The Changing Face of Health in North Carolina 2007 Conference for Excellence October 25, 2007

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The Changing Face of Health in North
Carolina2007 Conference for ExcellenceOctober
25, 2007
Steve Cline, DDS, MPH Deputy State Health Director
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Public Health Mission

• To promote and contribute
• to the highest possible
• level of health
• for the people
• of North Carolina

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Public Health Goals

• Improve health outcomes
• Eliminate health disparities

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Outline

• Demographics of NC
• Trends in Health Statistics
• Challenges to Health
• Strategies toward Better Health

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The Changing Faceof North Carolina

• The changing demographic characteristics of North
  Carolinas population affects trends in health
  indicators and also our standing on health
  measures relative to the United States.

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North Carolinas Surging Population

• According to estimates from the U.S. Census
  Bureau, North Carolina recently surpassed New
  Jersey to become the 10th most populous state in
  the country.
• In 2005, there were more than 8.6 million
  residents in the state - an increase of 8 percent
  from 2000.
• 86 of North Carolinas 100 counties experienced
  population growth from 2000-2005.
• This growth may put a strain on an already
  overburdened public health infrastructure.

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As the Baby Boom Generation reaches retirement
age, the growth of the elderly population (65)
in North Carolina is expected to accelerate
rapidly
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The Growth of the Hispanic/Latino Population in
North Carolina
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• In 2005, the leading cause of death for North
  Carolina Hispanics was Motor vehicle injuries
  (this ranked 10th for Non-Hispanics).
• Homicide was the 3rd leading cause of death for
  Hispanics in 2005, while it did not appear in the
  10 leading causes of death for non-Hispanics.
• In 2005 Hispanics made up 7 of HIV disease and
  in 2006 they made up 8

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African Americans/Blacks remain North Carolinas
largest minority
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Racial disparities in health persist in North
Carolina
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African Americans as Percent of People Living
with AIDS Top 10 States, 2005
10 of top 10 in the South (U.S. percent 43.1)

• District of Columbia 82.2
• Maryland 80.5
• South Carolina 73.9
• Mississippi 73.1
• Georgia 70.9
• North Carolina 68.7
• Delaware 66.9
• Louisiana 66.5
• Alabama 63.7
• Michigan/Virginia 58.4

Sources Centers for Disease Control and
Prevention, Division of HIV/AIDS
Prevention-Surveillance and Epidemiology, Special
Data Request, October 2006. Available at
www.StateHealthFacts.org
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Many North Carolinians live in rural areas
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Many North Carolinians Live in Poverty
Source Current Population Survey, U.S. Census
Bureau
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Trends inNorth Carolina Health Statistics
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Overall Mortality
Source National Center for Health Statistics
NC State Center for Health Statistics
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HIV Disease Mortality
Source North Carolina HIV/STD Prevention Care
Branch
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Persons Living with HIV/AIDS as of December 31,
2006 - race/ethnicity N19,996
non Hispanic
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Heart Disease Mortality
Source National Center for Health Statistics
NC State Center for Health Statistics
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Cancer Mortality
Source National Center for Health Statistics
NC State Center for Health Statistics
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Stroke Mortality
Source National Center for Health Statistics
NC State Center for Health Statistics
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Diabetes Mortality
Source National Center for Health Statistics
NC State Center for Health Statistics
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TRENDS INCHILD ADOLSCENT HEALTH
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Infant Mortality
Source National Center for Health Statistics
NC State Center for Health Statistics
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Infant Mortality by Race
Source State Center for Health Statistics
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Teen Births
Source CDC Division of Sexually Transmitted
Disease Prevention
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Childhood Immunizations
Source CDC National Immunization Survey
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North Carolina Trend Summary- Strengths

• Ready access to prenatal care (rank 11)
• High immunization coverage (rank 6)
• Few poor physical and mental health days
• Incidence of infectious disease decreased by 13
  in past year
• Prevalence of smoking down 28 since 1990

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North Carolina Trend Summary-Weaknesses

• High infant mortality rate (8.6) (rank45)
• High prevalence of smoking (22.6) (rank37)
• Low high school graduation rate (rank 40)
• Rate of uninsured increased from 12.6 to 16
  since 1990
• High rate of premature deaths (rank38)
• Health disparity in receipt of prenatal care
  70 for Hispanics and 91 for Whites

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Challenges to HealthTraditional Threats

• Access to Health Care
• Cost of Health Care
• Health Equity

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Characteristics of Health Care System

• Escalating costs and unequal access
• Considerable variation in
• primary care and specialists per population
• coverage for vulnerable populations
• coverage of mental health, substance abuse
  treatment and dental health
• Expanding technologies and treatments
• Financial pressures to control costs
• Increased push for quality and electronic health
  records

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Uninsured Rose 5.8 Million from 2000 to 2004,
with Adults Accounting for All of the Increase
45.8 million
40million
Source U.S. Census, March 2001 and March 2005
Current Population Surveys.
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Percent of Nonelderly UninsuredPopulation Varies
Widely by State, 20012003
WA
ME
NH
VT
MT
ND
MN
OR
WI
NY
MA
ID
SD
MI
RI
WY
CT
PA
NJ
IA
OH
NE
DE
NV
IN
IL
MD
WV
UT
VA
DC
CO
CA
KS
MO
KY
NC
TN
OK
AR
SC
NM
AZ
AL
GA
MS
TX
LA
FL
18 or more
AK
1517.9
1214.9
HI
Less than 12
Source Health Insurance Coverage in America
2003 Data Update Highlights,Kaiser Commission on
Medicaid and Uninsured/Urban Institute, September
27, 2004. Uninsured rates are two year averages,
20012003.
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Nearly 1 in 5 NC Residents have no Health
Insurance
Source Behavioral Risk Factor Surveillance System
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U.S. Health Expenditures as Share of GDP Expected
to Rise Through Next Decade
Expenditures as percent of gross domestic product
(GDP)
Projected
Source Center for Medicare and Medicaid
Services, Office of the Actuary, 19982003
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Disparities

• Race/ethnicity
• Language
• Gender
• Disability or functional status
• Socioeconomic status
• Geographic location

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Major Health Disparities

• Infant Mortality
• Obesity/Diabetes
• Cancer
• Heart Disease
• HIV/AIDS
• Alcohol, Tobacco Other Drugs
• Immunizations

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Comparison of National Infant Mortality Rates
United States, 1998
28th in the world
Deaths per 1,000 Live Births
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Challenges to HealthThe Real Threats

• System Imbalance
• Determinants of Health
• Need for Change

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The Problem

• Current health care system is imbalanced
• Health is influenced by factors in five domains
• Determinants of Health and their Contribution to
  Premature Death- Adapted from McGinnis et al 2002

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U.S. Investments in Health

• US spends more on health care (16 of GPD) than
  any other country in the world, but has worse
  health outcomes on most measures of health status
• US ranks 46th in life expectancy and 42nd in
  infant mortality
• Estimates indicate that spending on prevention
  accounts for only 2-3 of health spending

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The Real Threats to Our Health
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Obesity Among U.S. Adults 2001
Source Mokdad A H, et al. J Am Med Assoc
199928216, 200128610. Data from Behavior Risk
Factor Surveillance System (BRFSS)
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Overweight and Obesity

• Prevalence has nearly quadrupled in American
  children
• 2.5-fold increased risk of overall mortality
• 4-fold risk of cardiovascular mortality
• 5-fold risk of diabetes
• Risk of hypertension, gall bladder disease, and
  some cancers

Source Willet et al., New Eng J Med, 1999
Source Willet et al., New Eng J Med, 1999
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Environment and Obesity
Millions of Person-Miles in Automobiles, 1970-1990
Hours of TV Viewed Daily 1960-1992

• Suburbs disconnected and pedestrian-unfriendly

Percent of Workforce in Sedentary Occupations
1950-1996
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Why do these imbalances prevail?

• The public and its leaders are unaware of these
  disproportions?
• There are competing priorities?
• Change is hard winners and losers?

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How Do We Address Them?

• To maximize the health of its citizens, society
  should pursue interventions in proportion to the
  ability of those interventions to improve
  outcomes
• Need to Rebalance Health Spending - 38 of US
  deaths are attributable to 4 behaviors smoking,
  poor diet, physical inactivity, alcohol use

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Who Has the Answers?

• Bush Plan?
• Clinton Plan?
• Obama Plan?
• Edwards Plan?
• Massachusetts Plan?
• North Carolina Plan?

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Strategic Alignment of Governmental Health
Systems

• Goals can only be reached if the visibility,
  importance and value of the governmental health
  enterprise with the health system are realized

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Moving Forward

• Its all about leadership
• and
• Its all about partnership

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Key Principles of Practice

• Prevention is the key.
• Population-based approaches are most effective.
• Public health is a network of essential services.
• Public health is committed to partnerships.
• Programs must be based in science.
• Focus is on accountability (2010 Healthy
  Carolinians objectives).

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Governmental Public Health Officials Strategic
Map 2007-2009
Draft 06/22/07
Ensure Health Protection Create the 21st Century
Health System to Help the U.S. Become the
Healthiest Nation in the World
Provide Unified Leadership and Visibility in
Creating the 21st Century Health System
A
B
C
Assure System Accountability, Capabilities
and Improvement
Define, Deliver and Communicate Health Value
and Equity
Strengthen Alignment and Collaboration
of Governmental Public Health
Develop and Implement a Policy, Legal and
Investment Framework
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NC IOM Task Force on Prevention

• NC IOM, in partnership with the NC Division of
  Public Health, is proposing to create a Task
  Force to develop a comprehensive Prevention Plan
  for the State
• Funded collaboratively by
• NC Health and Wellness Trust Fund
• Blue Cross Blue Shield Foundation of North
  Carolina
• Kate B. Reynolds Charitable Trust
• The Duke Endowment
• Each foundation will be asked to have
  representatives on the Task Force

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Comprehensive Prevention Plan

• The Task Forces Prevention Plan will focus on
  broad topic areas, including
• 1) Preventing/reducing chronic diseases,
  morbidity and mortality
• 2) Integrating preventing health strategies into
  primary care
• 3) Preventing/responding to infectious diseases
  and emerging public health threats
• 4) Reducing intentional and unintentional
  injuries

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Goal is to Create a Statewide Action Agenda

• The goal of the NC IOM Task Force on Prevention
  will be to create a statewide action agenda to
  improve population health
• Will identify strategies that have the best
  chance of improving population health, in the
  areas of
• Personal behaviors
• Public and health policies
• Community and environment
• Clinical care

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Timetable

• Funding for three years
• Year 1 (Oct. 2007-June 2008)
• August-Nov Seek funding from NC foundations
• Oct.-Dec Create task force
• Dec.-June Monthly meeting of task force
• Year 2 (July 2008-June 2009) Task Force
  continues to meet (12 months) and completes
  report
• Year 3 (July 2009-June 2010)
• July-September NC IOM publishes report, hosts
  Prevention Summit in collaboration with DPH and
  four foundations
• July-June DPH take the lead in implementing Task
  Force recommendations

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For More Questions

• Contact
• Pam Silberman, JD, DrPHPresident CEONC
  Institute of Medicinepam_silberman_at_nciom.org919-
  401-6599 Ext. 23
• Steve Cline, DDS, MPHAssistant State Health
  DirectorNC Division of Public Healthsteve.cline_at_
  ncmail.net919-707-5024

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Parting Shots

• Global Health
• Zoonotic Diseases
• Pandemic Influenza
• Disasters

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Global Health-Global Poverty
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Zoonotic Diseases

• Zoonosis - When a pathogen from a non-human
  animal results in human disease
• Common occurrence 60-75 of all human
  infectious diseases shared with animals
• 5 of the 6 Bioterrorism Select Agents (A)
• Examples bubonic plague, yellow fever, West
  Nile fever, rabies, HIV, SARS

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Types of Influenza Viruses

• Influenza A
• epidemic or pandemic
• animals and humans
• differing pathogenicities
• divided into subtypes
• based on surface proteins (H N)
• 144 combinations
• constantly mutate
• variation within subtype

• Influenza B
• epidemic
• humans (primarily)
• not divided into subtypes
• Influenza C
• humans
• mild respiratory illness

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Pandemic Influenza

• Major mutation occurs
• Genetic reassortment of human and avian influenza
  viruses
• Direct animal (poultry) to human transmission
• Results in new subtype of influenza A
• Avian origin
• Adapted to humans
• No immunity in the human population
• Results in multiple simultaneous epidemics
  worldwide with enormous numbers of deaths and
  illness
• Six to eight weeks
• Multiple waves

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Pandemics of the 20th Century
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Global Migration of H5N1
October 5, 2007
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Change Driven By Highly Visible Public Health
Events Natural Disasters

• Security Now dominates national agenda
• Public health is part of national security agenda
• Growing public interest in health
• Protection prevention

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After 9/11 Majority of Americans Understand
They Benefit from Public Health
Would you say you and your community have
benefited from public health services?
Source Research!America/APHA National Survey,
2004 Harris
Interactive for Research!America
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• Without health there is no happiness.
• An attention to health then,
• should take the place of every other object.
• Thomas Jefferson 1787

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Creating A National Movement
All Americans need to be able to protect
themselves, their families, and their communities
from preventable, serious health threats.
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Questions?

• Steve Cline, DDS, MPH
• Deputy State Health Director
• NC Division of Public Health
• steve.cline_at_ncmail.net