Comments on Public Health and Mortality : What Can We Learn from the Past?

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Comments on Public Health and Mortality What
Can We Learn from the Past?

• Berkeley Symposium on Poverty the Distribution of
  Income and Public Policy
• Barbara Wolfe

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How do you define public health?A Little
Perspective on the paper

• the science and art of preventing disease,
  prolonging life and promoting healththrough
  organized community effort (Winslow 1920)
• Fulfilling societys interest in assuring
  conditions in which people can be healthy (IOM
  1988)

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Major Public Health Eras

• Prior to 1850
• Epidemics
• 1850 - 1949
• Sanitary reform through state and local
  infrastructure
• 1950 - present
• Gaps in medical care and expanding agenda

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A Simple Epidemiology Model of Human-environmental
interactions Or, where does the analysis of
this paper fit more broadly?

• Physical environment water, heat, air whose
  quality is influenced by sanitation, water
  purification, control of temp.
• Biological environment infectious agents,
  vectors that transmit disease (flies), reservoirs
  of infection (animals, soil), food, medicine
• SES environment quality of housing, nutrition,
  income, income certainty, income inequality,
  stress,

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A Newer Production function ModelComponents of
Papers Model are in purple.
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Issues of Measurement that raise concern with
analysis

• Relation of severity of illness to statistics
• _ not apparent ___mild____Moderate_____Severe
  _______Fatal___________
• 
  Likely to be seen by a doctor recorded?
• Likely to be hospitalized and
  recorded
• So how accurate are data?
• Role of Herd Immunity (pre vaccinations)
  Persons with the disease develop immunity which
  stops the spread of the disease. Measles is most
  commonly used example. (Hedrich 1933.) So there
  should be a natural pattern of decline and
  subsequent increase of measles cases without any
  public health interventions. Is credit given
  appropriate?
• Accuracy of Information on Death Certificate
  registration complete only for about last 50
  years disease incomplete and inaccurate. Change
  in composition of population. So, even with data
  on deaths are they sufficiently accurate?
• Breadth of Measures Mortality an extreme
  measure. Quality of life, disabilities also
  relevant. Are measures used sufficently broad?

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Does paper capture causality correctly?

• Could better record keeping go together with
  improved public health measures?
• Role of education
• Role of income

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Does Paper Include major Diseases of the time?
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Causes of Death, 1900
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Does it help us to understand public health
interventions and causes of disparities today?
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Causes of Death 2000
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What worked? According to the paper

• Environmental approaches
• e.g., fluoridation, sanitation, infect. Control
• But also
• Health policy changes
• e.g., school vaccination, seat belt laws, worker
  safety
• Preventive services
• e.g., high blood pressure rx.
• Public education
• e.g., schooling, food labels, smoking and health
• Income Transfer Policies
• e.g., Income, housing, food stamps, SSI

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Preventable Causes of Death, 2000, or what are
opportunities today to improve population health?
McGinnis and Foege
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Todays Public Health Challenges and Ties to
Health Disparities

• Smoking advertising and marketing
• Food Consumption everything now giant sized
• Use of time too little exercise
• Access to care
• Low cost housing, etc.

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Who is targeted by tobacco ads?
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Trends in Smoking by EducationU.S., 1966-1995
Percent
Year
Health U.S., 1998 (1966 from SGR 1989)
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Obesity is an increasing problem especially for
Black women with low incomes
Probit on Obesity (1 if BMI 30), NHANES IV data Probit on Obesity (1 if BMI 30), NHANES IV data Probit on Obesity (1 if BMI 30), NHANES IV data Probit on Obesity (1 if BMI 30), NHANES IV data Probit on Obesity (1 if BMI 30), NHANES IV data Probit on Obesity (1 if BMI 30), NHANES IV data
Female 0.257 (0.000)
Black 0.226 (0.000)
Hispanic 0.057 -0.277
Poor 0.244 (0.000)
Near Poor 0.272 (0.000)
Moderate Income 0.223 (0.000)

Observations 3918
p values in parentheses
significant at 1
age and other race also included age and other race also included
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Risk Factors and SESWell-known today

• Smoking Higher smoking rates among the poor and
  less educated
• Diet and obesity Higher fat diets, lower
  consumption of fruits and vegetables among the
  poor
• Health care Less access to and use of clinical
  preventive services

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Can we learn from Other countries experiences
today?

• Think of more universal access to care and
  greater equality of income
• Think of less work
• Less obesity (but indications of catching up)
• Perhaps it is time for observational study
  Gene?

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Genos Public Finance Travel Focus on the
economy, eating and drinking and the implications
for health. Lessons for U.S. policy?
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Where is red wine consumption in our models?
Surely a neccessity for maintaining health
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So Gene .

• We see you have much research (and travel) to do.
• To improve health of the population you need to
  travel far and wide, sample food and wine, engage
  in leisure activities and then write up your
• Advice for The Elderly on How to Stay Healthy
  though Travel and
• Campaign for part F of Medicare needed travel
  vouchers for health!
• We are counting on you.