Conversation with Manolis Kogevinas MD PhD

Manolis KogevinasManolis Kogevinas is an epidemiologist based at the Municipal Institute of Medical Research (IMIM) in Barcelona, Spain. He is also Professor of Epidemiology at the Medical School of Crete and affiliated with the Division of Cancer Epidemiology and Genetics at the National Cancer Institute here in the US. Dr. Kogevinas worked at the International Agency for Research on Cancer (IARC/WHO) early in his career, and is a leading authority on associations between environmental and occupational exposures and cancer. Manolis believes that it is his obligation both to do good science and to engage in debates about public policy. SKAPP’s Polly Hoppin and Dick Clapp spoke with him about his work and his perspective on the role of science in government decision-making, in Europe and in the US.

SKAPP: Much of your research in the last 20 or more years has focused on dioxin and other occupational cancer risks. How did you come to this focus?

Manolis Kogevinas: I did my thesis in London on social inequalities in cancer with Michael Marmot, a great person to work with on these issues. Later, I decided I wanted to develop a more specific focus, so I moved to IARC to work on the occupational and environmental aspects of cancer, in part because of my political views and interests.

SKAPP: What were these “political views and interests”? Did you have any particular experiences that led to your sense of conviction about this kind of work?

MK: Well, I currently live in Spain, but I’m Greek, and I grew up and studied in Athens. I was a student at the time of the dictatorship. Many people in my generation were involved in the student movement during that period. This involvement generated in many of us an interest to participate in common affairs, in politics and in society.

SKAPP: What has been the greatest achievement of your career thus far?

MK: I would say the research I did with my colleagues on dioxin. This research, which was done at IARC and many other places, brought an end to the controversy regarding dioxin carcinogenicity.

SKAPP: Please tell us more.

MK: Dioxin exposure is widespread but quite uniform across the population—as are exposures to many other organochlorinated compounds. Of course, it is very difficult to do epidemiologic research in such situations. In the early 1990’s, people had been doing research on dioxin for quite some time, but many of the studies were inconclusive, so people had very strong opinions about carcinogenicity, for and against. We needed answers relevant to the large numbers of people exposed, so the turning point, I think, was our work with big occupational cohorts with good exposure assessment that used a biomarker. For my personal development as a scientist, this work was critical, because it was where I first understood that if we want to change things in the society, we have to do studies—sometimes very large studies—with very strong methods.

SKAPP: What are the politics of dioxin in Europe? 

MK: First, there’s a big financial interest in dioxin—and related compounds—here in Europe, and controlling exposure to these compounds would mean more regulation of industry. The general policy of many industry-based organizations is to oppose control measures. They’re expensive. Second, there are so many sources of exposure to dioxin. For example, the Baltic Sea is contaminated from the pulp and paper industry—and from many companies, not just one. And, third, for quite some time there was a problem with the research on dioxin, as I mentioned. Scientists were concerned that we weren’t providing a good answer. 

SKAPP: Changing the subject: How does the rapid development of information about the human genome mapping impact your work right now?

MK: At different times in my career, my work has included research on genetics and on the techniques of molecular biology, and just this past year I’ve changed my opinion on the importance of these issues. I now think this research can help us do more conclusive studies, because the molecular epidemiology affects the evaluations of some of the committees—including the IARC committees. It’s extremely important for these committees to have mechanistic data. The second benefit of the advance of molecular biology—and not only of the genome—is that it helps those of us who do population research to better formulate our hypotheses. On the other hand, I think that there are also negative aspects related to a general distraction of scientists, government, and the public with these techniques. Without much scrutiny of what we may gain from their massive application—the gains are not immediate—much attention and money nevertheless go to genetics and molecular biology, which results in the abandonment of crucial areas of research. In the European Union, a serious problem is that the 6th and 7th frameworks [biomedical research programs sponsored by the European Union, Editor’s note] suggest that epidemiologists cannot lead any of the big multi-million Euro projects; we always have to be under a lab professional or a clinician. It’s a very serious situation.

SKAPP: Is it true that the molecular epidemiology studies at IARC are in the lab section?

MK: It’s complicated. There have been major reorganizations, and IARC seems to be losing responsibility for at least part of its main study—EPIC—a big collaborative corporate study of about half a million people. It will likely move to Imperial College, London, because the lead and collaborating PIs are not happy with how it has been handled at IARC, where there’s a lack of support for population-level research.

SKAPP: What are the issues regarding your work that keep you up at night?

MK: My concern about my adolescent sons!

In terms of work, the concerns are immediate issues related to my doctoral students, for example, rather than the long-term issues about how we do science and policy. I think a widespread problem is that we tend to take on too many things. Somehow we seem to voluntarily subscribe to some aspects of what we criticize about globalization: we are overworked as well as too fragmented and specialized. Interdisciplinary and collaborative work is shortchanged.           

SKAPP: What are the most important issues facing science related to occupational epidemiology?

MK: It depends on which part of the world you are talking about. In many regions, the main issue is how to take sufficient preventive measures to avoid having extreme work conditions (child labor, etc.). In industrialized countries, the problems are not so drastic, but the main issue is still how to apply our best knowledge and how to take different preventive measures. For the last 30 years, we have been extremely successful regarding occupational cancer and some of the respiratory diseases (e.g., asbestosis, silicosis, pneumoconiosis, Editor’s note). This work has been a big public health achievement and everyone who has been involved—the trade unions, the scientists, the governments—should be very proud. We have been much less successful in preventing other diseases, like occupational asthma, and accidents. We have very few ideas on stress-related issues in the workplace. I think that these are research priorities.

To give an example, I am doing work on occupational asthma among domestic cleaners. In the south of Europe, many of these cleaners are immigrants who are part of the underground labor market, and they tend not to go to doctors. As a result, asthma cases among cleaners are not identified in the surveillance systems. Our big population-based study finally confirmed occupational asthma in domestic cleaners. Specifically, rates of asthma are high among cleaners in Spain and we verified a similar pattern in many countries. Now the chest physicians see the occupational asthma in these patients. It was very important to do the occupational epidemiology in this very big, unregulated market.

SKAPP: And chest physicians need to be trained to look for the asthma.

MK: Exactly. We have a problem with a number of our surveillance systems. They are very important, but they capture only what we know, or what is generally accepted. So they can miss a big part of occupational diseases.

SKAPP:  Having watched the issue of the role of science in policy evolve over your career, how would you describe the state of the relationship today? Is this different in the EU than in the US, as far as you know?             

MK: I think it’s probably different in the European Union. For one thing, we don’t have federal research institutes, and this is a problem for us. Many of our professional organizations are relatively weak. The public health advocacy groups that we have are also weak. They’re not active and aren’t lobbying. So it is somewhat different.

However, it’s difficult to generalize about Europe as a whole. In the Scandinavian countries, which have a very engaged welfare state, the scientists are involved and there’s a rapid translation of science into policy. In the south, we benefit from the work in those countries, because of the European Union. Many of the policies that are applied here and throughout the Union reflect input from the Danes and the Swedes.

I think one problem is that EU policies are not as transparent as those in the US. You may not agree that you have transparent policies in the US, but the EU really does not promote transparent policies, so you don’t really know what is happening in committees, which are not open to the public. There is very little reporting. This is a very serious issue.

At the level of the individual scientist, there is little connection between science and policy. Here, it is difficult for many scientists to accept a role that might not be considered strictly scientific. This has an impact on some pressing issues that are not easy to solve and require input from scientists. For example, I have been working on the problem of incinerators in Spain. I have been advising ecological organizations, and in this capacity I have come before some of the parliamentary committees. The ecological organizations oppose incinerators for two reasons. First, they believe the incinerators are the main sources of dioxin exposure, and, second, they believe that promoting incinerators deemphasizes other, better policies for waste reduction. The ecological organizations don’t always accept the evidence from exposure studies on incinerators, which indicate lower exposures to dioxin than they expect. On the other hand, I think it is important to represent these organizations—to take their position, sign their petitions, etc. I can advise these groups as a scientist, and I can support them as a citizen concerned about political decisions.

The government asks certain questions as if they were scientific questions, when actually they are political questions, and sometimes we mix things up and try to respond to political questions using strictly scientific criteria. The real question is not whether the dioxin emission should be 0.1 nanogram/m3 or some other value. The real question is what we do with all the residues? The real question is whether we need a particular incinerator—or incinerators in general—as a means of waste reduction. Therefore I feel that the ecological organizations were right in putting forward a motion against incinerators, one that didn’t talk about the emission levels but focused on the fact that the government’s policies promote the destruction of the environment.

SKAPP: Why do you think your colleagues are tentative about engaging in the political questions?

MK: I guess for the same reasons as in the US. I don’t know what defines whether one is committed more, or less to issues that are important for the community. What would you answer?

SKAPP: Our academic culture says that you should focus on your methods and the validity of your results and that getting into a situation where you can be considered an advocate calls your methods into question.

MK: Absolutely.

SKAPP: In the US, there is concern about the role and influence of industry-funded research on universities. There is concern about the difficulties for scientists, particularly early in their careers, in working with environmental or ecological organizations because of the university hierarchy and the likelihood that they won’t advance if they are seen as being too much of an activist. Is that a reality in Europe as well?

MK: Yes, it is, but depending on where you are in Europe. Of course, there would be problems related to tenure if a scientist was thought to be following unscientific methods. Also, we have had many examples of scientists who took money from the tobacco industry and were thought to be doing research that was biased as a result. Many of these issues are unfortunately not discussed as much in many European countries as they are in the US. Most of the literature on this topic comes from the US, rather than from Europe. My Unit, which is the largest group on environmental health in Spain—and one of the biggest in Europe—doesn’t take industry money as a policy.

SKAPP: What would you say are the most important trends affecting the role of science in public decision-making?  Where do you see that going in the future?

MK: I’m not sure I know. As scientists, we have new responsibilities and have to be much more active in the public arena, because many governments have destructivepolicies. Many European countries had welfare states and at least some policies to prevent destruction of the environment, yet even these policies weren’t very aggressive. Now things seem to be changing away from regulation, more toward what we see as the American model. This change requires scientists to take on new responsibilities and getting more involved with the public issues. That’s where I see my role.

SKAPP: What do you see in young people?  Among your doctoral students and also young people more broadly, do you see support for that point of view, or more reluctance to engage in the political work?

MK: There is a tendency in many medical schools, particularly those in the south of Europe, to be very conservative. This was not always the case, but now we have fewer students from medical schools who are involved in public issues. Quite a few young people are very much involved in the public arena, but they tend to be from other schools—environmental sciences, biology, etc. It is a problem that we aren’t attracting medical students into public health. But I’m not sure what happens in the UK or in Scandinavia.

SKAPP: What about REACH [the proposed EU process for Registration, Evaluation and Authorization of Chemicals]? Is REACH something that you are called upon to give testimony about?

MK: This is an extremely important initiative and an example of a great activity at the EU level. But as you know, there are big changes coming in the European Union, so we’ll see whether REACH will survive, andhow much it will be applied. This is a crucial issue. In many of the EU countries, we had very progressive legislation and then much difficulty applying it because of lack of know-how. For example, about eight or ten years ago, with a socialist government in Spain, we passed a law to protect occupational health. This law has been extremely difficult to implement—because we didn’t have sufficient knowledge. The trade unions were not up to the job; obviously the industrial companies were not up to the job. It takes a long time to change things.

SKAPP: Was it a matter of resources as well, in terms of enforcement or inspections?

MK: Definitely, no doubt.             

SKAPP: Have you heard of the Union of Concerned Scientists’ statement expressing concern about political intervention in science? If so, what do you think of that statement? Are any of these “science integrity issues” that are of particular concern to you, or with which you’ve had direct experience? 

MK: We in Europe are less well-organized than you are and tend to have fewer initiatives of this type. As I said before, if you look at the scientific literature, many of these issues are discussed by North American scientists, not Europeans. I think it’s extremely important to fight back, because this is an extremely aggressive intervention from the government. We have to defend science from the direct political pressure that is present in the US and, to a degree, in Europe. The pressure affects young scientists. Many of our brightest students go into private sector—banks, stock markets, etc.—as a result.

Another problem which is perhaps equally dangerous is the problem of no action at all—of passive policies where the government simply does not promote science, or only specific areas of science. This has been the case in some EU countries. For example, we had a right-wing government in Spain for eight years, between 1996 and 2004. After the annual call for proposals, this government just didn’t give money for research for one year. This action—or inaction—requires a different type of intervention than opposition. It calls for a positive move to promote research.

In Europe, we probably have more of this problem—passive lack of action—than of aggressive dismantling of programs. We have situations where people are put on committees not necessarily because they are representatives of a specific industry, but because they are administrators in government. These appointments might be intentional, or just a result of incompetence by the administration to identify experienced persons. In any event the net result is that we have members of important committees in Spain and the European Union who are ignorant. I come from a country—Greece—that had a dictatorship from the extreme right, and I’m living in a country—Spain—that had a dictatorship 30 years ago. Under dictatorships, we experienced actions similar to those you’re experiencing in the United States—where the government puts in anyone they like. You seem to be going toward a situation where there is a regime of the extreme right. This is extremely dangerous, and undermines fundamental principles of fairness in democratic processes and research. It’s extremely important to fight back against this situation.

My own perspective on these issues comes from sitting on evaluation committees at IARC and at WHO. Such committees were not always as transparent as one would have expected. There were no policies to ensure that the public knew who was on the committee, or requiring that members sign a statement before they participated in a committee. This is changing. There are some new very positive initiatives at IARC, for example.

SKAPP: We are interested in your perspective on the issue of causal inference in the context of decision-making by governments and courts. What advice would you give to judges in the US who are charged with being gatekeepers who determine what science or scientific experts should be allowed to testify? If you were the President’s or the EU President's Science Advisor, what advice would you give about the sufficiency of the evidence base for decision-making by departments and agencies? 

MK: It’s different in Europe, where we have much less involvement and experience in court decisions. But I was involved with the first court decision for asbestos workers here in Barcelona. We won, which was surprising. I have very little experience aside from that. I know about the Daubert decision, but it’s difficult for me to judge whether this functions or doesn’t function in a setting and judicial system that I don’t know.

I think that the main issue is that the criteria that are used for many scientific organizations like IARC favor specificity rather than sensitivity, and these criteria are not exactly the same criteria that should be used in the court. Specificity criteria do not necessarily apply to decisions that are made by a government or a judge. There are other issues that have to be taken into account, like potential dangers of the future, and such issues can’t be answered with the same criteria as those used by IARC.

SKAPP: Are there such criteria articulated for judicial or for government decision-making that may not be appropriate for an IARC decision-making context but may be very helpful in a policy context?

MK: It’s very fortunate that EU commission approved the precautionary principle as an official policy of the EU. We also have REACH, and we have quite a few others based on the premise that information can be limited but still sufficient to justify reduced use of or exposure to a hazardous substance.

SKAPP: We’d like to wrap up with a question that you could answer from the professional or non-professional vantage point: What was the best advice you have received, and from whom?

MK: The most important advice I received was from a colleague of mine just after finishing medical school. This was just after the dictatorship and the junta in Greece, and most of the students were politically active. We wanted to become good clinicians—people who knew their jobs, did their jobs well, and worked for the people. Public health, for some reason, was not an option. One of my very good colleagues, Takis Panagiotopoulos, who is currently a professor of public health in Athens, went to the London School of Hygiene to do community medicine. He insisted that I visit and see what he was doing. I took a one-month leave and went to lectures, etc., and this was a turning point for me. In my training, I had never heard anything about class and other differences in health access and outcomes. After London, I decided that I didn’t want to focus on treating individuals, but instead address problems of populations—and that was when I decided to devote myself to epidemiology. Determining my career path? That was probably the most important advice I received from anyone.

SKAPP: Thank you Manolis. It has been fascinating to get a non-US perspective on these issues which are so prominent in public debate here.   

MK: My pleasure.