[What is social sciences' contribution in the context of health crises and emerging risks? An anthropologist's perspective]

What can the social science contribute during a public health crisis? Reflecting on this question, we turn to the medical anthropologist David Napier, who has developed research tools for understanding the complex drivers of health vulnerability and resilience. Interviewed by Nolwenn Bühler, he shares his vision of the Covid-19 crisis, and the role social sciences should be playing in understanding why populations either trust or mistrust policymakers. In that a crisis, by definition, involves demands on limited resources, social trust is itself put to the test. Napier cautions us about what this means at the level of inclusive health, and why we must be especially aware not only of how response policies themselves can create new vulnerabilities, but of why we must actively combat the xenophobia and stigma that insecurity can generate.

Drawing a pandemic vulnerabilities' map: The SoNAR-global Vulnerabilities Assessment digital and its output

This paper describes the process, advantages and limitations of a qualitative methodology for defining and analyzing vulnerabilities during the COVID-19 pandemic. Implemented in Italy in two sites (Rome and outside Rome, in some small-medium sized municipalities in Latium) in 2021, this investigation employed a mixed digital research tool that was also used simultaneously in four other European countries. Its digital nature encompasses both processes of data collection. Among the most salient is that the pandemic catalyzed new vulnerabilities in addition to exacerbating old ones, particularly economic. Many of the vulnerabilities detected, in fact, are linked to previous situations, such as the uncertainties of labor markets, having in COVID-19 to the greatest negative effects on the most precarious workers (non-regular, part-time, and seasonal). The consequences of the pandemic are also reflected in other forms of vulnerability that appear less obvious, having exacerbated social isolation, not only out of fear of contagion, but because of the psychological challenges posed by containment measures themselves. These measures created not mere discomfort, but behavioral changes characterized by anxiety, fearfulness, and disorientation. More generally, this investigation reveals the strong influence of social determinants throughout the COVID-19 pandemic, creating new forms of vulnerability, as the effects of social, economic, and biological risk factors were compounded, in particular, among already marginalized populations.

The European Association for the Study of Obesity (EASO) Endorses the Milan Charter on Urban Obesity

The Milan Charter on Urban Obesity highlights the challenges of urban environments as a battleground for human health, as cities are often organized to subvert public health goals, and promote rather than prevent the development of obesity and consequent non-communicable diseases. The Charter articulates ten principles which detail actions and strategies through which general practitioners, diverse medical specialists, related healthcare professionals, administrators and healthcare practice managers, policy actors - within health systems and at a national level - along with experts across disciplines, and citizens, can work in cooperation to meet this challenge and improve public health. The Charter urges the adoption of decisions that deliver the following: (i) policies which enable our cities to become healthier and less obesogenic, more supportive of well-being and less health-disruptive in general, and (ii) policies that fully support primary prevention strategies, that address social stigma, and that ensure fair access to treatment for people living with obesity. The Milan Charter on Urban Obesity aims to raise awareness of our shared responsibility for the health of all citizens, and focuses on addressing the health of people living with obesity - not only as a challenge in its own right, but a gateway to other major non-communicable diseases, including cardiovascular diseases, type 2 diabetes, and some cancers.

New competences to manage Urban Health: Health City Manager core curriculum

Health as a common good is a prior essential objective to be pursued by an alliance including citizens and local administrations. Role of cities in health promotion is emphasized by urbanization, entailing 70% of the global population living in urban areas. Cities are therefore perfect laboratories within which to act: studying and monitoring dimensions that determine the level of quality of life in cities, improving their sustainability and capacity for growth, is fundamental for a new governance model able of managing this complexity. Under the premises, the Health City Manager (HCM) has been launched, a professional gaining skills in PH management, sociology of communities, urban design and control in reducing health inequalities. A course lasting 80 hours gives then the opportunity to put into practice, at municipal level, knowledge, competences and abilities achieved. In the background, both the former EU Commissioner for Health and the Committee of the Regions warmly supported the establishment of HCMs, who would coordinate a process ensuring alignment of policies on a macro and micro scale. During G7 in 2017, Ministry for Health and Presidency of Italian Municipalities signed the Urban Health Rome Declaration, underlining the need for a stronger synergy facilitated by HCMs. In 2019, Ministry of Youth and Sport approved and financed the project. On the basis of a core curriculum, validated by a group of experts, the course is starting in 2020 for the first 120 HCMs. Innovation lies in the holistic approach, a multidisciplinary project managing method overcoming silos logic. Customization of public policies and participatory process make the figure ideal to be applied in all countries. Sustainability is ensured by a relatively high return on investment. Main impact relates to improvement of the quality of life through a full involvement and accountability of local administrations; contrast of climate change identifying strategies of urban resilience.

Key messages

Improvement of the quality of life through a full involvement and accountability of local administrations. Contrast of climate change identifying strategies of urban resilience.

Diabetes vulnerability in Rome

Background

To understand the presence and impact of social and cultural factors on health vulnerability it is important for improving diabetes care and management. In fact, through the social dimension, it is possible to identify the priorities and attitudes towards diabetes and diabetes care among those living with the condition.

Methods

The study was carried out as part of the global Cities Changing Diabetes programme, involved a sample of individuals living with diabetes in the Rome metropolitan area and employed mixed-method and qualitative approaches to data collection and analysis (survey, sorting procedure and focus group).

Results

Four specific sub-groups of participants have been identified, each with distinct but shared priorities and attitudes towards diabetes: Health conscious thanks to the context; Medicalized elderly people; Fatalistic citizens; Worried but undisciplined young people. The connection between the place where you live and the possibility to adopt a healthier lifestyle was confirmed. For these patients, the disease is mainly characterized by its relationship with food and its connections with psychological aspects are also relevant.

Conclusions

An important issue concerns information and the different understandings of diabetes. A clear need emerged for further elaboration of the various aspects of a disease that tends to be underestimated also by those who have it. Another aspect concerns the importance of the living environment and consequently of the actions on its urban planning, mobility, but also in everyday life organization, as factors that can make a difference in properly managing the disease. These results are very important to promote a joint action, that have to involve public and private stakeholders, in order to improve treatment opportunities and quality of life of people facing diabetes every day in the Rome metropolitan area.

Key messages

An important issue concerns information. A clear need emerged for further elaboration of the various aspects of a disease that tends to be underestimated also by those who have it. The living environment in important too and the actions on its urban planning, mobility, in everyday life organization, as factors that can make a difference in properly managing the disease.

New competences to manage urban health: Health City Manager core curriculum

A core curriculum is an essential step in development knowledge, competences and abilities and it defines educational content for the specialized area of practice in such a way that it can be delivered to new professional job. The Health City Manager core curriculum defines the strategic aspects of action to improve health in cities through a holistic approach, with regard to the individual, and a multi-sectoral approach, with regard to health promotion policies within the urban context. The Health City Manager core curriculum recognizes that the concept of health is an essential element for the well-being of a society, and this concept does not merely refer to physical survival or to the absence of disease, but includes psychological aspects, natural, environmental, climatic and housing conditions, working, economic, social and cultural life - as defined by the World Health Organization (WHO). The Health City Manager core curriculum considers health not as an "individual good" but as a "common good" that calls all citizens to ethics and to the observance of the rules of civil coexistence, to virtuous behaviours based on mutual respect. The common good is therefore an objective to be pursued by both citizens and mayors and local administrators who must act as guarantors of equitable health ensuring, that the health of the community is considered as an investment and not just as a cost. The role of cities in health promotion in the coming decades will be magnified by the phenomenon of urbanization with a concentration of 70% of the global population on its territory.

Assessment of factors affecting diabetes management in the City Changing Diabetes (CCD) study in Tianjin

OBJECTIVE

This study aimed to identify the local levels of vulnerability among patients with Type-II diabetes (T2DM) in Tianjin. The study was aimed at curbing the rise of T2DM in cities.

METHODS

229 participants living with T2DM were purposively sampled from hospitals in Tianjin. Collected data were coded and analysed following well-established thematic analysis principles.

RESULTS

Twelve themes involving 29 factors were associated with diabetes patients' vulnerability: 1. Financial constraints (Low Income, Unemployment, No Medical Insurance/Low ratio reimbursement); 2. Severity of disease (Appearance of symptoms, complications, co-morbidities, high BMI, poor disease control); 3. Health literacy (No/Low/Wrong knowledge of health literacy); 4. Health beliefs (Perceived diabetes indifferently, Passively Acquire Health Knowledge, Distrust of primary health services); 5. Medical environment (Needs not met by Medical Services); 6. Life restrictions (Daily Life, Occupational Restriction); 7. Lifestyle change (Adhering to traditional or unhealthy diet, Lack of exercise, Low-quality sleep); 8. Time poverty (Healthcare-seeking behaviours were limited by work, Healthcare-seeking behaviours were limited by family issues); 9. Mental Condition (Negative emotions towards diabetes, Negative emotions towards life); 10. Levels of Support (Lack of community support, Lack of support from Friends and Family, Lack of Social Support); 11. Social integration (Low Degree of Integration, Belief in Suffering Alone); 12. Experience of transitions (Diet, Dwelling Environment).

CONCLUSION

Based on our findings, specific interventions targeting individual patients, family, community and society are needed to improve diabetes control, as well as patients' mental health care and general living conditions.

Inhibition of the integrin/FAK signaling axis and c-Myc synergistically disrupts ovarian cancer malignancy

Integrins, a family of heterodimeric receptors for extracellular matrix, are promising therapeutic targets for ovarian cancer, particularly high-grade serous-type (HGSOC), as they drive tumor cell attachment, migration, proliferation and survival by activating focal adhesion kinase (FAK)-dependent signaling. Owing to the potential off-target effects of FAK inhibitors, disruption of the integrin signaling axis remains to be a challenge. Here, we tackled this barrier by screening for inhibitors being functionally cooperative with small-molecule VS-6063, a phase II FAK inhibitor. From this screening, JQ1, a potent inhibitor of Myc oncogenic network, emerged as the most robust collaborator. Treatment with a combination of VS-6063 and JQ1 synergistically caused an arrest of tumor cells at the G2/M phase and a decrease in the XIAP-linked cell survival. Our subsequent mechanistic analyses indicate that this functional cooperation was strongly associated with the concomitant disruption of activation or expression of FAK and c-Myc as well as their downstream signaling through the PI3K/Akt pathway. In line with these observations, we detected a strong co-amplification or upregulation at genomic or protein level for FAK and c-Myc in a large portion of primary tumors in the TCGA or a local HGSOC patient cohort. Taken together, our results suggest that the integrin–FAK signaling axis and c-Myc synergistically drive cell proliferation, survival and oncogenic potential in HGSOC. As such, our study provides key genetic, functional and signaling bases for the small-molecule-based co-targeting of these two distinct oncogenic drivers as a new line of targeted therapy against human ovarian cancer.

Abstract PD3-8: Whole exome sequencing reveals early mutational change on endocrine and targeted therapy in estrogen receptor (ER)-positive breast cancer

Background: Breast cancer treatment is guided by baseline tumor tissue which does not take into account tumor interaction with therapy. We hypothesized that mutational change may occur early after treatment initiation and that “on-treatment” tumor profiling may be more informative of tumor behavior and, ultimately, patient outcome.

Methods: We conducted whole exome sequencing on 49 tumor samples from 2 clinical trials of combined endocrine and targeted therapy (NCT00570921: with fulvestrant/everolimus, and NCT00525161: with tamoxifen/sorafenib). Tumor DNA was subjected to exome capture using Agilent V4+UTR 71Mb and Illumina's HiSeq2000 sequencer was used to generate 2×100bp paired-end reads. After mapping reads to the reference human genome (GRCh37), point mutations and insertions/deletions were detected using the Genome Analysis Tool Kit (GATK 2.6-5). We then retained breast somatic mutations from TCGA and COSMIC databases and excluded germline mutations from dbSNP. Further filtration was then done by removing modifier impact and synonymous mutations based on SnpEff, as well as removing mutations with <15X coverage depth.

Results: Across 8 paired tumors on day 28 vs. day 1, 4-pairs on fulvestrant/everolimus and 4 on tamoxifen/sorafenib, there were a total of 50 mutations lost and 77 gained for an average of 6.25 and 9.6 per tumor pair, respectively. This represented, on average, <5% of the total mutations detected, with >95% similarity in the mutational profile of paired tumors. One consistent mutational change in response to treatment was the gain of MUC2 single nucleotide polymorphisms (SNPs) in all 8 paired day-28 vs. day-1 biopsies. This MUC2 mutation pattern persisted even with removal of the coverage depth filter. Other MUC genes had SNPs gained or lost on day 28 but these were infrequent events. Additional notable changes were the gain of HLA-DRB1 SNP's in 2/4 everolimus-treated patients, loss of NCOA3 in one, and loss of TP53 in another. Interestingly, across 5-paired primary and metastatic tumors treated with endocrine therapy alone prior to enrollment, there were more mutations lost than gained (68 vs. 34) for an average of 13.6 and 6.8 per tumor pair, respectively. This represented only slightly over 5% of the mutations detected across these tumors with no consistent genomic event observed. One patient with lobular carcinoma on tamoxifen developed a contralateral lobular associated with metastasis and gain of PIK3CA and NCOR2 SNPs in the new tumor.

Conclusion: ER-positive breast tumors undergo early mutational change in response to therapy but the bulk of their mutational profile remains stable, even over long periods of time. MUC2 mutations emerge as a consistent early event which may reflect functional tumor differentiation in response to treatment pressure. Early emergence of mutational events suggests the need for a preoperative treatment window in future trials of this disease in order to interrogate tumor interaction with therapy prior to prolonged adjuvant therapy, which is currently based solely on pretreatment tumor assessment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD3-8.

The association of health risks with workers' compensation costs

The purpose of this study was to investigate the association between health risks and workers' compensation (WC) costs. The 4-year study used Health Risk Appraisal data and focused on 1996-to-1999 WC costs among Xerox Corporation's long-term employees. High WC costs were related to individual health risks, especially Health Age Index (a measure of controllable risks), smoking, poor physical health, physical inactivity, and life dissatisfaction. WC costs increased with increasing health risk status (low-risk to medium-risk to high-risk). Low-risk employees had the lowest costs. In this population, 85% of WC costs could be attributed to excess risks (medium- or high-risk) or non-participation. Among those with claims, a savings of $1238 per person per year was associated with Health Risk Appraisal participation. Addressing WC costs by focusing on employee health status provides an important additional strategy for health promotion programs.