Brian Altonen, MPH, MS

It is Veteran’s Day!

What important Public Health issues should this remind us of as public health, spatial epidemiology specialists?

War has always led to advancements in medicine.  The Crimean War between England and Russia led to the use of large hospitals, the discovery of contamination and infection on recuperating soldiers’ lives, and the need to better patient care; due to the work of the famous Florence Nightingale, the nursing profession and school were born.  The Civil War  or War of the Union in the United States is where physicians first demonstrated the power of the antiseptic and the value of clean surgical practices; this war led to many amputations, and with time resulted in a need for a new profession–the prosthetic limb manufactories.  It also demonstrated the value of ether in performing operations.

The Spanish-American way is where we developed the first large scale floating hospitals, with a complete hospital on board in terms of staff and supplies.  World War I unfortunately was the first war where chemical warfare became common, and where nutritional deficits and appropriate foot apparel often seemed to be the determinants.  During World War II, these ventures continued, and due to the development of the single winged airplane, the first studies of high altitude impacts on pilots were test, at research programs set up on Long Island, in order to document better ways for pilots to survive high elevation manuveurs, tolerating the cold and lesser oxygen pressures.

The Korean War gave us the MASH units.  The Vietnam War resulted in the exposure of soldiers to some of the least health environments, due to natural pathogens and toxins, and due to the chemicals, insecticides, pesticides and defoliating agents used indiscriminately across the battlegrounds that soldiers traveled through.

The most recent wars have exposed soldier to innumerable potential pathogens and health impacting materials.  From the Vietnam War on, the surgical practices of the military were forced to deal with high technology weapons and exposure to the unknown.  At first, short term impacts on health were well documented.  Now, as the decades have passed, the long term impacts of exposure to natural and manmade elements during the war are beginning to demonstrate another cycle in unhealthy effects upon the human body.  The long term effects of Liver Fluke disease recently reached the news.

Liver fluke disease has local or native forms and one highly important Asian borne form.  Whether the new cases documented for Chinese Liver Fluke are of some new local origin, or due to decades old exposure histories remains to be verified beyond any doubt.  The International spread of disease like Liver Fluke, due to human migration or business (military) related travel should be of concern to the U.S., which has for more than a century worked effectively at keeping foreign born infectious and vectored diseases out of this country, for the most part.  With the recent outbreaks of West Nile, Chikungunya, Yellow Fever, Ebola, and most recently Zika, the likely return of 19th century disease to this country seems inevitable.

For my listing of potentially intruding foreign diseases of concern to the near future in United States Public Health and Epidemiological history, see https://brianaltonenmph.com/gis/global-health-mapping/foreign-disease-intrusion/ .

A number of years ago I had the chance to, for the first time, generate maps of international diseases and how they were dispersing in the United States from about 2000 to 2010.  To achieve this goal, I drew up a series of US maps demonstrating where the diseases from particular parts of the world are derived.  As an example, the following is of Japan specific diseases, recognized by mapping the ICDs for these diseases and where their patients reside, based upon the 70M-110M patients EMRs that were evaluated years ago.

Japan

I also produced the following interesting review of disease from Africa . . .

Africa

The USSR:

U.S.S.R.

Middle and South America . . .

Middle and South America 

Asia in general . . .

Asia

Australia . . .

Australia

Etcetera, etcetera, etcetera.

The follow videos were used for teaching.  They were developed to show the value of using GIS/RS (remote Sensing) techniques to evaluate spatial data.  Standard algorithms were applied to this 3D model I generated of the US disease patterns, to demonstrate the value of regular, squared and cuboidal spatial data analyses.

This video was used to demonstrate how to evaluate a disease pattern up close (around the great lakes this time), to determine possible diffusion routes for the illness, or its biological, ecology and/or zoonotic causes.

The following is applied to an actual geomorphogenically defined disease region, a disease dependent upon densely population area with a certain climate pattern, and a certain rock and soil type that assists the organism in its survival.

For each of the above videos I present here (of the hundreds I developed), many of these were very brief, but are the first depictions of this kind for the country, for so many people (1/4-1/3 the nation).

Veterans-related Spatial Surveillance

Fifty years ago, United States soldiers serving in the Vietnam war exposed themselves to a variety of pathogens native to the local waterways.  Since the seventies, discussions on the long term effects of this war, besides the physical and psychological impacts of the war itself, focused on the long term effects of agent orange, exposure to local toxic chemicals, exposure to the waterborne schistosomes.

(for which, see )

Live fluke is one of the oriental water born diseases that has experienced its peaks and lulls in U.S. epidemiological history.  The disease ecology of liver flukes in fact entails a number of diseases, not just this particular fluke now possibly impacting some Vietnam war vets.

The Farmer’s Liver Fluke natural in the U.S. impacts mostly the eastern half of the United States.

Another liver fluke  is associated with domestic animals, the Feline Liver Fluke, which again demonstrates east coast dominance and lower latitude (high temperature) west coast dominance.

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The Liver Fluke that the Vets are now talking about in the U.S. may be something they captured decades ago.  But another possibility is the infection of these people due to their dietary patterns.  There is growing concern about the infection of people in the US by poorly processed foreign foods.  In particular, sushi is linked to a number of organism related diseases where the source is food that has not been fully processed.

Still, regardless of the source, veterans or in-migrating animals and people, the Chinese Liver Fluke has to be the most important growing concern for up and coming liver fluke outbreaks in the U.S.

The following illustrates the distribution of this disease in the US, up until 2012.

Notice the peak in the Seattle area, one near the Great Lakes, and two along the Mississippi River valley.  The latter two are situated along a common route traveled by in-migrating Asiatic populations over the years.

The cause for re-emergence of the Chinese Liver Fluke version of this disease pattern in the U.S. should be our primary concern.  Understanding its method of penetrating the U.S. might provide us with insights into how the other diseases from China and South Asia may penetrate this country.

The skills of analyzing a disease like Chinese Liver Fluke sets the stage for how spatial epidemiologists need to review other internationally dispersed zoonomic and microbial disease patterns.

There are also a variety of tick, fly and chigger born diseases that aren’t covered here, that may break out.  Several forms of meningitis and encephalitis may become epidemic or endemic in nature in the U.S., should the borders not be managed and secured properly.  Livestock diseases like Texas Fever and Bovine Tuberculosis, diseases eradicated in the nineteenth century, could very well return due to the lack of sophisticated monitoring systems established in the most important healthcare places–the managed care business settings.

In essence, this problem is in its infancy right now.  World Health Organization already failed several times these past years with Ebola, Chikungunya and Zika.  As the other opportunistic diseases arrive in the country, we will begin to demonstrate a reversal of the epidemiological transition that took place in the U.S. between 1820 and present.

For every century of growth that occurred in epidemiological transition, only a decade is required to reverse all of the accomplishments that were made.  This is well demonstrated by the last decade’s worth of changes in public health, disease ecology and epidemiological complexity.

Of all the countries out there, the U.S. has the most to lose in terms of public health security during the next few years.

Michael Baughman

From the article:

“DANVILLE, Calif. (AP) — Mike Baughman considered himself one of the lucky ones, returning from Vietnam without any major injuries or psychological scars. But after falling ill nearly a half-century later, he found out he did not escape the war after all. . . .

” . . . The U.S. government acknowledges that liver flukes, endemic in the steamy jungles of Vietnam, are likely killing some former soldiers. Ralph Erickson, who heads post-deployment health services at the Department of Veterans Affairs, said about 700 cholangiocarcinoma patients have passed through the agency’s medical system in the past 15 years.”

From “Still fighting: Vietnam vets seek help for rare cancer” by
ROBIN McDOWELL and MARGIE MASON, Associated Press.

For more on this growing crisis in U.S. Public Health, see the related article, posted this VETERAN’S DAY, at

https://www.yahoo.com/news/still-fighting-vietnam-vets-seek-051634300.html