Philippe Boucher's Rendez Vous Annie Sasco
Rendez-vous with Annie Sasco
By Philippe Boucher
Thursday, March 30 2000
Chief of the Unit of Epidemiology for Cancer Prevention at the International Agency for Research on Cancer (IARC), World Health Organization (WHO) in Lyon, France
Thank you Annie for accepting our rendez-vous.
May I ask you to introduce yourself ?
I am currently Chief of the Unit of Epidemiology for Cancer Prevention at the International Agency for Research on Cancer (IARC), World Health Organization (WHO) and Director of Research at the Institut National de la SantÈ et de la Recherche MÈdicale (INSERM). The Unit I am responsible for is located within the IARC in Lyon, France.
The title of my Unit, which I chose, describes exactly what I always wanted to do. Since the age of 4 1/2, I wanted to be a doctor, in order to help people and since the age of 12, to work for WHO to have an impact on the health of the world population. In many ways these childhood objectives are partly fulfilled.
But lets' go back on what happened up to now.
Born in a Basque traditional family, I fought all my life long and still do to demonstrate that women may be at least as good as men, although they do not yet receive equal recognition in many parts of the world, including France. I went to medical school at the University of Bordeaux. I loved clinical work and dealing with patients, in particular in obstetrics. Yet, I decided to go into public health because I wanted to deal with populations at large, in all parts of the world and not be limited to clinical practice. This was a difficult choice as I missed and still do the rewards coming from satisfied patients. Statistics do not have this warm feeling. In order for my public health activity to be efficient, I followed many specialized courses and got many degrees in preventive medicine, public health and hygiene; occupational health; spatial and aeronautical medicine, social medicine, sociology and human sciences applied to work, ergonomy, informatics. At the same time, I was preparing my MD thesis, under the directorship of Professor Paul FrÈour, one of the pioneers of the fight against smoking in France. My research topic was the evaluation of the efficacy of a smoking cessation clinic in Bordeaux. This thesis defended in July 1978 was at that time one of the very few MD theses dealing with smoking cessation. I owe Professor FrÈour my sense of the crucial importance of fighting tobacco if health of the population is our goal. For this, I remain much indebted to him. At that time, I had already realized how difficult it would be to get efficient further training in France. This is when I decided to go to the States and of course why not to Harvard. I was accepted in the Master of Public Health program but my problem was to get funding. I applied to several scholarships but soon realized that my chances of getting one were slim. As a high level scholarship official told me in France: "We prefer to give scholarships to surgeons to allow them to learn new techniques or to basic researchers but public health is so vague ..." Fortunately, I am incredibly stubborn, and sometimes lucky. In April of that year, were held, as they are each year, the "entretiens Bichat", a meeting for MDs. In 1978, they were opened by the then President of France, Valery Giscard d'Estaing.
He had the great idea to say how important public health was.
I immediately wrote to him to explain my situation and described to him the difficulties of getting good training in this field.
Some time later, I was awarded a scholarship from the MinistËre des Affaires EtrangËres to go to Harvard. Instead of staying there just one year I finally stayed five, getting 2 Masters (MPH and MS in Biostatistics and Epidemiology), and finally in 1986 a Doctor of Public Health in the field of Epidemiology, benefiting after the two years of French scholarship of three years from the Victor Emmanuel Chapman Memorial Fellowship from Harvard University. My years at Harvard were the best in my life. I learned a huge amount and felt appreciated and recognized.
I had the best teachers in Epidemiology, such as Professors Miettinen or Hutchison, in Biostatistics such as Professor Drolette, and also in Behavioral Sciences, such as Professor MacAlister. I learned there the tools I needed in my work and the self-confidence crucial for pursuing my task. I returned to France in 1983 and have been since then at IARC, working, as an INSERM scientist, first in Biostatistics and then in Epidemiology.
Since 1995 I head my own program, which became an independent Unit in 1998. During all these years, from 1976 to now, tobacco has been one of my constant fields of research.
First question : in a recent article in a French medical journal was presented a study you supervised on school kids and smoking. Can you tell us about it? The procedure, your partners, the results?
The data which were presented refer to preliminary results of a still on-going study, for which final results will only be available in 2001. The only reason some results came out was because I wanted the adolescents who had been followed for more than 6 years now in three schools and will be dispersed next year in various universities to get results before they leave their current schools.
The only time I could do so was during this school year and that's what I did.
The program was conceived back in 1993 by Gilles Freyer from the Association de Lutte Etudiante contre le Cancer (Student association for the fight against cancer) (ALEC). Martine Jambon, the founder of the ALEC a then law student asked me to take full responsibility for the scientific evaluation of the program to be started: le Projet pour la Vie (Project for Life).
The program aimed at following-up adolescents from the age of around 11 to 18, offering them each year for seven years health promotion programs on topics such as smoking, drinking, substance abuse, general hygiene, nutrition, sexuality, contraception, etc. One or two surveys each year were conducted in 2 schools where health promotion activities were carried out, one by student volunteers, built up around the peer-effect and one led by teachers.
In parallel, surveys were conducted in a control school where no action was carried out. The data collection is now being completed corresponding to surveys in the last school year. Analyses will then be carried out on the complete data set and results published, hopefully in 2001. For the time being, only preliminary results for the first five years of the study are available. Overall, they show clear increases with age in most deleterious habits such as tobacco smoking, alcohol use, illegal substance abuse, lack of physical exercise, etc.
2. A few days after this article were published the results of a much bigger (in size) survey managed by the Institute for Health Research (Inserm). I think the results are comparable, in the sense that both surveys show a growth of smoking among the youth. One of the researchers was quoted as being surprised by this growth. What about you?
Unfortunately, I cannot be surprised by the increase in smoking and substance abuse. For a long time, part of the decline we saw in France in the national statistics among 12 to 18 year-olds was mostly a reflection of a decline among the very young, with a later entry into smoking.
Figures from age 14 and especially 16 to 18 are exceedingly worrisome.
They clearly demonstrate the failure of preserving the health of French adolescents.
3. Beside being surprised the Inserm's researcher did not offer any other comment except for waiting for the next survey, 4 years from now. Your attitude seemed quite different since you were quoted as pointing the discrepancy in France between the political talk and the reality: a lot of talk about prevention and tobacco control but nothing done for school programs, no money for school based tobacco control programs.
How do you explain the lack of involvement of most of the French researchers in tobacco control advocacy? Don't they care about this epidemics? Do they consider themselves pure spirits without any political responsibility?
The classical and strongly encouraged attitude for French researchers is to provide results, present scientific findings, but never get involved in what follows.
My own philosophy is different. When means are limited, experts few and problems big, I personally think it is legitimate to make sincere efforts in translating scientific knowledge into effective public health action.
In this regard, I tend to behave as Dr Wynder did in the USA.
The first one to ever publish a case-control study on lung cancer and smoking, back in May 1950, he devoted his whole life (16 hours a day, 7 days a week) to epidemiologic research and active health promotion.
My objective is similar.
As far as I am concerned, I do not wish to separate out my actions as a researcher, as an MD, from the ones as a woman, a mother and a concerned citizen wishing to build a better world.
4. It seems to me the researchers in English speaking countries are much more ready to jump into the public debate about tobacco control while in France they keep very much silent. Is that because there is so little research done anyway? Or most of them smoke?
What happens when you speak out and rock the boat? Are you getting ostracized? Do you foresee any chance of an evolution? How long will it take?
I do not have lessons to give to others. Every one should do the way they see as being right for them. Yet I suffer for being too active. This is clearly not the best way to ever get a University position at least in France, nor probably any other big professional success. What's worse is that one then gets criticized, on one side by fellow researchers judging you too involved in action and on the other side also by activists, judging you too shy. It is very frustrating and discouraging. Although I still dare to hope things may evolve, and important changes have already occurred for example within WHO with the advent of a new director, I have a much greater skepticism regarding France.
5. Looking at the public funds devoted to tobacco control in France one sees a substantial increase in the last two years because the starting point was so low: from 4 million dollars in 97 the budget grew to $ 8 million in 98 and supposedly $ 20 million in 99. But as you noticed almost nothing for school programs and if one compares with the amounts invested in the US this is still very little: the State of Washington for instance, also plans to spend
$ 20 million but considering its population it's ten times more per capita than in France. Are things better at the European level? Or are tobacco control budgets still very low compared to the magnitude of the problem?
The funding situation is currently catastrophic in France. Although both governmental and non-governmental groups talk a lot about prevention, their budget lines are ridiculous. If we really want things to change, money has to be put in it. Large funds go to the genome project. If we want to advance prevention, then epidemiology and public health should receive similar funding. Currently this is not the case and unfortunately will not be so in the coming 2 to 3 years. In other European countries, situation tends to be better in Nordic rather than southern countries. Huge efforts are still needed everywhere.
6. Do you have anything else you would like to add ?
We can all do something for health promotion. It requires good will, hard work and willingness to share efforts. No one can pretend to have the perfect solution. We all have to work on it.
Thank you Annie for taking the time to be with us today.
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Cyberjournalist Web Consultant 9424 Windsong Loop Bainbridge Island, WA 98110 USA e-mail: boucher@globalink.org
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Prepared by Philippe Boucher mailto:IslandErsk@aol.com
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