Harvard Public Health Review Winter 2007
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A Geographer of Health

Nicos Middleton
NEW FRONTIERS Epidemiologist Nicos Middleton, a research fellow in the HSPH-Cyprus Initiative for the Environment and Public Health, is studying the long-term health effects of traffic pollution in Boston and Nicosia, the capital of Cyprus.

Nicos Middleton is looking for the story behind the data. He focuses intently on his laptop as the screen fills with numbers, each one representing a resident of Nicosia, on Cyprus, the Eastern Mediterranean island nation where he was born and raised. Could poor air quality be to blame for sending these people to the hospital with heart or lung problems? For that piece of the puzzle, Middleton, a researcher in the Department of Environmental Health’s Exposure, Epidemiology, and Risk Program at the Harvard School of Public Health (HSPH), turns to his weather data files, tracking a source of the island’s airborne grit: sandstorms.

Environmental Health Snapshot
A few times a year, storms blow millions of tons of Saharan Desert sand across the Mediterranean Sea from North Africa to Cyprus. Middleton has documented this phenomenon’s impact on Cypriots’ health, but the infrequency of the storms and Nicosia’s tiny population of around 200,000 complicate his quest for statistically reliable results. To strengthen his analysis, Middleton is on the hunt for evidence of additional storms. He’s retracing the origins of air masses that reached Cyprus on days when high levels of particulate matter were recorded, and then digging through paper records from the Meteorological Services to help confirm his suspicions. It’s all part of an environmental health snapshot that he and his colleagues in the HSPH-Cyprus Initiative for the Environment and Public Health are creating for the island, a hub of commerce that sits in a geopolitically pivotal spot at the crossroads of Europe, the Middle East, and Africa.

Wheezing Map

It’s been well established in the United States and Europe that excessive exposure to fine particles in the air, be they from sand, traffic, or industrial pollutants, contributes to respiratory and cardiovascular health problems that can lead to premature death. But according to Middleton, the effects have never before been studied in Cyprus. With heart and lung diseases now the leading causes of death in the country, and childhood asthma rates rising, particularly in congested areas of Nicosia, the HSPH-Cyprus Initiative is building scientific evidence that will have an impact on public health policies. Its programs also aim to boost research capacity in the Eastern Mediterranean in order to address a range of complex problems, from air and water pollution to workplace safety and tobacco control. The Initiative, a partnership between HSPH and the government of the Republic of Cyprus, comprises research centers in both Boston and Nicosia.

The Initiative’s work inspired Middleton, 32, to come to HSPH in 2005 for a training fellowship after 10 years in England, where he studied medical statistics and secured a tenure-track position at the University of Bristol. As an epidemiologist there, his research included studying the long-term impact of children’s diet, growth, living conditions, and health on their later development of heart disease and cancer. Much of his earlier work focused on suicide rates in the UK, calling attention to the high rates in the most urban and rural areas.

In the spring of 2007, Middleton transferred from HSPH to the Initiative’s center in Nicosia to complete his fellowship and teach graduate-level epidemiology. “As a Cypriot scientist living abroad for all these years, I wanted to do research in Cyprus and work with Cypriot data,” he says. “It’s rewarding to feel that you’re contributing to research in your own country, especially when not much has been done.”

Environment and Risk
While Middleton is new to the study of the physical environment’s impact on health, he has long been fascinated with the ways in which people’s physical and social environments determine the quality and quantity of resources available to them and consequently influence their health-related behaviors and risk of disease.
“Socioeconomic differences are the things we definitely know largely explain health inequalities,” he says, “but I’m also keen to look at other characteristics of neighborhoods where people live and work that might affect their health.” Examples include their proximity to parks and shops, whether they live in high-rise apartments or suburban homes, and how easy or hard it is for them to come by fresh food or health care.

It was in England that Middleton first encountered the pervasive influence of social class. “There, growing up on the right or wrong side of a street really matters when it comes to what school you attend, who your friends are, what sort of job you’re likely to have, where you spend your holidays,” he says, his animated gestures revealing the Mediterranean behind his refined British accent. “Class affects opportunities you have and the choices you make in life—which in turn greatly affect behaviors like smoking, diet, exercise, and how often you see a doctor.”
“We’re beginning to understand that the social environment plays a role in how people react to the physical environment,” said Douglas Dockery, HSPH’s chair of Environmental Health and one of Middleton’s faculty mentors. “Nicos brings a set of skills and talents that can help us develop this perspective.”

Middleton currently has three projects underway. In addition to linking air quality to hospital admissions, he is investigating the connection between living on or near main roads and the prevalence of asthma in Cypriot schoolchildren (see map above). This project is in collaboration with HSPH Professor of Environmental Sciences Petros Koutrakis, who directs the Initiative’s Harvard-Cyprus Program in Boston. Middleton is also exploring the long-term effects of traffic pollution in Greater Boston. His study builds on the work of Joel Schwartz, HSPH professor of environmental epidemiology, one of the first scientists to link minute particles of black carbon from motor vehicle exhaust and other sources to elevated death rates. For this study, Middleton is using a new statistical model developed by his department colleagues, one that estimates more accurately than ever before variations in particulate levels among households.

But analyzing the data is just the first step, Middleton says. “Once you identify an area with a problem, the point is not to just stick a pin on a map. You need to do something about it.”

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Amy Roeder is the development communications coordinator for the Office for Resource Development at HSPH.

Photo, Kent Dayton/HSPH; banner illustration, Peter Horvath; Wheezing map, courtesy of Nicos Middleton

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