Editor's Choice |
Shock and awe: waking the dead
‘Paranoia, for the exile, is a pre-requisite of survival’ says Salman Rushdie in the Satanic Verses.1 Mental health is the theme of this issue in which Veling and colleagues2 show a graded relationship between the degree of discrimination experienced by immigrants to The Netherlands and the incidence of schizophrenia and other psychotic disorders. The authors consider the biological mechanisms that might be involved in adapting or reacting to the experience of immigration—‘a severe cognitive and emotional challenge’—and invoke rat experiments that show that repeated social defeat leads to sensitization of the mesolimbic dopamine system.
For me, Rushdie has the upper hand in explanatory power—a heightened level of alertness to potential threats in immigrant populations (a positive adaptive response) will likely follow a continuous, not binary, distribution with the mean level in the population determining the proportion with diagnosable psychopathology. In an analysis of risk of schizophrenia in African Americans, Bresnahan and colleagues3 are more guarded in their interpretations of the similarly increased risk of schizophrenia they observed in the Netherlands among ethnically very different people. As these authors note, the impact of race on mental health outcomes ‘may be mediated through different mechanisms at different times, and/or be cumulative’. As a second generation immigrant (of mixed race) to the UK, I wonder about the ability of epidemiological analysis to render accessible and interpretable the complex individual life stories that constitute the ‘exposure’ of being from an ethnic minority. The kindness of strangers, the fascination of the host country with the exotic, the inter-ethnic marriages and friendships, along with the economic and educational advantages, are the positives that make better lives possible.
These ideas are echoed in Vikram Patel and Anna Goodmans’ editorial4 which focuses on the need to develop an understanding of the protective and promoting factors in mental health rather than focusing on the causes of mental illness, and makes the important point that these are not simply mirror images of each other. The issue here is why do a majority of people remain happy and healthy despite disadvantages? A familiar theme to readers of Editor's Choice is the importance of moving from simply describing the ‘fact’ of ethnic and social differences in disease outcomes towards understanding the mechanisms involved. Herein lie the clues for prevention.
Preventing deaths in Iraq, and the possibility of escalation of war to Iran, lies with both the USA and UK and requires fairly simple interventions—the removal of their president and prime minister, respectively. Many liberal academics in epidemiology and population sciences wonder what to do about the war—protest on the streets seems futile and voting takes too long to achieve change. We could all take the example of Sheila Bird and Clive Fairweather5 and start counting and calculating rates—something in which we are experts. The figures they present are startling—in Afghanistan between May and September last year, death rates for UK and Canadian troops were four times those of US soldiers in Iraq. Media coverage at the time from Iraq outweighed markedly that from Afghanistan, giving the impression that the dominant risks and action were in Iraq. Was the strategic decision to increase UK troop deployment to Afghanistan taken with the benefit of knowledge of the extremely high risks involved? Yet, as Bird and Fairweather show, the death rates fell markedly in Afghanistan in the subsequent 6 month period. In the period February 2007 to 14 June 2007, totals of 448 and 58 deaths occurred among US and UK armed forces in Iraq and Afghanistan, respectively. While we have research groups in both USA and UK conducting research on the long-term consequences of wars in the Middle-East, where are the groups who major in the epidemiological assessment of the immediate short-term hazards? In modern theatres of war, where ‘winning’ seems difficult to define—much less achieve—might we consider promoting the idea of evidence-based military policy?
It is always comforting to return to old, well-known enemies—as editors of IJE we sometimes think we should award a prize every year to the authors who come up with the most imaginative way of demonstrating that tobacco still kills. Peter N. Lee will be well known to many as a tobacco researcher funded by Philip Morris International, and some may wonder why we accept publications funded by the tobacco industry. We take the view that censorship is unacceptable and debate is essential. So what about smokeless tobacco and its effects on health? Well, the evidence is limited, and what there is shows a substantially smaller risk than that of smoking tobacco.6 A Swedish colleague complained to me that teaching male medical students is increasingly unpleasant as many of them locate a plug of chewing tobacco under the upper lip during clinics and ward rounds which gives them an arrogant looking sneer. I wonder if the patients notice?
The International Epidemiology Association have important news for you—the Sir Richard Doll Prize for Epidemiology. The prize will be awarded to an epidemiologist of the highest scientific standard in an active part of his/her career. The recipient will be honoured for scientific achievements that have advanced our understanding of the determinants of a disease of importance for health in populations through a body of research that may involve a series of studies, rather than a single publication. The prize will be presented at the triennial IEA World Congress of Epidemiology (WCE) together with £ 20 000 and a plaque produced by the IEA. Members of IEA are invited to make nominations, and full details are available on the IEA website (http://www.dundee.ac.uk/iea/).
A clean water supply figures in the Disease Priorities for Developing Countries II project7 as just about the most cost-effective intervention any country borne down by World Trade Agreements and lacking in GDP would want to have. But water supplies breakdown and as populations migrate from the economically failing regions of Europe, small towns are faced with problems of maintenance. The risks described in Nygård and colleagues' paper8 of increased gastrointestinal illness associated with low pressure and pipe breakages in Norway are a clear problem. However, they are not on quite the same scale as that achieved in the late 1970s by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDRB) where an epidemic of cholera in Mohakhali, the district of Dhaka which ICDDRB is located, was traced to the mixing of sewage from the institute's hospital into the main water system. The story was reported to me as a junior researcher in Bangladesh—and is a lesson in how research can harm those it seeks to protect.
Finally, Jacquemin et al.9 promote the idea that public annoyance due to air pollution in European countries would be a useful adjunct for health surveillance. As over half the general population reported annoyance, I think that they may be missing an important public health lever for increasing political action on measures to reduce pollutants. Annoyance levels, rather than measures of air pollutants, analysed by political voting areas might encourage members of European and country governments to take air pollution more seriously.
References
1 Rushdie S. The Satanic Verses (1988) London: IV. Ayasha. Viking. 207.
2 Veling A, Selten JP, Ezra Susser E, et al. Discrimination and the incidence of psychotic disorders among ethnic minorities in The Netherlands. Int J Epidemiol (2007) 36:761–68.
3 Bresnahan B, Begg MD, Brown A, et al. Race and risk of schizophrenia in a US birth cohort: another example of health disparity? Int J Epidemiol (2007) 36:751–58.
4 Patel V, Goodman's A. Researching protective and promotive factors in mental health. Int J Epidemiol (2007) 36:703–7.
5 Bird SM, Fairweather CB. Military fatality rates (by cause) in Afghanistan and Iraq: a measure of hostilities. Int J Epidemiol (2007) 36:841–46.
6 Lee PN. Circulatory diseases and smokeless tobacco in Western populations: a review of the evidence. Int J Epidemiol (2007) 36:789–804.
7 Jamison DT, Breman JG, Measham AR, et al, eds. Disease Control Priorities in Developing Countries (2006) 2nd edn. USA: OUP. http://www.dcp2.org/pubs/DCP.
8 Nygård K, Wahl E, Krogh T, et al. Breaks and maintenance work in the water distribution systems and gastrointestinal illness: a cohort study. Int J Epidemiol (2007) 36:873–80.
9 Jacquemin B, Sunyer J, Forsberg B, et al. Annoyance due to air pollution in Europe. Int J Epidemiol (2007) 36:809–20.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  G. Davey Smith Smoking and lung cancer: causality, Cornfield and an early observational meta-analysis Int. J. Epidemiol., October 1, 2009; 38(5): 1169 - 1171. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||