All posts by Ulysses Labilles, DMD, PhD

”Every dream comes from a speck of hope. It is through hope where we gain our strength to make a change."

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

The Thin Red Line of Moral Dilemma in Research

research-1

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.

References

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.

 

Violent Radicalization: An Impending Public Health Issue

Empathy Gap

Violent Radicalization An Impending Public Health Issue

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

Background

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.

References

Adapa, A., Caporale, C., Griffin, N., Hrab, M., Jeong, C., Kim, M., … & Vanarsdall, R. (2016). The Effect of Psychological Distance on Willingness to Engage in Ideologically Based Violence (Doctoral dissertation). Retrieved from http://drum.lib.umd.edu/bitstream/handle/1903/18086/Judgment_PDF.pdf?sequence=1

Bouhana, N. &Wikstrom,  P.O. (2008). Theorizing Terrorism: Terrorism as Moral Action. UCL Jill Dando Institute of Security and Crime Science: London, UK.

Bhui, K. (2015). Radicalisation: A mental health issue, not a religious one. New Scientist. Retrieved from https://www.newscientist.com/article/mg22630160-200-radicalisation-a-mental-health-issue-not-a-religious-one/

Bhui, K., Everitt, B., & Jones, E. (2014). Might Depression, Psychosocial Adversity, and Limited Social Assets Explain Vulnerability to and Resistance against Violent Radicalization? Plos One, 9(9), e105918.

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

Bhui, K., Dinos, S., & Jones, E. (2012b). Psychological process and pathways to radicalization. Journal of Bioterrorism & Biodefense, 2014.

Cudeck, R. (2000). Exploratory factor analysis. Handbook of applied multivariate statistics and mathematical modeling, 265-296.

Department for communities and local government, United Kingdom. (2010). Citizenship Survey: April – December 2009, England and Wales: Attitudes towards Violent Extremism (experimental statistics). Retrieved from http://webarchive.nationalarchives.gov.uk/20120919132719/http://www.communities.gov.uk/publications/corporate/statistics/citizenshipsurvey2009extremism

Dodd, V. (2016). Police study links radicalisation to mental health problems. The Guardian. Retrieved from https://www.theguardian.com/uk-news/2016/may/20/police-study-radicalisation-mental-health-problems

Global Terrorism Index. (2014). Measuring and understanding the impact of terrorism. Institute for Economics and Peace. Retrieved from http://www.visionofhumanity.org/sites/ default/files/Global%2 0Terrorism, 20

Interlandi, J. (2016). The Brain’s Empathy Gap. Retrieved from http://www.nytimes.com/2015/03/22/magazine/the-brains-empathy-gap.html?_r=0

Jenkins, B. M. (2010). Would-be warriors: Incidents of jihadist terrorist radicalization in the United States since September 11, 2001. Rand Corporation.

Kiendrebeogo, Y & Ianchovichina, E. (2016). Who Supports Violent Extremism in Developing Countries?. Middle East and North Africa Region: World Bank Group.

Malthaner, S., & Waldmann, P. (2014). The radical milieu: Conceptualizing the supportive social environment of terrorist groups. Studies in Conflict & Terrorism, 37(12), 979-998.

National Consortium for the Study of Terrorism and Responses to Terrorism (NCSTRT). (2015). Annex of statistical information: Country reports on terrorism in 2014. Retrieved from http://www.state.gov/documents/organization/239628.pdf

Reid Meloy, J., & Yakeley, J. (2014). The violent true believer as a “lone wolf”–psychoanalytic perspectives on terrorism. Behavioral sciences & the law, 32(3), 347-365.

Schils, N., & Pauwels, L. (2014). Explaining Violent Extremism for Subgroups by Gender and Immigrant Background, Using SAT as a Framework. Journal of Strategic Security, 3(7), Article 3.

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.

Trope, Y., & Liberman, N. (2010). Construal-level theory of psychological distance. Psychological review117(2), 440.

Wikstrom, P.O., Oberwittler, D., Treiber, K., & Hardie B. (2012). Breaking Rules: The Social and Situational Dynamics of Young People’s Urban Crime. Oxford: Oxford University Press.

 

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.

References

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 http://www.cdc.gov/parasites/chagas/gen_info/detailed.html

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.

Schofield, C. J. (1978). A comparison of sampling techniques for domestic populations of Triatominae. Transactions of the Royal Society of Tropical Medicine and Hygiene, 72(5), 449-455.

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.

World Health Organization. (2002). Control of Chagas disease: second report of the WHO expert committee.

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.

References

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 http://www.start.umd.edu/pubs/START_HFD_CommRadReport.pdf

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.

 

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.

Reference

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A Promise to a Dying Brother

When I was inducted into the Honor Society in winter 2013, I thought that being on top of my batch will be enough to get me through my journey as a Public Health Ph.D. candidate. Recruiting a dissertation chair is the most challenging so far, especially getting a response from them. What if I do not get a dissertation chair who will be a good match with my dissertation topic? Can I submit my premise and finish my dissertation to another university? A night before my youngest brother passed away; I was on the phone with him. He told me that he is too tired, and I responded that it is okay to let go. He asked me to promise him to go back to school and take on a graduate degree to make a difference. “Promise me that at some point to be involved in a research project that could make a difference to individuals diagnosed with pancreatic cancer.” He passed away in 2007, a few weeks before his 40th birthday, and three months before his only daughter’s first birthday.

Focusing on the impact of cigarette smoking as a factor that promotes pancreatic cancer rather than initiates it will amplify the importance of behavioral change, and enhance the quality of life. The outcome of pancreatic cancer remains dismal, even with treatment combinations of surgery, radiotherapy and chemotherapy with an estimated annual economic burden of $4.9 billion annually (Pandol, Apte, Wilson, Gukovskaya, and Edderkaoui, 2012). Advances in patient management and understanding the biology of pancreatic cancer has taken substantial progress over the years. Herman, Schulick, Hruban and Goggins (2011) found that screening first-degree relatives of individuals with family members affected by pancreatic cancer can identify non-invasive precursors of the disease. In this 2011 study shows the gradual rise in the incidence and number of deaths caused by pancreatic tumors, even with the decline in incidence and mortality of other common cancers. Furthermore, Vincent et al. found that despite developments in detection and management of pancreatic cancer, only about 4% of patients will live five years after diagnosis. Moreover, Vincent et al. (2011) found that present surgical resectioning offers the only chance of cure and improve the survival rate for those with malignant disease localized to the pancreas. Statistical analysis in 2012 study shows 80–85% of patients with advanced unresectable disease responds poorly to most chemotherapeutic agents. Therefore, it is warranted to have continued understanding of the biological mechanisms contributory to the development and progression of pancreatic tumors. On the other hand, Klein et al. (2004) emphasized the significance of quantification of the risk of individuals with a family history of pancreatic cancer as a rational basis for cancer risk screening and counseling. In a prospective registry-based approach of this 2004 study, the risk of these individuals showed an increased risk of developing the disease. Klein et al. (2004) performed standardized incidence ratios and compared the number of incident pancreatic cancers observed with those expected using Surveillance, Epidemiology and End Results (SEER) rates. It was quantified in this registry-based study the pancreatic cancer risk in kindreds with a family member who was diagnosed with the disease, supporting the hypothesis of increased risk in association with family history. While Blackford et al. (2009) failed to identify the signature tobacco-related mutation in cigarette smokers that could have strong implication to the development of pancreatic cancer; this 2009 study found the nonspecific DNA damage caused by tobacco carcinogens. Furthermore, the combined causality of non-tobacco-related mutagenic risk factors such as inherited predisposition to cancer may share mutagenic properties with the tobacco mutagens active in pancreatic tissues (Ding et al., 2008; Prokopczyk et al., 2002). The types and patterns of these mutations provide insight into the mechanisms by which cigarette smoking causes pancreatic cancer (Blackford et al., 2009). Porta et al. (2009) and Blackford et al. (2009) suggested that smoking enhances the risk for pancreatic cancer through mechanisms other than genetic mutation. The development of pancreatic cancer may have a non-significant association to pipe smoking and smokeless tobacco use, but in a large collaborative pooled analysis of non-cigarette tobacco use in 11 studies within the International Pancreatic Cancer Case-Control Consortium (PanC4) found that cigar smoking is associated with an excess risk of the disease (Bertuccio et al., 2011). Cigarette smoking was found to be an established risk factors— both exposure to environmental tobacco smoke (ETS), and active cigarette smoking (Vrieling et al., 2010). Over 40,000 individuals are diagnosed with pancreatic cancer, and less than 5% of patients diagnosed has a survival rate of five years. The component of the smoke of cigarettes that produced in the body as a metabolite of nicotine and the most abundant carcinogens in tobacco smoke is 4-(methyl nitrosamine)-1-(3-pyridyl)-1-butanone (NNK). Vary widely in nicotine content and carcinogenic nicotine metabolites, cigarettes, cigars, and other tobacco products—nicotine reaches the lungs and is quickly absorbed into the bloodstream during smoking. A cigar containing as many as 20 grams of tobacco can have nicotine between 5.9 and 335.2 mg per gram of tobacco (Henningfield, Fant, Radzius, & Frost, 1999). Prokopczyk et al. (2002) noted that the nicotine levels in pancreatic juice in smokers is seven times higher than non-smokers. Blackford et al. (2009) concluded that smokers diagnosed with pancreatic carcinomas harbors more mutations than the non-smoker, therefore, doubles the risk, accounting for 20 to 25% of pancreatic cancers.

Pandol et al. (2012) stated that the pro-carcinogenic effects of smoking on the pancreas are inadequately studied, confirming that tobacco smoking is the strongest avoidable risk and the major environmental factor for pancreatic cancer. Pandol et al. provided valuable insights into the pathogenesis of pancreatic cancer, particularly in the initiation and progression of the disease. Determining the mechanisms underlying the effect of smoking compounds on fibrosis and inflammation will improve our limited knowledge of pancreatic biology. Pancreatic cancer can be classified as genetic, environmental, or both; as well as a disease caused by inherited DNA mutation or mutation by chance. While advances in Genomics gives the promise to early pancreatic cancer detection through better understanding of pancreatic biology, it is paramount to embrace the significance of lifestyle habits that can be modified to evidence-based healthier concepts that translates to reduced cancer risk. Applying lessons learned from the outcome of my proposed study, and existing body of knowledge will prevent the emergence of pancreatic cancer, reduce cancer risk and advance population health. Early behavioral change and interventions will improve the survival rate and quality of life during the time course of pancreatic cancer progression.

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In Texas, Everything is Bigger: In the context of data collection—is bigger better?

The traditional researcher concept that big data equates statistical significance could always eclipse the importance of understanding the interrelationship between the effect size, power, and sample size that could translate to both practical and statistical significance. In Texas, everything is bigger, everything a Texan do is bigger, but in the context of data collection—is bigger better? Current big data opportunities facing science, technology communities, and the health community is facing a tsunami of health- and healthcare-related content generated from numerous patient care points of contact, sophisticated medical instruments, and web-based health communities (Chen, Chiang & Storey, 2012). Two primary sources of health big data are payer–provider big data (electronic health records, insurance records, pharmacy prescription, patient feedback and responses), and data from my favorite field-genomics. I cannot help to imagine how many interesting research studies I could do with genomics-driven big data (genotyping, gene expression, sequencing data). Extracting knowledge from health big data poses significant research and practical challenges, especially considering the HIPAA (Health Insurance Portability and Accountability Act) and IRB (Institutional Review Board) requirements for building a privacy-preserving and trust-worthy health infrastructure and conducting ethical health-related research (Gelfand, 2011). Setting aside these challenges, can big data provide both practical and statistical significance? Just think about terabytes of expected raw sequencing data that associate variants that affect variation in two common highly heritable measures of obesity, weight and body mass index (BMI). For this discussion, let me broach the 2012 study of Hutchinson and Wilson in improving nutrition and physical activity in the workplace. The cumulative knowledge found in the meta-analysis of Hutchinson & Wilson (2012) found the extant results of 29 intervention studies examining physical activity or nutrition interventions in the workplace, published between 1999 and March 2009. The results from these 29 intervention studies were synthesized using meta-analyses in terms of the effectiveness of workplace health promotion programs to resolve inconsistent findings. The challenge of extant results that are sometimes discordant, Hutchinson & Wilson (2012) took into consideration the limitations in the methodology of some of the studies reviewed that demonstrated modest success in achieving long-term change. The importance of interventions’ association with successful outcomes that includes behavior maintenance and generalization was also considered in this study. Weighted Cohen’s d effect sizes, percentage overlap statistics, confidence intervals and failsafe Ns were calculated. The increased prevalence of obesity and its association with increased risk for chronic diseases including cancer, diabetes, cancer and cardiovascular disease warrants the needs for innovative and efficient interventions. Green (1988), stated that the workplace is a valuable intervention site for a number of reasons including the amount of time people spend at work, access to populations that may be difficult to engage in different settings and the opportunity to utilize peer networks and employer incentives. These reasons justify the practical significance of the study. Moreover, the statistical significance was established by the methodology of Hutchinson & Wilson (2012) developing inclusion criteria of the 29 identified studies. The inclusion criteria are published studies on workplace intervention; a control group, not receiving the intervention, health, and in particular diet, nutrition or physical activity as outcome measures; and statistical information for the calculation of effect sizes, (e.g. means and standard deviations, the results of t-tests or one-way F tests).Change over time (mean and standard deviation) data were requisite to calculate effect sizes for interventions. Studies that did not provide this data, the means and standard deviations at the end of the intervention of controls and interventions groups were compared. Statistical analyses was performed such as Cohen’s d to calculate effect sizes for the difference between the intervention and control groups on each outcome measure (diet measures: fruit, vegetables, fat; physical activity measures: activity, fitness; health measures: weight, cholesterol, blood pressure, heart rate or glucose). Based on outcome measures and the form of intervention, effect sizes were aggregated. Mean effect size, standard deviation and 95% confidence interval were calculated for each grouping (Zakzanis, 2001). Fail safe Ns (Nfs) were calculated to address the potential for studies with statistically significant results. The conclusion of this 2012 meta-analysis in terms of study design—randomized controlled trials were associated with larger effects; therefore, long-term maintenance of changes should be evaluated in order to determine the extent to which workplace interventions can make sustainable changes to individuals’ health.

References

Chen, H., Chiang, R. H., & Storey, V. C. (2012). Business Intelligence and Analytics: From Big Data to Big Impact. MIS quarterly36(4), 1165-1188. Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Academic press. Ellis, P. D. (2010). The essential guide to effect sizes: Statistical power, meta-analysis, and the interpretation of research results. Cambridge University Press. Forthofer, R.N., Lee, E.S. & Hernandez, M. (2006). Biostatistics: A Guide to Design, Analysis and Discovery. 2nd Edition [Vital Source Bookshelf version]. Retrieved from http://online.vitalsource.com/books/9780123694928 Gelfand, A. (2011). Privacy and biomedical research: building a trust infrastructure: an exploration of data-driven and process-driven approaches to data privacy. Biomed Comput Rev2012, 23-28. Green, K. L. (1988). Issues of control and responsibility in workers’ health. Health Education & Behavior15(4), 473-486. Hutchinson, A. D., & Wilson, C. (2012). Improving nutrition and physical activity in the workplace: a meta-analysis of intervention studies. Health promotion international27(2), 238-249. Labilles, U. (2015). Big Data: Does it matter? Can it give a practical significance? Is bigger better? (Unpublished, Advanced Biostatistics (PUBH – 8500 – 1), 2015 Spring Qtr. Wk2DiscLabillesU) Walden University, Minneapolis. Thorleifsson, G., Walters, G. B., Gudbjartsson, D. F., Steinthorsdottir, V., Sulem, P., Helgadottir, A., … & Stefansson, K. (2009). Genome-wide association yields new sequence variants at seven loci that associate with measures of obesity. Nature genetics41(1), 18-24. Zakzanis, K. K. (2001). Statistics to tell the truth, the whole truth, and nothing but the truth: formulae, illustrative numerical examples, and heuristic interpretation of effect size analyses for neuropsychological researchers. Archives of clinical neuropsychology16(7), 653-667.

Socioeconomic Status and Public Health Financing

Health financing is the cornerstone of strategy development based on both in terms of raising resources and of ways to manage resources. It is critical to emphasize the need for greater evaluation of the distributional impact of policies and programs. Socioeconomic status could affect public health financing such as people with insurance or money, creating higher expenditures. On the other hand, medically underserved, uninsured and underinsured create greater expenses because they enter the health system at the advanced stages of diseases and in weakened conditions (Laureate Education, Inc., 2012). In addition to socioeconomic status, other social determinants that affects both average and distribution of health includes physical environment, lifestyle or behavior, working conditions, social network, family, demographics, political, legal, institutional and cultural factors. Since funding is considered as a scarce resource, it is paramount to allocate resources based on the identified gaps in care. The significance of socioeconomic data in US public health surveillance systems should be emphasized in order to monitor socio-economic gradients in health. Socioeconomic data is important in determining the allocation of resources for public health financing. Krieger et al. (2003) stated that the use of multilevel frameworks and area-based socioeconomic measures (ABSMs) for public health monitoring can potentially overcome the absence of socioeconomic data in most US public health surveillance systems. Moreover, political will is essential to bridging public health and action that will help in the development and implementation of public health policy based on scientific evidence and community participation. Epstein, Stern and Weissman (1990) found that hospitalized patients with lower socioeconomic status have longer stays and require more resources. It was suggested in this study that supplementary payments allocated to the poor merits further consideration. Strategies for more efficient provision of care for patients with low socioeconomic status can be developed at the managerial and clinical levels.

Inequality or disparity is defined as the difference in health status, inequalities in access to and quality of health care services. Additional disparities are attributed to factors such as discrimination in relation to health care system and the regulatory climate. The Institute of Medicine (IOM) found that disparities continue to dwell even when socio-demographic factors, insurance status, and clinical needs were controlled for racial and ethnic health care. Disparities dictate funding requirements for public health initiatives for the underserved populations. Furthering social justice and maximizing individual liberties will advance traditional public health goals. Socioeconomic status of communities drives the financing needs for public health initiatives; therefore, burdens of the program must be minimized and identified to reduce pre-existing social injustices. Social benefits, public health programs that stimulate dignified employment, and strengthening of communities are important benefits that should be given high consideration. Public health professionals and health department leaders may not have the capacity to implement all programs that could be beneficial to a target population or community, but advocacy is paramount to improving health. Sufficient data is critical to justify the necessity of the program. I believe that it is our duty as healthcare and public health leaders to remove from policy debates and decision-making any discriminatory procedures or unjustified limitations on personal liberties. Public policy should be based on an ethics perspective and multiple considerations.

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