenced from past trauma and manifests itself into the present as violence (Reid & Yakeley, 2014). The psychoanalytic theory suggests that individual behaviors determined by the culture and large group identity (Reid & Yakeley, 2014). Large group dynamics influences individuals where rational thoughts give way to terrorist views (Reid & Yakeley, 2014).

Construal level theory (CLT). Initially proposed by Trope and Liberman (2010) and stated that as psychological distance increases, thoughts become more abstract and distal, while as psychological distance decreases thoughts become more concrete or immediate. CLT under the lens of a public health professional, policy maker local and state leader, an ethnic enclave could be like a forest, to see the trees in a forest you need to move closer. Adapa et al. (2016) related to this angle as someone in a high-level construal will use an abstract thought process, perceiving the big picture (the forest), whereas someone in a low-level construal will use a real process of reflection recognizing its details (the individual trees).

Evaluation of Methods within the Literature

Szlachter et al. (2012) explored how psychosocial adversity, economic, psychological, social, political and religious factors aligned in the process of violent radicalization among Islamic believers living in Poland. A survey method was used to collect economic, psychological, social, political, and religious factors among 536 individuals. The researchers used mixed data collection strategies including individual and small group survey at particular settings to ensure the anonymity. The scales of socio-political attitudes and beliefs included in the survey method demonstrated reliable score, where Cronbach’s alpha values ranging from 0.60 to 0.91 (Szlachter et al., 2012). However, they used a convenience sample which might result in biases findings, where the sample might not be representative of the study population.

Bhui et al. (2014) explored depression, psychosocial adversity, and limited social assets and its perceived effects to violent radicalization vulnerability. A cross-sectional design and an interview survey method were used to identify risk and protective factors (e.g., depression, psychosocial adversity, limited social assets, and demographics and psychological characteristics) associated to violent radicalization. The interviewers were trained to handle sensitive and personal experience, data aggregation using a computer-assisted format, among 608 individuals of Pakistani or Bangladeshi origins, aged 18 to 45, of Muslim heritage and living in East London and Bradford. The interview survey includes questions about social, lifestyle, health outcomes, safety issued for Muslim, and demographic characteristics.  These methods measured radicalization by 16 items including a comprehensive literature review and focus groups assuring the face and content validity. However, this approach excluded factors that might be associated to violence radicalization; as well the respondents’ perceived anonymity could be influenced, which may affect the validity of the study. Also, the cross-sectional design the causality cannot be directly inferred.

Adapa et al. (2016) hypothesized that high-level construal could increase an individual’s likelihood to engage in ideologically based violence, and low-level construal decreases an individual’s likelihood to engage in ideologically based violence. Vignettes were developed and refined in the pilot study and were used in the second stage. Construal level manipulation (high construal, low construal, or no construal) was performed in the second stage. Multi-part statistics analysis was conducted in the final stage to analyze the impact of construal level manipulations on likelihood to engage in ideologically based violence. A total of 1,112 individuals completed the pre-screening process, and 139 qualified participants completed the entire study. Adapa et al. (2016) found that many of the statistical results did not support the hypothesis of the study which could be explained by the vulnerability in the study paradigm, and the construal level does not affect or has a non-significant effect on willingness to participate in ideologically based violence. While the study design aimed to establish a robust data aggregation model, the logistical limitations, vignette ideology issues, and novel features of this study that could have adversely impacted the results. Researchers asserted that future research could use vignettes time distance manipulations to induce construal shifts, rather than using low-level and high-level manipulations. The understanding of decision-making patterns and ideologically based violence is dependent upon a fundamental knowledge of the way abstract and concrete mindsets alter thought processes.

Malthaner and Waldmann (2014) conducted a systematic review of social movement studies that involved protests, studies that examined terrorist groups and their social environment, and works about to the influence of the social environment. Researchers introduced the radical concept milieu to focus attention on interactions and patterns between terrorist groups and their social environment (Malthaner & Waldmann, 2014). Through this method, researchers identified the relationship between these groups and individuals and the impact of their social environment, providing critical data on how individuals influence political violence from relationships and the dynamics of interactions. However, these methods lack to examine how the immediate social environment further influences the terrorist. Reid and Yakeley (2014) conducted a literature review of theoretical databases over the past 15 years from a psychoanalytic perspective, and introduced the stratum of lone-wolf violent radicalization with the argument of conscious and unconscious reasons to exert violence towards others. The lone wolf terrorist includes suicide bombers in the Middle Eastern conflict, or mass shooters in the U.S. Lone wolf terrorists rationalize their violence as moral outrage based on personal grievances which outweigh any moral reasoning (Reid & Yakeley, 2014). These mental disturbances are thought to begin in adolescence but may be earlier because of genetic influences and environmental adversity (Reid & Yakeley, 2014). This method was focused on the psychodynamics of the lone wolf to determine what motivates them to act violently towards others. Conversely, through this approach, it is difficult to attribute the disturbed state of mind of lone wolf terrorists to the high-risk developmental probability. Researchers review of empirical research of the psychoanalytic thoughts of lone wolf terrorists and future research should include large groups and case study analysis.


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Szlachter, D., Kaczorowski, W., Muszynski, Z., Potejko, P., Chomentowski, P., & Borzol, T. (2012). The radicalization of religious minority groups and the terrorist threat – report from research on religious extremism among Islam believers living in Poland. Internal Security, 4(2), 79-100.

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Ethical Concepts of the New Public Health

I am currently working on two essays that I needed to submit with my fellowship application, but the event in Paris made me stop for a few minutes and reflect on the scorching reminder that terrorism has no religion, a brand of madness, not faith. Such event amplified the urgency to stress the significance of New Public Health that carries a high potential for healthy less aggressive societies.  The main principles of living together in healthy communities were summarized by Laaser et al. (2002) as four ethical concepts of the New Public Health essential to violence reduction – equity, participation, subsidiarity, and sustainability. The coupling of current economic, demographic, and social issues will play a role in guiding future policy revisions. While my fellowship of interest is in epidemiology and infectious diseases, increased understanding of the interrelated dimensions of deracination or forced migration using the modern concept of public health is warranted. It is critical to understand the determinants of violence: the type of stigmatization; the process of urbanization; religious, ethnic, and racial prejudices; women’s status; the level of education; employment status; socialization of the family; availability of firearms;  alcohol and drug consumption;  and poverty.


Laaser, U., Donev, D., Bjegovic, V., & Sarolli, Y. (2002). Public health and peace. Croatian medical journal, 43(2), 107-113.

Indoor Tanning and Melanoma: A Public Health Issue

Indoor TanningIndoor Tanning and Melanoma: A Public Health Issue

Ulysses Labilles and Jennifer Beito

In Minnesota and other parts of the U.S., increase melanoma continue to be common among women than men younger than 50 years. Lazovich et al. (2016) highlighted the gap between age- and the sex-specific association studies between indoor tanning and melanoma. It was found that the strongest correlation between indoor tanning and melanoma is the anatomic site, commonly developed on the trunk in women. Lazovich et al. (2016) stated that while not as strong as for women, 2-fold increase among men who tanned indoors was found to have a higher risk of developing melanomas of the trunk. Furthermore, the findings in this 2016 study are “consistent with the divergent pathway hypothesis for melanoma, which suggest that intermittent solar ultraviolet radiation exposure among those with many nevi, in contrast to chronic solar ultraviolet radiation exposure in persons with fewer nevi, induce the development of the lesion at a younger age, with tumors developing on anatomic sites typically protected from the sun” (Lazovich et al., 2016). Whereas Lazovich et al. (2016) found considerable variation in the correlation between indoor tanning and melanoma by anatomic site, confirming indoor tanning as a possible predictor, responsible for the increased among younger women. Given the timing of increased risk among women indoor tanning users, it is expected for the melanoma epidemic to continue unless indoor tanning is restricted and reduced (Lazovich et al., 2016).


The field of melanoma genetics with new platforms to investigate, makes this area epidemiology move at a high pace. According to Ribero, Glass and Bataille (2016), genes involved in the cell cycle and senescence, identified in the genome-wide association studies over the last ten years, explains the development of the lesion, in addition to telomere biology that further links to reduced senescence. In this study, the role of clinicians was highlighted in recognizing the phenotypic, environmental, and familial risk factors for melanoma to identify those patients at risk who require screening and long-term follow-up (Ribero et al., 2016, p. 338). In this country, skin cancer is the most commonly diagnosed cancer and increasingly becoming a major public health problem with more than 60,000 melanomas diagnosed in 2010 (Rogers et al. 2015; Guy et al. 2015). The potential causality for increased melanoma incidence was discussed by  Rivera, Han, and Qureshi (2013), traced to the 1980 obbligato explosion in indoor tanning. It is, therefore, essential for continued investigation from scientists, professional societies and legislators (Rivera et al., 2013). Using REP resources aggregated from residents of Olmsted County, Minnesota between 1970 and 2009, 256 young adults their first lifetime diagnosis of melanoma, between the ages of 18 and 39 years of age (Reed et al. (2012). The study confirms the arguments of Bleyer et al. (2006) that “the incidence of cutaneous melanoma is increasing among young adults, with this rate increasing more than 6-fold among adult men than women, but incidence are reversed among young adults and adolescents, with the female-male incidence ratio of 1.8 in young adults aged 20 to 24 years.” (Reed et al., 2012, p. 331) Reed et al. (2012) noted that the results of studies from the Rochester Epidemiology Project (REP) might be explained by some sex-specific behaviors such the increase likelihood of young women to participate to different UV light exposure than young men. While De Giorgi et al. (2012) stated that only minimal changes in mortality had been observed, there is a continuous increase in melanoma incidence worldwide. De Giorgi et al. (2012) supported the argument that indoor tanning may have been responsible for increased melanoma incidence in women and younger tanning bed users with higher estimated risk ratio in the general population. Debates over reducing indoor tanning tend to dominate discussions for its potential to reduce melanoma incidence, mortality, and treatment costs, the findings of the 2016 study of Guy et al. underscored the increased economic benefits and quantified the significance of continued efforts to reduce indoor tanning in preventing melanoma. Using a Markov model to estimate the expected number of melanoma cases,  lives and treatment costs saved, Guy et al. (2016) estimated 61,839 melanoma cases, prevent 6735 melanoma deaths, saving $342.9 million in treatment costs over the lifetime of the 61.2 million youth age 14 years or younger in the U.S. by restricting the use of  indoor tanning among minors younger than 18 years (, n.d.).

Discussion. Melanoma remains a public health issue, despite efforts to reduce indoor tanning, making melanoma incidence to rise continuously in the U.S. and globally, over and above-attempted prevention efforts (Le Clair, & Cockburn, 2016). The increased risk of malignant melanoma and other forms of skin cancer are found to be correlated with the ultraviolet radiation from indoor tanning device, considered to be an urgent public health issue need to adopt the Action Model to Achieve Healthy People 2020. Ultraviolet light emitted from tanning beds is classified carcinogenic by the World Health Organization International Agency for Research on Cancer (IARC) in 2009, as an interceptive response to the associated risk of exposure with the initiation of melanoma (El Ghissassi et al., 2009). Tanning beds and its carcinogen, the length of time the skin is exposed, and whether or not the skin is protected with prescribed protection such sunscreen are all the key influences contributing the increased risk. Many individuals are exposed to sunlight during their quotidian lives, and popular alfresco activities elevate a person’s chance of developing skin cancer. For example, athletes who spend countless hours training and competing in the sun, workers who need to be under the direct sun exposure all day and children who play outside for countless hours are more prone to developing skin cancer. Exposure to UV radiation during childhood plays is a major role in the future development of melanoma and non-melanoma skin conditions. Many studies have determined that even short, intermittent but excruciating exposure to sunlight during childhood and adolescence significantly increase one’s risk of developing melanoma. More than one moiety of a person’s lifetime UV exposure occurs during childhood and adolescence. If a person has a history of one or more blistering sunburns during childhood or adolescence, such exposure could put these individuals two times greater risk to developing melanoma than those who did not have such exposures (Glanz, & Wechsler, 2002). Ultraviolet radiation is divided into three wavelengths ranges, however; only two of the ranges authentically perforate our atmosphere, UVA, and UVB. Scientists initially believed that only UVB rays played a role in the formation of skin cancer. UVB light does cause deleterious transmutations in skin cell DNA. UVB rays are responsible for sunburn and many basal and squamous cell cancers (English, Canchola & Finley, 1998). However, there are no safe UV rays. UVA rays withal contribute to skin cancer. These rays could cause a deeper skin damage than UVB, emasculates the skin’s immune system and increases the peril of cancer development, especially melanoma. Tanning lamps and tanning beds distribute high doses of UVA, which makes them especially hazardous (Goldstein & Goldstein, 2001). A 2002 Dartmouth study as noted by Goldstein and Goldstein (2001) showed tanning bed users had 2.5 times the peril of SCC and 1.5 times the jeopardy for BCC. Individuals more predisposed than others to the damaging effects of UV radiation could develop skin cancers. The increased risk of melanoma is shown to be higher among individual with family history. Melanoma and other types of skin cancer, risk factors include light or fair skin color, natural blond or red hair, sun sensitivity, immune suppression disease, vocation and geographic location (Goldstein & Goldstein, 2001).

Cases ascertained by a population-based, statewide cancer registry known as the Minnesota Cancer Surveillance System Skin Health Study and approved by the Institutional Review Board at the University of Minnesota, Lazovich et al. (2010) addressed the limitations on past studies in adjusting sun exposure and dose response of individuals using indoor tanning. Individuals diagnosed with any histologic type of melanoma between July 2004 and December 2007, between the ages of 25 and 59 was collected based on state driver’s license or state identification card. Previous studies show that indoor tanning use decreases with age. Therefore, the researchers truncated the age limit to 59 years old. Multiple regression was performed, and adjusted odd ratios show the likelihood of melanoma among users of indoor tanning, and never users were similarly elevated regardless of the age when indoor tanning began (Lazovich et al., 2010). The study of Lazovich et al. (2010) has several significant findings: “First, melanoma was found to be more frequent among indoor tanners compared with persons that never engaged in this activity. Second, measured by total hours, sessions, or years, a strong dose-response relationship was found between melanoma risk. Lastly, an increased risk of melanoma was found with the use of each type of tanning device examined as well as with each period of tanning use, suggesting that no device could be considered safe. Burns from indoor tanning seemed to be fairly common and conferred a similar risk of melanoma to sunburns, strengthening the associations explored significant even after adjusting for the potential confounding effects of known risk factors for melanoma.” (pp. OF9-OF10) Le Clair and Cockburn (2016) asserted the importance of prevention through doctor’s consultation, focusing on the significant impact of behavioral change than written intervention. The findings of this study suggest that knowledge of sun sensitivity in individuals with high UVR sensitivity may reinforce a positive outcome in sun exposure habits, and could represent a useful tool for reducing indoor tanning (Le Clair, & Cockburn, 2016, p.142). Spending an abundance of time alfresco for work or recreation without protective apparel and sunscreen increases the risk to develop skin cancers.  However, no matter what treatment you may cull; the primary cause is something which is kenned and avoidable – natural and artificial UV rays. As a result, the 2 primary aversion methods are simple to recollect, edify and implement – they are endeavored and proven (Goldstein & Goldstein, 2001): “Significantly limit exposure to the sun between the hours of 10 am and 4 pm, utilizing a sunscreen with an SPF of 15 or higher at all times each day, cover your skin with apparel, wear a hat and use sunglasses. Second, verbally express “no” to all other sources of UV radiation such as tanning beds and tanning lamps. Ergo, the next time you visually perceive someone exiting the tanning salon, relaxing midday in the direct sun at the beach or ambulating around with a flamboyantly discernible tan, do not be envious. Instead, view this person as you would a person smoking a cigarette. They are acting temerariously and jeopardizing their lives in an endeavor to imitate what is occasionally introduced by the media. Recollect, despite what the media may lead you to believe; you do not require a tan to look good. During the 2012 meeting by the Centers for Disease Control and Prevention (CDC), it was concluded that future cases of skin cancer could be prevented, along with the associated morbidity, mortality, and healthcare costs through discussion of research gaps and current body of evidence on strategies to reduce indoor. The overarching goals of Healthy People 2020 should be the framework of existing and future studies embracing the state of the evidence on strategies to reduce indoor tanning; the tools necessary to adequately assess, monitor, and evaluate the short- and long-term impact of interventions designed to reduce indoor tanning; and strategies to align efforts at the national, state, and local levels through transdisciplinary collaboration and coordination across multiple sectors (Holman et al., 2013).

Conclusion. The participation of health care providers is required for information dissemination as well as physical and psychological screenings to improve education to address the misconception about tanning safety. According to Friedman et al. (2105) “Public perception of the purported health benefits of indoor tanning can be blamed for the popularity of tanning salons as a desire to prepare the skin before sun exposure, the most commonly cited motivations for indoor tanning.” improve education to address the misconception about tanning safety. Artificial UVR is often misconceived to produce a “safer” tan than outdoor sunlight (CDC, 2014). Le Clair, & Cockburn (2016) argued that this belief is  “contradicted by scientific evidence, and must be addressed to effectively reduce the burden of indoor tanning on health outcomes worldwide.” (p. 140) According to Whitmore et al. (2001), Karagas et al. (2002), and Green et al. (2007), DNA damage in skin cells caused by exposure to indoor tanning UVR is associated with an increased risk of melanoma induction and other types of non-melanoma skin cancers. In-depth understanding of clinicians providing public health education outreach programs is critical from the epidemiology of melanoma to the increased risk of the developing tumors with the frequent use or use of tanning beds. Lobbying efforts such as the Indoor Tanning Association are the most significant barrier to state indoor tanning legislation (Obayan et al., 2010). The risk and benefits of indoor tanning was discussed during the 2012 report of the minority staff of the House Committee on Energy and Commerce, asserted that 80 % of tanning salons told investigators that indoor tanning was beneficial to fair-skinned teenage girls, while 90 % of tanning salons denied that sunlamp use posed any health risks to this vulnerable group (Gottlieb et al., 2015). Such argument not supported by peer-reviewed study should always be challenged, and leaders both political, healthcare and public health should continue to cooperate in drafting evidence-based legislations to ease the economic and individual burden of melanoma induced by indoor tanning. It is paramount to increase the height of prevention efforts, not only limiting the use of tanning beds to children aged 18 or younger, but also to young adults over 18 years old who have increased the risk to melanoma. The transdisciplinary, multilevel, and coordinated approach has the potential to combat future cases melanoma and other forms of skin cancers by reducing indoor tanning, withal many barriers and challenges. While the role of new common sense legislation in tandem with public education campaigns is paramount, mass media campaigns are critical in introducing strategies and highlighting shared environmental risk, as well as the avoidable risk of indoor tanning use. Holman et al. (2013) posit that by reducing indoor tanning use, future cases of skin cancer could be prevented through tailored interventions following the context of comprehensive skin cancer prevention that promotes sun protection and sunburn avoidance when outdoors (Coups, Manne & Heckman,2008). Addressing contextual factors that promote tanning, including environmental and systems changes, social norms, the indoor tanning industry and the media will be dependent upon close coordination and collaboration of key partner across multiple levels. Continued literature must be encouraged among legislators, clinicians, and public health leaders, spreading its highlights through effective mass media outreach.


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Coups, E. J., Manne, S. L., & Heckman, C. J. (2008). Multiple skin cancer risk behaviors in the US population. American journal of preventive medicine, 34(2), 87-93.

CDC (2014). The Burning Truth. Retrieved from (2014)

El Ghissassi, F., Baan, R., Straif, K., Grosse, Y., Secretan, B., Bouvard, V., … & Cogliano, V. (2009). A review of human carcinogens—part D: radiation. The lancet oncology, 10(8), 751-752.

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De Giorgi, V., Gori, A., Grazzini, M., Rossari, S., Oranges, T., Longo, A. S., … & Gandini, S. (2012). Epidemiology of melanoma: is it still epidemic? What is the role of the sun, sunbeds, Vit D, betablocks, and others?. Dermatologic Therapy, 25(5), 392-396.

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Friedman, B., English, J. C., & Ferris, L. K. (2015). Indoor tanning, skin cancer, and the young female patient: a review of the literature. Journal of pediatric and adolescent gynecology, 28(4), 275-283.

Glanz, K., Saraiya, M., & Wechsler, H. (2002). Guidelines for school programs to prevent skin cancer. MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports/Centers for Disease Control, 51(RR-4), 1-18.

Goldstein, B. G., & Goldstein, A. O. (2001). Diagnosis and management of malignant melanoma. American family physician, 63(7), 1359-68.

Gottlieb, M., Balk, S. J., Geller, A. C., & Gershenwald, J. E. (2015). Teens and Indoor Tanning: Time to Act on the US Food and Drug Administration’s Black-Box Warning. Annals of surgical oncology, 22(3), 701-703.

Green, A., Autier, P., Boniol, M., Boyle, P., Doré, J. F., Gandini, S., … & Westerdahl, J. (2007). The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers. International Journal of Cancer120(5), 1116-1122.

Guy, G. P., Machlin, S. R., Ekwueme, D. U., & Yabroff, K. R. (2015). Prevalence and Costs of Skin Cancer Treatment in the US, 2002− 2006 and 2007− 2011. American journal of preventive medicine, 48(2), 183-187.

Guy, G. P., Zhang, Y., Ekwueme, D. U., Rim, S. H., & Watson, M. (2016). The potential impact of reducing indoor tanning on melanoma prevention and treatment costs in the United States: An economic analysis. Journal of the American Academy of Dermatology.

Holman, D. M., Fox, K. A., Glenn, J. D., Guy, G. P., Watson, M., Baker, K., … & Sampson, B. P. (2013). Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention. American journal of preventive medicine, 44(6), 672-681.

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Lazovich, D., Vogel, R. I., Berwick, M., Weinstock, M. A., Anderson, K. E., & Warshaw, E. M. (2010). Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidemiology and Prevention Biomarkers, 1055-9965.

Lazovich, D., Vogel, R. I., Weinstock, M. A., Nelson, H. H., Ahmed, R. L., & Berwick, M. (2016). Association between indoor tanning and melanoma in younger men and women. JAMA Dermatology, 152(3), 268-275.

Le Clair, M. Z., & Cockburn, M. G. (2016). Tanning bed use and melanoma: Establishing risk and improving prevention interventions. Preventive Medicine Reports, 3, 139-144.

Obayan, B., Geller, A. C., Resnick, E. A., & Demierre, M. F. (2010). Enacting legislation to restrict youth access to tanning beds: A survey of advocates and sponsoring legislators. Journal of the American Academy of Dermatology63(1), 63-70.

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Reed, K. B., Brewer, J. D., Lohse, C. M., Bringe, K. E., Pruitt, C. N., & Gibson, L. E. (2012). Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota. In Mayo Clinic Proceedings (Vol. 87, No. 4, pp. 328-334). Elsevier.

Ribero, S., Glass, D., & Bataille, V. (2016). Genetic epidemiology of melanoma. European Journal of Dermatology, 26(4), 335-339.

Rivera, A. R., Han, J., & Qureshi, A. A. (2013). Has too much blame been placed on tanning beds for the rise in melanoma diagnosis?. Expert Review of Dermatology, 8(2), 135-143.

Rogers, H. W., Weinstock, M. A., Feldman, S. R., & Coldiron, B. M. (2015). Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US population, 2012. JAMA Dermatology151(10), 1081-1086.

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misleading practices. Retrieved from HTTP://

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The Thin Red Line of Moral Dilemma in Research


The ethical challenges in the 2009 study of Osrin et al. are consent from cluster guardians, consent by individuals, benefits to control areas and requests by participants. The ethical issues that revolved around cluster guardianship noted in this study are the participants’ perceived adequate information about the trial according to the guidelines of the Declaration of Helsinki. In a complex society or in a society where participation is decided by the concept of a utilitarian judgment there will always be a burning concern for the guaranteed unalloyed voluntary nature of involvement. While cluster randomized controlled trials have been around for a long time, there is a growing concern to evaluate the delivery of health services, public education, and policy on social care (Edwards et al., 1999). Utilitarianism and Kantian ethics are the two most important moral traditions that the ethical aspects of medical practice and medical research are most often discussed. Concerned with increasing social utility (value), utilitarianism, in the long run, the social utility will not be served by demanding that individuals be self-sacrificing for the common good. The collective decision of a local guardian or representative may be contested given that communities are usually amalgams of smaller communities. There is the question whether the decision is in the best interest of the participants or the expected interest is based on the hidden personal agenda of the cluster guardian. It is a matter of distributive justice whereby utility and disutility, benefits and costs, are distributed as fairly and evenly as possible across society (Edwards et al. 1999). On the other hand, Kantian tradition refers to our moral duty to respect a person’s autonomy, significant in individual-cluster trials that differ with the paramount importance of the utilitarian welfare of the cluster in cluster-cluster trials.

Positioning ourselves as researchers within the ethical folds, and not cross the thin red line of a moral dilemma; we should remember that ethics establish the fundamental principles of “right and wrong.” While laws may set the legal parameters that govern data use, ethics are critical to the appropriate management and use of research data. The burning questions are: Do we have the prior knowledge on the unethical collection of the data? Did we learn about the breach after we are done analyzing the data?  I believe, it is our responsibility to assess the quality and the manner data was collected. Even if the intent of the research is for the better good, we should not be blinded by the urgency of the endeavor and justify the beneficial outcomes at the expense of the suffering of the participants. Using a secondary data obtained unethically for the better good that could impact a community, presents a blur between right and wrong. Would the use of unethically collected secondary data a personal choice? Assuming that the institutional review board (IRB) approved the use of such data, would it give us the option to use the data for the common goods? A point to ponder, given that the Nuremberg Code was not established until after World War II, the collection of NAZI experiments could not be considered “illegal’ (Vollmann, 1996). Given this scenario, would current researchers be free to use the data from these experiments for ethical and beneficial results? Would it justify the use of Dr. Sigmund Racher’s data on hypothermia and altitude experiments at Dachau to inform on ethically sound studies on hypothermia prevention and treatment? The study of Dr. Robert Pozos of the University of Minnesota was denied publication in the New England Journal of Medicine (NEJM) after using Dr. Racher’s data on rewarming techniques to fill in critical gaps in his research (Cohen, 1990). Having this said, personally, regardless how comprehensive the secondary data, if unethically aggregated, I would refrain from using such data even if the data could have a positive outcome. Within the argument of guilty by association, I believe that using unethically collected research data; we are as guilty as the person/individuals who collected the data. The best recourse is to look for a more superior data that follows the prescribed ethical guidelines. On the other hand, if the data could lead to discovery to save lives of the many, for example, a vaccine to prevent the spread of an infectious disease, or prevent a bioterrorism event, then it is justifiable to use such data considering the benefits outweigh the harms of the methods.


Cohen, B. (1989). The ethics of using medical data from Nazi experiments. Journal of Halacha and Contemporary Society, 103-126.

Edwards, S. J., Braunholtz, D. A., Lilford, R. J., & Stevens, A. J. (1999). Ethical issues in the design and conduct of cluster randomised controlled trials. British Medical Journal, 318(7195), 1407.

Ford, N., Mills, E. J., Zachariah, R., & Upshur, R. (2009). Ethics of conducting research in conflict settings. Confl Health3(7).

Osrin, D., Azad, K., Fernandez, A., Manandhar, D. S., Mwansambo, C. W., Tripathy, P., & Costello, A. M. (2009). Ethical challenges in cluster randomized controlled trials: experiences from public health interventions in Africa and Asia. Bulletin of the World Health Organization, 87(10), 772-779.84-887.

Steinberg, J. (2015). The Ethical Use of Unethical Human Research. New York University, nd Web30.

Vollmann, J., & Winau, R. (1996). Informed consent in human experimentation before the Nuremberg code. BMJ: British Medical Journal,313(7070), 1445.


The Silent Killer: Improving the Understanding of Chagas Disease

Chagas Disease

The protozoan parasite Trypanosoma cruzi was first described by Carlos Chagas after isolation of the organism from the blood of a Brazilian patient in 1909 (Garcia et al., 2015). An estimated 7.5 to 10 million persons are infected with Chagas disease worldwide (Hotez et al., 2008; Hotez et al., 2014). In the United States, the disease is anecdotally referred to as a “silent killer” with a 30% chance of those infected to develop a potentially fatal cardiac disease. According to Cantey et al. (2012), Chagas disease is emerging as a significant public health concern in the United States. Given the proximity of Texas to Latin America, cases imported from highly endemic areas in Latin America would likely occur in Texas. Recent communication from the Centers for Disease Control and Prevention that the bite of blood-sucking triatomine bugs in the subfamily Triatominae also termed “kissing bugs” that transfers the parasites to humans have now been found in 28 states, including California and Pennsylvania. Garcia et al. (2015) argued that despite the numerous publications related to Chagas disease in the southern US and northern regions of Mexico, very little is known about the disease burden from imported and locally acquired T. cruzi infection.There is concern that Chagas disease might be undiagnosed in the US as a result of documented low physician awareness (Stimpert & Montgomery, 2010). While the zoonotic nature of Chagas’ life cycle implies unfeasible eradication; entomological surveillance is and will remain crucial to containing Chagas disease transmission (Tarleton et al., 2007).

While it is considered safe to breastfeed even if the mother has Chagas disease (Centers for disease control and prevention, 2013); people can also become infected through blood transfusion, congenital transmission (from a pregnant woman to her baby), organ transplantation, accidental laboratory exposure and consumption of uncooked food contaminated with feces from infected bugs. If the mother has cracked nipples or blood in the breast milk, it is warranted to pump and discard the milk until the bleeding resolves and the nipples heal  (Centers for disease control and prevention, 2013). The enduring challenge of household reinfestation by locally native vectors as stated by Abad-Franch et al. (2011), horizontal strategies works better when the community takes on a protagonist role. Encouraging vector notification by residents and other simple forms of participation can substantially enhance the effectiveness of surveillance (Abad-Franch et al., 2011). Therefore, control programs in concert with community-based approaches as a strategic asset from inception that requires a timely, professional response to every notification, benefiting from a strengthened focus on community empowerment. According to Schofield (1978), when bug population density is low, vector detection failures are unavoidable. Decision-making will be dependent upon the accurate estimation of infestation rates (World Health Organization, 2002), and imperfect detection can seriously misguide Chagas disease control management program. Continued attentiveness from governmental and health organizations are warranted, as this disease continue to be a globalized public health issue. Improved diagnostic tools, expanded surveillance and increased research funding will be required in maintaining existing effective public health strategies and in preventing the spread of the disease to new areas and populations (Bonney, 2014). To improve outbreak control, and improve Chagas disease response, it is essential to discuss the gaps in the scientific knowledge of the disease. Moreover,  crucial in improving the morbidity in the state of Texas and neighboring states is the recommendation of the needed steps to enhance the understanding of T. cruzi.


Abad-Franch, F., Vega, M. C., Rolón, M. S., Santos, W. S., & de Arias, A. R. (2011). Community participation in Chagas disease vector surveillance: systematic review. PLoS Negl Trop Dis, 5(6), e1207.

Bonney, K. M. (2014). Chagas disease in the 21st century: a public health success or an emerging threat?. Parasite, 21, 11.

Cantey, P. T., Stramer, S. L., Townsend, R. L., Kamel, H., Ofafa, K., Todd, C. W., … & Hall, C. (2012). The United States Trypanosoma cruzi Infection Study: evidence for vector‐borne transmission of the parasite that causes Chagas disease among United States blood donors. Transfusion, 52(9), 1922-1930.

Centers for disease control and prevention. (2013). Parasites-American Trypanosomiasis (also known as Chagas Disease). Retrieved 21 July, 2016, from

Garcia, M. N., Woc-Colburn, L., Aguilar, D., Hotez, P. J., & Murray, K. O. (2015). Historical perspectives on the epidemiology of human chagas disease in Texas and recommendations for enhanced understanding of clinical chagas disease in the Southern United States. PLOS Negl Trop Dis, 9(11), e0003981.

Hotez, P. J., Bottazzi, M. E., Franco-Paredes, C., Ault, S. K., & Periago, M. R. (2008). The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Negl Trop Dis, 2(9), e300.

Hotez, P. J., Alvarado, M., Basáñez, M. G., Bolliger, I., Bourne, R., Boussinesq, M., … & Carabin, H. (2014). The global burden of disease study 2010: interpretation and implications for the neglected tropical diseases. PLoS Negl Trop Dis, 8(7), e2865.

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Stimpert, K. K., & Montgomery, S. P. (2010). Physician awareness of Chagas disease, USA. Emerging infectious diseases, 16(5), 871.

Tarleton, R. L., Reithinger, R., Urbina, J. A., Kitron, U., & Gürtler, R. E. (2007). The challenges of Chagas disease—Grim outlook or glimmer of hope?. PLoS Med, 4(12), e332.

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Significance of Public Health Approach on Violent Radicalization

imagesIn most countries, public health approaches to address violent radicalization are already applied in street violence and bioterrorism; but leaders and stakeholders need to embrace the significance of public health interventions and research on violent radicalization (Bhui et al., 2012). While past studies (Bakker, 2006; Loza, 2007) found that overwhelming majority of people who become radicalized to violence in the West are young and male, generally aged between mid-teens and mid-20s; scarcity of research findings on the extent and nature of women’s roles in group and community radicalization (Carter, 2013). The recent acts of terrorism around the world, especially the event in San Bernardino California, it is important to note the urgent need to look at the significance of a public health approach to understanding violent radicalization. Recognizing this sense of urgency introduce the possible role of collective responsibility of leaders in epidemiology, sociology, psychology and other behavioral sciences in developing novel epidemiologic measures towards prevention strategies (Bhui, Hicks, Lashley, & Jones, 2012). While most nation’s counterterrorism approaches are grounded in inter-governmental intelligence data exchange and criminal justice systems, embracing the perceived belief that existing legal system can deal with violent radicalization effectively; it is paramount to argue that new players be included in the collection of relevant data needed in the development of public health approach to address violence such as the World Health Organization’s Violence Prevention Alliance, and the Centers for Disease Control and Prevention (CDC). The goal of CDC’s “Public Health Approach to Violence Prevention” is to decrease risk factors and increase protective factors. The logical argument for this proposed study is the need for public health research, and establish a new approach to guard against violent radicalization.

Given the current integrated surveillance system that monitors death and injuries as a direct effect of terrorism events, it is critical to recognize the risk and protective factors for violent radicalization. Bhui et al. (2102) noted “the perceived discrimination in the population as a whole or amongst distinct segments of the population; trust in authorities and their counterterrorism approaches; perceived or real economic inequalities patterned by ethnicity or religious groups; and international conflict in which the authorities appear to be biased or unfair towards a specific migrant, religious or ethnic group.”  For future research, it is paramount to identify the possible independent variables that are associated with the increased probability of radicalization in certain communities such as marginalized communities, diaspora communities, and ideology. The perceived feeling of inclusion or integration in a larger, popular community was theorized to amplify the extent of susceptibility to radicalization. Baumeister and Leary (1995) asserted on the importance of adapting psychological theories on stable interpersonal relationships. It is critical to examine the perceived instability in diaspora communities that could increase the risk of marginalization. Indicators related specifically to diaspora communities are language, the size of the community, the arrival age of immigrant(s) to the community, the age structure of the population, and the spatial concentration of the community.  Marret et al. (2013) asserted the importance of understanding the core of radicalization process that demands the necessity to question and debate the concept of violent radicalization at the theoretical level and the empirical level. The motivation for an individual or group to commit extremist violence or terrorism is not grounded in a single ideology, but selectively demonstrate their commitment from different clusters of belief systems. Behavioral indicators as stated by Fishman (2010) could be generated from social media, chat rooms, and involvement in public ideologically motivated legal activities might provide insights into community-based ideological sentiments.


Bakker, E. (2006). Jihadi terrorists in Europe, their characteristics and the circumstances in which they joined the jihad: an exploratory study.

Baumeister, R. F., & Leary, M. R. (1995). The need to belong: desire for interpersonal attachments as a fundamental human motivation. Psychological bulletin, 117(3), 497.

Bhui, K. S., Hicks, M. H., Lashley, M., & Jones, E. (2012). A public health approach to understanding and preventing violent radicalization. BMC medicine, 10(1), 16.

Carter, B. (2013). Women and violent extremism. GSDRC Helpdesk Research Report.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2008). The public health approach to violence prevention. Atlanta, GA: CDC.

Fishman, Shira. (2010). “Community-Level Indicators of Radicalization: A Data and Methods Task Force.”  Report to Human Factors / Behavioral Sciences Division, Science and Technology Directorate, U.S. Department of Homeland Security. Retrieved from

King, G., & Zeng, L. (2001). Logistic regression in rare events data. Political analysis9(2), 137-163.

Labilles, U. (2016). The significance of Public Health Approach on Violent Radicalization (Unpublished, Advanced Epidemiology Methods, PUBH-8520-1, 2016 Winter Qtr. Wk9Proj) Walden University, Minneapolis.

Loza, W. (2007). The psychology of extremism and terrorism: A Middle-Eastern perspective. Aggression and Violent Behavior12(2), 141-155.

Marret, J. L., Feddes, A. R., Mann, L., Doosje, B., & Griffioen-Young, H. (2013). An Overview of the SAFIRE Project: A Scientific Approach to Finding Indicators and Responses to Radicalization. Journal Exit-Deutschland. Zeitschrift für Deradikalisierung und demokratische Kultur, 2, 123-148.


One Nation’s Echo (O.N.E.) will break the silence and create the echo needed to advance public health.

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