History By Sylvia Wassertheil-Smoller, Ph.D., F.A.C.E., F.A.H.A. Sylvia Wassertheil-Smoller, Ph.D. Medical School departments don’t exist just in their own professional world. They exist in the context of the culture of their medical school, which in turn exists in the broader cultural milieu of the society at a given point in time. And so it is with our Department, which has been variously named in reflection of the priorities of the times. I would like to give you a brief history of the department and its metamorphoses — its evolution really, along with some personal reminiscences. The precursor to the current modern Department of Epidemiology andPopulation Health, was known as the Department of Preventive and Environmental Medicine and its first Chairman was the founding Dean of the College, Dr. Marcus Kogel. That name given to the Department in 1955 surely reflected the emphasis that the faculty and its Chairman Dean Kogel wished to convey -- teaching and research in prevention and health promotion. Programs of instruction in those early years included the traditional epidemiology and statistics, some material on the organization of health services and most particularly "environmental values and hazards in man's natural habitats". In 1960, Dr. Leonard Greenberg, an expert on environmental and occupational medicine, assumed the Chairmanship. Over the following six years, Dr. Greenberg and Dr. Herbert Schimmel engaged in a number of important air pollution studies under a grant from the United States Public Health Service and in cooperation with the Department of Health of the City of New York. This series of epidemiological studies clearly demonstrated the relationship between air pollution, morbidity and mortality in the city and most certainly contributed to the development on a national, state and local level, of significant environmental control legislation and regulation. With the retirement of Dr. Greenberg and the assumption of the Chairmanship in 1966 by Dr. Martin Cherkasky, the goals, program and research of the department changed significantly. Dr. Cherkasky, as Director of Montefiore Hospital, had a long-standing major interest in social medicine -- reflected in the numerous innovative community programs sponsored by the Hospital. Important both symbolically and as a response to the new programmatic emphasis, the department at that time was renamed the "Department of Community Health". When I first came to Einstein in 1969, the summer of Woodstock, the summer when man first landed on the moon, the Department was known as the Department of Community Health. These were the days when students were activists whose goal was to improve society. I was hired by Dr. Cherkasky and Mr. Herbert Lukashok, and they made me feel the Department "was going places". And it was. There was a major expansion of the Department which began in the fall of 1969, and included recruitment of Dr. Chuck Arnold an epidemiologist, Dr. Steven Jonas, and Dr. Raymond Lerner. Jutta Zankl, was the departmental administrative secretary and continued in that role over many years. Those were heady days. This was the time, in the late sixties and early seventies, when major institutions, including medical schools and hospitals, were mobilized to address the serious problems of poverty in urban ghettos and in the rural areas of the nation. Major grants from the Rockefeller, Milbank and Commonwealth Funds provided resources for the department to develop new educational programs for students directly relating to health problems in the urban core. Curriculum changes reflected new program initiatives designed to improve the health of the minority populations of the Bronx. Students spent a significant amount of time in field placements in the Bronx - mostly in Family Health Centers operated by the School and Hospital. Teaching was an interesting and sometimes difficult experience in those days — when students mounted strikes of classes they didn’t like, held sit-ins at Dean’s offices, and called professors by their first name. Actually, that was flattering — when a student called you by your first name, it meant you were in — you were not part of the enemy force, and so I was honored when that happened the first time. But the big word was "relevance" — and most students (and faculty) thought biostatistics and epidemiology were not relevant to the problems of society, and so my own specialty was held in rather low regard. Our Department as a whole, however, was at the forefront of dealing with social issues. Dr. Jonas was the Medical Director at Morrissania; Lincoln Hospital, with its turbulent politics and deep social problems, was in the Einstein orbit; Dr. Lerner established the Bronx Information Project so that we would know the demography and needs of the Bronx; Dr. Mildred Morehead, a pioneer in the evaluation of quality of care of hospitals, established systems for improving that quality, and Drs Arnold, and Lerner and I worked on an epidemiological project that had political implications. Around that time New York State was poised to pass a law allowing abortion. It was widely thought that it would be de facto useless since most gynecologists would not perform abortions. We did a statewide survey of all obstetrician/gynecologists which showed that around 90% would either themselves perform or refer a patient to someone else who would perform an abortion. Our survey was brought to the attention of legislators and perhaps had an impact. The law of course passed, and I wonder how many young people today can imagine what it was like when abortions were illegal. When William Glazier assumed the Acting Chairmanship of the Department in 1971, the programmatic emphasis of the previous years continued. He defined the role of the Department of Community Health to be "a concern with those social, economic and environmental factors which impinge upon and affect the health status of the individual and the community in which they live". Programmatically, the department provided support and technical assistance to school-wide efforts to develop primary care and health manpower initiatives. Mr. Irving Lewis joined the department at around that time, coming from a government post in Washington. He brought a public policy and economic perspective to the work of the department and his wise counsel was held in high regard over the time of his tenure at Einstein. As I noted at the beginning, a medical school and its departments are placed within the context of the larger society, and society at that time was not yet revolutionized with regard to women. At the Einstein Campus, I was only the second woman to join the full-time faculty in our department; Mildred Morehead was in our department from its inception. But these were still times when I would be asked to get coffee, not in any way because of any sexist bias — it most certainly was not anything at all conscious — but rather it was an absent-minded sort of thing; it was just taken for granted that a young woman gets the coffee, or runs the errand. I did not mind that at the time, was even unaware of it, until on one occasion which I remember so clearly, Dr. Chuck Arnold, who was my age, put his hand on my arm as I started to get up from the conference table, and said quite deliberately, "No, sit down, I will do it". A truly liberated man for his time! It should be noted however, that in the intervening years, our department had six full professors who were women, a superb record in the medical school. Michael Alderman, M.D. and Jutta Zankl Meanwhile, on the West Campus, in the mid-sixties, with the establishment of the formal affiliation between the College of Medicine and Montefiore Hospital, the Department of Social Medicine at Montefiore became an academic department of the College parallel to the Department of Community Health at Einstein, with Dr. Victor W. Sidel as its Chair. Though the departments remained separate until 1984, one policy governed appointments and promotions. There was a unified medical student teaching program and close collaboration on overall program planning and activities. Under Dr. Sidel’s leadership, the department became a strong advocate for underserved and underprivileged populations. The Department embarked on international health programs, with Dr. Roberto Belmar, and union health programs, prison health service and other community health programs, such as the Methadone Treatment Program directed by Dr. Ernest Drucker. Dr. Drucker became well known in research and in programs for substance abuse; Dr. Nancy Dubler initiated a law and ethics program and pioneered clinical applications of ethical principles with "bedside consultations" at Montefiore. Dr. Sidel, became internationally known as President of the American Public Health Association, President of the Physicians for Social Responsibility, and a leader in other organizations devoted to promoting public health and social justice. A notable member of the Department of Social Medicine was Dr. Steven M. Safyer, whose pioneering work on Riker’s Island Prison resulted in various reforms. We are proud to say that he went on to become President and Chief Executive Officer of Montefiore Medicine from 2008 to 2019. Back on the East Campus at Einstein, Herbert Lukashok became Acting Chairman in 1975. For the next nine years he led the department with unparalleled grace. A true scholar and a gentleman, in his unassuming and principled manner, he brought people together, resolved differences and showed respect and compassion to students, faculty, staff. Under his leadership, a Health Psychology program was initiated jointly with the Ferkauf School under the direction of Dr. Gil Levin, and after he retired, Dr. Charles Swencionis. Students from Ferkauf worked on the research projects of our faculty and many do their dissertations under the supervision of Department faculty. One of the star graduates of that program, Dr. Carol Morgan, joined the Department upon her graduation and developed a program in cancer education. After her untimely death, Dr. Alyson Moadel-Robblee assumed direction of that program in our Department and greatly expanded it. Herbert Lukashok also laid the groundwork for a major activity in Bioethics at the College with the recruitment of Dr. Ruth Macklin, who is internationally known in the field and who brought great stature to the department and the medical school which nurtured her activities. Times were changing and epidemiological research was becoming more relevant to the students, and the research endeavors in our department were becoming more collaborative with other departments. My own major research activities in the latter part of the 1970’s and early 1980’s were originally in collaboration with Dr. Donald Blaufox, then Chairman of Nuclear Medicine, and included the landmark Hypertension Detection Follow-up Program (HDFP) and its multiple successors, such as TAIM (the Trial of Antihypertensive Interventions and Management), and SHEP (The Systolic Hypertension in the Elderly Program) -- randomized clinical trials concerned with the treatment, control, and public health aspects of hypertension. Clinical trials research in multi-center, collaborative studies became the primary focus of my own research, and my experience and involvement with the major hypertension trials of these decades led to my later work in stroke epidemiology, including the genetics of stroke as part of the International Stroke Genetics Network. Cardiovascular disease epidemiology constituted the major part of the Department’s research efforts during these years and this included diabetes research and health promotion. Dr. Roger Mazze joined our department and worked with the beloved Sam Rosen in the area of diabetes. When Dr. Judith Wylie-Rosett joined our department in the 1980’s, she launched a major effort in nutrition, both in teaching and research. Initially, the areas she worked in were nutrition and cancer, in collaboration with Dr. Seymour Romney and the Department of Obstetrics and Gynecology, and subsequently, up to the present, in diabetes, obesity, and cardiovascular disease. She has been a leader in nutrition and health promotion in the major diabetes prevention trials, in demonstration and evaluation projects in obesity treatment, in nutrition curriculum development and in dietary interventions in the Womens’ Health Initiative along with Dr. Mossavar-Rahmani who is a nutritional anthropologist and who has developed her own area of research in metabolic markers of nutrition. Dr. Jonathan Tobin joined our faculty in the 1980’s and expanded our departmental collaborations to neurology in his work on the Bronx Aging Project and the Teaching Nursing Home project, along with work in health services research on gender bias in referral patterns for cardiovascular disease diagnostic procedures. This work was carried forward by Dr. Janice Barnhart who looked at non-clinical factors in diagnostic and treatment decision-making in cardiovascular disease. Thus, the work of the Department was integrated with the mission of other departments and the inter-departmental collaborative model was firmly established. In September of 1984, Dr. Michael H. Alderman became Chairman of a newly unified department -- combining the Department of Community Health at the College with the Department of Social Medicine at Montefiore. The name of the new, unified department became the Department of Epidemiology and Social Medicine, reflecting the blend of scientific purposes and philosophical goals. Dr. Alderman led the department for fourteen years, and during his tenure, the department expanded both on the East Campus at Einstein and on the West Campus at Montefiore. The choice of a clinical epidemiologist to head the department was consistent with the prevailing view of the College that research and training in epidemiology must be the primary focus of the newly unified department. Dr. Alderman has described epidemiology and its quantitative science biostatistics as "the basic sciences of clinical medicine" -- reflecting his belief that clinical epidemiology provides the scientific basis for the practice of personal encounter medicine. Therefore, the primary initial goal of the new department was to establish a strong, academically credible research and teaching activity in clinical epidemiology in the department and throughout the College of Medicine. Dr. Alderman was able to unify the diverse department and earn it a high degree of respect throughout the medical community. This new direction certainly did not imply a diminishing interest in community health. Rather, it demonstrated the strong belief on the part of the Chairman and faculty that a solid base of epidemiological and health services research was the most effective way for an academic department in a medical school to address the health problems of its community. I should say that this view was not unanimously accepted, and there was initially a perceived tension between the objectives of focusing on immediate social problems and engaging in epidemiological scientific research, a tension, that I believe Dr. Alderman dispelled by his leadership and genuine interest and commitment to public policy issues as well as to scientific rigorousness (but a tension that was re-visited when Dr. Alderman stepped down in 1998 and I assumed the Interim Chairmanship). During Dr. Alderman’s tenure as Chair, our teaching program grew and under the direction of Dr. Paul Marantz, became highly respected throughout the College and well-liked by the students. Dr. Marantz further expanded our teaching mission by starting the 2 year Master’s in Clinical Research Program for Physicians. This master’s program is state-certified and highly successful. Dr. Marantz received a federal grant to expand and continue this program. Our department embarked on a great deal of teaching to medical students in a first year course, as part of case-conferences in subsequent years, and in the Master’s program. The emergence of AIDS, other sexually transmitted disease and more recently TB, as major threats to health in the inner city provoked the rapid development of research and demonstration projects led by Department members at Montefiore. Dr. Ellie Schoenbaum began major programs in the epidemiology, prevention and treatment of AIDS and recruited faculty in this area, including Dr. Mayris Webber, who has addressed psychosocial and health care issues. At the same time, social scientists in the Department contributed substantially to the evolution of National Health Policy in this arena. Dr. Peter Arno headed major and important efforts focusing on economics and health policy, particularly in relation to the race and social class disparities in health and access to care. As science advanced, epidemiology was becoming more collaborative with the basic sciences, and Dr. Gloria Ho, who came to Einstein from Johns Hopkins, initiated a new direction in our department: molecular epidemiology. Together with Dr. Robert Burk, an expert in molecular biology whose laboratory studies the genetics of human papillomavirus and more recently the role of the microbiome in cancer, she made seminal findings regarding the transmission of the human pappillomavirus and the identification of viral subtypes which posed greatest risk of cervical cancer. Janice Barnhart, M.D. Dr. Alderman’s own main research interest has been in the epidemiology of hypertension and the determination of risk factors in the prevention of cardiovascular disease. Prior to arriving at Einstein, Dr. Alderman founded and directed the pioneering Worksite Hypertension Control Program which continued to be an integrated effort for hypertension and hypercholesterolemia intervention maintained by a union-sponsored, occupationally-based program in New York City. Dr. Alderman, during and after his role as Chair, has been a leader in major collaborative multi-center clinical trials of hypertension treatment (e.g., ALLHAT) and in other national clinical trials in cardiovascular and diabetes risk reduction modalities. He has also served as President of the American Society of Hypertension and editor of the American Journal of Hypertension, and is considered an "opinion leader" in this field. During this time also, our department served other departments and centers within the College in providing statistical and epidemiological expertise, and we were helpful in the successful grant applications for the NCI-designated Cancer Center and the General Clinical Research Center, as well as for ongoing consultations and collaboration with those centers. My own research also continued to flourish during Dr. Alderman’s stewardship. Together with a multi-disciplinary team both from within and outside of our department, notably Obstetrics/Gynecology and Medicine, we became a clinical center for the Women’s Health Initiative, a 40-center, national study of 160,000 women, consisting of a set of interrelated clinical trials and an observational study of postmenopausal women to address the prevention of heart disease, cancer and osteoporosis, as well as Alzheimer’s disease and other health problems of aging. This study has reported important results from one of its components, which affects millions of women and has changed medical practice. The randomized, double-blind, clinical trial of estrogen plus progestin versus placebo was halted three years before the scheduled completion in 2005, on the recommendation of the Data and Safety Monitoring Board, because women in the active treatment group had more breast cancer, heart attacks, strokes and blood clots than women in the placebo group and the overall risks exceeded the benefits. Women receiving these hormones also had twice the rate of dementia as women taking placebo. Other parts of the Women’s Health Initiative continued as planned, and follow-up of all WHI components is continuing still, with over 26 years of active follow-up to-date. In addition there are about 600 ancillary studies to WHI which have been funded or approved, using the rich genetic, biologic and phenotypic data resources and obtaining additional data in the areas pursued by the ancillary studies. In 1998 I became Interim Chair of the Department and Dr. Ellie Schoenbaum at Montefiore became the Interim Vice-Chair. The stated research mission of the Department was to design and implement translational research in three phases: translation of basic science discoveries to clinical studies; translation of clinical studies to population-based studies; translation of population-based findings to health services delivery applications and public policy issues. Our educational mission was to train future physicians who can critically evaluate the medical literature and future investigators who will create that literature. It was during this time that Dr. Robert Kaplan joined the Department and went on to develop major programs in cardiovascular disease epidemiology. His research includes studies to clarify risks of cardiovascular complications of long-term HIV infection and its treatments and he is a leading member in several consortia on the genetics of cardiovascular disease. Even though I was Chair for just two years, it was during a critical time in the history of the Department. As the search for a permanent Chair proceeded, there was talk of splitting the Department again and absorbing the Montefiore component of our department into Family Medicine and keeping the Einstein part as a pure Epidemiology Department. Our faculty did not favor that, but there was a concern on the part of Montefiore administration that it would be difficult to find a Chair to lead such a diverse department. Some candidates who had come for consideration were either not acceptable to one side or to the other. I was very opposed to such a split because I believed our Department was unique in its broad scope and its activities ranged across the whole spectrum of issues relating to the improvement of health among all people. We had a communality of purpose and a collegial affinity and I believed that cutting off a whole arm would be going backwards. Happily, we were able to keep this from happening. Ultimately, we were fortunate in recruiting the current Chair of the Department, Dr. Thomas Rohan, and so the Department remained unified under the name of Department of Epidemiology and Social Medicine. Dr. Ellie Schoenbaum was the Vice-Chair on the Montefiore Campus. Dr. Thomas Rohan became Chairman in the spring of 2000. He came to Einstein from the University of Toronto Faculty of Medicine, with a distinguished research career with special focus in cancer epidemiology. He also became Associate Director for Population Sciences in the Albert Einstein Cancer Center. He is Principal Investigator of a number of collaborative studies in cancer, and editor of an important book on Precursors of Cancer. Shortly after his arrival at Einstein, on 9/11/2001, New York City and the world were shocked by the terrorist attacks on the World Trade Towers. I am sure that every person in the U.S. remembers exactly where he or she was on that fateful morning. I was in Washington, D.C. for a meeting of the Women’s Health Initiative Steering Committee at NIH. When I saw the first plane hit the first tower on the TV as I was about to leave my hotel room, I thought how foolish it was of these small planes to fly so low as to hit a building. It was only in the cab on the way to the NIH Campus that I heard on the radio what really happened and that another airplane had hit the Pentagon. My instant thought was — we are at war. And indeed we were at a different kind of war and life as we knew it changed. Do people still remember how it used to be with no security checks in buildings; what it was like to get on a shuttle to Washingon or Boston as if it were a local bus, without having to take your shoes off to pass through an airport scanner? How distant those days seem. In our Department, Dr. Charles Hall became the lead statistician for the World Trade Center (WTC) Health Program at the Fire Department of the City of New York. He studies the health effects of the exposre to the World Trade Center disaster and has been PI on several Cooperative Agreements funded by NIOSH that examine respiratory disease, cancer, and mortality in WTC rescue/recovery workers. Dr. Rohan initiated a large expansion of the Department, with recruitment of new faculty in the areas of biostatistics, diabetes and cancer epidemiology and prevention. Our involvement in cancer research grew substantially. Dr. Howard Strickler, who came to the Department from the National Cancer Institute, became the leader of the Cancer Epidemiology Prevention & Control Program at the Einstein Cancer Center, and he studies the viral causes of cancer and the hormonal and growth factor influences on viral pathogenesis and tumorigenesis. A new Division of Biostatistics was created with Dr. Mimi Kim as the Head, which now has 20 doctoral or master’s level statisticians who develop new statistical methods to deal with the increasingly complex problems encountered in “big data” situations, and who collaborate with numerous departments. The Biostatistics Division is central to the school’s research mission. Dr. Xiaonan (Nan) Xue, is the Director of the Biostatistics Shared Resource which serves the Einstein research community. The division has grown to include a major genetic analysis capability under the direction of Dr. Tao Wang who is the Director of the Genetic and Genomics Data Analysis Unit. New faculty also joined our department on the West Campus. Dr. Bruce Rapkin joined our department and was based initially at Montefiore, as head of a new division called Community Collaboration and Implementation Science. He brought with him another member of his team Dr. David Lounsbury, a community psychologist and a psycho-oncologist with expertise in systems science methods. Dr. Tia Powell became the Director of the Montefiore Einstein Center for Bioethics, focusing on bioethics issues in public policy, dementia, mediation/consultation, end of life care, and bioethics education. Margie Salamone, Celeste Broquadio, Minerva Manickchand, Elizabeth Abbate, Yolanda Cassidy (from left) In keeping with our wider focus, shortly after Dr. Rohan became Chair, our name was changed to the Department of Epidemiology and Population Health. During this period we were awarded a large grant from NHLBI for a landmark and unprecedented, multi-center study of the health status of 4,000 people of Hispanic/Latino origin in the Bronx,called the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Dr. Robert Kaplan is PI of this study, with myself and Dr. Carmen Isasi being Co-PIs. The HCHS/SOL now has 21 ancillary studies encompassing psychosocial, cognitive, and biomarker studies as well microbiome and genetic studies in many different areas. Dr. Isasi is interested in life-course effects of socio-cultural and biological aspects of diabetes and cardiovascular disease across the lifespan. Also during this period, Dr. Phillip Castle joined our Department, bringing an impressive record of global research in HPV and cervical cancer. He recently left Einstein to become Director of the Division of Cancer Prevention at the National Cancer Institute. In keeping with the rapidly increasing scientific advances of our times, our department now encompasses research that employs many of the “omics” technologies, including work in genomics, proteomics, metabolomics, and the microbiome, brought forward by Dr. Qibin Qi whose research focuses on multi-omics, in relation to obesity, diabetes and cardiovascular disease. Currently, in 2020, the Department has over 50 full-time faculty with primary appointments in the Department grouped into 4 Divisions, (Biomedical and Bioethics Research Training led by Dr. Tia Powell; Biostatistics led by Dr. Mimi Kim; Epidemiology led by Dr. Howard Strickler; and Health Behavior Research & Implementation Science led by Dr. Judith Wylie-Rosett), as well as numerous additional faculty with secondary appointments. An important part of the department is the Epidemiology Informatics and Study Management Unit (EISMU), with Mindy Ginsberg as its Director. This unit specializes in the development of comprehensive web-based Study Management Informatics Systems which administer study protocols and monitor all phases of single center and multi-center research studies and clinical trials. An additional notable program and affiliation is the Department of Outcomes Analysis and Decision Support at Montefiore Medical Center, headed by Dr. Eran Bellin, a Professor in our department. Dr. Bellin works with systems pertaining to the electronic medical record (EMR) which is becoming increasingly important to researchers. Throughout several Chairmanships, the Department was administratively supported for many years by Merrily Calabrese, and then the Unified Department was supported first by Paul Meisner, and now by Paul Toth and his team. In the past 50 years the field of epidemiology has vastly changed. From the days of Fortran programming and punch cards to PLINK; from simple t-tests to machine learning and sophisticated programs for gene sequencing data; from single institution studies to multi-center collaborations to consortia of multi-center studies, and even consortia of consortia; from studies of a few hundred people to thousands, and hundreds of thousands as in the UK Biobank, or even millions, as in 23andMe, we are in the era of big data, open science, and global collaborations. Our faculty are involved in international studies and collaborations all across the world. Sadly, progress in addressing disparities in the social determinants of health has been much slower. The new, intensified conversations about the injustices of racial discrimination, conversations which are probably universal in academia, are wrenching but perhaps also a hopeful sign that some changes may be made. Our Department is committed to addressing such disparities to improve health. We are now facing a new crisis. The coronavirus pandemic has again changed our professional (as well as personal) lives. Our clinical research studies that require patient visits have been on pause or we have adjusted some of our protocols, and our collegiate in-person contacts are aborted. We adjust, as we usually do, and engage with the scientific questions of our time. A number of faculty in our Department, including Drs. Bellin, Kaplan, Isasi, Burk, and myself, are involved in doing Covid-19 studies. Thanks to Zoom, we continue to have departmental interactions, and with an innovative idea, Dr. Rohan has instituted a bi-weekly “hang-out” where we can meet virtually and retain the companionship we treasure. The evolution of our Department has been mirrored in the epochal name changes it has seen: from a focus on epidemiology and preventive medicine as the Department of Preventive and Environmental Medicine, through a period of social change and a focus on community action as the Department of Community Health, to a marriage of social purpose and the advancement of scientific knowledge, as the Department of Epidemiology and Social Medicine, and now as a department whose mission encompasses a wide spectrum of activities along the continuum from molecular discoveries to population-based studies and programs to advance and preserve health, as the Department of Epidemiology and Population Health. Under Dr. Rohan’s leadership, we have grown to be an outstandingly productive department in research and teaching while nurturing our historic commitment to improve the health of underserved populations. Such unity of purpose among our faculty, in the milieu of our diversity in research interests and methods, is a tribute to Dr. Rohan’s vision. It is an exciting place in which to work, exceptional in its collegiality, diversity and intellectual stimulation. Thus, even though I officially became Emerita a few years ago, I remain working on my various projects and in particular mentoring students and junior faculty, because why stop when you’re having fun and hopefully, continuing to contribute to the scientific endeavor, in the company of such wonderful colleagues and friends. On a more personal note, I want to use this opportunity to express my thanks to the Department, its Chairmen and the Medical College, for providing me with such a rich professional home and with so much personal warmth during some difficult times in my life. It is that special feeling of connection that makes working in this Department and this school, such a great pleasure.