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
How do you define
public health?
A Little Perspective on the paper
“the science and art of preventing
disease, prolonging life and promoting
health…through organized community
effort” (Winslow 1920)
“Fulfilling society’s interest in assuring
conditions in which people can be
healthy” (IOM 1988)
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
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,
A Newer Production function Model
Components of Paper’s Model are in purple.
Health
Insurance
Public
Sector
Supply
medical care
Physical
Environment
Medical
Care
Income
(Poverty)
Health
Status
Behavior
Endowment
Race/ethnicity
Knowledge
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 death’s are they sufficiently accurate?
– Breadth of Measures: Mortality an extreme measure. Quality of life,
disabilities also relevant. Are measures used sufficently broad?
Does paper capture causality
correctly?
• Could better record keeping go together
with improved public health measures?
• Role of education
• Role of income
Does Paper Include major
Diseases of the time?
Causes of Death, 1900
Pneumonia
Tuberculosis
Gastritis
Heart disease
Stroke
Kidney disease
Injuries
Cancer
Diphtheria
Other
Does it help us to understand
public health interventions and
causes of disparities today?
Causes of Death 2000
Heart dz
Cancer
Stroke
COPD
Injuries
Pneumonia
Diabetes
Suicide
Other
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
Preventable Causes of Death, 2000, or what
are opportunities today to improve population
health?
Tobacco
Diet/activity
Alcohol
Microbes
Toxins
Sexual act.
Firearms
MVC
Drugs
McGinnis and Foege
Today’s 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.
Who is targeted by tobacco ads?
Trends in Smoking by Education
U.S., 1966-1995
Percent
50
40
< HS
High school
Some college
College degree
30
20
10
0
1966
1974
1985
Year
Health U.S., 1998 (1966 from SGR 1989)
1995
Obesity is an increasing problem especially for Black
women with low incomes
Probit on Obesity (=1 if BMI ≥ 30), NHANES IV data
Female
0.257
(0.000)**
Black
0.226
(0.000)**
Hispanic
0.057
Poor
0.244
(0.000)**
Near Poor
0.272
(0.000)**
Moderate Income
0.223
(0.000)**
Observations
3918
p values in parentheses
-0.277
Risk Factors and SES
Well-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
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?
Geno’s Public Finance Travel: Focus on the economy,
eating and drinking and the implications for health. Lessons
for U.S. policy?
90
80
70
Rates
60
50
40
30
20
10
0
Aus
GR
IT
NL
SP
US
RU
Countries
Butter Cons /c
LF as % entire Pop
Unemployment rate
Life Expectancy at birth
AR
Where is red wine consumption in our models? Surely a
neccessity for maintaining health
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.