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EP43 Live from the 2019 NYC Epidemiology Forum [Part 2]
Chris Alexander: Hello and welcome to part two of a special live edition of the I AM GPH podcast. I'm Chris Alexander, Director of Communications and Promotion here at the College of Global Public Health and in this episode we get to hear from a variety of researchers who presented their work at the sixth annual New York City Epidemiology Forum held at the NYU School of Law. This annual event provides a forum for students and epidemiologists working in the New York City area to network, present their work and discuss opportunities for hopefully future collaborations. We learned about environmental pollution, the stigma of violence, sexual health, health data and analytics, cardiovascular disease, and so much more. So please enjoy this wide ranging selection of short interviews from the sixth annual New York City Epidemiologists Forum.
Chris Alexander: Can you start off by introducing yourself and tell us a little bit about the research that you are presenting today, and you've already presented on this morning.
Akhgar Ghassabian: I am Akhgar Ghassabian. I'm an Assistant Professor of Pediatrics Population Health and Environmental Medicine at NYU Langone Health and today the research I presented today was on a traffic related air pollution, and the thyroid function in pregnant women results from five birth cohorts in the United States and in Western Europe.
Chris Alexander: Can you give us a rundown of what was involved? What did you find out?
Akhgar Ghassabian: Yes. So the question was whether exposure to air pollution, and a specific traffic related air pollution is associated with thyroid function in pregnant women. Thyroid functioning pregnancy is important for brain development of the fetus. And also thyroid function of the mother influences thyroid function of the newborns. That's why factors influencing thyroid function is always of interest. One of the factors that we studied in our work was air pollution exposure. So in five birth cohorts, we use home addresses to estimate exposure to concentrations of different pollutants. We also measured thyroid function in about 9,000 pregnant women. And then we looked at the the prospective association between exposure to air pollution and thyroid function. And we found that if they remember exposing the first trimester of pregnancy to particulate matter, they had higher odds of developing hypothermic sinemia, which is a condition specific to pregnancy saying that the woman doesn't have enough thyroid hormone for herself and also for a developing fetus.
Chris Alexander: So why this area of research? What drew you to this, to looking into this question?
Akhgar Ghassabian: Well, the importance of air pollution exposure, I don't need to comment on that because we know that exposure is widespread and women and young children are in particular sensitive to the harmful effect. WHO and UNICEF published a report in 2016 emphasizing on the impact of air pollution exposure in children younger than age five years on their brain development. So they reported that more than 300 million children across the world live in areas that have pollutants higher than standards. And that's why it is important to know what would be the impact on brain development for the children and what are the potential mechanism of that association. In my research before the last 10 years, I have worked on a maternal thyroid function in pregnancy because after a series of work we did, we found that if women have a thyroid function that is good enough for their own health, it might not be enough for the developing fetus because the demand is high in pregnancy. And we showed that this condition might have influences on the developing brain and also can be a contributing factor to neurodevelopmental disabilities in children like autistic symptoms or ADHD symptoms or having lower IQ. So that's why I was interested in what will be the factors influencing low thyroid function in pregnant women. And that's why we put together this collaborative work of five cohorts across Europe and the United States to have enough power, the large number of women, to be able to find an even small effect if you have a larger sample.
Chris Alexander: What would you say was the biggest challenge that you faced in doing this research and how did you approach it? Did you have any creative perspectives, creative approaches? Tell us how that went.
Akhgar Ghassabian: Well, I would say that in this type of research, the challenge is always that if you're doing a collaboration among the different studies, they all have different protocols, different politics that are very complex in terms of different way of measuring air pollution, different way of measuring thyroid function. So first thing we had to come up with a definition for measure we had and also we needed to harmonize exposures and also outcome. The other challenge we had was we were in two continents and in five, six countries. So we had to centralize the analysis. We were able to because we had an infrastructure in Barcelona that could help us to bring all these teams together and harmonize the measurements and analysis. And finally we could do that.
Chris Alexander: Thank you so much for sharing.
Akhgar Ghassabian: Thank you.
Michael Megafu: Okay, so my name is Michael Megafu. I'm actually an MPH student at SUNY Downstate School of Public Health. Basically I've presented on the association between forced sexual intercourse or sexual assault and condom use. I basically just found out that you know, a lot of people who actually are raped or go through some type of sexual assault, they don't use a lot of condoms. They don't use condoms at all. And it was kind of good to see that there was an association in terms of, not only gender. And I stratified for gender and saw that it was more prevalent in males than females, which is something that's usually overlooked. And obviously there are a lot of biases because it's adolescence and this is YRBS dataset, but just to see that a lot of programs, they don't really address adolescents who actually went through these things. They always assume that everyone is abstinent, et cetera, et cetera. So policies need to be able to incorporate educations that are comprehensive enough to create avenues that people can actually come and have some types of support.
Chris Alexander: So what drew you to this area of interest? How did you find your way to this topic?
Michael Megafu: Honestly, I had to do this for homework. It was a homework for a class and I love kids, so I was really interested. I used to be a high school teacher, so I'm really interested in the adolescent population. Then stumbling across it through my research. And that's how I honestly came into it. And really, I don't regret it at all. It's really good. Yeah.
Chris Alexander: What would you say was the biggest challenge that you faced when doing this research or looking into this topic? And did you have any kind of creative approaches to getting over that challenge?
Michael Megafu: It's such a sensitive issue, so it's kind of hard to really address it sometimes because you don't know the audience that you're talking to. But honestly, just looking at the research, stating out the facts, and I've shown that there are ways in which we have a raised awareness in terms of like the "Me Too" movement. Some of the programs that CDC instituted to show ways that we're building on this. Yes, we know that this exists, that this association has hold true and we're trying to actively make steps towards alleviating it.
Chris Alexander: So lastly, what would you say would be the biggest myth or misunderstanding or something that's misinterpreted by the public or unknown about this, this area of research, now that you've dived into the data and what's the reality? What sort of message would you want to put out there?
Michael Megafu: Yeah, I think the common misinterpretation is that this only happens in the adults. Cause a lot of myths is that it's only women's violence or domestic violence and intimate partner violence only occurs in the adult population but also occurs with adolescents as well. And I'm trying to show that we need to make active movements in addressing the adolescent population and that this is not only true in adults but also true in adolescents. It's not only in females, it's also men as well and males as well. So we need to look at it from both sides, not just the feministic perspective.
Chris Alexander: Cool. Thanks so much for sharing.
Michael Megafu: Thank you so much, I really appreciate it.
Diana Klatt: Hi, my name is Diana Klatt. I am doing research with HealthRight International. That is an NGO that is located here, headquarters in New York. My research is using data from Ukraine, from UNFPA, which is the United Nations Population Fund. Yeah. So I'm doing research on post-conflict Ukraine and around gender based violence. And the research I'm presenting today is about male survivors of domestic violence.
Chris Alexander: Why would you say this issue is so important and how could we raise awareness around it? What would that look like?
Diana Klatt: I guess I'll back up a little bit. Ukraine is pretty much still in conflict even though it's post-conflict Ukraine, but the initial conflict with Russia is over and a lot of different factors go into violence and then since it's already a place where there's a lot of violence happening, there's this thing called a cycle of violence where if you're experiencing violence, you are more likely to be a perpetrator of violence. It's kind of become the norm and the culture in Ukraine to accept violence as a use of asserting power, asserting dominance and it's become so normalized that a lot of people don't know how to react with it. Then there's also this report that came out recently at the end of 2018 last year from UNFPA about the role of masculinity in Ukraine. And they're holding very tight to gender norms there. So the traditional male as the breadwinner, female is the housekeeper type of situation. But since there is such large conflict and displacement in East Ukraine, a lot of people are not really employed or a lot of people are getting financing still what they call pensioners instead of retirement. And so there's this imbalance of where people can find work. So a lot of shift has been happening, but still so many of the males use violence as a tactic to get more funding from whatever sources. Like for example, their fathers or other people in the house, which kind of goes with more of what I'm doing since I'm doing domestic violence for research. But also a lot of research out there is more focused around females that experience violence. But according to the Gold Burden of Disease, males are the ones that experience more violence typically because of all the other factors of firearm misuse and more than just domestic violence or domestic abuses. And frequently I feel like men are overlooked or it's interesting. So I'm working with HealthRight, and we have mobile teams on the ground in Ukraine and we're looking to change the way that our mobile teams function. And at present, males can come report to us, but we don't really have safe houses or as many resources for them to use afterwards. So they don't typically come to us because there's no reason to. Whereas for females that report, we can refer them to safe houses, we can shelter them, we can do a lot of different things. But basically I'm trying to do this research and increase awareness of males that are also experiencing different types of violence and trying to make a case for why we should modify our mobile teams and our outreach teams so that way we can actually provide those that are experiencing these things some more resources.
Chris Alexander: So lastly, what would you say is the biggest challenge that you've been facing doing this research? Looking at the data and how did you approach that challenge? Do you have any sort of creative approaches? How did you work through that?
Diana Klatt: I don't speak or read Ukrainian or Cyrillic. So that's been a challenge because our data, while the majority of it is quantitative, so it's checked boxes and translated. A lot of things that help qualify everything are just interviews. So it's all in Ukrainian. Luckily, I have found an undergraduate from Kazakhstan and she is fluent in Russian and can read Cyrillic. So she is translating some stuff for me. So I'm hoping to be able to validate a lot of what I'm seeing because it's kind of interesting. The numbers that we're seeing for male survivors is really peculiar. It's a lot more than you would expect. And it's confusing to try to understand it or qualify it because so much of what we have in resources are around female that those are pretty stereotypical situations. So it's been difficult to be why is this actually like this? It doesn't go with what that masculinity report that came out says so it's trying to figure out how to qualify everything because it doesn't really match up and it's actually quite interesting that all of these males are experiencing this.
Chris Alexander: Thanks so much for sharing and thanks for joining us.
Diana Klatt: Yeah, thanks.
Mostafijur Rahman: I am Mostafijur Rahman and I am a student in the environmental health science program at the Graduate School of Arts and Science. I'm working with professor Josh Treston and I'm investigating the short term effect of ambient air pollution on cardiovascular hospital admission, emergency department visit and mortality in Dhaka, Bangladesh.
Chris Alexander: What drew you to this? Why this area of research, why did you choose this area?
Mostafijur Rahman: Yeah, that's a very good question. Yeah, away we are looking for the Dhaka. Yeah. New meta study conducted in a developed nation have documented strong association between exposure to ambient air pollution and increased risks of cardiovascular morbidity and mortality. But there are few studies conducted in developing nations with a poor understanding how PM 2.5 EP is compared with more developed nation. And also Dhaka is an extreme example of air pollution according to who report the ranked part polluted mega city in the world. And also the population oriented pollution concentration in Dhaka is 10 times higher than the developed nation. Not only that, like many other developing cities in the world, Dhaka is distinctly different from the other developed cities in the world in terms of source of pollution. Because, the greater prevalence of biomass burning in the season in terms of the order in Dhaka is lastly dominated by rainy monsoon season in terms of exposure to the pollution. It is obvious that the population health status in developing city and developed cities, it's distinctly different. So it is very important to know that it isn't specific expos or distance function on PM 2.5 on healthy fit.
Chris Alexander: Can you talk about a challenge that you had during the research? Looking at the data, what was the hardest thing and how did you overcome it?
Mostafijur Rahman: Yeah, that's a very nice question. Yes, that Dhaka data collection was the most difficult part of our research because it is the developing country, we all know that, the electronic patient registration system has not yet been implemented in many developing countries as well as in Dhaka. It was a very long story, but in short, my professor just touched based and led us to this hospital to convince them that we are going to get your data. We collected this data in a handwritten format. It was a very long data set. Then we converted these handwritten data into digitalized data. And my wife, she was at that time in Bangladesh. She helped me a lot to collect this data, so it was a big challenge to convince them that we are not... Actually, this is kind of fast of studies, so they are not used to it that how we have to provide data to the others. They will make anything against our organizational reality. So we have to convince them that, no we are just using this data for the research. It says we are not going to write anything against you. So it was very challenging for us because they are not used to it that to provide data to the others.
Chris Alexander: So how would you let the world know about this? How would you raise awareness about this? How do you think that would happen?
Mostafijur Rahman: We transcripted this data into these digitalized format, then we applied strong statistical method to analyze this data and after controlling for every confounder, seasonality, longterm chain, and also this is the Muslim majority country, so they have Ramadan, we controlled for the Ramadan and we saw that wow, PM 2.5 that means fine particulate matter is significantly associated with all the health outcomes: CBD health count, increased emergency department visit, increased hospital admission and increased mortality.
We didn't expect that much. It will be significant with all the kinds. And also we found that it varies in season. They have the monsoon season and during the non-monsoon season, pollution concentration is six times higher during the monsoon season. Because monsoon season we know that they have lots of rain there. So we're investigating that and we also found that during the high pollution day, if you look, the pollution is lower because during high pollution did a lot of biomass burning there, the biomass burning has a less CBD toxicity. So it's lowering the toxicity of PM 2.5. So we are still investigating it and it will be very fascinating if we really can find this.
Chris Alexander: That's very exciting. Thanks so much for sharing.
Mostafijur Rahman: Yeah. Thank you so much.
Spriha Gogia: I'm Spriha Gogia. I'm an associate director in the office of Population Health at New York City Health and Hospitals. Health and Hospitals is New York City's safety net hospital system. What that really means is that we are payer agnostic and take care of all patients regardless of their ability to pay or insurance status. So in our system, which is a large system, we comprise of eleven acute care hospitals, six diagnostic and treatment centers as well as many other standalone clinics. In total, we take care of about a million or more patients every year. And to give you a sense of the diversity of patients that we see, preferred spoken languages among our patients are more than 35. So we see patients in all five boroughs and we are geographically everywhere. So as I said, we are payer agnostic and depending on how you define it, we see about 30 to 35% uninsured patients among total in the year. So we're really taking care of New York City's most vulnerable population. So our office, as I said, is the Office of Population Health. And really we take care of public health among our patient populations. And our team specifically is, we call ourselves the Data Corp, but we do enterprise level analytics projects based on the data that we have. The idea is to assist in and promote data driven decision making. The research that I'm presenting today came out of an ongoing project that we have to be able to predict patients who would see us a lot in the acute care setting in the coming year. So those who would be high utilizers in our ED and/or the inpatient setting. It's well known that social factors are very closely linked with a person's health outcome. However, even though this is very well established data on this, particularly in hospital systems, is severely lacking. And what we did in this work is to try and arrive at proxy variables to get at the social determinants of our patient population. So by that I mean, we don't have data on whether the patient is homeless or is housing insecure, whether they have food insecurity or are their income insecure and clearly that is going to affect their health in the future.
Chris Alexander: So do you think we should be raising awareness about this issue and if you could, and if you did, what would that look like? How would that happen?
Spriha Gogia: I think the awareness is there. As I said, it's pretty well established that social factors are linked. However, it's just not collected well enough. So, that is a big issue. And hospital systems are already walking on that. They're building better and more robust social screeners, including ours. And some are ahead in the trajectory while others are a little behind. But our patients need this care today. So think about a mom who has two kids and needs a steady income, but is also living with a chronic condition like diabetes and needs to be taking her meds all the time and needs to see the doctor for every appointment. But that takes a backseat when she can't find childcare or when she can't take time off from work because she needs to make money to make ends meet. So now what happens is she misses a bunch of appointments and now her disease has worsened and she's in a downward trajectory and now she's going to hit us in the ER or the inpatient several times. And that's not good for her and that's not good for us. So we need to get upstream of that and figure out what these issues are so we can take care of them. An example would be, in this scenario that I just painted, maybe we can find a way to embed childcare services. Or, maybe we can open late clinic hours so that she can come after work. Or, a third option, which we are also getting into a lot, is televisits. So having a proportion of her visits from the comfort of her home and that would help her and again help us. So as I said, there is definitely a need to build in data into our systems. Healthcare data overall is pretty fragmented and is all over the place. But even with that, there's just isn't data on social factors. And so what we did in our work was we created proxy variables from available administrative data. An example would be trying to figure out patients who are housing insecure. Not just those who are completely homeless, although that's definitely a concern and that is something that a colleague of mine is actually presenting on today, but those who are couch surfing or are evicted several times. So they're on the way to getting homeless but not there yet. So if we can capture those and intervene ahead of their homeless status that would help us a lot and of course help them. A way to get at that, that we sort of used was counting the number of times a patient changed their zip code in our data in the year. So if they came to us and then they came to us again and had a different zip code, then we counted that as a one and then we counted the number of times that happened. We found that about roughly a little more than a percent of our total population had three or more support changes in the year and that's huge, right? That's not just moved. It's three times means that I moved several times in the year but among our high ED utilizers, that numbers rises to 26%. That's a huge jump and shows that there is some kind of a relationship between high EDUs and that housing insecure proxy variable that we created. Going further, we tried to see was this predictive of future high utilization at our system and we found that this variable was consistently predictive of future high utilization in every model like we've done. As I said, this is created from data that is collected routinely and not just our system but every system and so it can be approximated or adapted by other systems to get at this kind of a social factor.
Chris Alexander: It sounds like amazing work. Thank you so much for sharing and thanks for joining us.
Spriha Gogia: Thank you.