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Making America Healthy Again: The Role of Academia ISER Anchorage, June 27, 2006 Stephen Bezruchka MD, MPH International Health Program University of Washington.

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Presentation on theme: "Making America Healthy Again: The Role of Academia ISER Anchorage, June 27, 2006 Stephen Bezruchka MD, MPH International Health Program University of Washington."— Presentation transcript:

1 Making America Healthy Again: The Role of Academia ISER Anchorage, June 27, 2006 Stephen Bezruchka MD, MPH International Health Program University of Washington Seattle

2 ISER Mission Enhances the well-being of Alaskans and others, through non-partisan research that helps people understand social and economic systems and supports informed public and private decision- making SER pursues its mission by Focusing attention on critical economic and social issues in Alaska, the Arctic, and similar regions; Engaging in basic and applied research leading to better understanding of those issues; and Disseminating knowledge through publications, community involvement, public service, and teaching.

3 Agenda What makes a population healthy? -circumpolar focus: Japan, Sweden, US, Canada -Alaska Academia role in dissemination of population health understanding TOMORROW More general discussion on health and aging, especially in Alaska and advocacy at Aging Advocacy Conference 9:15 to 10:45 and 1 to 2 pm 1300 East 19th Avenue

4 Learning Objectives: At the end of this presentation participants will List more than twenty countries that are healthier than the US Prioritize reasons why they are healthier Describe effects of the Alaska Permanent Fund as one reason why income inequality hasn't increased in Alaska and health has improved relative to other US states Dissect why individual behaviors and health care services don't matter as much for the health of populations as structures of society Role of academia in improving health in USA

5 Bad New GOOD News USA is not very healthy compared to other nations, no matter what indicator or group of indicators we consider, We all die much younger than we should

6 Bad News GOOD News USA is not very healthy compared to other nations, no matter what indicator or group of indicators we consider We all die much younger than we should It won't cost a penny to make USA healthy again

7 What would you do to produce a healthy individual? What do you do yourself to be healthy? If you have children, what do you do for them to be healthy?

8 What would you do to produce a healthy individual? What do you do yourself to be healthy? If you have children or grand children, what do you do for them to be healthy? HOW WOULD YOU KNOW IF YOU ARE SUCCESSFUL?

9 What would you do to produce a healthy family? Next generation of families in the USA to be healthy?

10 What would you do to produce a healthy family? Next generation of families in the USA to be healthy? HOW WOULD YOU KNOW IF YOU ARE SUCCESSFUL?

11 What would you do to produce a healthy USA?? HOW WOULD YOU KNOW IF YOU ARE SUCCESSFUL?

12 In any discussion 3 questions to ask: What are the facts? What are the interpretations of those facts. What are the presuppositions behind the interpretations. FACTS data!!

13 How healthy is the US? Health Olympics Number one Gold 1-5 _______ 6-10 _______ _______ _______ _______ _______ 31+ _______

14 Health Olympics 2003 Top 30 countries United Nations Human Development Report 2005

15 Yanagishita & Guralnik 1998

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17 Munnell 2004

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19 "If they can get you asking the wrong questions, they don't have to worry about answers" -Thomas Pynchon, in Gravity’s Rainbow

20 INTERPRETATIONS OF FACTS What makes a population healthy? Health has been improving most of the last century Health improvements are not shared equally Health Inequalities (poorer people have poorer health)

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22 Wilkinson 1992 BMJ MORE EQUALITY BETTER HEALTH

23 Where is our health? Female Life Expectancy by County 1990 C. Murray, Harvard, 1998 Female Life Expectancy 70.0 to to to to to to to to 90.0

24 Kaplan 1996 BMJ BETTER HEALTH MORE EQUALITY

25 Ross et. al. BMJ 2000 BETTER HEALTH MORE EQUALITY

26 "For years, the life expectancies of both men and women in the United States have lagged behind those of their counterparts in most other industrialized nations. … In 1998 the United States also ranked 28th in infant mortality among 39 industrialized nations. In the area of chronic disease, reported incidence rates in 1990 for all cancers in males and females were highest in the US among a group of 30 industrialized nations." National averages mask serious disparities [Black IMR 2.5 Whites] Pg 20-1

27 "more egalitarian societies (i.e., those with a less steep differential between the richest and the poorest) have better average health" pg. 59

28 State Health Ranking

29 State Health Ranking Trends Washington Alaska Minnesota M/F (05) 106/100 M/F (60) 132/100

30 Role of HEATLH CARE?

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32 Highest Life Expectancy And disability free years Lowest Life Expectancy And disability free years Life expectancy disparity is 16 years

33 NYT Feb 11, 2001

34 Public Health Textbook: “ with modern investigations and treatments, patients are now regularly saved and make very good recoveries from infections, injuries, and a variety of other conditions that were almost uniformly fatal even a few years ago. Surprisingly it is more difficult to demonstrate conclusively the impact of these medical advances on the health of whole communities ” pg 238 –Detels, R., W. W. Holland, et al., Eds. (2002). Oxford Textbook of Public Health. Oxford, Oxford University Press.

35 Health monograph: “To conclude, a universal health care system is definitely the right policy tool for delivering care to those in need, and for this it must be respected and supported. However, investments in health care should never be confused with, or sold as, policies whose primary intent is to improve population health or to reduce inequalities in health. Claims to that effect are misleading at best, dangerous and highly wasteful at worst.” Healthier Societies Chapter 5, Universal Medical Care and Health Inequalities: right objectives, insufficient tools. Heyman, Hertzman et al., Eds. (2006). Oxford University Press.

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37 Epistemology Research Process ? hard wired how raised views of parents, associates teaching Experience Ultimately most things are simple and can be explained simply ? POLICIES / OUTCOMES ?

38 Epistemology Research Process ? hard wired how raised views of parents, associates teaching Experience Ultimately most things are simple and can be explained simply -Multi-factorial, complex -Ask simplified question -Answer that question soon -Work to get it published –Discussion always requests more research -More research on another simplified question -Get academic promotions -Avoid controversy, generalizations, overviews -Retire ? POLICIES / OUTCOMES ?

39 BIOLOGY Population health Causal inferences ? Epidemiology approaches multiple studies dose-response direction of causation biological plausibility Austin Bradford-Hill 1956 Surgeon General's Report Smoking and health 1964

40 How Might Society Hierarchy work to produce health?

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45 impact of early childhood on adult health? How important? EXTREMELY

46 pathway latent cumulative Life cycle approach to Population Health

47 Of all aspects of children’s early environment, the family’s socioeconomic status is most powerfully associated with children’s cognitive skills when they enter school. … the influence of socioeconomic status during early childhood years appears to be stronger than SES in later years. Children in single-parent families are at greater risk for poor developmental outcomes. There are a few critical periods in brain development during which impairment of stimulation of the nerve pathways will forever limit functioning

48 Comparing populations in different nations Child health outcomes (mortality measures) U5MR, IMR, Child Abuse deaths, Child Injury deaths Teen births, youth homicides Child poverty Educational outcomes HIERARCHY?

49 SCF State of the World's Mothers 2004 A fifth of 20-yr old women in the US gave birth in their teens In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 women aged 15 to 19 - a rate higher than in 94 developing countries. checking indicators

50 *Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore rates were not calculated. Youth violence Olympics—Homicide rates among youth aged (most recent year available) from the World Health Organizations’ World Report on Violence and Health, 2002*

51 VIOLENCE AND INEQUALITY

52 Pickett AJPH 2005

53 Child Poverty Olympics (2005)

54 UNICEF League Table of Child Abuse Deaths

55 BASIC IDEA SO FAR Societal hierarchy matters most for our health when we are children Our children aren't doing so well compared to other countries HIERARCHY (gap between rich and poor) Most important determinant of a society's health: Bigger gaps lead to worse health Effect is complex but robust

56 Socio-Economic-Politico GLOBAL Gradient

57 Income Inequality in America "Inequality of income takes the broad, safe and fertile plain of human society and stands it on edge so that everyone has to cling desperately to her foothold and kick off as many others as she can." George Bernard Shaw 1927

58 Piketty 2006

59 1.27 M per day

60 Multinational Monitor Nov 2004

61 0

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63 Alaska Income Gains 1980s-2000s

64 Dollars and Sense May/June 2000

65 Alaska Washington

66 Top/Bottom Fifth Income ratios 2000s

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68 (last paragraph) "The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart."

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70 Structural Medicine Tobin Tax Legal status of corporations Fair trade, not “free trade” Abandon IMF/WB/WTO policies that concentrate wealth Foreign aid not based on US political agenda Liveable wage ordinances Affordable Housing Support early childhood Consumption tax, Support labor Income Equity Act HR Tax capital gains IRS auditing strategy Wealth tax Military vs Social spending US GLOBALLY

71 Summary Health of populations determined by structural factors Health requires more economic and social justice Structural medicine is about ensuring everyone gets a more equal share In US, our situation is comparable to rethinking about smoking being not good for our health (1950s, 60s)

72 Summary Health of populations determined by structural factors Health requires more economic and social justice Structural medicine is about ensuring everyone gets a more equal share In US, our situation is comparable to rethinking about smoking being not good for our health (1950s, 60s)

73 Benjamin’s Law POPULATION HEALTH FORUM Listserve info GENES

74 Making America Healthy Again Academia's Role: Action oriented steps dissemination Change needed MOST at national level Tides of Change

75 What needs to be done? Educate yourself Inform others –plant brush fires in other people’s minds Change rules or make new ones Maintain your livelihood

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77 Personal income tax rate changes over last 55 years

78 Family Assistance Plan Aug 8, 1969 President Nixon proposed "that for the first time in America's history we establish a floor under the income of every American family with children" –Editorials 95% in favor "A new and promising approach" Business Week "A bold new blueprint" Los Angeles Times Passed the House, defeated in the Senate in 1970, 72

79 What needs to be done? Educate yourself Inform others –plant brush fires in other people’s minds Change rules or make new ones Maintain your livelihood

80 What needs to be done? Educate yourself Inform others –plant brush fires in other people’s minds Change rules or make new ones Maintain your livelihood

81 Dysfunctional social systems change when Problem begins to attract popular and political attention Major players agree upon a refined and feasible proposal and a transforming political event takes place, creating open policy window (John Kingdon) -a major electoral realignment, -natural disaster, -economic depression, -war

82 Population Health Dissemination TEACH WHAT YOU HAVE CHOSEN TO LEARN at whatever level you can -University courses -work on primary school curricula -high school

83 Population Health Dissemination TEACH WHAT YOU HAVE CHOSEN TO LEARN at whatever level you can -University courses -work on primary school curricula -high school

84 Population Health Dissemination TEACH WHAT YOU HAVE CHOSEN TO LEARN at whatever level you can -university courses -work on primary school curricula -high school

85 Before I came here, I though there was something wrong with those people, like why would you want to become a teenage mom when you don't even have an education or something, but I realize they don't have a choice.

86 Produce Posters, Graphics,

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88 Create Organizations

89 What needs to be done? Educate yourself Inform others –plant brush fires in other people’s minds WRITE ABOUT POPULATION HEALTH Maintain your livelihood

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93 produce a website on population health ideas aimed at (high school students) Option for those familiar and facile with web design. -Need to have rehearsals with groups of students at a high school in your town.

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96 give a lecture to some group near your home or place of work on these concepts. a talk to homeless, a presentation at schools or clubs, some similar audience that you have access to.

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98 Inequality Breakfast

99 Inequality Breakfast

100 Campaign to Make Alaska #1

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102 NEXT STEPS Organizing

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