[MUSIC] Hi, I'm Dr. Megan Latshaw. I work at the Johns Hopkins University in Baltimore, Maryland in the United States. I also studied at Hopkins and all three of my degrees are from here. My bachelors is in biology and my masters and doctorate are in environmental health. My joke is that I gave all my money to Hopkins and now, I am trying to work here to get some of it back. But it's a great place to be and in between my degrees, I worked in Washington, DC at the Association of State and Territorial Health Officials and also at the Association of Public Health Laboratories. And did a brief stint in Costa Rica, Pura Vida. Our field focuses on how the environment impacts our health, whether it's through the air that we breathe, the water we drink or the neighborhoods in which we live. My work, in particular, focuses on translating science into the real world either through policies or actions. I oversee two of our masters programs in environmental health, so if you're interested in getting a degree in this area, please let me know. Here's a picture of me and here is Dr. Ellen Silbergeld who is also co-directing this course. Ellen also trained at Hopkins in geography and environmental engineering, and as a post-doctoral fellow in environmental health sciences. She worked at the National Institutes of Health, the Environmental Defense Fund and the University of Maryland Medical School. Dr. Silbergeld has served as a scientific advisor to many national agencies and states in the United States, as well as the World Bank, the International Labour Organization, United Nations Environment Programme, World Health Organization, and the Pan-American Health Organization. Her research and professional activities also bridge science and public policy. Areas of her current focus include cardiovascular and immunological risks, arsenic, lead, cadmium, and mercury. And the health and environmental impacts of industrial food animal production. Dr. Silbergeld has won many awards, including a MacArthur Foundation Genius Fellowship. We both live in Baltimore, with our husbands, and both love to travel and read. So, now that you know who we are. I hope that you'll consider introducing yourselves to everybody else on the discussion board. This is a great opportunity to meet other people from around the world who are interested in the same topic as you. I want to extend thanks to some of our other speakers, as well as a student. So I'm going to actually start from the bottom of this slide and acknowledge Michael Koropsak, who was a student at Goucher College, and who worked with me to develop the ideas for this course, and also drafted an outline. And then I want to thank the three guest lecturers that we have. Michele Roberts is the co-director of the Environmental Justice and Health Alliance for Chemical Policy Reform. Suzanne Condon is an associate in our Department of Health Policy and Management here. And Dr. Clifford Mitchell works at the Maryland Department of Health. So now that I've introduced you to all of the people, the who part is done. Let's move on to the why part. Why are we offering this course? Well, most environmental health happens behind the scenes. Our drinking water gets protected, our restaurants get inspected, our children get tested for lead poisoning, industries are regulated to prevent pollution. And so, when entire communities start to worry, that something is in their environment that might be impacting their health. They might not have even heard of the term environmental health. And so we're offering this course, A, to help community groups who want to figure out what's going on in their community when it comes to rates of disease. But also to introduce folks to the field of environmental health which is part of public health and basically recognizes that everything around us affects our health and well-being. In these pictures, you can see a picture of somebody during the Great London Smog Event. And this picture was actually taken at noon, although it looks like it's the middle of the night. And that juts goes to show you how much we have improved our air pollution levels around the world, although we still struggle in some areas and we can always do better. The next picture is a picture of our former president Obama drinking water in Flint, Michigan after it was declared safe to drink by the EPA. And the last picture is a picture of a neighborhood in Washington, DC and it's meant to show you the ways that neighborhoods might impact health. You can see there are parks, there are highly populated areas, and there are streets that are in a semi-gridlike pattern. All of these different, disparate pictures and areas are all part of environmental health. This course, though, is focusing in on the study of disease clusters and we are targeting community members who might be concerned about potentially higher rates of disease in their community than would be expected if you knew about the disease in the broader population. The goal is to help you understand disease, how it is studied and especially disease clusters. Much of what is out there about disease clusters is found in the scientific or the public health practice literature. And so we aim to bring the basics to an everyday audience who might not have a science background or a public health background. We hope this will be a tool to use when engaging with your health department, so you will be familiar with the jargon or the concepts that they might use. If you want to learn more about the study of disease, we recommend taking some epidemiology courses that are also offered on this platform. And if you haven't taken it already, there's a Chemicals and Health MOOC that might also be of interest. So after you finished this course, what will you be able to do? You will be able to define disease. You'll be able to explain how disease is studied. You'll be able to list risk factors for diseases associated with environmental exposures. You'll be able to describe what happens during a disease cluster investigation. You'll be able to assess the two main parameters of a disease cluster investigation, time and space. You'll be able to explain challenges in studying disease clusters, including why they often yield inconclusive results. And you'll recognize that cancer is not one disease but rather, it's an entire set of diseases. We have some considerations about this class that we want to bring to your attention. The first one is that sometimes the science says, there is no disease cluster. Sometimes these clusters might actually be due to a lot of people living in your area. And so while there might be a high number of cases, the actual percentage of people that have the disease might be what is expected based on what we know about that disease in the general population. So there's a difference between the actual number of people with disease and the percentage of people with disease. Sometimes, another reason that perceived clusters don't actually end up being called clusters is because we live in an age of improved communications and social media. So that means that more people are sharing information about their health, and so their might be a perception that there is more disease. Whereas back in the day, we just didn't realize we weren't talking about it and so we didn't know that there was much disease already in the population. Also, the diagnosis treatment and prevention of disease actually changes the occurrence of disease. And so, sometimes it might seem like there's a cluster, but there actually isn't. Maybe we are diagnosing disease earlier, and so we are catching more of it earlier than we used to, and it seems like there's higher numbers or there actually isn't, we're just catching it earlier. The bottom line with number one, is that sometimes a perceived cluster isn't always a disease cluster. The second consideration we want you to keep in mind is that our tools are often inadequate to actually assess whether illness is due to a specific exposure. This is what a lot of communities really want to know. They want to know, is my disease being caused by a specific exposure. And our tools in public health to detect illness In a community are limited, and sometimes we just can't provide the answer the communities want or need. And even when a disease cluster is identified and we say yes, this is a cluster, it's often very difficult to say what's causing the increased illness. And at the end of the day, sometimes it comes down to educated guesses. So, while we're going to teach you the tools used by public health officials, we acknowledge they need to be better. The third consideration is that community science, which is also sometimes called citizen science, offers both strengths and weaknesses. When community scientists are collecting health data, you need to be aware not only of the strengths but also of the pitfalls of community science. Many factors can influence what you find. And you need to maintain a healthy skepticism about your conclusions. And you need to talk two scientists who know how to study disease, both before, during, and after your own collection or analysis of the data. Epidemiology, the study of disease, offers a lot of tools to control for potential biases. And it offers ways to make sure that you're collecting good data so that you can come up with good conclusions. The fourth consideration is many diseases can cluster, not just cancer. And one of the more common concerns that we hear about from community groups is cancer, and it has some really special considerations that go along with it because it is an unusual set of diseases. So we do discuss it often in this class, but I want you to keep in mind that much of this course is applicable to any disease, whether it is cancer or not. And lastly, the fifth consideration is that this course does not cover in depth exposure assessment, political influences or historical context. Although these are all really important aspects of disease cluster investigations, we just won't be covering them in this course. So what is this course going to look like? You're listening right now to the introduction. Next, you're going to hear from Dr. Silbergeld who's going to talk to you about what disease is? How we define it? What types of diseases there are? What are the risk factors for diseases? And she's also going to talk about cancer in particular. Then you're going to hear about a case study of Breast Cancer in Cape Cod. Dr Silbergeld is going to present an investigation there, and then you're going to have your first assignment. You will be expected to watch a video and answer questions on the discussion board. After that, Dr. Silbergeld will talk about how disease is studied, she's going to cover the fields of epidemiology, biostatistics, toxicology, spatial analysis, and biomarkers. Then you're going to have a quiz. And after that, you're going to hear from Dr. Clifford Mitchell who is going to discuss what happens during a disease cluster investigation. So at first, he's going to focus on the first part of a disease cluster investigation which is, what is the process for determining whether there's evidence of a cluster and what might be causing it? He'll cover establishing a case definition, case confirmation, and also what approaches are used and considerations along the way. And then you'll hear two case studies. The first will be on cholera in London, and the second will be on spina bifida on the Texas and Mexico border. After that, Dr. Mitchell will cover who does what during a disease cluster investigation. I'll talk about doctors, public health agencies, and community members. Then, you'll have a second quiz. And after that, we'll hear from Ms. Condon who will talk about why these investigations are often unsuccessful. She'll cover the fact that diseases might be not common enough to study well. It might have a different sign or symptom. Some diseases can take decades to develop after you're exposed to something in the environment, even if you do find a high-level disease, Ms. Condon will talk about how hard it is to identify a cause. She'll talk about the lack of surveillance systems to look for these types of diseases and causes in the population. She'll also maybe touch upon the fact that some people just don't want to know if there are problems. And that the system can be tough to navigate if you're not familiar with it. And you'll have a third quiz, and then we'll hear from Ms. Michele Roberts about what community scientists can do. Getting organized, assembling evidence in clear and comprehensive ways, partnering, contacting different agencies and departments. Talking to representatives and politicians, and finding nonprofits that might be able to help you. Lastly, we'll have an assignment where you will have to compose a plan for investigating a disease cluster in your geographic area. And if you don't have one, we'll help you out. These are some resources that provide some good information. It's not meant to be exhaustive. They will also be on the actual page. So if you can't click from this slide, you would be able to access them on Coursera. Thank you so much for signing up for this course. Please post any questions, comments, or suggestions you might have on the discussion board. We will be monitoring that regularly. 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