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Special Session: Epidemiology across the Americas: Bringing Together Latin American, Caribbean, and North American Epidemiologists – a panel discussion

IEA blog – joint for N. American region & Latin American & Caribbean Region (11/16/15)
— Nancy Krieger (N. American Region)
— Rita Barata (Latin American & Caribbean Region)

We share here our brief reportback on a special session jointly organized by: (a) our two IEA regions (North American, and Latin American and the Caribbean), and (b) the Epidemiology Section of the American Public Health Association (APHA). We are happy to say our session, which took place on Monday, November 2, 2015, stands as the first event ever jointly co-sponsored by the IEA and the APHA Epidemiology Section! The APHA Epidemiology Section notably has the most members of any of the North American epidemiology associations, and is also APHA’s second largest Section. The APHA annual meeting is one of the larger regular gatherings of public health professionals, with attendance typically between 12,000 and 15,000 participants.

The session was titled:

Special Session: Epidemiology across the Americas: Bringing Together Latin American, Caribbean, and North American Epidemiologists – a panel discussion

It took place at the 143rd annual meeting of the APHA, held in Chicago, IL (October 29-November 3, 2015). The session was attended by approximately 60 people, which is twice the average attendance at an APHA scientific session. The website for the abstracts is at: https://apha.confex.com/apha/143am/webprogram/Session45235.html

Jointly introducing the session were: (1) Nancy Krieger, PhD (Professor of Social Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA; IEA North American Councilor; and Chair, Spirit of 1848 Caucus, APHA) and (2) Howell Sasser, PhD, MPH (American College of Physicians, and Chair, APHA Epidemiology Section).

Dr. Krieger explained that purpose of the session was to introduce North American public health workers to the creative conceptual and empirical epidemiological work taking place in the many countries of Latin America and the Caribbean, as well as to promote greater and more equitable collaboration among epidemiologists across the Americas. Encouraging more – and more equitable – international collaboration among epidemiologists, especially oriented to health equity, has long been a goal of the IEA. Indeed, the IEA was founded in 1954, in the thick of the Cold War, and its first name was the International Corresponding Club. Its first meeting took place in 1956, with 49 members from 18 countries – and it was at its second meeting, held in Cali, Colombia, in 1959, when the IEA took on its formal name. Our session at the 2015 APHA meeting sought to continue this tradition, by building better ties between epidemiologists across the Americas. Dr. Sasser then introduced the speakers, and below we provide a brief description of who the participants were and what they said.

Rita Barata, MD, Professor: Epidemiology in Latin American and Caribbean Region: An overview
— Dr. Rita Barradas Barata, the IEA Councilor for the Latin American and Caribbean Region, is a leader in epidemiology in Brazil. Currently a Professor in the Collective Health Department in the Santa Casa de São Paulo School of Medical Sciences in São Paulo, Brazil, she is a physician with a master and PhD in Preventive Medicine, she served as the chair of the Epidemiology Committee of the Brazilian Association of Collective Health (ABRASCO) from 1984 to 1997, and as its President from 1997-2000, and also serves as Scientific Editor of the leading Brazilian, if not Latin American, public health journal: Revista de Saúde Pública. Dr. Barata’s expertise is in the epidemiology of communicable diseases, health inequalities, social determinants of health, and health research policies, and has been bestowed the Oswaldo Cruz Award (gold medal) by the Brazilian Ministry of Health for her outstanding service to Public Health.
— In her presentation, Dr. Barata reminded participants that the Latin American and Caribbean Region includes 33 countries, and these countries have considerable economic, political, and cultural heterogeneity. This heterogeneity extends to the capacity to engage in epidemiologic research and teaching as well. Academic training programs in epidemiology exist in 18 of the region’s countries: 161 master programs, and 46 PhD programs (70% of which are in Brazil). National scientific associations for epidemiology are active in 11 countries, most of which were formed after the 1970s (except for the two oldest, which date back to the 1940s, one in Mexico, the other in Puerto Rico), and only four countries regularly host national epidemiology meetings (Chile, Cuba, Argentina, Brazil). A new Ibero-American Alliance for Epidemiology and Public Health currently includes Argentina, Colombia, Chile, Mexico, Portugal and Spain. The IEA has held 3 World Congresses of Epidemiology in the Latin American and Caribbean region: the 2nd, in Cali, Colombia, in 1959; the 8th, in Puerto Rico, in 1977; and the 18th, in 2008, in Porto Alegre, Brazil. Currently, 37 public health journals are published in the region, 6 of which are focused on epidemiology, and it is difficult for institutions to gain access to the global epidemiological literature, given the expenses involved. The main producer and funder of epidemiologic research in the region is Brazil. The primary focus remains on transmissible diseases, with most research being descriptive and reliant on survey data. There is a pressing need for greater scientific cooperation both within the region and outside the region, including with multi-lateral organizations, so as to increase scientific contributions. It would be useful to see more comparative work on: (a) the region’s diverse national epidemiologic profiles, over time; (b) national variation and similarities in the social determinants of health; and (c) the evaluation of the impact of diverse national and regional health policies and interventions. Also needed is collaborative research to address shared health problems and to promote development of theory and methods.

Dr. Mauricio Barreto: Congress of the Americas: An opportunity to create stronger equitable ties between North American & Latin American & Caribbean epidemiologists – and an update on conference plans
— Dr. Barreto is the Latin American/Caribbean Co-Chair of the 2016 Epidemiology Congress of the Americas. Having first been trained as a physician in Brazil, he was awarded a PhD in Epidemiology from the London School of Hygiene and Tropical Medicine, and is presently a full Professor of Collective Health Epidemiology at the Institute of Collective Health at the Federal University of Bahia, in Brazil, as well as an Honorary Professor at the London School. Dr. Barreto’s interests include the study of macro and micro determinants of infections and infectious diseases, the social determinants of health, and the evaluation of the impact of health technologies and social programs on health. In addition to being a prior IEA Councilor for the Latin American and Caribbean Region, Dr. Barreto recently served, until 2011, as Editor-in-Chief of the Journal of Epidemiology and Community Health.
— Dr. Barreto began his presentation with a brief history of the region, showing maps starting with changes brought about during the period of independence (1804-1865) on through the current period of rapid urbanization and the new challenges of mega-cities (31 with populations greater than 5 million). At the same time, the population of the region is both aging and having a lowering of fertility rates. The region has diverse populations, mixing together Indigenous populations, colonial-settlers from Portugal and Spain, immigrants from other countries, and Afro-Latin Americans, especially in Brazil, who initially were brought over as slaves, with emancipation in Brazil not occurring until 1888. With regard to their epidemiological profiles, common characteristics of all the countries in the region is their high level of social inequalities –both inequalities in income and inequalities in health. Moreover, although rates of undernutrition are declining, rates of diabetes and other chronic noncommunicable diseases are on the rise, as are social inequalities in these outcomes. The region is also marked by a high homicide rate. His presentation concluded by reviewing several occasions of dialogue between North American and Latin American epidemiologists, including at a session at the last North American Congress of Epidemiology (in 2014), which was facilitated by the IEA. He emphasized the importance of engaging in more dialogue at the upcoming 2016 Congress of the Americas, which is being sponsored by 5 epidemiological organizations, four from North America, plus the IEA (for the first time ever). This Congress promises to create important new possibilities for engagement of epidemiologists across the Americas. It will take place in Miami, FL from June 21-June 24, 2016; the website is: http://epicongress.org/

After these two presentations, the session’s four panelists briefly shared their views in their 5-minutes presentations (1 in-person, 3 via video) about: (a) critical issues, including health inequities, facing epidemiologists within and across their countries and regions, and (b) challenges and opportunities for building equitable inter-regional collaborations that extend across the Americas.

Dr. Affette McCaw-Binns: Obstetric and Epidemiological Transitions in the Americas Require Complex Interventions to Further Improve Maternal Health: Jamaica’s Experience
— Dr. Affette McCaw-Binns is a Professor of Reproductive Health & Epidemiology, and Head of Department, for the Department of Community Health & Psychiatry at the University of the West Indies, in Jamaica. She received her BA at NYU, her MPH at Tulane, and her PhD in Epidemiology at the University of Bristol, and her focus is on maternal & perinatal health, including program and policy design, planning and evaluation.
— In her in-person presentation, Dr. McCaw-Binns reviewed what she termed “the rocky road to women’s health.” Starting with the slave trade, she recounted how, after emancipation in 1838, the doctors charged with providing care to pregnant slaves left the plantations, further worsening maternal outcomes, and it was not until 1878 that the colonial government issued the first General Report on Health, which reported a maternal mortality rate of 661/100,000. Midwives were deployed to reduce rates, which continued to decline up until independence in 1962. In the 1980s, questions began to arise about underreporting of maternal deaths and in 1998 an independent maternal mortality surveillance system was put into effect. Since 2001, fertility rates have been falling faster than maternal mortality, and threats to reproductive health include not only ongoing problems of low economic resources and economic inequality, coupled by increasing reliance on remittances, rising rates of obesity (due to rising consumption of low cost high calorie nutritionally poor food), and inadequate and shrinking funds to improve roads and transportation, thereby making travel for needed medical care that much more difficult. The larger message is that social inequity produces clinical complexity, such that improving maternal health is not a matter just of obstetrics and health systems, but involves human rights and economic good sense – and this holds true for other health outcomes as well. More South-South and North-South collaboration is needed to analyze these issues and design and evaluate interventions to promote health and health equity.

Dr. Helia Molina: Epidemiology and Health in All Policies: the Chilean experience
— Dr. Helia Molina is the previous Minister of Health for Chile, where she advocated for a focus on “Health in All Policies,” especially in relation to children’s health, and she currently serves as the Vice-Dean of Research and Development at the School of Medicine at the Universidad de Santiago de Chile. As a physician, her specialty is in pediatrics and nephrology, and she has served as the Director, Vice President, and President of the Chilean Society of Pediatrics, and has also served as the Director of the Chilean Society of Epidemiology.
— In her video, Dr. Molina discussed the importance of moving away from a focus on individual “risk factors” to instead taking a population perspective. Doing so requires employing methods of the social sciences along with epidemiological methods, and also requires democratizing the tools of science at all levels. Social epidemiology is especially needed to challenge the rising rates of non-communicable diseases. One promising approach is to implement “Health in All Policies,” aided by epidemiologic conduct of health impact assessment of policies. For example, epidemiology was a key tool for designing and evaluating Chile’s “National Policy of Child Protection,” both for assessing the impact on outcomes and also to help establish links between contextual factors and population health. Epidemiology as a field can also train new health workers and immerse them in a population perspective, and this requires both South-South and South-North collaboration.

Dr. Jorge Bacallao: Epidemiological insights from Cuba and the case for cross-regional collaboration
— Dr. Jorge Bacallao is a Doctor in Mathematics in the Higher Institute of Medical Sciences of Havana, in Cuba. One focus of his research is on the epidemiology of diabetes, hypertension, and tobacco-related illnesses. Related, Dr. Bacallao is also co-editor of a new publication issued in late 2014 by the Pan American Health Organization (PAHO) titled: “Obesity and Poverty: A New Public Health Challenge,” and his chapter in this volume focuses on “Epidemiologic and Demographic Transition: A Typology of Latin American and Caribbean Countries.”
— In his video, Dr. Bacallao emphasized the need for better trained researchers. He argued that measuring health inequalities requires not only not only good technical skills, but also a well-developed moral framework, in order to ensure that use of methods is ethical. Both absolute and relative inequalities matter, as do absolute and relative change in these inequalities. In Cuba, he noted that health inequalities do exist, typically in relation to multiple identities, and this requires better empirical articulation. More work employing a lifecourse perspective is also needed, to identify health impacts of both exposures at critical points in time and also in relation to cumulative exposures. As one example, he discussed a collaborative project with Nicaragua, focused on leptospirosis, for which he and colleagues created a vulnerability index that took into multiple identities and multiple exposures over times.

Dr. Marion Piñeros: Building up epidemiologic surveillance of cancer across Latin America and the Caribbean
— Dr. Marion Piñeros is a cancer epidemiologist engaged in both cancer surveillance and etiologic research. Previously based in the National Cancer Institute of Colombia, which is located in Bogotá, Dr. Piñeros is now the Liaison Officer for the Latin American Hub for the Global Initiative for Cancer Registry Development. Her office is based within the Cancer Surveillance Section of the International Agency for Research on Cancer (IARC), which is part of the World Health Organization.
— In her video, Dr. Piñeros focused on the need to build up surveillance of cancer and other chronic non-communicable diseases in Latin American and the Caribbean. She emphasized that this work requires different resources, skills, and objectives compared to work on infectious disease surveillance, for which the key task is to interrupt transmission. For cancer, it is necessary to count all cases and the total population, so as to generate accurate incidence, prevalence, survival, and mortality data. Additionally, for prevention, data are also needed on exposures affecting the population. The data needed also cut across different health care systems. Skilled epidemiologists are needed to build up the surveillance capacity within the region. Collaborations are also needed, both South-South and South-North, and these collaborations need to define, carefully, the terms of collaboration: whether about projects, programs, or technical assistance with monitoring. One example is a new collaborative initiative being started by IARC to build up cancer registries in the region. Also, to date only four countries provide cancer and other health data on their Indigenous populations (Brazil, Chile, Guatemala, and Guyana) and this is a challenge that also has to be addressed. Although the Indigenous populations within and across the countries of the region have many differences, a common problem is barriers to health care.

The question & answer period provided an opportunity for audience members to ask more questions about ways to better facilitate regional (South-South as well as North-South) cooperation in research and in pedagogy. A show of hands indicated that only a few people planned on attending the 2016 Congress of the Americas, with the small number reflecting concerns about finding the funds to attend. The APHA Epidemiology Section also hosted a reception that same evening, to allow for more informal and fun discussion between the Latin American, Caribbean, and North American epidemiologists assembled.

Lastly: we will be featuring an updated version of this session as a symposium at the 2016 Congress of the Americas, which again will be jointly sponsored by the IEA (North American Region and Latin American and Caribbean Region) and the APHA Epidemiology Section. We hope to see you there!

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