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Vol. LXVI, No. 24
November 21, 2014

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Global Health
From Ebola to E-Cigarettes: Experts Discuss Global Challenges

NIEHS/NTP director Dr. Linda Birnbaum

NIEHS/NTP director Dr. Linda Birnbaum

As Ebola rages on in West Africa, the world caught itself unprepared to quell the outbreak of this deadly, infectious disease. Meanwhile, in the battle to combat HIV/AIDS worldwide, U.S.-led efforts have helped save millions of lives but much work remains to eradicate this deadly virus. Still other global challenges, from air pollution to climate change, threaten countless lives. And safety debates continue over the growing global phenomenon of e-cigarettes. These provocative issues were the focus of a lively symposium, “Hot Topics in Global Health,” held Sept. 11 in Natcher Bldg.

Infectious Diseases: Ebola and HIV/AIDS

The Ebola epidemic is ravaging West Africa and threatening to unfold in other parts of Africa. Laurie Garrett, a senior fellow at the Council on Foreign Relations, speaking via Skype, lamented the lack of a global health infrastructure to prevent or address such a pandemic.

“I’m angry about the global health negligence that has permitted the explosion of this epidemic in West Africa,” said Garrett, a Pulitzer Prize-winning author. “We are at a very dangerous point and infuriating juncture for global health today.” She warned that an unchecked Ebola epidemic could threaten the stability of West Africa and have dire global security and economic implications.

Garrett said countries have refused landing rights to flights going in and out of Liberia, Guinea and Sierra Leone—the hub of the Ebola outbreak—so medical personnel can’t get in, compounding the shortage of doctors and health care workers. Also scarce are hospital beds, so many people are dying at home. Further, the number of Ebola cases is likely triple what’s being reported, as high as 12,000-15,000 people infected and at least 6,000 dead, and growing daily. Garrett said, so far, the only strong responder on the ground has been the French agency Doctors Without Borders.

“We’re right at the cusp of whether this epidemic will come under control or whether it’s going to become a permanent, endemic feature in these countries,” said Garrett. To combat Ebola, she said, we need genuine leadership; a central bank account that can receive donations; trained medical personnel; patient screenings; supplies; real-time information; and a vaccine and treatment drug with a timeline for delivery. “We know how to stop Ebola; we’ve done it before, more than once,” she said. “You find it fast and you move in with a heavy response.”

In 2003, the United States moved in with a heavy response to fight HIV/AIDS by creating PEPFAR—the President’s Emergency Plan for AIDS Relief—the largest effort by any nation toward combatting a single disease worldwide. Thanks to PEPFAR, 6.7 million men, women and children worldwide are on anti-retroviral therapy; and more than 1 million babies have been born HIV-free. Last year alone, some 57.7 million people were tested for HIV, while prevention services reached 21 million people.

“The great news about PEPFAR has been [the reversal] of the terrible declines in life expectancy due to this pandemic in sub-Saharan Africa,” said Dr. Deborah Birx, ambassador-at-large and coordinator of U.S. government activities to combat HIV/AIDS. She said PEPFAR currently is devoting much of its resources toward the program for vulnerable children and hard-to-reach populations. By increasing transparency, accountability and impact, Birx said, PEPFAR has attracted new investors and recently launched the Accelerating Children’s HIV/AIDS Treatment Initiative to double the number of children on treatment.

Laurie Garrett Dr. Deborah Birx

Speakers at the recent symposium on global health included Pulitzer prize-winning author Laurie Garrett (l) and Dr. Deborah Birx, ambassador-at-large and coordinator of U.S. government activities to combat HIV/AIDS.

Photos (Except Garrett): Bill Branson

To eradicate HIV/AIDS, “We need a cure and a vaccine, and I know NIH is working on both of those,” Birx said. But we need to ramp up commitment. “We’re at a moment in time where we can utilize our resources in the most concentrated, effective way and get control of this pandemic, or we’re going to end up…where there’s not enough resources globally to ever contain it again.”

E-Cigarette Use Sparks Debate

The growing popularity of e-cigarette use is sparking health debates around the world; further study is needed to gauge the potential risks to users and bystanders. E-cigarettes are battery-powered devices that heat a liquid containing nicotine, flavorings and other chemicals, which the user inhales as an aerosol, explained Dr. Michele Bloch, chief of the Tobacco Control Research Branch at the National Cancer Institute.

In the United States, more than one-third of adult cigarette smokers have tried e-cigarettes, said Bloch. A key concern is the potential for increased e-cigarette use by children and youth. In 2011, among U.S. high school and middle school students who had never smoked, 79,000 reported having tried e-cigarettes; in 2013, the number jumped to 263,000.

Some say that because e-cigarettes emit fewer chemicals than regular cigarettes, they are safer. Propo nents also argue that e-cigarettes can help people quit smoking. But others argue that e-cigarettes have not been proven to help people quit and could be harmful if they deter or distract people from quitting smoking completely. Further, they may be a gateway to cigarette smoking or other drug use and may “renormalize” cigarette smoking, particularly among youth, said Bloch.

NCI’s Dr. Michele Bloch also spoke at the symposium.

NCI’s Dr. Michele Bloch also spoke at the symposium.

“Nicotine-containing products comprise what we might call a continuum of risk in their delivery,” said Bloch, with conventional cigarettes at the high end of the spectrum, the nicotine patch at the low end and e-cigarettes somewhere in between. “E-cigarettes may deliver fewer toxicants but they do expose people who are around them to nicotine and other toxic chemicals...They may provide the user with nicotine in a less hazardous form, but they may or may not reduce harm at the individual or population level.”

E-cigarettes are widely available around the world but some countries are implementing regulations or banning them. A recent World Health Organization report calls for tougher rules for e-cigarettes, including prohibiting unsubstantiated health claims, banning the use of e-cigarettes indoors where smoking is banned and restricting advertising, promotion and sponsorship, especially ads aimed at youth.

Addressing the Environment

WHO estimates at least 13 million deaths each year could be prevented by improving environmental conditions. Some researchers estimate nearly two-thirds of U.S. cancer cases, and 1 in 5 cancer cases worldwide, are related to environmental factors—from smoking and sun exposure to air, water and soil pollutants.

Environmental factors play a role in many diseases worldwide, including cardiovascular disease, respiratory infections, as well as birth defects, obesity and mental health disorders, said Dr. Linda Birnbaum, director of the National Institute of Environmental Health Sciences and the National Toxicology Program. She said epigenetic changes may not be evident early in life but pollutants have long-lasting, often trans-generational effects.

Birnbaum also cited a steady rise in diabetes, asthma and autism in recent years. “All of these [conditions] are happening too rapidly to be explained by changes in our genes,” she said. “It has to be related to changes in our environment and their interaction with our genes.”

Indoor air pollution is a silent killer. Millions die annually from cooking with solid fuels, said Birnbaum, and half of the deaths among young children are from pneumonia from inhaling soot in their homes.

NIEHS is collaborating with WHO on addressing cookstove and other indoor air pollution; childhood environmental health; and climate change effects. Birnbaum said more extreme temperatures and rising precipitation will cause mounting food- and water-borne disease, respiratory problems, anxiety, infectious diseases and other health problems particularly among poor and other vulnerable populations. Reducing greenhouse gas emissions and other public health measures could help alleviate some of the environmental health burden, she said.

“You can’t change your genes,” Birnbaum concluded, “but you can change your environment. That offers a pathway to improve health for all.”

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