TODAY news - Dec. 19, 2002

Thursday, December 19, 2002 TODAY issue

School of Public Health

School of Public Health fights the chemical terrorist in food
School of Public health receives $1 million grant to fight tobacco in Southeast Asia

School of Public Health fights the chemical terrorist in food

It's the chemical terrorist in our food. It affects the immune system by increasing cancer risk, infection rates, and other negative health factors. Dioxin is a hormone-disrupting chemical that is causing an emerging problem.

E. K. Fujimoto
Edward K. Fujimoto, DrPH, MPH, CHES, professor and coordinator of the DrPH program in preventive care, presents his research on dioxin at the School of Public Health preventive medicine ground rounds in November.

Edward K. Fujimoto, DrPH, MPH, CHES, professor and coordinator of the DrPH program in preventive care, School of Public Health, presented his research on dioxin at a preventive medicine grand rounds held last month. His research has been aired on various news media including FOX, Toronto Television, and a Hawaii radio station.

"The dioxin levels in the United States are skyrocketing," states Dr. Fujimoto. "The most important factor we need to be aware of is the fact that the biggest source of dioxin is in our food."

Dioxin is a group of 75 chlorinated hydrocarbon chemicals that is an endocrine disruptor. It mimics the endogenous hormones and acts to activate or inactivate at the wrong time, block normal hormone activity, and trigger the wrong response at the wrong time, or the right response at the wrong time.

These hormone disruptors come from food, contamination of food from packaging and preparation, as well as paints, plastics, detergents, solvents, etc.

There are many problems observed in wildlife and humans because of dioxin. In wildlife, reduced fertility has been a factor. Fish are having a low egg production and low reproduction rate. Birds have a similar situation with a low reproduction rate and thin-shelled eggs. Other issues with wildlife include altered sexual behavior, masculinization of females, feminization of males, cancers of female and male reproductive tract, and altered bone density and structure.

Problems seen in humans include losses in motor coordination, short-term memory, verbal skills, and psychomotor development. It is also possible that dioxin increases the risk for attention deficit disorder and aggressive behavior.

In 1992, more than 60 studies from numerous countries have reported that sperm counts are falling. In fact, the United States sperm count decreased by 50 percent in 1990 when compared to 1938.

The European sperm count declined even more. Dioxin also increases rates for testicular cancer as well as developmental problems. Testicular cancer has increased by two-to-four times in the United States, Australia, New Zealand, the Nordic and Baltic countries, and England.

Health problems for women include shortened menstrual cycles, a delay in getting pregnant, early puberty, and masculinization. Studies have found that in 339 countries, the breast cancer rate is higher where there are hazardous waste sites than in other areas. Dioxin also increases the risk of lupus and possibly fibrocystic breast disease, polycystic ovary, endometriosis, and uterine fibroids.

However, it doesn't end there. Mothers can even pass this toxic chemical to their children through breastmilk.

The Environmental Protection Agency (EPA) found dioxin to be one of the highest cancer threats in 1985, but industry protests stopped the report. In 1991 and 1994, the EPA reassessed dioxin cancer risk potential as one in 1,000. Last year, they stated that dioxin causes cancer in animals and should be regulated in the United States.

It is already regulated by the World Health Organization (WHO) and in several countries including Japan, the Nordic and Baltic countries, and others.

The EPA has finally announced that they will pass a strict regulation of dioxin, the chemical they consider the most toxic made by man, and persistent organic pollutants (POPs) that each person is allowed.

So how does one reduce their exposure to dioxin? It boils down to four things: eat a low-fat, high fiber diet; avoid food from the higher levels of the food chain (dairy products, meat, fish, shellfish, poultry); eat foods as close as possible to organic and natural state; and do not prepare or store high-fat food in plastic containers.

To learn more about this toxic chemical in food and the environment, there will be a one-day seminar on Monday, January 27, 2003, in Wong Kerlee International Conference Center.

Dr. Fujimoto along with top experts from the EPA and Greenpeace International will disclose breaking information on dioxin and POPs.

This seminar will be presented in an easy-to-understand format. Anyone and everyone is welcome to attend.

Five points will be discussed at the seminar: human health affects sources of dioxin and POPs, dioxin and POPs measurements, national and international policy, and personal and institutional responsibilities.

For more information, call the SPH office of continuing professional education at (909) 558-4595 or visit the website at <www. llu.edu/llu/sph/cpe/events>.

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School of Public health receives $1 million grant to fight tobacco in Southeast Asia

An Ung Sam, MD, MPH, director of National Institute of Public Health (NIPH) in Cambodia, stands in front of the NIPH headquarters in Phnom Pehn. The tobacco education courses will be held at this site.

The School of Public Health received a $1 million grant from the National Institutes of Health Fogarty International Center to combat the growing epidemic of tobacco-related illnesses and deaths in developing Southeast Asian countries. TODAY recently spoke with Linda Hyder Ferry, MD, MPH, associate professor and principal investigator, about the project.

Dr. Ferry, tell us about your work in Cambodia, Laos, and other Southeast Asian countries. What exactly is being done to fight tobacco-related illnesses and deaths?

In Southeast Asian countries there is really very little that has been done historically on tobacco control, but a few countries are now making real progress, like Thailand and Malaysia.

Last summer, we were asked to partner with Adventist Development and Relief Agencies (ADRA) to apply for a grant from the National Institutes of Health Fogarty International Center to work in Cambodia and Lao People’s Democratic Republic (Lao PDR). We were awarded research funding for the Cambodia and Laos project for five years.

Our background search found that there are only a few small research studies on tobacco control. For example, in Cambodia, when I visited there only two weeks ago, I found only one billboard with an anti-smoking message near the Central Marketplace in Phnom Penh. It was a cooperative effort of ADRA and the Cambodian health authorities.

So there is a long way to go. Our hope is that the faculty at Loma Linda University School of Public Health, partnering with ADRA staff (who are in the local country), can create a strong bond between the government and the leaders there. Through their ministries of health, we may influence leaders to change the priorities for tobacco control in their country and pay more attention to the long-term health consequences of smoking.

What do you plan to accomplish through this project, and how?

The purpose of our project is to bring faculty from the School of Public Health and the School of Medicine at Loma Linda to Cambodia every four or six months. We would recruit people who work in positions of influence in ministries of health, medical schools, research department, and economics department.

Basically, any individual that can influence decisions on tobacco control research and policy in their country. These individuals would join us for a two-week teaching session, to cover the essential skills of tobacco control research, such as epidemiology, statistics, and how to design a research survey. Also, trainees will learn how to analyze their research data and publish the results.

We hope that the relationships that we build will provide the evidence for them to develop an agenda that will go on for the next decade to gradually and effectively increase tobacco control. The outcome in the long run is to decrease the use of tobacco by men and to prevent women from ever starting to use tobacco. Right now in Southeast Asia, there is a much bigger gap between the smoking rate of men and women in many regions than we see in the developed western countries.

When will you start the classes in Cambodia?

We will be starting our very first class at the end of March, 2003. We hope to bring in scholars to our program from surrounding countries, such as Vietnam to the east, and Malaysia, Thailand to the west and maybe even Mongolia. That way, there can be a real intermingling of leaders in Southeast Asia to understand just what tobacco control means.

The government structure, politics, and the economics of these countries are very different, so one method will not work everywhere.

What is your long-term goal for the students?

Our long-term goal with these students is that they finish what we call an Asian Leadership Global Tobacco Control Certificate Program. This program will teach them the skills needed for leadership in global tobacco planning, grants management, strategic planning, and how to communicate professionally to the media in their country. At the end of the project, after we complete five sessions (every four to six months), we hope that we will have inspired people who are empowered to become the leaders in their country in tobacco control and save the lives of hundreds of thousands who would otherwise continue smoking.

Why do you do this? What motivates you to work on behalf of these countries and their people?

Well, medical school teaches you how many diseases people develop from smoking, and in medical school all you really learn is, “tell them to quit!” We are trying to change that here at Loma Linda so that our medical students not only know how to tell people to quit, but know how to help them quit.

After I finished my master’s in public health from Loma Linda University, I realized that the largest preventable health problem in the world is tobacco-related diseases. Nearly five million people will die this year on our planet from a tobacco-related disease. They will usually die 10, 15, or 30 years before they would have naturally passed away, robbing their families and their communities of tremendous potential from their lives. All because of an addiction to nicotine.

So when I put together my medical training and my public health training, it dawned on me how big the need is for improving people’s understanding of the risks and the ability to get effective help to stop smoking.

This project just seems like such a natural way to take what we have believed about healthful living for nearly 100 years here at Loma Linda University and partner with a developing country who is rebuilding their health-care in Cambodia after the devastating war in the 1970s. In the last 10 to 15 years, they have opened their medical school again after all the years of war that they went through. Everything was dismantled in their government and their medical education system.

So going back to partner with them is a real mission. Helping them learn how to protect their own population from the predation of the tobacco industry is the second part.

Because the tobacco companies are eagerly hoping to partner with developing countries, trying to get partnerships with them economically, they may become dependent on them, and won’t enact effective tobacco control.

We are also trying to partner with the mission of the World Health Organization. They created what is called the Framework Convention of Tobacco Control (FCTC). This worldwide effort in uniform tobacco control basically says that every country needs to take seriously the impact of tobacco on the health of their people. The government leaders need to enact certain laws, policies, and health decisions in regards to health-care that will decrease tobacco-related diseases in their population.

The first measure of success is to have the trainees finish our certificate program, then develop the skills to do effective research, and contribute to the published body of knowledge of tobacco control in Southeast Asia. And, in the process, their efforts will effectively reach out to thousands and potentially millions of people who want to be free from the addiction of tobacco.

How aware are the people in Southeast Asian developing countries about the effects of tobacco? Is this new information they don’t know about?

Eighty percent of the people in Cambodia live in a rural environment. They grow their own tobacco. They start using homegrown tobacco leaves at an early age and don’t have any idea of the health impact of their behavior.

The number of people who live in the urban centers is only 15 to 20 percent of the population. There are 10 to 12 million people in Cambodia and about four to five million in Lao PDR.

They have not yet seen the long-term health consequences increasing from lung cancer, emphysema, and heart disease. They have not been smoking in large numbers long enough, and they don’t have the health information tracking systems to see those trends developing.

So I would say they are at least 30 to 40 years behind the efforts that are seen in the western world in regards to tobacco control. Many people only have a vague idea that smoking may be harmful. There are very few “clean indoor air” laws or workplace enforcement of eliminating passive smoke.

There are basically only a handful of research projects that are done or ongoing at the moment. However, there is one very interesting project in Cambodia. They have a project that is funded by Rockefeller Foundation with ADRA Cambodia where they are taking the anti-smoking message to the Buddhist temple compounds, called wats. They are encouraging the entire compound to be declared tobacco free. When all of the new monks take their initiation vows, they are encouraged to abstain from all tobacco. Several wats are cooperating with this program in Cambodia.

Now, this is a very interesting concept because many young men spend a short period of time doing this in Cambodia. Then, they go on to their normal work. To influence 18- to 22-year-old men in Cambodia when they are in a spiritual, searching period of their young lives to choose to not smoke could have an impact on their country. They return to their communities which can really be an opportunity to start changing the accepted norms and thinking in the community.

We just need to continue to be open and creative and let the Lord’s spirit lead as we find ways to work with them in their culture (a Buddhist culture primarily), and with a very low education and income level. They don’t have a big health budget to spend on tobacco control, but the tobacco companies have a huge advertising and promotion budget to entice them with.

What do you foresee as your biggest challenge in this project?

Our biggest challenge is to convert our American perspective on tobacco control into a sensitive approach to their Asian cultural issues, in order to translate what the real core message is, in a way that is not offensive. That’s going to really be the biggest challenge. Conducting large research surveys in another country half a world away is also going to take some exquisite planning and cooperation between the LLU-based research team and the Southeast Asian researchers.

The knowledge base about the harmful effects of tobacco use is clearly in the literature. We don’t have to convince them of these facts. But the challenge is to learn how to translate that into relevant research efforts, health policies, working with the political structure of their country, the business angle, and the economic impact of reducing sales of tobacco eventually. For example, how could they benefit from a tobacco tax as Thailand recently passed?

So all of those issues that need to be considered in order to improve the health by more effective tobacco research are going to have to be faced one at a time, as we go forward. We are praying that the Lord gives us the wisdom to know how to avoid the pitfalls so we can improve the health of the people in Cambodia and Lao PDR. Overall, we’re excited about the prospects and eager to see where the Lord leads us.

Is there anything else that you would like to add?

In ADRA, the work of humanitarian relief and assistance to people who are really hurting is probably not any more acute then it is in countries like Cambodia. For several years in the 1970s and early 1980s, the people were living under the most primitive conditions because of oppressive communist rule. They had no medical professionals, medications, and no outside help.

Planned genocide occurred all around them, fear dominated their lives and very few have received a higher education. The whole age group of the population that lived in the mid 1970s has been cruelly affected.

So what we hope is that as ADRA’s partner, we create more opportunities for Christian non-government organizations to be received in a way that allows us to improve the health of people in these countries and to be led by God’s wisdom. That’s what God calls us to do—to go to the most needy and to show Him to them, in a loving way, providing for their needs. This is really the ministry that Christ had. This is the adventure that we are looking forward to. I’m eager to come back in a couple of years and tell you how our project is going.


Liane Hewitt, MPH, chair, department of occupational therapy, School of Allied Health Professions, ensures there is enough pumpkin, cherry, and apple pie available during the department's pie feed.	Tiffany Williams, occupational therapy student, enjoys a piece of pie with her invited guest Ernest R. Schwab, PhD, associate professor, department of physical therapy, School of Allied Health Professions.


The research team discusses their project. Pictured are (from left) Emmanuel Rudatsikira, MD, MPH, assistant professor, department of international health; Pramil Singh, DrPH, assistant professor, department of epidemiology; Jayakaran S. Job, MD, DrPH, associate professor, international health, epidemiology/biostatistics, preventive medicine, Schools of Medicine and Public Health; Susanne Montgomery, PhD, director, center for health research, professor, department of health promotion; Linda Hyder Ferry, MD, MPH, associate professor, department of health promotion, principal investigator for project; Floyd Peterson, MPH, assistant professor, biostatistics, director, health research consulting group; and Alex Lozano, research assistant.	The medical school in Laos will participate in research every two years for the next six years to see whether the Lao medical students' health practices change.

This anti-smoking billboard, the only one of its type seen by Dr. Ferry, is located near the central marketplace in Phnom Penh. The billboard is co-sponsored by the Adventist Developement and Relief Agency (ADRA) and the Cambodian health authorities.

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Thursday, December 19, 2002 TODAY issue | School of Public Health