Tag Archives: Quality of Life

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

Dallas’ Renaissance Plan: A Response to the Second Wave of Environmental Justice

Dallas is the seventh largest city in the United States with a population exceeding 1.1 million citizens in the year 2000. Dallas is the fourth largest park system in the United States. The second wave of the environmental justice movement is a concept concerned with urban design, public health, and availability of outdoor physical activities. The upgrade to the 21,526 acres of parkland will amplify the quality of and access to outdoor recreation. The Dallas Park and Recreation Department’s “Renaissance Plan” is a response to  the increased demand of the citizens for new and expanded park facilities, recreation programs, open space areas, and unique recreational amenities. Physical activity is one of the health indicators for Healthy People 2010, and responding to these demands is a step forward of meeting its goals.  Dallas’ wide spectrum of park facilities will provide physical activities that will have positive health outcome to Dallas residents including the low-income population of the Dallas County and contiguous counties. Recognition of environmental exposure affecting economically and politically disadvantaged members of the community gave birth to the first wave of environmental justice movement. In addition to health problems related to environmental exposures, environmental justice (EJ) also cover disparities in physical activity, dietary habits, and obesity among different populations. Disparities on the access of public facilities and resources for physical activity (PA) is an EJ issue that has a negative impact on health among low-income and racial/ethnic minorities (Labilles, 2013). The 2007 cross-sectional study of Taylor et al. suggest an association between disproportionate low access to parks and recreation services (PRS) and other activity-friendly environments in low-income and racial/ethnic minority communities.  The prevalence of lower levels of PA and higher rates of obesity was observed in the minority population, which is a direct outcome of the prevalence of lower levels of PA. These differences violate the fair treatment principle necessary for environmental justice.

The treatment of health conditions associated with physical inactivity such as obesity poses an economic cost of at least $117 billion each year. Physical inactivity contributes to many physical and mental health problems.  The reported 200,000-deaths per year in the US is attributed to physical inactivity, and data from surveillance system indicate that people from some racial/ethnic minority groups experience disproportionately higher rates of chronic diseases associated with physical inactivity. Taylor, Poston, Jones & Kraft (2006) findings, provided preliminary evidence for the hypothesis that socioeconomic status disparities in overweight and obesity are related to differences in environmental characteristics. However, most of the studies had encountered epidemiologic “black box” problem, making it impossible to determine which characteristics of the environment (e.g., density of food service outlets or physical activity resources) may be most important (Labilles, 2013). Ellaway et al. found that body-mass index (BMI), waist circumference, and prevalence of obesity, and greater obesity risk is associated with low area or neighborhood socio-economic status.


Behavioral Risk Factor Surveillance System (BRFSS). Atlanta: Centers for Disease Control and Prevention; 2000.Centers for Disease Control and Prevention; 2000.

Ellaway A, Anderson A, Macintyre S. Does area of residence affect body size and shape? Int J Obes Relat Metab Disord. 1997; 21:304-308.

Labilles, U. (2013). Environment Matters: The Disproportionate Burden of Environmental Challenges. PUBH 8115-1 Environmental Health Spring Qtr. Minneapolis: Walden University.

Taylor, W., Floyd, M., Whitt-Glover, M. & Brooks, J. (2007).  Environmental Justice: A Framework for Collaboration between the Public Health and Parks and Recreation Fields to Study Disparities in Physical Activity. Journal of Physical Activity & Health, 4, supp 1, s50-s63.

US Dept of Health and Human Services. Physical activity and health: A report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.

US Dept of Health and Human Services. Healthy People 2010: With understanding and improving health and objectives for improving health (2nd ed). Washington: US Govt Printing Office; 2000.

Wolf AM, Manson JE, Colditz GA. The economic impact of overweight, obesity, and weight loss. In: Eckel R, ed. Obesity Mechanisms and Clinical Management. Philadelphia: Lippincott, Williams, & Wilkins; 2002.



A Summer Phenomenon

For 26 days in 2011, every place in Texas showed higher concentrations of lung-damaging ozone than allowed by federal air-quality standards, especially in Dallas. The federal standard set in 2008 is 75 parts per billion. The spike in ozone which is particularly a summer phenomenon is exacerbated by trucks carrying drilling materials that emit nitrogen oxides, and natural gas escaping from pipelines or storage tanks that emit volatile organic compounds, or VOCs. Known ozone “precursors” such as nitrogen oxides and VOCs can react with each other to form ozone when aided by sunlight. The most difficult environmental issue North Central Texas face today is air quality. Dallas Forth Worth (DFW) region meets the standard for five of six criteria air pollutants defined by the EPA. The six pollutants are carbon monoxide, lead, nitrogen dioxides, ozone, particulate matter, and sulfur dioxide. The only air pollutant for which DFW do not meet the National Ambient Air Quality Standard is the ozone. In hot summers, combination of nitrogen dioxides and VOCs and concentrations of traffic and industry, Dallas is an ideal incubator for the creation of ground-level ozone.


Under the Clean Air Act, ozone pollution has long been regulated because of its tremendous hazards to the public. Under the Clean Air Act, ozone poses tremendous hazards to the public health and the environment. High ozone levels lead to respiratory distress and disorders; decreased lung function; increases in the emergency room visits and sick days. To address the serious problem of ozone, the Clean Air Act provides a multi-step process for ensuring that all areas of the country achieve acceptable ozone levels. EPA establish nationwide air quality standards for ozone (called National Ambient Air Quality Standards), which are required to be strong enough to protect public health with an adequate margin of safety. The next step, EPA designate areas of the country that meet the standards, and those who do not. The last step, requiring states to submit plans for achieving and maintaining compliance with EPA’s ozone standards — with especially strict requirements for areas that currently do not meet the standards. The U.S. Environmental Protection Agency (EPA) updated its ozone air quality standards in March 2008. The EPA towards the end of 2012 promised the DFW residents for stronger protections against the harmful public health and environmental impacts of ground-level ozone. The agency announced on January 7, 2012 about its determination that Wise County, Texas contributes to high ozone levels in nearby Dallas-Fort Worth. This action required polluters in Wise County  to do their fair share to reduce ozone levels in Dallas-Fort Worth. Wise County was included in the DFW ozone designation due in large part to the emissions of nitrogen oxides, and volatile organic compounds from a recent boom in oil and gas production in the area. According to the Technical Support Document (TSD), the final area designations in the Dallas-Fort Worth (DFW) area for the 2008 ozone national ambient air quality standards are based on several factors and indicators. The population density and degree of urbanization were analyzed. TSD stated: EPA evaluated the population and vehicle use characteristics and trends of the area as indicators of the probable location and magnitude of non-point source emissions. These include ozone precursor emissions from on-road and off-road vehicles and engines, consumer products, residential fuel combustion, and consumer services. Areas of dense population or commercial development are an indicator of area source and mobile source NO2 and VOC emissions that may contribute to ozone formation that contributes to nonattainment in the area. Rapid growth in population or vehicle miles traveled (VMT) in a county on the urban perimeter signifies increasing integration with the core urban area and indicates that it may be appropriate to include such perimeter area(s) as part of the nonattainment area.


It is very important to recognize the effect of ozone to a population, especially adults and children who are already had chronic respiratory diseases such as asthma. Exposure may compromise the ability of the body to fight respiratory infections. Bell et al. (2004) a multisite time-series study of 95 large US urban communities throughout a 14-year period  found that widespread pollutant such as ozone adversely affects public health.


Area Designations for the 2008 Ozone National Ambient Air … (n.d.). Retrieved from http://www.epa.gov/airquality/ozonepollution/designations/2008standards/documents/R6_DFW_TSD_Final.pdf

Bell, M., McDermott, A., Zeger, S., Samet, J. & Dominici, F. (2004). Ozone and Short-term Mortality in 95 US Urban Communities, 1987-2000. JAMA;292(19):2372-2378. doi:10.1001/jama.292.19.2372.

Dallas Fort-Worth Breathes Easier Following EPA’s Decision … (n.d.). Retrieved from http://blogs.edf.org/energyexchange/2013/01/16/dallas-fort-worth-breathes-easier-following-epas-decision-on-wise-county-ozone-petitions/

Green Dallas…building a greener city! (n.d.). Retrieved from http://www.greendallas.net/air_quality.html

Labilles, U. (2013). Obstacles of Disease Surveillance Interoperability: A Challenge to Public Health. (Unpublished,  PUBH-8115-1/HUMN-8115-1-Soc Behave Cultural Fact in Public Health. 2013 Spring Qtr. WK7Disc) Walden University, Minneapolis.





A Challenge to Public Health Surveillance Interoperability and Clinical Research

The obstacles that impact interoperability of the disease surveillance systems starts with the issue of balance between the public interest in the collection of information and the privacy rights. In theory, properly utilized, surveillance is a fundamental government activity, indispensable in nature (Gostin & Gostin, 2000). The legal complications brought about by the Fourth Amendment prohibition against unreasonable searches and seizures, triggered the social impetus behind HIPAA and the HHS Report. The Fourth Amendment is a constitutional protection against wrongful enforcement of the law on access to private medical records. These offers insight into the growth and development of non-Fourth Amendment protections for medical records privacy, and examines later actions that appear to restrict or undercut these potential medical record protections. The shared goals of both public health surveillance and the protection of health information privacy will encourage individuals to fully utilize health services and cooperate with health agencies. The key to protecting the well-being of the community is the optimum balance between public health activities and privacy protection. This balance is challenged by the enactment and enforcement of current legislation such as the Health Insurance Portability and Accountability Act’s Privacy (HIPAA). The way public health exception of HIPAA Rule was drafted resulted to confusion and put this balance in jeopardy, as well as recognized reluctance to provide information to state and local public health agencies. Wilson (2009) stated that the exception ambiguously defines the role of public health authorities in maintaining the privacy of personally identifiable health information. Incertitude about privacy can be equipoised by initiatives by state and federal policy makers such as the report “Confidentiality of Individually-Identifiable Health Information” issued by the Department of Health and Human Services (HHS).  This report reflected a legitimate interpretation and representation of the best aspects of constitutional and judicial protections of medical records privacy using current innovative technology in health information and communication.

State, local, and tribal public health authorities shares the privacy challenges that are inherent in data sharing. Wilson (2009) stated that, in the process of promulgating the Privacy Rule, HHS recognized the need to inscribe an exception for public health purposes in order to allow authorities at all levels of government to continue to collect, analyze, and use health information that would otherwise be unavailable without prior patient consent. State courts and policy makers have produced some protection for individuals’ medical histories which are characterized more by their diversity and conflicting standards than by the quality of protection. Unfortunately, state laws offer little additional support for medical records protection from law enforcement intrusion, thereby it is paramount for continued collaboration between public health professionals, health leaders and policy makers to focus on needed amendments to protect the interest of both the public, patients and researchers which will then bridge the divide on the interpretation of the law. It is critical to acknowledge that challenge of law- and policy-makers in finding common ground between individual privacy expectations and the communal health authorities’ needs for identifiable health data. The dissemination and use of identifiable health data for public health purposes are typically supported by the public, but it relies on how the government and other entities maintain appropriate privacy and security protections in acquiring the data. It is warranted for the continued improvement on the level of protection afforded to the public and patients by state laws governing medical records privacy. Moral justifications should be considered in establishing firm, consistent set of rules governing law enforcement’s use and exchange of private medical records and data needed in clinical research. The obstacles that forestall data-sharing practices should be assessed and remedied within each jurisdiction. Legal interpretations should be openly discussed to properly develop and implement model policy to strengthen disease surveillance, and increase the efficiency of data-sharing practices between researchers and public health authorities at all levels.


Aarestrup, F. M., Brown, E. W., Detter, C., Gerner-Smidt, P., Gilmour, M. W., Harmsen, D., … & Schlundt, J. (2012). Integrating genome-based informatics to modernize global disease monitoring, information sharing, and response. Emerging infectious diseases18(11), e1.

Act, A. (1996). Health insurance portability and accountability act of 1996.Public Law104, 191.

Bernstein, A. B., & Sweeney, M. H. (2012). Public health surveillance data: legal, policy, ethical, regulatory, and practical issues. MMWR Surveill Summ, 30-4.

Carroll, L. N., Au, A. P., Detwiler, L. T., Fu, T. C., Painter, I. S., & Abernethy, N. F. (2014). Visualization and analytics tools for infectious disease epidemiology: A systematic review. Journal of biomedical informatics.

Chan, M., Kazatchkine, M., Lob-Levyt, J., Obaid, T., Schweizer, J., Sidibe, M., … & Yamada, T. (2010). Meeting the demand for results and accountability: a call for action on health data from eight global health agencies. PLoS Med7(1), e1000223.

Chowdhary, S., & Srivastava, A. (2013). Cloud Computing: A Key to Effective & Efficient Disease Surveillance System. In Int. Conf. on Advances in Signal Processing and Communication. ACEEE (Lucknow).

El Emam, K., Hu, J., Mercer, J., Peyton, L., Kantarcioglu, M., Malin, B., … & Earle, C. (2011). A secure protocol for protecting the identity of providers when disclosing data for disease surveillance. Journal of the American Medical Informatics Association18(3), 212-217.

Gostin, L. O., & Gostin, L. O. (2000). Public health law: power, duty, restraint (Vol. 3). Univ of California Press.

Gostin, L. O., Hodge, J. G., & Marks, L. (2002). The Nationalization of Health Information Privacy Protections. Tort & Insurance Law Journal, 1113-1138.

Hodge Jr, J. G., Torrey Kaufman, J. D., & Jaques, C. (2012). Legal Issues Concerning Identifiable Health Data Sharing Between State/Local Public Health Authorities and Tribal Epidemiology Centers in Selected US Jurisdictions.

Kulynych, J., & Korn, D. (2003). The New HIPAA (Health Insurance Portability and Accountability Act of 1996) Medical Privacy Rule Help or Hindrance for Clinical Research? Circulation108(8), 912-914.

Labilles, U. (2014). Obstacles of Disease Surveillance Interoperability: A Challenge to Public Health. (Unpublished, PUBH-8270-2. Health Informatics and Surveillance. 2014 Spring Qtr. WK11Disc) Walden University, Minneapolis.

Lenert, L., & Sundwall, D. N. (2012). Public health surveillance and meaningful use regulations: a crisis of opportunity. American journal of public health, 102(3), e1-e7.

Office for Civil Rights, H. H. S. (2002). Standards for privacy of individually identifiable health information. Final rule. Federal Register67(157), 53181.

Van Der Goes Jr, P. H. (1999). Opportunity Lost: Why and How to Improve the HHS-Proposed Legislation Governing Law Enforcement Access to Medical Records. University of Pennsylvania law review, 1009-1067.


Bridging the Technology Gap and Geographic Divide

This morning, I attended a webinar on the transitioning to ICD-10 CM and its impact on Public Health Surveillance presented by Peter Hicks of Centers for Disease Control and Prevention (CDC). While its benefits and challenges were discussed, the question to ask is the cost implications of the transition. Another question to ask is its compatibility to existing health information technology. I believe at this point, we need to embrace its advantages, and explore the merging of this initiative on its potential for higher quality and patient-centered care. Setting this topic aside for future dialogue, let me follow-up last week’s discussion on the true, meaningful use of personal health records (PHR), and health information exchange (HIE). In this milieu, let me discuss the promise of telehealth on higher quality and patient-centered care. The geographic separation between regional multi-site healthcare system in which one site is 32 miles or even 51.4 miles away is no longer a logistic problem using telehealth. The quality of care of the traditional model, where health care takes place when the patient and the provider are together at the same time and place can be amplified by current modern system of healthcare. It is important to acknowledge the importance of modern telecommunications and information technologies in providing management flexibility to providers, administrators and managers. It bridges the geographic separation between the patient-provider and management-staff, and allow us to challenge the notion of location and time. Video conferencing can be used to communicate with the provider, where the patient is located one part of the state and the physician is located at another part, or to show new Mohs technicians to perform cryotomy or frozen section immunohistochemistry. In this model, we can remotely monitor patient’s physical condition. Telehealth in concert with disease-specific surveillance data can assess the need for community outreach to educate and inform about the significance of the intervention.

The ability to capture and transmit images using the internet, teleconsultation can be used as an additional approach to teaching new surgical techniques, unbiased by doctrine or surgeon’s experience, enabling accurate quantitative criteria to evaluate the effectiveness of surgical cuts. In the context of cutaneous surgery, whereby contemporary research tools may become one of the criteria in the designing and performing of operations—telemedicine could be an innovative teaching platform presenting systematic pursuit of accurate, optimal cutting patterns and new surgical techniques. This capacity, when used in combination with digital pathology, could offer an alternative method to comply with Clinical Laboratory Improvement Amendments (CLIA) proficiency testing compliance on sharing Mohs slide images with another laboratory to confirm the quality of test of patient frozen section samples. In a multidisciplinary approach, it could bridge the consultation with dermatopathologist on the critical success of a high-quality Mohs surgery program. The dermatopathologist can play a role in quality assurance by reviewing Mohs slides at regular intervals to satisfy the requirement for proficiency testing. Teleconsultation and digital pathology can help assess margins in rare and difficult tumors. Moreover, consultation with dermatopathologist helps in ruling out residual disease or for further immunohistochemistry studies, as well as consultation to assess perineural involvement and uncertain frozen section diagnosis of unusual proliferative lesions. High ground such as remote monitoring of the progress of surgical repairs; we need to acknowledge the challenge in which many of these technologies can impact privacy and security. Telemedicine network structure may have an advantage over competitive hospital- or university-based networks, but the challenge will always be funding and organizational support.


Edwards, M. A., & Patel, A. C. (2003). Telemedicine in the state of Maine: A model for growth driven by rural needs. Telemedicine Journal and e-Health9(1), 25-39.

Labilles, U. (2014). Telehealth: Bridging the Geographic Challenge. (Unpublished, PUBH-8270-2. Health Informatics and Surveillance. 2014 Spring Qtr. WK8Disc) Walden University, Minneapolis.

Laureate Education, Inc. (Executive Producer). (2011). Introduction to health informatics and surveillance: Telehealth. Baltimore, MD: Johnson, K. & Speedie S.

Sanders, T. B., Bowens, F. M., Pierce, W., Stasher-Booker, B., Thompson, E. Q., & Jones, W. A. (2012). The Road to ICD-10-CM/PCS Implementation: Forecasting the Transition for Providers, Payers, and Other Healthcare Organizations. Perspectives in health information management/AHIMA, American Health Information Management Association9(winter).

Terry, N. P. (2012). Anticipating Stage Two: Assessing the Development of Meaningful Use and EMR Deployment. Annals Health L.21, 103.

Tilleman, T. R. Optimization of Incisions in Cutaneous Surgery including Mohs’ Micrographic Surgery.



“Personal Health Records (PHR) and Health Information Exchange (HIE) in Managing Regional Multi-Site Medical Specialty Practice”

The true, meaningful use of personal health records (PHR), and  health information exchange (HIE) between regional sites or multi-site specialty practice could amplify coordination and efficiency for higher quality and  patient-centered care. PHR and HIE have been advocated as key new components in the effective delivery of modern health care. What is the impact of PHR and HIE to healthcare system? How can sharing health information between regional sites or multi-site specialty practice bridge the communication gap?  What is the role of specific-disease surveillance system in enhancing the management and delivery of quality of care? The effective use of cancer-related information aggregated from evolving health communication and information technology can help identify disease cluster such as the incidence of skin cancer in a geographic area which could improve communication strategy on a population wide basis. The processes of health communication and supportive health information technology infrastructure can influence patients’ health decisions, health-related behavior, and health outcomes. These make health communication and health information technology play an increase central role in health care delivery and public health. HINTS data could help a regional manager harness the appropriate communication channel to coordinate between facilities, and to identify barriers to the use of health information across community. Gauging the target group’s attitudes, regarding perceptions of health-relevant topics such as cancer screening will help develop more effective communication strategies. For example, a marked increase in the incidence rate of non-melanoma skin cancer (NMSC) based on a comprehensive surveillance system could help Mohs Micrographic Surgery facilities coordinate with dermatologists and dermato-pathologists. HINTS data can help refine information age health communication theories, and offer unique recommendations for managers, communication planners and researchers in their common aim to reduce the population cancer burden through effective, evidence-based, and patient- or public-centered communication (Hesse et al., 2006; Hesse et al., 2005; Nelson et al., 2004). The concept that captures an interactive phenomenon such as shared decision-making (SDM) utilized in concert with HINTS data recommendations will improve clinicians and patients communication. Kasper, Légaré, Scheibler & Geiger (2012) asserted that the complexity of challenges physicians have to face in critical decision making, can be alleviated by outsourcing parts of the information and decision making process to other health or medical professionals to provide optimal conditions for communication in the physician patient dyad.


Finney Rutten, L. J., Davis, T., Beckjord, E. B., Blake, K., Moser, R. P., & Hesse, B. W. (2012). Picking up the pace: changes in method and frame for the health information National Trends Survey (2011–2014). Journal of health communication17(8), 979-989.

Hesse, B. W., Nelson, D. E., Kreps, G. L., Croyle, R. T., Arora, N. K., Rimer, B. K., . . . Viswanath, K. (2005). Trust and sources of health information: The impact of the Internet and its implications for health care providers: Findings from the first Health Information National Trends Survey. Archives of Internal Medicine, 165, 2618–2624.

Hesse, B. W., Moser, R. P., Rutten, L. J. F., & Kreps, G. L. (2006). The health information national trends survey: research from the baseline. Journal of Health Communication11(S1), vii-xvi.

Kasper, J., Légaré, F., Scheibler, F., & Geiger, F. (2012). Turning signals into meaning–‘Shared decision making’meets communication theory. Health Expectations15(1), 3-11.

Labilles, U. (2014). The Role of Disease-specific Surveillance and Health Information Exchange (HIE) in Managing Regional Multi-site Medical Specialty Practice. (Unpublished, RSCH-8100H-2. Research Theory, Design, and Methods. 2014 Spring Qtr. WK7Assgn) Walden University, Minneapolis.

Nelson, D. E., Kreps, G. L., Hesse, B. W., Croyle, R. T., Willis, G., Arora, N. K., . . . Alden, S.
(2004). The Health Information National Trends Survey (HINTS): Development, design,
and dissemination. Journal of Health Communication, 9, 443–460.

Office of Disease Prevention and Health Promotion. (2010). Healthy People 2020. Retrieved
from http://www.healthypeople.gov/2020/default.aspx

Scholl, I., Loon, M. K. V., Sepucha, K., Elwyn, G., Légaré, F., Härter, M., & Dirmaier, J. (2011). Measurement of shared decision making–a review of instruments. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen105(4), 313-324.

Viswanath, K. (2005). Science and society: The communications revolution and cancer control. Nature Reviews Cancer, 5, 828–835.

Wen, K. Y., Kreps, G., Zhu, F., & Miller, S. (2010). Consumers’ perceptions about and use of the internet for personal health records and health information exchange: analysis of the 2007 Health Information National Trends Survey.Journal of medical Internet research12(4).

“What the Patterns Tell Us” Socioeconomic Status and Health

Fifty years ago, President Lyndon Johnson began his quest for a more just and honorable America with the passage of the Civil Rights Act of 1964, passed the Voting Rights Act of 1965 and the Fair Housing Act of 1968.  This week, President Barack Obama joined three former Presidents delivered remarks at the Civil Rights Summit at the Lyndon B. Johnson Presidential Library and Museum, and acknowledged racism has hardly been erased and that government programs have not always succeeded. Let us talk about socioeconomic and racial/ethnic disparity patterns in public health. What the patterns tell us? In Europe, the presence of detailed socioeconomic information in routine health data has facilitated the monitoring of socioeconomic patterns in diverse health indicators (Braveman, Cubbin, Egerter, Williams &  Pamuk, 2010). This socioeconomic information gave Public health professionals and researchers the ability to compare health of socioeconomically disadvantaged population with health differences among middle-class subgroups and, potentially, comparisons with the wealthy.  Braveman et al. (2010) gave emphasis on Europe’s data collection in contrast with routine the routine public health statistics in the United States.  Health difference across groups defines by socioeconomic factors have been examined less frequently. It was further noted by the study that routine health reporting should examine socioeconomic and racial/ethnic disparity patterns, jointly and separately. According to Collins (2004) “race and ethnicity are poorly defined terms that serve as flawed surrogates for multiple environmental and genetic factors in disease causation, including ancestral geographic origins, socioeconomic status, education and access to health care. Research must move beyond these weak and imperfect proxy relationships to define the more proximate factors that influence health” (para. 1).

Health disparities in many instances will hardly to do with genetics, but more directly associated in socioeconomic status (SES), access to health care, education, social marginalization, discrimination, culture, stress, diet and other factors. SES is one of the strongest and most consistent predictors of morbidity and mortality. As a complex phenomenon, the impact of SES on disease makes its definition and measurement of vital importance. SES is typically measured by determining education, income, and occupation (Winkleby, Jatulis, Frank & Fortmann, 1992). The Farquhar et al study is the only U.S. study on the associations between separate SES dimensions and risk factors or disease outcomes (Winkleby et al., 1992).  In the Farquhar et al. study (1985): Subjects aged 25 to 64 were drawn from the two control cities of the Stanford Five-City Project, a communitywide cardiovascular disease intervention study that contains data from four separate cross-sectional surveys, conducted from 1979 to 1986. Participants who were unemployed (n = 98), students (n = 130), or retirees (n = 146) were excluded because they had no occupation that could be ranked (Winkleby et al., 1992, p. 816).  Associations between one measure of SES and one risk factor, morbidity, or mortality in other studies have found that education is more strongly associated with disease than income or occupation.  One of the most complete studies of mortality differentials (Kitagawa et al., 1973) found “lower SES groups exhibited higher rates of all-cause mortality than did higher SES groups, irrespective of whether education, income, or occupation was used as the measure of SES” (p. 819). Lower levels of education are associated with hypertension, cigarette smoking, high cholesterol, cardiovascular disease (CVD) morbidity and mortality. According to Winkleby et al.,  there are no SES measure that is universally valid and suitable for all populations. The study noted  “if economics and time dictate that a single parameter be chosen, and if the research hypothesis does not dictate otherwise, the conclusion is that higher education, rather than income or occupation, may be the strongest and most consistent predictor of good health” (p. 819).


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What we do and don’t know about ‘race’, ‘ethnicity’, genetics … (n.d.). Retrieved from http://www.nature.com/index.html?file=/ng/journal/v36/n11s/full/ng1436.html

Major Trends in Genomic Research and Development: Emerging Challenge to Public Health and Global Security

Shortly after I heard about the shooting at Fort hood on Wednesday, it again reminded me about the November 2009 massacre when Army Maj. Nidal Malik Hasan opened fire, killing 13 people and injuring 32. The first question that crossed my mind—is this another terrorist attack? Three days after the April 15, 2012 Boston marathon bombings, President Barack Obama travelled the city and reassure us as a nation to keep our spirit strong. The President stated “We carry on. We race. We strive. We build and we work, and we love, and we raise our kids to do the same. And we come together to celebrate life and to walk our cities and to cheer for our teams when the Sox, then Celtics, then Patriots or Bruins are champions again, to the chagrin of New York and Chicago fans”. This again assert the reality, that after the attack of 9/11 our lives will never be the same again. The increasing recognition that advances in biology is the center of current concerns about the heightened probability of genetics in facilitating the development of a new generation of biological weapons. The scientific and security communities should increase their vigilance on the misuse of genomic data and the ongoing trend of revolution on biology (Labilles, 2013b).  Advances in Genomics may have a significant impact to public health, but serious concerns have been raised about the consequences of the misapplication of this field for hostile purposes. Therefore, it is critical for the continued development of sophisticated analytic techniques to better distinguish anomalies from baseline data. Likewise, combined expertise amongst systems enhance early detection performance for detection of infectious diseases. Professor Thomas D. Cabot of Harvard University has said: “A world in which these capabilities are widely employed for hostile purposes would be a world in which the very nature of conflict had radically changed.” Labilles (2013c), we need to be aware of the implications of programs such as the Free Trade Agreement (FTA), and the need of strict surveillance of the methods and what is being traded between boundaries” (para.3). Our understanding of the brain and human behavior is reaching the point at which precise manipulation for beneficial reasons is clearly feasible. The information presently available has become widely used for military purposes, and there will be knowledge available for misuse, and there will be some willing to misuse it. The line of differentiation between chemical and biological weapons is getting thinner as the genomics revolution continuous.  An individual intentionally infected by Variola major and cross the border will be a deadly moving biologic weapon. This will cause high mortality, public panic and social disruption (Labilles, 2013b, p. 2). The terrorists’ main goal is always to challenge Americans’ sense of safety and confidence, a small chemical, biological, radiological, or nuclear (CBRN) attack could be successful.

According to Richard (2000), highest estimates of the Central Intelligence Agency (CIA) indicate that as many as 100,000 people may be trafficked into the U.S. each year. Modified traditional agents targeted at specific physiological processes can be carried or injected to any individuals estimated to be trafficked into the United States annually. The office of transnational Issues of the US CIA issued a bleak warning in the late 2003 about the future of biological weapons. The report, titled The Darker Bioweapons Future, argued “growing understanding of the complex biochemical pathways that underlie life processes have the potential to enable a class of new, more virulent biological agents engineered to attack distinct biochemical pathways and elicit specific effects” (Wheelis & Dando, 2005).  The report cited of specific examples of new biological weapons and noted about the effects of some of these engineered biological agents could be worse than any disease known to man.

The CIA estimated prevalence of human trafficking vary widely both by year and by the source, with no particular trend (Hopper, 2004, p. 125). A free and open society like the U.S. will always be tested by people who hated the kind of freedom we inherited from our founding fathers. While lethal chemicals are easy to acquire, getting large quantities, and weaponizing are difficult; biological agents can be acquired in nature or from medical supply houses. Like cyberthreats, biothreats are relatively inexpensive compared to explosive, nuclear, and chemical weapons. Both cyber and biothreats can replicate themselves and spread again in their respective cyber and physical borders (Rosen, 2011). To improve psychological profiling of terrorist groups and to develop better theories regarding the roots of terrorism, the need of scientific methodology application must be recognized. It is essential to be informed on the four biosecurity trends in order to avert the concept of militarization of biology, and focus on the potential for hostile manipulation of the human nervous system.

  1. Chemical, biological, and the manipulation and misuse of Emerging Infectious Disease: There is an unequivocal distinction between terrorism with chemical and biological (CB) materials, and terrorism with chemical and biological weapons. Rosen & Lucey (2001): Terrorism with CB materials deals with the use of any toxic substance or pathogen in pursuit of certain goals. Terrorism with CB weapons refers to the use of warfare agent that is a toxic chemical designed, developed and selected by the military to support specific missions laid out in the military doctrine of a state. This distinction highlights the deeper significance of the 1995 sarin attack in the Tokyo underground: for the first time a terrorist organization turned to a warfare agent (p. 172). Unknown potential threats of the emergence of dual-use technologies such as synthetic biology and nanotechnology pose additional security and containment challenges.  Nanoscale-manipulated biological agents evading current detection capabilities and the unpredictable dissemination patterns of synthetic microorganisms is a major challenge. As a proactive posture to a rapidly changing global environment, the US National Strategy for Countering Biological Threats is emphasizing prevention while continuing to support the national preparedness goals and response/recovery capabilities. The study Perkins & Nordmann (2012) aim to enhance the collective capability of the United States and the international community to address emerging health security threats. The study emphasized the need to increase our knowledge of health effects of various types of nanomaterials, and how to assess, control, and prevent harmful exposure, taking into consideration the numerous gaps that currently exist with regard to the distinct behavior of nanoparticles compared to the same chemical or material at “macro-scale”.
  2. Mass-casualty Terrorism: A large scale bio-terrorist (BT) disaster would create a public health disaster in which the number of victims would exceed existing health care resources. It is an intentional disaster with the objective of causing fear, illness and death. The study of the Committee on Research and Development for improving Civilian Medical Response to Chemical and Biological Terrorism Incidents—suggest that in most cases, the United States will have some or little capability for BT mass casualty management, and triage at four levels of medical care. The four levels of medical care are local responders, initial treatment facilities, state, and federal. At the time of the study, existing conventional management and triage protocols for disasters is not fit for casualty management needs for a large-scale BT event. The three phases of management and triage process after BT event are discovery phase, epidemiological analysis phase, and lateral decision-making/triage management phase. The discovery phase of a BT event will most likely occur in an emergency department, doctor’s office or clinic (Burkle, 2002). Assumptions about the nature of the event will initially guide triage and management during the discovery phase. Syndromic surveillance is an essential component of the discovery phase base on signs and symptoms and supporting public health information. The early clinical manifestations of disease caused by most BT agents could be non-specific, or certain syndromes would be a characteristic of a potential BT attacks. Awareness of these syndromes by practitioners is significant to early discovery of an exposure. The syndromic events are a perfect determinant for surveillance to control the spread of an infectious pathogen. Agent-based models (ABM) can be used to establish structured epidemiological description of a population or infected individuals and local interaction. Agent-based Model (ABM) algorithm allows one to keep the number of active (Exposed and Infectious) agents low at the beginning of the epidemic process and thus decreases the computational burden. As the number of activated agents increases, and increases the amount of required computational resources. Using ABM, an individual is considered to be in one of the following four states: (1) Susceptible (can contract the disease given the contact with an infected individual), (2) Exposed (contracted the diseases, but is in a latent state without showing symptoms), (3) Infectious (showing symptoms and capable of infecting others), and (4) Recovered (obtained permanent immunity and cannot infect others). When an infected individual passes infection to a Susceptible individual, a corresponding susceptible agent is activated (Bobashev et al., 2007). Epidemiological analysis phase is of paramount importance in recognition of an epidemic caused by terrorism. An epidemiological investigation must occur in tandem with case definition development, once an abnormality is evident, whether it is a single or unexplained disease cluster, or mass illness event. The visual representation of a quantitative evaluation using epidemic curves will be initially useful to obtain answers to questions concerning origin, propagation, incidence, prevalence and modes of transmission. Details on unique characteristics of the BT agent can also be achieved through curve analysis. In this phase, mathematical models of disease is also essential to link the biological process of transmission and the emergent dynamics of infection at the population level. At the minimum, a team effort is significantly will dictate the success of lateral decision-making/triage management phase. Emergency managers (local and FEMA), Department of Justice (FBI), political authorities (mayor, governor), technical experts, tactical field scientists with expertise in epidemiology and infectious disease) will make up the lateral decision making at the local level. At the hospital level, the triage officer will be composed of pharmacists, infectious disease specialists, administrators, pulmonary care technicians and auxiliary hospital personnel.
  3. Gross Violations of the Biological and Toxin Weapons Convention (BTWC):  The 1972 Biological and Toxin Weapons Convention was formed as a result of the end of the Cold War and the first Gulf War. The gross violations of BTWC is of great concern, and had been violated for the two decades following its entry into force that led to a six year international negotiations of a compliance protocol. A number of BTWC signatories are suspected to be involved in illegal activities. President George W. Bush withdrew from these negotiations in 2001 and has declared BWC to be “inherently unverifiable”.

Dramatic Advances in Biotechnology: In 1999, the biotechnology industry in the United States doubled in size, and its globalization is being driven not only by national decisions, but also by biotechnology firms. Growing apace in the knowledge and techniques in genomics, and genetics, giving scientists the ability to locate specific genes and identify their associated genes through genetic sequencing. Bio-informatics have supported the collection and dissemination of vast quantities of data, making it easier for knowledge and technology to be misused. Growing international subcontracting, transfer of knowledge to other entity could be the first probable breach enabling terrorists to develop new forms of bioengineered weapons to augment or replace existing capabilities. Detection, mitigation and remediation from exposure to agent strains could become much more difficult if they were modified to hide telltale signatures (Rappert, 2003). In the mid-1990, Russian scientists made detection tests for anthrax ineffective through genetic engineering techniques.  The impact of biotechnology on the threat of biological warfare is graphically represented in figure 1 (Petro et al., 2003, p. 163). The graphical representation of figure 1 depicts the timeline of relative threat level presented by traditional, genetically modified traditional and advanced biological agents. Dramatic advances in biotechnology will lead to a new class of advanced biological warfare (ABW) agents developed to bring forth novel effects. Biological research will bring new agents and delivery system that will provide a multiplicity of new options, expanding the paradigm of biological warfare.The implications of these four trends led to a re-conceptualization of the bio-terrorist threat away from misplaced analogies to nuclear or chemical weapons, and towards placing the threat in the context of the public health measures needed to combat disease (Chyba & Greninger, 2004).

Contributing Factors

The individual, interpersonal and environmental contributing factors that open the probability of biological and chemical threats could be trace to the lack of verification measures and the widespread availability of the general materials, equipment and biological knowledge necessary for weapons development. BTWC has no criteria to differentiate offensive from defensive development, production or stockpiling activities. Unless otherwise justifiable, all biological agents and toxins are banned, but it has long been a cause of concern of reported violation of BTWC by some member State Parties and countries. It has been a topic of much debate about the feasibility that individuals, sub-state groups, terrorists the capacity to develop bio-weapons. A genetically engineered infectious agent could have a probable effective means of systematic dispersal by trafficking an individual physically carrying a deadly agent or infected with deadlier viral strain that rapidly spread to a target population. With existing knowledge and technology, studies shows that terrorists or anyone can make biological weapons without obtaining a natural virus. American scientists Jeronimo Cello and colleagues at the State University of New York at Stony Brook synthesized a polio genome from scratch by stringing together commercially available strands ofDNA purchased over the Internet in accordance with the map of the RNA polio genome, which is published onthe Internet (Selgelid, 2007). Through gene splicing, the survivability of a bacterium across a range of environmental conditions could be improved. The ease to conceal legitimate biological research further energize other countries, and terrorist organizations to continue to pursue biological warfare.


The theoretical framework of emerging biotechnologies will lead to the development of new biological agents. Technologies developed across multiple disciplines in the biological sciences will have a profound global impact and concurrently have the potential to revolutionize biological warfare by facilitating an entirely new class of fully engineered agents referred to as advanced biological warfare (ABW) agents (Petro et al., 2003). The Biological Weapons and Toxins Convention (BWTC) have done little to prevent foreign bio-weapon programs. Compounded by the possibility of terrorist organizations’ intention or capability to acquire bio-weapons—bioterror threat represents a significant challenge to our leaders, and agencies responsible for directing biodefense efforts. Prevention will be dependent upon counter proliferation, environmental detection, and medical countermeasures. The aim of the creation of a national biodefense strategy is to focus largely on addressing existing threats posed by a select group of naturally occurring pathogens and toxins. Petro et al. noted that agents traditionally associated with biological warfare likely will remain the predominant threat over the next 10 years. The implications of current and emerging biotechnologies on development of new biological agents should be considered and factored into any long term biodefense strategy (p. 161).

Public Health Policy Implications

 Dual-use research that can be used for both good and harmful purposes is plagued with ethical challenge and debates on the needs of relevant policy developments. The growing debate on “the dual-use dilemma” in life sciences research stressed the essential need of safety and security guidelines on biosecurity. Life sciences community and the security community share the common goal of protecting our Nation’s human, animal, plant and environmental health. These communities recognize this inherent tension between the need to protect the conduct of biological research from unnecessary restrictions, and mitigate potential threats to the greatest extent possible. I believe that a comprehensive review of U.S. terrorism policy, organizational structure, and preparedness are essential to respond with the shifting nature of biological research impacting existing offensive capability, and scientific advances that will be more available and applicable over the next 5 to 25 years. The National Research Council (NRC) recommended the increased education of the scientific community about the dual-use dilemma. The recommendations include that the significance of the role of institutional biosafety committees. The expanded role of institutional biosafety committees must include the function to review of research proposals for dual-use risks including environmental dangers. NRC recommendations also include self-governance of the scientific community as opposed to governmental censorship in matters related to publication of dual-use research findings.  The National Science Advisory Board for Biosecurity (NSABB) was established to provide guidance to the government regarding the oversight of dual-use research. The public health community, law and policymakers, and society in general need to address a series of critical choices (Hodge Jr., 2002). The critical and most important choice are not to decide where the power to protect the health public lies or which level of government has the primary power to act, but to decide the center of leadership during a bioterrorism event.


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Figure 1


Parental Obesity and New Mentality: Raising the Risk of Child Obesity

Our nation’s most urgent health problem is the disparities in health care. There are stark disparities in health by gender and socioeconomic status. According to Davis et al. (2005), “the social and community environments affect health directly as well as indirectly by influencing behavior”(p. 2168). Which group do we put parents who have a distorted perception of their child’s body size? This phenomenon is most prevalent among low-income women and Hispanic mothers. But regardless of race or socioeconomic background, the obesity epidemic is eroding the general impression of what healthy looks like. What if obese is the new normal? If obese is the new normal, then it will be our failure as Public Health professionals to emphasize the importance of the role of parents and family to combat child obesity. Parents should play a crucial role in influencing children’s food habits and physical activity. Parental obesity may increase the risk of a child becoming obese. Wrotniak et al. (2004) is the first study to examine the incremental effects of parental weight change on child weight change while controlling for variables that influence child weight loss. The study stated that youth benefit the most from parents who lose the most weight in family-based behavioral treatments (Wrotniak et al., 2004, p. 342).

The prevalence of obesity is increasing in all pediatric age groups according to the Health and Nutrition Examination Survey (NHANES). Genetics, environment, metabolism, lifestyle, and eating habits are among the factors believed to play a role in the development of obesity. More than 90% of cases are idiopathic; less than 10% are associated with hormonal or genetic causes. Hirschler et al. (2008) found an association between mothers’ distorted perception of their children’s shape and eating habits and mothers’ obesity and their children’s overweight. The study provides clues for obesity prevention programs. There is a multitude of health problems that are associated with obesity. Without dealing with the new trend of maternally distorted perception of their child’s body size, health problems faced by family care physicians will continue to rise. There will be continued prevalence of obesity associated diseases such as type 2 diabetes and heart disease to hyperlipidemia, asthma, and obstructive sleep apnea. According to Friedman & Schwartz (2008), “A key concept in developing obesity-related policies is creating ‘optimal defaults’17. When there is an optimal default, the health promoting behaviors are those that come most easily, require the least effort or thought, and offer a more healthful option” (p.718).


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