North Carolina Health News
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Back to School, at a National Institute of Health


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What did some N.C. science teachers do on their summer vacations? They spent time in a lab in RTP.

By Gabe Rivin

Sula Teachey had not been in a professional science lab since the mid-1980s, when she was an undergraduate student. But she, along with other high school science teachers, recently had the opportunity to work with some of the nation’s top scientists, in a program that aims to bring current environmental-health research into classrooms across the state.

Tonya Adams, a high school science teacher in Monroe, and one of the teachers in the STaRS program. Photo courtesy: NIEHS

Tonya Adams, a high school science teacher in Monroe, and one of the teachers in the STaRS program. Photo courtesy: NIEHS

Teachey was one of 11 teachers in the Science, Teachers, and Research Summer Institute, or STaRS, a program hosted by the National Institute of Environmental Health Sciences. For two weeks in July, the teachers traveled to the NIEHS’s campus at Research Triangle Park, where they learned from, and shared lab benches with, federal health researchers.

Teachey and the others performed gel electrophoresis, a technique used to separate and analyze DNA. They studied the connections between genes, cancer and the environment. And, among a number of other topics, they learned how federal researchers follow strict requirements for animal testing.

“It was great getting to work with real scientists, and to do the lab work,” said Teachey, who teaches science at Goldsboro’s Wayne School of Engineering. She said that the experience will allow her to show students what a career in health sciences would look like.

And that’s the point, according to Huei-Chen Lao, an education and outreach coordinator at the NIEHS, who helped develop the program. Lao said that students often don’t get to see the exciting sides of science, those that touch directly on their lives.

“We like the students to realize science is a very relevant part of our day-to-day lives,” she said.

The NIEHS’s goal is to introduce teachers to some of the biggest trends in health research, with the hope that the lab work and scientific theories will find their way into the classroom. In doing so, the NIEHS is helping to cultivate the next generation of health researchers. It’s a generation that, according to Lao, will have access to a large pool of jobs.

North Carolina is home to several major science-related industries, including pharmaceuticals, biotechnology and university research. High-tech industries, in fact, account for about 10 percent of the state’s jobs, according to a 2013 report by the N.C. Department of Commerce. Biotech companies alone employ 55,000 people in the state, according to the industry’s trade association.

Those employment figures are something that students should be aware of, according to Linda Sutton, a science teacher at Polk County Early College High School and another participant in this year’s STaRS program.

“More and more, you think the students need to be trained in some sort of biotech field, because that’s where they’re going to find jobs,” she said. “There is such a wide range of career opportunities that they need to be made aware of.”

Connecting to students’ lives

Beyond employment, the STaRS program could impact students’ decisions about their health.

Sutton said that she studied the interactions between our genes and our environment.

A group photo with the 2014 STaRS participants, high school science teachers who spent two weeks at the National Institute of Environmental Health Sciences. Photo courtesy: NIEHS

A group photo with the 2014 STaRS participants, high school science teachers who spent two weeks at the National Institute of Environmental Health Sciences. Photo courtesy: NIEHS

“I got some neat information about that that I could pass onto students, about how some people are more prone to certain diseases,” she said. “So if you have a history of lung cancer in your family, that you might have that gene, you have to be even more cautious about smoking yourself.”

Teachey said that it’s important to connect scientific lessons to students’ lives. Her students, she said, have shown a large interest in the problems with drinking water, a concern that could tie into a class lesson.

“They have in their lives constantly heard about exposure to heavy metals or exposures to things that might be carcinogenic,” she said. She added that she hopes to “get them in some kind of project that would help them look for water quality and how they could make connections with that and the quality of their health.”

Building those connections between the lab and our lives was a major focus of the program. So too was the development of lesson plans, which will bring that information into the classroom.

Though teachers spent their first week learning from researchers and working in labs, in their second week they spent time collaborating on classroom material.

Sutton said that she often benefits from these sorts of experiences.

“That’s really valuable – for the teachers to get together and share that information,” she said.

The NIEHS was careful to make sure that its lessons could find a place in high school classrooms. Lao said that the program aligned with state science standards, and therefore related to the material that teachers need to cover in their classrooms.

Making it work

STaRS launched in 2012 with just one teacher. It didn’t run in 2013. So how did a federal agency develop a program with 10 times as many participants as when it started?

Huei-Chen Lao works for NIEHS and helped to develop the summer program. Photo courtesy: NIEHS

Huei-Chen Lao works for NIEHS and helped to develop the summer program. Photo courtesy: NIEHS

Ericka Reid, who directs the Office of Science Education and Diversity at the NIEHS, said that the institute had a crucial collaboration with North Carolina New Schools, which offers professional development and other services in schools across the state. The organization helped the NIEHS recruit teachers, which would have been difficult for the institute, Reid said.

“We as a federal agency cannot necessarily knock on the doors of schools and say, ‘We want to do this program with you,’” she said

The partnership also helped fund the program. North Carolina New Schools offered teachers a stipend for their time, which the NIEHS matched with its own funding.

In addition to the funding, teachers received a significant incentive to participate: free housing for two weeks.

“I live five hours away,” Sutton said. “Providing a place to stay – that allowed me to do it.”

But beyond funding and accessing teachers, the NIEHS could not have pulled off the program without its researchers, more than 20 of whom volunteered their time, Lao said.

Keeping the connection

With glowing feedback from 2014’s participants, the NIEHS plans to continue offering the program in the future.

In the meantime though, Lao and other NIEHS researchers are keeping their connections with this year’s crop of STaRS teachers. They will be visiting some of the teachers’ classrooms, including a visit on Oct. 10 to Rocky Mount’s Early College High School, where they’ll co-teach for the day.

Sutton and Teachey said they’re grateful that the NIEHS has continued to offer resources even after the program ended. And Teachey said the program helped her realize that she could tap federal resources for her high school classes.

“It led me to see how available resources are,” she said. “In the past, I hadn’t seen that as an option.”

A Face Full of Pie Against Huntington’s Disease


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Instead of allowing Huntington’s disease to defeat her, Sarah Foster has decided to leave a legacy of activism.

By Taylor Sisk

Sarah Foster was feeling a change come over her, and preferred not to consider its source.

Nonetheless, she accepted that it was best to know, to “put a name to whatever was invading my mind.” So she decided to get her blood drawn.

The answer was what she suspected, and dreaded. She was positive for Huntington’s disease, an inherited neurological disorder that causes nerve cells in the brain to waste away, affecting control of movement, cognitive abilities, mood and behavior. She knew that HD is a disease that’s progressive and fatal.

Sarah Foster learned she had Huntington's Disease in 2010. She decided her legacy would be increased awareness for the disease, and funding for HD research.

Sarah Foster learned she had Huntington’s disease in 2010. She decided her legacy would be increased awareness of the disease and funding for HD research. Photo courtesy Sarah Foster.

That was in December 2010.

Though it took some months to pull herself out of the depression that followed her diagnosis, and a few more until she was “back,” she discovered that she wasn’t ready to give up.

Foster is a proponent of the seventh stage of pioneer psychoanalyst Erik Erikson’s theory of psychosocial development: “generativity versus stagnation.” That’s the stage in which adults between the ages of, roughly, 40 and 65 challenge themselves to create something of benefit that will outlast them, a legacy.

Foster, who falls within this demographic, considers herself to be undertaking that challenge.

Since her diagnosis, she’s become an activist in the effort to find a cure for HD, a disease that’s affected the lives of more than 30,000 Americans who have been diagnosed. More than 250,000 others are at risk of having inherited it.

She organized an annual paddler’s event that will be held in April on the Neuse River, near her New Bern home, open to “anything that floats that doesn’t have a motor on it,” she says.

More recently, she’s taken her efforts online.

“First there was a blog,” Foster said on a recent late morning over ice coffee, “and a lot of people started going to the blog, and I was getting some good feedback. So I thought, ‘What else can I do?’”

So, with an appreciative nod to the ALS Ice Bucket Challenge, she launched the HD Pie In the Face Challenge.

“I thought, ‘Pie In the Face,’ because one of the things I’ve always wanted to do was get a pie in the face. So I figured, “I’ll get to experience that,” and raise some funds as well.

Since Foster took the first pie in the face on Aug. 15, in her front yard, videotaped by her husband, Randy Foster, editor of the New Bern Sun Journal, the challenge has taken off. One of the two organizations that Foster requests donations be made to, the Huntington’s Disease Society of America, reported a quadrupling of online donations in the two weeks following the launch.

Pies have been propelled faceward in several European countries now, with particular enthusiasm in the UK. A Pie in the Face campaign is underway in Canada. A serviceman in Afghanistan didn’t have at his ready disposal the ingredients to make a pie, so he improvised, using yogurt. He then did a push-up into his concoction.

In videos submitted, people have been prematurely pied, in the middle of their spiels; others have received an unexpected second or third pie. There’s been some synchronized serial pieing. A lot of folks have very cleverly done the HD Pie in the Face and then the ALS Ice Bucket to wash it off. “I’ve only seen one person do it the other way around,” Foster said.

The challenge has also gotten a mention on cbsnews.com.

Of the whole experience, Foster said, “It’s pretty amazing.”

‘Simple signs’

The Pie in the Face Challenge has given Foster focus. HD can be all consuming. Its effects are cognitive – leading to poor impulse control and trouble with memory and organizational skills – physical – in advanced stages, jerky, uncontrolled movements and trouble with balance – and emotional, triggering depression, irritability and apathy. In time, it robs those afflicted of the ability to walk, talk and swallow.

HD can strike at any age, but onset comes most typically in the mid-30s to mid-40s. Death most commonly comes 15 to 25 years post-onset. There is yet no cure.

But there is, for Foster, generativity versus stagnation. Her latest challenge is jazzing her.

“To me, [the Pie in the Face Challenge] has been, like, the coolest and most important thing I’ve done other than have a family,” she said. “I feel like any kind of awareness of HD is a victory.”

That she herself remains fully aware of her condition is, today, a celebration: Awareness slips from those who live with HD as the disease takes deeper hold. Eventually, that’s arguably both a curse and grace.

“Part of me hopes that by the time my hard symptoms hit, I will lose my awareness,” Foster has written on her blog. “The notion of living through HD and being fully aware of it seems horrific, like enduring a surgery that lasts for 25 years without anesthesia. Perhaps the lack of awareness is a blessing.”

For now though, there’s this work. Foster is mindful of the importance of keeping things in perspective. For a while, she focused on bringing actor James Franco aboard the cause after he tweeted about the Pie in the Face challenge. But that prospect now looks dim. Time to move on.

Her focus is now primarily on progressing in increments: She’s channeling her Pie in the Face efforts on a grassroots, statewide campaign, hoping to spread the challenge a hospital at a time, meeting with the PR folks at one and encouraging them to challenge another nearby.

She’s encouraging advocates to get their schools and churches involved. She wants to see Pie in the Face booths at fall county fairs. And she’s aiming to get local celebrities and politicians on board. (New Bern Mayor Dana Outlaw took one to the mug, calling it a “smear campaign” he could get behind.)

“[I]f I was somehow able to face the thing with my eyes wide open, it might make the road easier for my caregivers,” Foster continued on her Huntington’s Disease and Me blog, “I might be more compliant, more reasonable. I would certainly be more like me. If there is such a thing as an awareness muscle, I am exercising it now in the hopes that I can stick around and notice the ride.”

For today, it’s compliance in pursuit of outcome, a vigorous exercise regimen: generativity versus stagnation.

“Generativity,” says Wikipedia, “in essence describes a self-contained system from which its user draws an independent ability to create, generate, or produce new content unique to that system.”

That’ll work for Sarah Foster, today and for the foreseeable future.

“I am developing simple signs to use with my loved ones,” she concluded in that recent blog, describing her preparations for what may lie ahead. “One means ‘I love you.’ The other means ‘I’m still in here.’

“I hope I will be.” Regenerative energy onward.

Pregnant Women in Durham Test High for Cadmium, Study Finds


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The link between cadmium and smoking is clear, but researchers aren’t sure why nonsmokers also test high for the heavy metal.

By Gabe Rivin

A group of pregnant women in Durham County has been found to have high blood levels of cadmium, according to a new study from researchers at UNC-Chapel Hill and the University of Michigan.

But while the researchers noted that a surprisingly large number of pregnant women in the study smoked cigarettes, which contain cadmium, even the nonsmokers in the study had high levels of the element in their blood. But the reason for the exposure in nonsmokers was unclear.

Cadmium, a heavy metal, is both acutely toxic and carcinogenic. Humans are exposed to the metal from industrial air pollution and food, among other sources. Photo by Alchemist-hp, courtesy Wikimedia Commons

Cadmium, a heavy metal, is both acutely toxic and carcinogenic. Humans are exposed to the metal from industrial air pollution and food, among other sources. Photo by Alchemist-hp, courtesy Wikimedia Commons

Cadmium, a heavy metal, has been linked to miscarriages and low birth weight, in addition to lung cancer and kidney disease.

According to UNC professor Rebecca Fry, one of the researchers involved in the study, cadmium can harm humans even at low levels.

“Cadmium is a toxic metal and serves no function in cells,” Fry said. “So any level can be potentially harmful.”

Focusing on lower exposures

Cadmium has a long history of study among health researchers. For years, it’s been a concern for workers in manufacturing plants, such as refrigeration compressor plants and battery factories.

Researchers have accumulated a dizzying list of the ways cadmium can harm human health. Cadmium can cause lung cancer and kidney damage, according to the U.S. Occupational Safety and Health Administration. Inhaling large amounts can have severe, even fatal, effects on the respiratory system. Some studies have linked cadmium to prostate cancer.

Yet in recent years, health researchers have begun looking at chronic, low-level exposure to heavy metals such as cadmium, according to Carmen Marsit, a professor in Dartmouth College’s school of medicine.

“A lot of the older literature was focused on more industrial accidents, or major pollution events, or very highly exposed regions of the world,” he said. “Now we’re starting to think about it in areas where we may have lower levels of exposures.”

Marsit said that this sort of research has increasingly focused on pregnant women.

“The developmental period is a time when there’s rapid differentiation of cells as the fetus develops,” he said. “At any point along that line, if an exposure in any way can disrupt the way that that process happens, you can imagine that that can lead to various types of health effects, and that they may have long-lasting implications.”

The researchers found a surprising number of pregnant women still smoked cigarettes, a cause of often-dramatically higher cadmium blood levels. Photo by Fried Dough, courtesy Flickr Creative Commons

The researchers found a surprising number of pregnant women still smoked cigarettes, a cause of often-dramatically higher cadmium blood levels. Photo by Fried Dough, courtesy Flickr Creative Commons

Fry’s recent study doesn’t specifically link cadmium to any health effects. But she and her colleagues are preparing to release a new study that does.

The study, which is about to be published by PLoS ONE, links mothers’ blood levels of cadmium to lower birth weights among their babies. Fry said her group observed these effects at varying levels of cadmium in the women’s blood.

“Every individual can respond differently, even to very low doses of a toxic metal,” she said.

A surprising number of smokers

Fry, along with colleagues from the University of Michigan  tracked 1,229 pregnant women in Durham from 2005 to 2010. The women received care at either Duke University’s obstetrics clinic or Durham County Public Health’s Prenatal Clinic, and had their blood sampled between weeks 23 and 42 of their pregnancy.

The researchers found that about 60 percent of participants exceeded the U.S.’s median blood level for cadmium, which is 0.32 micrograms per liter. Among smokers, cadmium was measured as high as 4.02 micrograms per liter, more than 12 times the national median, while nonsmokers’ measurements reached up to 2.26 micrograms per liter.

Smoking carries a number of dangers for pregnant women, according to the Centers for Disease Control and Prevention. It increases the risk of miscarriages, premature births, cleft lips and Sudden Infant Death Syndrome, among other problems. Still, the study found that about 25 percent of the pregnant women followed were smokers. On average, smokers in the study were found to have twice as much cadmium in their blood as nonsmokers.

Fry said she was struck by the number of women who still smoked while pregnant.

But the study also found that 53 percent of nonsmokers had cadmium levels above the U.S. median. The researchers didn’t offer a clear explanation for this, but said that the women could have been exposed to cadmium from the food they ate or industrial sources nearby.

Rebecca Fry, second from right, is a professor at UNC’s school of public health. Fry and researchers at the University of Michigan found that pregnant women in Durham had elevated levels of cadmium in their blood. Photo courtesy UNC Gillings School of Global Public Health

Rebecca Fry, second from right, is a professor at UNC’s school of public health. Fry and researchers at the University of Michigan found that pregnant women in Durham had elevated levels of cadmium in their blood. Photo courtesy UNC Gillings School of Global Public Health

According to the U.S. Environmental Protection Agency, the main sources of airborne cadmium are coal- and oil-fired power generation and the burning of municipal waste. The EPA also says that food can have increased amounts of cadmium when farmers apply phosphate fertilizers or sewage sludge to their crops.

Fry added that private water wells could also have exposed the Durham women to cadmium. But she made clear that the researchers don’t yet have a clear explanation about the cadmium measurements in nonsmokers.

Translating research to medical advice

“We are aware of the fact that academic research often takes a long time to translate into the average OB/GYN’s practice or the pediatricians’ practice or medical practice in general,” said Kevin Ryan, who recently stepped down as the head of the women’s and children’s health section at the N.C. Department of Health and Human Services. “We try to make sure we have mechanisms in place that effectively translate important research into practice.”

Those mechanisms, he said, include the Perinatal Quality Collaborative, a statewide group that includes neonatologists and obstetricians, and which tracks research. The group issues best-practice recommendations to health care providers.

And though DHHS doesn’t have immediate plans to act on the cadmium study, it does offer a number of programs that can help women to quit smoking, Ryan said.

Every local health department, for example, must offer prenatal care that includes counseling to help women quit smoking, according to Belinda Pettiford, who heads the women’s health branch within DHHS’s women’s and children’s health section. The same is true for clinics that offer family-planning services.

Cancer Care Disparities: Where You Live Matters


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When it comes to cancer care, where a patient lives makes a difference. But in some instances, distance could be an advantage.

By Stephanie Soucheray

All cancer care is not created equal. That’s the main message of two studies published in the most recent edition of the North Carolina Medical Journal.

Using provider data, Medicaid and Medicare enrollees and census information, researchers illustrated that where patients live and how their care is managed were major factors in the quality of care they received during cancer treatments.

Cancer cells in tissue culture from human connective tissue, at a magnification of 500x.

Cancer cells in tissue culture from human connective tissue, at a magnification of 500x. Image source: National Cancer Institute

“Often [it’s] related to things outside of the biology of the disease,” said Stephanie Wheeler, an assistant professor in health policy and management at the Gillings School of Global Public Health at UNC-Chapel Hill.

There are “vast differences” in the quality of care, she said.

Wheeler studied publicly insured cancer patients being treated in so-called patient centered medical homes to measure the frequency and severity of chemotherapy-related adverse events.

“The majority of the Medicaid population in this time is enrolled in the medical home, but we don’t know the data in terms of outcomes,” she said. Medicaid provides coverage for about 1.6 million low-income children, pregnant women and people with disabilities in North Carolina.

Community Care of North Carolina (CCNC) is a medical-home program started in the 1990s that has long received national attention for its patient-centered care and positive outcomes for approximately 750,000 North Carolinians on Medicaid, most of whom are women and children.

Wheeler said studying this group was important because the Affordable Care Act has many medical-home provisions and more states will start relying on medical homes for managing the care of their Medicaid patients.

She and her colleagues looked at low-income women who received chemotherapy for early-stage breast cancer between 2003 and 2007. Those in the medical-home system had fewer inpatient admissions for adverse events.

However, patients enrolled in a medical home had no difference in outpatient and emergency room admissions.

Still, breast cancer is the most prevalent cancer among women in the state and the diagnosis makes up one-third of all new cancer diagnoses, Wheeler said. Any reduction in patient visits ends up reducing Medicaid costs.

Location, location, location

Wheeler also performed a second study which investigated the connection between rural and urban living and access to radiation. Patients receiving radiation therapy have to come to the hospital for treatment daily, which can be burdensome in terms of time and travel.

For this study, Medicare enrollees who were recommended to receive radiation therapy for cancer were followed for two years during and after treatment.

Medicare is the federally funded program for seniors and some people with disabilities. Almost everyone in the U.S. over the age of 65 years old is covered by Medicare, and data about these patients is available to researchers.

By geocoding the provider and patient’s addresses, Wheeler and her colleagues were able to determine how geographic settings encouraged or detracted patients from getting radiation therapy.

“The results were somewhat counterintuitive,” she declared.

“For urban patients, increased distance meant a lesser likelihood in receiving radiation,” Wheeler said. “For rural patients, those living less than 10 miles away from a provider were also less likely to receive [radiation therapy].”

map of rural counties around Wake Forest

Map of rural counties around Wake Forest Baptist Medical Center from which patients come to the hospital’s Comprehensive Cancer Center. Data courtesy Kathryn Weaver

But she found the patients most likely to comply with recommendations for radiation therapy were rural patients living 10 to 20 miles away from their provider.

“These patients are used to driving these distance of about a half hour,” said Wheeler. She said the disparity among urban patients could have to do with their reliance on public transportation, rather than having cars of their own.

“This study shows that where you live does matter,” she said.

Urban vs rural

The results in Wheeler’s studies both echo and complicate the results of a study published by Wake Forest Baptist Medical Center last year. In particular, that research looked at the health behaviors of about 7,600 adult cancer survivors in rural and urban settings throughout the country and found that these survivors had very different lifestyle factors. Her data came from the National Health Interview Survey, a population-based sample of adults, conducted by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.

rural urban cancer stats

Data courtesy Kathryn Weaver, Wake Forest Baptist Medical Center

Weaver, who practices at the Wake Forest Baptist Comprehensive Cancer Center said the center draws patients from the western half of the state, which is largely rural. “We needed to get a better sense of who our rural cancer survivors are and what they are facing.”

“We found that rural survivors were more likely to smoke and were more sedentary,” said Kathryn E. Weaver, assistant professor of social sciences and health policy at Wake Forest Baptist, author of the study, which was published in Cancer Causes and Control. “And survivors who smoked reported worse health and were more likely unemployed.”

Weaver said both smoking and being sedentary are health factors and behaviors that link cancer survivors to subsequent cancer diagnoses and survival rates. She said previous studies have showed that rural cancer patients were more likely to be uninsured, and said access to care is a considerable issue for this patient population.

“In my own clinical practice, I’ve seen patients who have to drive an hour to get to the Cancer Center,” said Weaver. “They routinely live more than 60 miles away.”

Weaver said she hopes her study can help open the conversation about meeting patients’ needs where they live. She said telecounseling for smoking cessation and at-home fitness routines should be part of post-cancer patient education for rural survivors.

“Meeting patients where they are has to be a priority,” she said.

 

Big Money, Big Research for Global Health at UNC

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By Hyun Namkoong

The evaluation of how well public-health dollars are spent in nations across the globe received a major boost yesterday, with the announcement of the second-largest research grant UNC-Chapel Hill has ever received.

A group of deans, researchers and politicians gathered at the Carolina Inn for Chancellor Carol Folt’s announcement of a $180 million grant from the U.S. Agency for International Development.

UNC-Chapel Hill Chancellor Carol Folt and TKTK celebrate their U.S.AID grant with a cake and balloons.

UNC-Chapel Hill Chancellor Carol Folt and MEASURE Evaluation project director Jim Thomas celebrate their U.S.AID grant with a cake and balloons. Photo credit: Hyun Namkoong

The recipient is the university’s Carolina Population Center for its Monitoring and Evaluation to Access and Use Results Evaluation project, more commonly known as MEASURE Evaluation.

“[Funding] is for phase four of this project and it will keep the work going for another five years,” Folt said.

The MEASURE Evaluation project is the U.S. AID’s flagship program for identifying gaps in data, collecting and analyzing data and making decisions to fund projects based on data.

In the past, many projects had been funded based on political favors or hunches, according to Jim Thomas, MEASURE Evaluation project director and an associate professor of epidemiology at UNC-Chapel Hill’s Gillings School of Global Public Health. Better data has helped change that paradigm throughout the developing world.

The goal of the project is to measure and evaluate public-health programs worldwide to ensure government dollars in 80 countries are used wisely.

The overall emphasis of phase four, Thomas said, “is to build sustainability so that these [health information] systems can continue on long term without us.”

Sustainability has long been identified as a priority of public-health projects, particularly those implemented in low- and middle-income countries.

Among those attending the press conference were Rep. David Price; Aldona Wos, secretary of the state Department of Health and Human Services; and representatives from the office of U.S. Sen. Richard Burr.

The MEASURE Evaluation project began in 1997 and has received funding from a number of sources, including the President’s Emergency Plan for AIDS Relief.

The project has developed several methodologies for collecting data to better inform public-health programs and policies, especially in the areas of reproductive health, HIV/AIDS and other infectious diseases.

“Monitoring and evaluation – what’s important here is that not only are we applying a toolkit, we’re inventing the toolkit,” said Barbara Entwisle, vice chancellor for research at UNC-Chapel Hill.

Benefits to the state

While the focus of MEASURE Evaluation is on global health and strengthening health information systems worldwide, Folt and Thomas believe that North Carolinians will benefit from the $180 million grant.

“It’s a global project with a lot of local influence,” Folt said. “It’s supported more than 100 jobs here in North Carolina.”

Folt also said that research at UNC has led to the creation of spinoff companies such as FHI 360, which is headquartered in Durham.

MEASURE Evaluation has worked on public-health projects for infectious diseases such as HIV/AIDS in South Africa and tuberculosis in Latin America, both of which can result in epidemics, or even pandemics.

“Epidemics that are controlled worldwide are less able to affect our own country,” Thomas said.

He also said that the Triangle has become a hub for global-health research similar to how Wilmington has become a hub for the film industry.

When asked about how phase four of the MEASURE Evaluation project might directly affect and translate into health improvements for North Carolinians, Thomas said, “We don’t have [anything] in place for making sure that it translates, but that’s something that we would be very much open to talking about.”

“For decades, I did work domestically in epidemiology in the public sector,” he said. “I would be very interested in talking to anyone who wanted [to learn] about how we could translate some of these things that we’re doing in MEASURE Evaluation to benefit, in particular, some of the rural areas of the state.”

Study: BPA Can Activate Breast Cancer Cells


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A study from Duke University researchers offers new evidence of BPA’s dangers

By Stephanie Soucheray

It’s everywhere, lining metal cans, in sippy cups, on receipts from the store: It’s BPA, a chemical used to make plastics and epoxy resins.

BPA has been in the news the last two years as the Food and Drug Administration has weighed the pros and cons of banning it in food containers. The chemical has been widely banned throughout the European Union and is currently banned from baby bottles in the United States. A known endocrine disruptor, BPA has been shown to mimic estrogen in the body.

Unlike other breast cancers, inflammatory breast cancer may not cause a lump in the breast. Instead, it may cause the breast to be swollen, red, and warm.

Unlike other breast cancers, inflammatory breast cancer may not cause a lump in the breast. Instead, it may cause the breast to be swollen, red and warm. Image courtesy MyHealth, Alberta, Canada

Now, more bad news about BPA: Duke researchers shared new evidence this week that Bisphenol A, or BPA, not only accelerates cell growth in breast cancer but also makes disease treatment less effective.

“We hope to alert clinicians that this is a potential risk factor,” said Scott Sauer. Sauer‘s work was presented as an abstract at the annual joint meeting of the International Society of Endocrinology and the Endocrine Society in Chicago this week.  “Doctors should look to see if women with breast cancer have high circulating BPA.”

In 2011, about 160 women per 100,000 in North Carolina were diagnosed with breast cancer. Five percent of those women were diagnosed with inflammatory breast cancer.

Though rare, inflammatory breast cancer is hard to treat because it’s often detected at an already advanced stage and can be hormone receptor negative – meaning traditional hormone inhibitors, like tamoxifen, don’t work to block the growth of cancerous cells. One drug, lapatinib, is often used successfully to treat the cancer if it is HER2-positive.

HER2 is the human epidermal growth factor receptor, and is found in inflammatory breast cancer, or IBC.

Sauer and his colleagues wanted to see which commonly circulating chemicals were most active in cancer cells. In the study, they screened markers in breast cancer cells for a panel of compounds found in plastics, fertilizers and pesticides.

BPA was clearly the most active in IBC cells.

Though many plastic manufacturers now advertise BPA-free products, the chemical is not widely banned in the United States.

Though many plastic manufacturers now advertise BPA-free products, the chemical is not widely banned in the United States. Image credit: Wikimedia creative commons

Sauer’s work showed that BPA, the chemical commonly found in plastic and food-container linings, stimulated the aggressive cell line that causes IBC. What’s worse, even at normal blood levels BPA blocked the efficacy of cancer drugs used to fight IBC.

“I think this is going to be an interesting area of study because targeted therapies are popular because they shouldn’t have off-target effects,” Sauer said. “But when you rely on only one mechanism for treatment, anything in the environment can throw it off course.”

“These results are certainly consistent with a long line of prior studies showing that BPA can enhance proliferation in breast cancer cells,” said Heather Patisaul, a professor and researcher at North Carolina State University. “What’s striking about this study is the potential mechanism of action. Although BPA has primarily been considered a chemical that interferes with estrogen, this work emphasizes that it may also act via other means.”

Sauer said the work offers a new opening for the FDA to understand just how disruptive BPA can be in adults.

“We’re hoping this will add to a body of evidence,” he said. “The FDA has said, ‘Yes, BPA in fetal development is not good, but we’re not prepared to make a comment on how it effects adults.’ Now we can show it increases cancer and affects treatment.”

Mapping Access to Clean Water in the State


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A group of students and professors at UNC’s school of public health is breaking new ground when it comes to the study of race, water quality and health in the South.

By Stephanie Soucheray

Historically, nothing has been more important to the protection of public health than access to safe, potable drinking water. And while several Triangle researchers are attempting to maximize exposure to clean water in the developing world, some scientists at UNC-Chapel Hill are looking at disparities in accessibility to clean drinking water closer to home.

A professor of environmental science and students from The Water Institute are using census data, mapping technology and interviews to establish a definitive map of water-access sites in the state.

Water Drips

Image courtesy of Gaz Haywood, Flickr Creative Commons

“This is the first study of its kind,” said Jackie MacDonald Gibson, a professor of environmental science and engineering at UNC’s Gillings School of Global Public Health and part of UNC’s Water Institute. “To my knowledge, no one has looked at each county in a state before to map water access and disparity.”

Gibson, who leads a team of graduate students on this project, first got interested in the idea after a conversation with former state health director Jeff Engel.

“We were working on a project and discussing water priorities,” she said. “We were looking at the issue of community water service, or piped water coming to homes from a community water supply.” These communities rely on private wells, which can suffer from a lack of maintenance and high septic-system failures.

Engel queried county health directors on how many North Carolina communities had water systems like this.

“Less than half of county health people could get that information,” Gibson said.

Gibson is using water samples and public records along with mapping tools to create a map of water access in the state, and is currently in the middle of her two-year project. She said the communities most at risk for poor water access are those like Rogers Road in Chapel Hill, the historically black community on the city’s borders.

“It’s not very urban or very rural communities where we see [disparity],” said Gibson. “It’s communities near towns and cities that could have clean water just across the street.”

map of Wake County African American census tracts lacking community water service.

Wake County African American census tracts lacking community water service. Map courtesy The Water Institute, UNC-Chapel Hill

Households that rely on these wells have septic systems with high failure rates (approximately 40 percent) and no sewers. Gibson said these communities are common throughout the South.

“It’s a legacy of Jim Crow,” she said. “These communities got left behind.”

For example, Gibson said preliminary results from Wake County show that black communities are significantly less likely than white communities to access municipal drinking water.

Julia Naman recently graduated from UNC with a master’s degree in public health and is working on the project. She conducted in-depth interviews with several people in unincorporated communities in the Piedmont, along the coast and in the mountains. She also interviewed other stakeholders, including mayors, county commissioners and utility providers.

“People talk about septic tanks overflowing and going into nearby creeks,” said Naman, who noted that children also play in yards where untreated water sits.

She said that many of the people she interviewed live only a mile or two outside the city limits but have no access to municipal police, fire department, garbage pickup or water and sewer access.

Hannah Leker, a current master’s student, works with GIS technology to create maps of these communities.

“We’re trying to figure out if race is a predictor, and what information we can get through the census,” she said. “It’s a very interesting environmental-justice issue.”

Last year, the Pender County community of Maple Hill, near Wilmington, made news when it successfully implemented a wastewater treatment system after years of failing to get the community incorporated. Instead, citizens used funds from the N.C. Rural Economic Development Center and the N.C. Clean Water Management Trust Fund.

Naman said there are small pockets of communities just like Maple Hill throughout the state.

“We have to find them,” she said.

Research Indicates Health Disparities for Lesbian, Gay and Bisexual Communities


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By Taylor Sisk

Results released recently from a study conducted by researchers at UNC-Chapel Hill’s Gillings School of Global Public Health indicate that lesbian, gay and bisexual North Carolinians face heightened health risks in several regards.

Stress-related mental health issues are of particular concern.

Derrick Matthews

Derrick Matthews co-authored and conducted the analysis in a study of health disparities among sexual minorities. Photo credit: UNC Gillings School of Global Public Health

The report, titled “A Profile of North Carolina Lesbian, Gay and Bisexual Health Disparities, 2011”  was published in the American Journal of Public Health, offering the first statewide evidence of these disparities. In 2011, the state asked about sexual orientation for the first time in its Behavioral Risk Factor Surveillance System polling.

The survey helped develop a profile for lesbians, gays and bisexuals that includes health status, chronic-disease risk behavior, injury prevention, screening behavior, health care access and variables in social environment that can influence health or health behavior.

“For the first time, we have really good data,” said co-author Lee, a Gillings School doctoral student. “For us to intervene and work against existing health disparities, we first have to know what they are.”

The South experiences poorer health outcomes than the rest of the country in a number of areas, regardless of sexual orientation, said co-author Derrick Matthews, a recent Gillings School graduate now on faculty at the University of Pittsburgh’s Graduate School of Public Health. Many health indicators were no different for sexual minorities than for the general population.

But disparities were revealed that are consistent with findings from other states, including those related to mental health and smoking.

Approximately 2 percent of survey respondents identified as lesbian, gay or bisexual. These individuals were more likely to report experiencing five or more days of bad mental health in the past 30 days.

“It’s a very strong and consistent finding across states and surveys, especially for mental health outcomes that are stress related,” Lee said, citing anxiety and depression that result from feelings of alienation or exposure to discrimination.

The survey also found that sexual-minority women were more likely than heterosexual women to smoke and to be stressed about having enough money to pay rent or a mortgage.

James Miller, executive director of the LGBT Center of Raleigh, expressed surprise at the higher incidence of smoking, saying that considerable effort had been made to discourage tobacco use among the people for whom his organization advocates.

He called QuitlineNC, a free phone service that helps people kick tobacco, an “example of an amazing government-funded program” that works.

Advocacy ahead

“From a policy standpoint, making the case for change requires this data,” Miller said.

“Research being done on this topic moves the dial forward and it gives individuals and organizations the knowledge base to best advocate for our communities,” he said. “We’ve known these disparities exist anecdotally, but having evidence to support our causes truly empowers us.”

Lee hopes to use the data to “build into the state’s programs and policies better strategies for including LGBT people and working on reducing some of these disparities.”

It’s important, he said, that LGBT communities be key participants in public-health efforts, serving, for example, on advisory boards and helping shape communication initiatives.

The researchers now plan to look at the effects of the passing of Amendment One on the health of sexual minorities in North Carolina. Lee said that data from other states has indicated that when similar legislation has been passed, there’s been a spike in stress-related mental health outcomes, and when marriage-equality legislation is passed there’s a drop.

NC Researchers Take a Position on Climate Change

By Stephanie Soucheray

Hot on the heels of the White House statement on climate change, North Carolina researchers are sharing their findings on climate change’s potential to impact North Carolinians’ health.

And they’re finding that North Carolina possesses unique vulnerabilities because of its varied geography, vulnerable coastline and rural populations.

picture of high waves hitting houses on the coast

Photo courtesy David Baird, Geograph creative commons

Last October, researchers and scientists along with municipal leaders convened at the sixth-annual Research Triangle Environmental Health Collaborative summit to discuss climate change and public health. Their findings have been recently published and will be summarized in an upcoming editorial in Environmental Health Perspectives, published by the National Institute of Environmental Health Sciences.

“One of the things that was helpful and interesting that came out of the workshop, something we’re trying to promote on a federal level, is good collaboration between different sectors to help people respond to increased risk for climate change,” said John Balbus, a senior advisor on climate change at NIEHS.

The researchers presented their findings from working groups and suggested that climate change will continue to lead to adverse weather events along the coast, in both rural and urban areas.

While the National Climate Assessment does provide state-by-state analysis for the country, the collaborative incorporated North Carolina’s vast regional differences when considering how climate change could effect the population.

“We have mountains, the Piedmont and the coast to consider,” said Martin Armes, spokesperson for the collaborative.

Balbus agreed and said the variety of the state’s geography was one of the recurring themes of the workshop.

“One of the things that’s interesting about North Carolina is our varied vulnerabilities,” he said. “Land and agricultural workers are effected by high heat and flooding, for example.”

Balbus said he crafted the summit to capture the differences among these areas and determine what’s similar so researchers can attack climate-change problems in the most efficient ways possible.

“We need to bring together people who are front lines of health in North Carolina,” he said. “Mayors, people from local health departments, industry leaders [have to] work together to attack climate-change health threats.

The threat to the coastline represents the potentially biggest loss of revenue for the state, as tourism, fishing and other industry rely on a healthy coastline. Flooding, sea-level rise and damaged infrastructure are the main threats to public health on the coast, according to the collaborative’s editorial.

Rural areas, which tend to be agricultural hubs in the state, could suffer the most from temperature rises.

“This is a warm state, and the heat can be a threat to people in the summer months, especially the elderly,” said Balbus. The editorial makes mention of a dearth of medical centers, cooling centers and other places for medical care in rural areas.

There was also concern raised over environmental-justice issues, including access to water sources. In urban areas, air pollution and disaster management were the main issues.

UNC Chancellor Carol Folt spoke at the meeting, and emphasized the role the state’s universities – including UNC – will have in finding solutions to the problems posed by climate change. Armes said the collaborative’s next step is to convene a planning committee to develop official recommendations.

The Research Triangle Environmental Health Collaborative was organized in 2006 as an environmental-health think tank to identify and discuss environmental-health problems, given the unique research concentration in the area. The group is nonpartisan and, Balbus said, does not look at climate change as a political issue.

“Climate change is a health issue everyone should be concerned with,” he said.

Domestic Abuse Linked to Perinatal Mood Disorders


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Pregnancy was once considered to be a “protected time” for women, but now research is revealing how pregnant and newly delivered  moms are at risk for depression, violence and worse.

By Stephanie Soucheray

A new study from researchers at NC State University shows just how harmful domestic abuse can be for pregnant and postpartum women.

In a survey of 100 women who responded to ads posted in YMCAs, yoga studios and doctors’ offices, 70 percent reported experiencing abuse (physical, emotion or sexual) from their partner in pregnancy, while 61 percent had symptoms of perinatal mood disorders. Forty-seven reported symptoms at “clinical” levels, which means symptoms were of moderate severity, meaning psychiatric medications, counseling or a combination of both would be recommended.

The paper, titled “Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems,” is published online in the open-access journal BMC Pregnancy and Childbirth.

Sarah Desmarais headshot

Sarah Desmarais. Photo courtesy NC State University

“This response is pretty alarming,” said Sarah Desmarais, one of the lead authors of the paper and an assistant professor of psychology at N.C. State. “Eighty-four percent of participants said they experienced intimate-partner abuse before they got pregnant.

“Pregnancy is usually seen as a respite in abusive relationships, but this survey offers another take.”

Desmarais said that any abuse was associated with higher rates of perinatal mood disorders, and that certain types of abuse were associated with different mental health disorders. Physical abuse, for example, was correlated with post-traumatic stress disorder, while sexual abuse was linked to depression. Marital status, education and poor socioeconomic levels all were correlated with higher rates of abuse.

Fifty years ago, doctors thought that pregnancy and the postpartum period were protected times, when elevated levels of estrogen defended against depression. Now depression, anxiety, obsessive-compulsive disorder and post-traumatic stress disorder are known to be among the most common afflictions of the perinatal period. Many estimates suggest that 20 percent of women will experience a perinatal mood disorder in her lifetime.

Dramatic hormonal fluctuations in the gestational and postpartum period play a role, but clinicians have long hypothesized that social and environmental stressors can prime some women for perinatal mood disorders.

“We found that women who suffered previous abuse were much more likely to experience a perinatal mood disorder,” said Desmarais, who noted that the closer the abuse was to the pregnancy, the more likely the woman suffered from a mood disorder.

“I think that [postpartum depression] is linked with all kinds of abuse and trauma in the relationship,” said Edith Gettes, a psychiatrist specializing in women’s mood disorders who practices at the UNC Center for Women’s Mood Disorders. “It certainly seems they are at a higher risk for PPD.”

Although abuse is highly correlated to postpartum mood disorders, women are not currently screened for abuse at their six-week postpartum check-up, when tests like the Edinburgh Postnatal Depression Scale help providers screen for depression and anxiety. Gettes said she currently asks her patients if they feel supported by their partner or in their home, but doesn’t explicitly ask about abuse.

Desmarais said one of the goals of her study was to push for better and more thorough screening of pregnant and postpartum women, and to open up the definition of “abuse.”

“We included psychological and sexual abuse, and that could mean being coerced into a sexual situation you don’t want,” she said.

Desmarais also said the women who participated in the study answered an advertisement to participate in a wellness survey; neither postpartum mood disorders nor domestic abuse were mentioned in the fliers.

“This was not a clinically based population at high risk for abuse or perinatal mood disorders,” she said. “That’s what’s really surprising.”

Last month, state attorney general Roy Cooper announced that there were 108 North Carolinians killed in acts of domestic violence in 2013. That’s 14 fewer than in 2012.

Guilford County had the most domestic violence killings, with 11.

States and counties keep track of domestic-violence murders, but abuse is notoriously hard to monitor, said Dana Mangum, interim executive director of the North Carolina Coalition Against Domestic Violence. Many incidents are underreported, and Desmarais’ study included a broad definition of abuse, not just physical violence.

Moreover, Mangum said her coalition does not track the number of pregnant women seeking services in the state.

But she said that there is a push for more health care providers to screen for domestic abuse during the perinatal period.

“The Affordable Care Act has a mandate for health care professionals to do domestic-abuse screening,” said Mangum. “That’s a huge open door to address this issue through health care providers.”

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