Foundations of Public Health
PH-200 Fall 2009
Week 2
Outline
• 9:30 AM – 9:45 AM : Questions and Review
• 9:45 AM – 11:00 AM : Where we are: Core contents of public health
education.
• 11:00 AM – 11:15 AM : Recess
• 11:15 AM – 12:15 PM : How we got here: Evolution of public health
understanding and the debate over causation
The Global Burden of Diseases
• Case studies on disease eradication; Injury
• AJPH articles
• 12:15 PM – 12:30 PM : Review
Pop-quiz
• Describe the core functions of public health.
– How do these translate into essential public health
services in communities?
• Describe the five core subjects of public health?
– Do these demarcations make sense to you? Explain.
• What are the seven cross-cutting, interdisciplinary
themes included in public health education?
– Are these too many or too few?
– How should these themes be embedded in the
curriculum?
Where are we? Or what is the role of
“Academic” Public Health?
• Public health is the art and science of
protecting and improving the health of a
community through an organized and
systematic effort that includes education,
assurance of the provision of health services
and protection of the public from exposures
that will cause harm.
http://www.whatispublichealth.org/
Cost-Effective Disease Prevention
• Public health is often summarized
by the phrase “disease
prevention” but it is broader, as it
includes “improvement to quality
of life” even in disease-free states
as defined by clear diagnosis.
• The path from health to disease is
a continuum. The challenge is to
move the fulcrum of expenditure
and results so that the balance is
tilted more toward health
maintenance and improvement
than toward disease and
treatment.
Those are the ideals. How does it work in practice?
The State of Health Care….
Dr Manuel Carballo of the World Health Organization said in 1987:
• “the health systems of most developed regions have become highly
bureaucratized, over structured, regimented and unable to respond
to their population’s needs;
• they are basically medical, curative care systems, creating
dependency, unable to stimulate social autonomy or empowerment
and are, in nearly all cases, becoming financially deficient ...
• health plans are developed in an ivory tower by elites who often do
not understand the people they are working with, and in many
cases do not even know them ... we must try to move towards [a
health system] in which we all participate in defining needs and
expectations, imposing guidance on the health care system at a
political level.”
Public Health Care and Reform in the
United States
• The U.S. Gross Domestic Product as of September 2009 is ~ $14.3
Trillion. (http://www.forecasts.org/gdp.htm)
• We spend ~16% on health care ($2.25 Trillion / year).
• This is much more than any other nation spends on health care,
and as a percentage of GDP, we spend twice as much as other
developed countries.
• The trend is growing in the U.S., and we are expected to be
spending 20% of our GDP on health care within the next decade
or two.
• Yet, we are not leading in terms of the metrics of quality-adjusted
life expectancy, and composite measures of morbidity and
mortality (Disability-Adjusted Life Years, or DALYs).
Distribution of “Public” Health Resources
• Of the $2.25 Trillion that we
spend on we spend on health
care, almost 90% is dedicated to
diagnosis and treatment after we
get sick.
•
Only 2% is spent on prevention
and health promotion, 3% on
community health, and 3% on
public health.
• Thus, in combination,
approximately 8% of our health
budget is dedicated to “public
health” or prevention (The
balance is spent on continuing
care of patients).
The path forward: Training public health professionals in the core competencies
and cross-cutting themes in public health education
Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century
(2003)
Board on Health Promotion and Disease Prevention (HPDP)
Institute of Medicine (IOM)
The “Ecological Model of Public Health”
“It is important that the education provided by
these programs and institutions is based upon
an ecological model of health. An ecological
model assumes that health and well being are
affected by interaction among the multiple
determinants of health….”
• Core competencies
• Cross-cutting themes
Biostatistics
• Biostatistics
– Biostatistics is the development and application of
statistical reasoning and methods in addressing,
analyzing and solving problems in public health;
health care; and biomedical, clinical and
population-based research.
– UC Irvine Department of Statistics
• Dr. Hal Stern (Chair)
(Bio) Upon graduation a student with an MPH should be able
to…..
•
1. Describe the roles biostatistics serves in the discipline of public health.
•
2. Describe basic concepts of probability, random variation and commonly used statistical probability distributions.
•
3. Describe preferred methodological alternatives to commonly used statistical methods when assumptions are not
met.
•
4. Distinguish among the different measurement scales and the implications for selection of statistical methods to be
used based on these distinctions.
•
5. Apply descriptive techniques commonly used to summarize public health data.
•
6. Apply common statistical methods for inference.
•
7. Apply descriptive and inferential methodologies according to the type of study design for answering a particular
research question.
•
8. Apply basic informatics techniques with vital statistics and public health records in the description of public health
characteristics and in public health research and evaluation.
•
9. Interpret results of statistical analyses found in public health studies.
•
10. Develop written and oral presentations based on statistical analyses for both public health professionals and
educated lay audiences.
Environmental Health Sciences
• Environmental Health Sciences
– Environmental health sciences represent the study
of environmental factors including biological,
physical and chemical factors that affect the
health of a community.
• UC Irvine Center for Occupational and Environmental
Health
– Dr. Dean Baker, Director
(EHS) Upon graduation a student with an MPH should be able
to…..
•
1. Describe the direct and indirect human, ecological and safety effects of major environmental and
occupational agents.
•
2. Describe genetic, physiologic and psychosocial factors that affect susceptibility to adverse health
outcomes following exposure to environmental hazards.
•
3. Describe federal and state regulatory programs, guidelines and authorities that control
environmental health issues.
•
4. Specify current environmental risk assessment methods.
•
5. Specify approaches for assessing, preventing and controlling environmental hazards that pose risks
to human health and safety.
•
6. Explain the general mechanisms of toxicity in eliciting a toxic response to various environmental
exposures.
•
7. Discuss various risk management and risk communication approaches in relation to issues of
environmental justice and equity.
•
8. Develop a testable model of environmental insult.
Epidemiology
• Epidemiology
– Epidemiology is the study of patterns of disease
and injury in human populations and the
application of this study to the control of health
problems.
• UC Irvine Department of Epidemiology
– Dr. Hoda Anton-Culver, Chair
(EPI) Upon graduation a student with an MPH should be able
to…..
•
1. Identify key sources of data for epidemiologic purposes.
•
2. Identify the principles and limitations of public health screening programs.
•
3. Describe a public health problem in terms of magnitude, person, time and place.
•
4. Explain the importance of epidemiology for informing scientific, ethical, economic and political
discussion of health issues.
•
5. Comprehend basic ethical and legal principles pertaining to the collection, maintenance, use and
dissemination of epidemiologic data.
•
6. Apply the basic terminology and definitions of epidemiology.
•
7. Calculate basic epidemiology measures.
•
8. Communicate epidemiologic information to lay and professional audiences.
•
9. Draw appropriate inferences from epidemiologic data.
•
10. Evaluate the strengths and limitations of epidemiologic reports.
Health Policy and Management
• Health Policy and Management
– Health policy and management is a multidisciplinary
field of inquiry and practice concerned with the
delivery, quality and costs of health care for
individuals and populations. This definition assumes
both a managerial and a policy concern with the
structure, process and outcomes of health services
including the costs, financing, organization, outcomes
and accessibility of care.
– UC Irvine Center for Health Policy and Research
• Dr. Shelly Greenfield, Director
(HPM) Upon graduation a student with an MPH should be able
to….
•
1.Identify the main components and issues of the organization, financing and delivery of health services and
public health systems in the US.
•
2. Describe the legal and ethical bases for public health and health services.
•
3. Explain methods of ensuring community health safety and preparedness.
•
4. Discuss the policy process for improving the health status of populations.
•
5. Apply the principles of program planning, development, budgeting, management and evaluation in
organizational and community initiatives.
•
6. Apply principles of strategic planning and marketing to public health.
•
7. Apply quality and performance improvement concepts to address organizational performance issues.
•
8. Apply "systems thinking" for resolving organizational problems.
•
9. Communicate health policy and management issues using appropriate channels and technologies.
•
10. Demonstrate leadership skills for building partnerships.
Social and Behavioral Sciences
• Social and Behavioral Sciences
– The behavioral and social sciences in public health address
the behavioral, social and cultural factors related to
individual and population health and health disparities
over the life course. Research and practice in this area
contributes to the development, administration and
evaluation of programs and policies in public health and
health services to promote and sustain healthy
environments and healthy lives for individuals and
populations.
– UC Irvine Department of Population Health and Disease
Prevention
• Dr. Oladele Ogunseitan, Chair
(SBS) Upon graduation a student with an MPH should be able to…..
•
1. Identify basic theories, concepts and models from a range of social and behavioral disciplines that are used in public
health research and practice.
•
2. Identify the causes of social and behavioral factors that affect health of individuals and populations.
•
3. Identify individual, organizational and community concerns, assets, resources and deficits for social and behavioral
science interventions.
•
4. Identify critical stakeholders for the planning, implementation and evaluation of public health programs, policies and
interventions.
•
5. Describe steps and procedures for the planning, implementation and evaluation of public health programs, policies and
interventions.
•
6. Describe the role of social and community factors in both the onset and solution of public health problems.
•
7. Describe the merits of social and behavioral science interventions and policies.
•
8. Apply evidence-based approaches in the development and evaluation of social and behavioral science interventions.
•
9. Apply ethical principles to public health program planning, implementation and evaluation.
•
10. Specify multiple targets and levels of intervention for social and behavioral science programs and/or policies.
Cross-cutting Themes
• Communication and Informatics
– The ability to collect, manage and organize data to
produce information and meaning that is
exchanged by use of signs and symbols; to gather,
process, and present information to different
audiences in-person, through information
technologies, or through media channels; and to
strategically design the information and
knowledge exchange process to achieve specific
objectives.
(C&I) Upon graduation a student with an MPH should be able to…..
•
1.Describe how the public health information infrastructure is used to collect, process, maintain, and disseminate
data.
•
2. Describe how societal, organizational, and individual factors influence and are influenced by public health
communications.
•
3. Discuss the influences of social, organizational and individual factors on the use of information technology by end
users.
•
4. Apply theory and strategy-based communication principles across different settings and audiences.
•
5. Apply legal and ethical principles to the use of information technology and resources in public health settings.
•
6. Collaborate with communication and informatics specialists in the process of design, implementation, and
evaluation of public health programs.
•
7. Demonstrate effective written and oral skills for communicating with different audiences in the context of
professional public health activities.
•
8. Use information technology to access, evaluate, and interpret public health data.
•
9. Use informatics methods and resources as strategic tools to promote public health.
•
10. Use informatics and communication methods to advocate for community public health programs and policies.
Diversity and Culture
• Diversity and Culture
– The ability to interact with both diverse individuals
and communities to produce or impact an
intended public health outcome.
(D&C) Upon graduation a student with an MPH should be able
to…..
•
1.Describe the roles of, history, power, privilege and structural inequality in producing health disparities.
•
2. Explain how professional ethics and practices relate to equity and accountability in diverse community settings.
•
3. Explain why cultural competence alone cannot address health disparity.
•
4. Discuss the importance and characteristics of a sustainable diverse public health workforce.
•
5. Use the basic concepts and skills involved in culturally appropriate community engagement and empowerment with
diverse communities.
•
6. Apply the principles of community-based participatory research to improve health in diverse populations.
•
7. Differentiate among availability, acceptability, and accessibility of health care across diverse populations.
•
8. Differentiate between linguistic competence, cultural competency, and health literacy in public health practice.
•
9. Cite examples of situations where consideration of culture-specific needs resulted in a more effective modification
or adaptation of a health intervention.
•
10. Develop public health programs and strategies responsive to the diverse cultural values and traditions of the
communities being served.
Leadership
• Leadership
– The ability to create and communicate a shared
vision for a changing future; champion solutions
to organizational and community challenges; and
energize commitment to goals.
(L) Upon graduation a student with an MPH should be able to…..
•
1. Describe the attributes of leadership in public health.
•
2. Describe alternative strategies for collaboration and partnership among organizations, focused
on public health goals.
•
3. Articulate an achievable mission, set of core values, and vision.
•
4. Engage in dialogue and learning from others to advance public health goals.
•
5. Demonstrate team building, negotiation, and conflict management skills.
•
6. Demonstrate transparency, integrity, and honesty in all actions.
•
7. Use collaborative methods for achieving organizational and community health goals.
•
8. Apply social justice and human rights principles when addressing community needs.
•
9. Develop strategies to motivate others for collaborative problem solving, decision-making, and
evaluation.
Public Health Biology
• Public Health Biology
– Public health biology is the biological and
molecular context of public health.
(PHB) Upon graduation a student with an MPH should be able
to…..
•
1. Specify the role of the immune system in population health.
•
2. Describe how behavior alters human biology.
•
3. Identify the ethical, social and legal issues implied by public health biology.
•
4. Explain the biological and molecular basis of public health.
•
5. Explain the role of biology in the ecological model of population-based health.
•
6. Explain how genetics and genomics affect disease processes and public health policy and practice.
•
7. Articulate how biological, chemical and physical agents affect human health.
•
8. Apply biological principles to development and implementation of disease prevention, control, or
management programs.
•
9. Apply evidence-based biological and molecular concepts to inform public health laws, policies, and
regulations.
•
10. Integrate general biological and molecular concepts into public health.
–
http://www.asph.org/document.cfm?page=928.
Professionalism
• Professionalism
– The ability to demonstrate ethical choices, values
and professional practices implicit in public health
decisions; consider the effect of choices on
community stewardship, equity, social justice and
accountability; and to commit to personal and
institutional development.
(P) Upon graduation a student with an MPH should be able to…..
•
1. Discuss sentinel events in the history and development of the public health profession and their relevance for practice in the field.
•
2. Apply basic principles of ethical analysis (e.g. the Public Health Code of Ethics, human rights framework, other moral theories) to issues of
public health practice and policy.
•
3. Apply evidence-based principles and the scientific knowledge base to critical evaluation and decision-making in public health.
•
4. Apply the core functions of assessment, policy development, and assurance in the analysis of public health problems and their solutions.
•
5. Promote high standards of personal and organizational integrity, compassion, honesty and respect for all people.
•
6. Analyze determinants of health and disease using an ecological framework.
•
7. Analyze the potential impacts of legal and regulatory environments on the conduct of ethical public health research and practice.
•
8. Distinguish between population and individual ethical considerations in relation to the benefits, costs, and burdens of public health
programs.
•
9. Embrace a definition of public health that captures the unique characteristics of the field (e.g., population-focused, community-oriented,
prevention-motivated and rooted in social justice) and how these contribute to professional practice.
•
10. Appreciate the importance of working collaboratively with diverse communities and constituencies (e.g. researchers, practitioners,
agencies and organizations).
•
11. Value commitment to lifelong learning and professional service.
Program Planning
• Program Planning
– The ability to plan for the design, development,
implementation, and evaluation of strategies to
improve individual and community health.
(PP) Upon graduation a student with an MPH should be able
to…..
•
1. Describe how social, behavioral, environmental, and biological factors contribute to specific individual and community
health outcomes.
•
2. Describe the tasks necessary to assure that program implementation occurs as intended.
•
3. Explain how the findings of a program evaluation can be used.
•
4. Explain the contribution of logic models in program development, implementation, and evaluation.
•
5. Differentiate among goals, measurable objectives, related activities, and expected outcomes for a public health
program.
•
6. Differentiate the purposes of formative, process, and outcome evaluation.
•
7. Differentiate between qualitative and quantitative evaluation methods in relation to their strengths, limitations, and
appropriate uses, and emphases on reliability and validity.
•
8. Prepare a program budget with justification.
•
9. In collaboration with others, prioritize individual, organizational, and community concerns and resources for public
health programs.
•
10. Assess evaluation reports in relation to their quality, utility, and impact on public health.
Systems Thinking
• Systems Thinking
– The ability to recognize system level properties
that result from dynamic interactions among
human and social systems and how they affect the
relationships among individuals, groups,
organizations, communities, and environments.
(ST) Upon graduation a student with an MPH should be able
to…..
•
1. Identify characteristics of a system.
•
2. Identify unintended consequences produced by changes made to a public health system.
•
3. Provide examples of feedback loops and “stocks and flows” within a public health system.
•
4. Explain how systems (e.g. individuals, social networks, organizations, and communities) may be viewed as systems
within systems in the analysis of public health problems.
•
5. Explain how systems models can be tested and validated.
•
6. Explain how the contexts of gender, race, poverty, history, migration, and culture are important in the design of
interventions within public health systems.
•
7. Illustrate how changes in public health systems (including input, processes, and output) can be measured.
•
8. Analyze inter-relationships among systems that influence the quality of life of people in their communities.
•
9. Analyze the effects of political, social and economic policies on public health systems at the local, state, national and
international levels.
•
10. Analyze the impact of global trends and interdependencies on public health related problems and systems.
Evolution of Public Health Understanding, or, “how did ‘we’ get
here?
 ISBN 0801846455
 A History of Public Health
George Rosen
expanded edition
1993, 632 pp.
 Johns Hopkins University Press
Miasma versus Germ Theory:
The origin of scientific public health
• John Snow and the Cholera epidemic in
London
•
•
• (1849 – 1854).
“Snow was a skeptic of the then-dominant miasma theory that
stated held that diseases such as cholera or the Black Death
were caused by pollution or a noxious form of "bad air". The
germ theory was not widely accepted at this time, so he was
unaware of the mechanism by which the disease was
transmitted, but evidence led him to believe that it was not due
to breathing foul air.
He first publicized his theory in an essay On the Mode of
Communication of Cholera in 1849. In 1855 a second edition was
published, with a much more elaborate investigation of the
effect of the water-supply in the Soho, London epidemic of
1854.”
Austin Bradford Hill (1897-1991): Contributions
to the core foundations of public health
RICHARD DOLL: Sir Austin Bradford Hill has largely been forgotten about
nowadays because he is dead. But he was my boss and my teacher, and
the methods and techniques we developed together in order to find out
why lung cancer was increasing so dramatically are still used to this day.
Bradford Hill later codified these into what he termed “nine guidelines”,
(often wrongly referred to as “criteria”) which are universally accepted
now. They are cited in courts of law.
I (Richard Doll) wrote an article about three years ago on proof of
causality – proof that something is actually a cause of a disease – which
made use of what I'd learnt from Bradford Hill, and which is now used as a
reference point for epidemiologists. And of course our report that
established smoking as an important cause of lung cancer
was very important. That was the first serious epidemiological study ever
done into cancer, at a time when there were probably no more than a
dozen of us working on this issue worldwide.
Looking back with the benefit of more than 50 years' hindsight, I can
honestly say that we did a good job.
Hill’s Guidelines
1.
2.
3.
4.
5.
6.
7.
8.
9.
Precedence
Correlation
Dose-response
Consistency
Plausibility
Alternatives
Empiricism
Specificity
Coherence
Precedence
• The cause must precede the disease…
– Snow’s work on drinking water contamination and
cholera in London
Correlation
• Occupational exposures
Muscovite
– E.g. Asbestos mining and mesothelioma
Asbestos fibers
Dose-response
• “The dose makes the poison”
– Ionizing radiation?
– “Hormesis (from Greek hormæin,
meaning “to excite”) is the term for
generally-favorable biological responses
to low exposures to toxins and other
stressors. A pollutant or toxin showing
hormesis thus has the opposite effect in
small doses than in large doses.”
Paracelcus
Consistency
• Observable health
effects of risk factors
should cut across
populations and
generations.
– E.g. “mad hatter disease”
from mercury exposure.
The crippled
hand of a
Minamata
disease victim
(photo: W. E.
Smith)
Autism?
Obsessively
stacking or
lining up
objects may
indicate
autism.
Plausibility
• Lead (Pb) poisoning
– Saturnism, Plumbism or Painter's colic
– Variation in disease endpoints is explained by
the understanding of the biochemical and
genetic basis of effects associated with Pb
exposure.
• Anemia – Pb binding to delta-aminolevulinate
dehydratase, crucial for heme synthesis.
• Neurological effects due to accumulation of
precursor and crossing of blood-brain barrier.
• Gout – accumulation of uric acid in joints –
inflammation.
• Crime ??
Alternatives
• Alternative explanations for disease causation
should be considered alongside plausible
environmental associations.
– Low level pesticide exposures and chronic disease
conditions.
• Gina Solomon, Oladele Ogunseitan and Jan Kirsch.
2000. Pesticides and Human Health. Physicians for
Social Responsibility & Californians for Pesticide
Reform.
• http://www.psrla.org/documents/pesticides_and_human_health.pdf
Empiricism
• The course of an environmental
disease should be alterable
with intervention and removal
of exposure.
– Chelation therapy for toxic metal
exposure.
– Disinfection and antibiotic therapy
for water-borne diseases.
– Koch’s postulates
Robert Koch (1843 – 1910)
Empiricism continued:
Modified Koch’s postulates
• 1. Exposure to environmental agent must be demonstrable in all
organisms suffering from the disease,, but not in healthy
organisms.
• 2. The identity, environmental concentrations, and transformation
pathways of the agent must be known as much as possible.
• 3. The agent should cause disease when introduced into health
organisms.
• 4. Biomarkers showing modification of the physiological target
must be observable in experimentally exposed organisms.
Specificity
• An environmental disease should be
associated with one environmental agent.
• Strengthens the argument for causality.
• Extremely rare situation.
– Neurodegenerative diseases associated with prion
protein remains mysterious. Are toxic metals
involved?
– Nanoparticles and respiration health.
Coherence
• The cause-and-effect interpretation of our
data should not seriously conflict with the
generally known facts of the natural history
and biology of the disease.
Where are we headed?
• Population growth and public health
Outline
• The real causes of death and disability: “The
Global Burden of Diseases.” Essential
Resource: World Health Organization’s GBD
project
• (http://www.who.int/topics/global_burden_of
_disease/en/)
The World Health Organization
• http://www.who.int/about/agenda/en/index.html
Dr Margaret Chan, from the People's Republic of China, obtained her medical degree from the
University of Western Ontario in Canada. She joined the Hong Kong Department of Health in 1978,
where her career in public health began.
In 1994, Dr Chan was appointed Director of Health of Hong Kong. In her nine-year tenure as
director, she launched new services to prevent the spread of disease and promote better health.
She also introduced new initiatives to improve communicable disease surveillance and response,
enhance training for public health professionals, and establish better local and international
collaboration. She effectively managed outbreaks of avian influenza and of severe acute respiratory
syndrome (SARS).
In 2003, Dr Chan joined WHO as Director of the Department for Protection of the Human
Environment. In June 2005, she was appointed Director, Communicable Diseases Surveillance and
Response as well as Representative of the Director-General for Pandemic Influenza. In September
2005, she was named Assistant Director-General for Communicable Diseases.
Dr Chan was appointed to the post of Director-General on 9 November 2006. Her term will run
through June 2012.
Established 7 April 1948
(Annual World Health Day – April 7th)
http://www.who.int/about/brochure_en.pdf
WHO Six Regional Offices
The role of WHO in public health
• WHO fulfils its objectives through its core functions:
– providing leadership on matters critical to health and engaging in
partnerships where joint action is needed;
– shaping the research agenda and stimulating the generation, translation
and dissemination of valuable knowledge;
– setting norms and standards and promoting and monitoring their
implementation;
– articulating ethical and evidence-based policy options;
– providing technical support, catalyzing change, and building sustainable
institutional capacity; and
– monitoring the health situation and assessing health trends.
Future Projections of Public Health Needs:
The 2008 World Population Data Sheet
Presentation by Bill Butz, Carl Haub,
Richard Skolnik, and Linda Jacobsen
of the Population Reference Bureau
August 19, 2008
© 2008 POPULATION REFERENCE BUREAU
Global Demographic Divide Widens
World Population (in Billions): 1950-2050
Source: United Nations Population Division, World Population Prospects: The 2006 Revision.
© 2008 POPULATION REFERENCE BUREAU
Scaled World
Population by
Region
Public Health
Spending
Danny Dorling of the University of Sheffield: Worldmapper Project – PLOS-Medicine 2007
Number of
working physicians
Preventable Deaths
The United States Has Been Growing Faster Than Expected.
United States Population (in Millions): 1970-2050
Source: Population Reference Bureau, analysis of data from U.S. Census Bureau.
© 2008 POPULATION REFERENCE BUREAU
Continued Population Growth Sets the United States Apart From Other
Developed Countries Around the World.
Percent Change in Population, Selected Countries: 2008-2050
Source: Carl Haub and Mary Mederios Kent, 2008 World Population Data Sheet.
© 2008 POPULATION REFERENCE BUREAU
Focus on Geriatrics and Chronic Diseases:
By 2050, One in Every Five Americans Will Be Age 65 or Older.
Percent of U.S. Population in Selected Age Groups: 1970-2050
Source: Population Reference Bureau, analysis of data from U.S. Census Bureau.
© 2008 POPULATION REFERENCE BUREAU
Focus on Socio-cultural Diversity and Health:
The U.S. Will Continue to Become More Racially and Ethnically Diverse.
Percent of U.S. Population by Race and Ethnicity: At 300 Million and 400 Million
AT 300 MILLION
(2007)
AT 400 MILLION
(2039)
White Alone*
66
51
Black or African American Alone*
12
12
Asian, Native Hawaiian, and Other Pacific Islander
Alone*
5
7
American Indian and Alaska Native Alone*
1
1
Two or More Races*
1
3
Hispanic (of any race)
15
26
100
100
TOTAL
* Excludes Hispanics.
Source: Population Reference Bureau, analysis of data from U.S. Census Bureau.
© 2008 POPULATION REFERENCE BUREAU
Ten Percent of U.S. Counties Have Already Reached MajorityMinority Status.
Counties at or Nearing Majority-Minority Status (Total Population), United States: 2007
Source: Population Reference Bureau, analysis of data from U.S. Census Bureau.
© 2008 POPULATION REFERENCE BUREAU
Minorities Make Up at Least 50 Percent of the Youth Population
in One in Seven Counties Nationwide.
Counties at or Nearing Majority-Minority Status (Under-20 Population), United States: 2007
Source: Population Reference Bureau, analysis of data from U.S. Census Bureau.
© 2008 POPULATION REFERENCE BUREAU
How do we prioritize health research and translational projects?
The Global Burden of Disease Project
http://www.who.int/healthinfo/bodproject/en/index.html
Measuring Burden of Diseases
World Health Organization
•
The disease-adjusted life year is a composite indicator of the
time lived with a disability (YLD) and the time lost due to
premature mortality (YLL) (Murray & Lopez, 1996).
•
DALYi [0,0] = YLLi + YLDi
Where:
•
YLLi = Years of Life Lost due to disease i
–
•
(# deaths x standard life expectancy at age of death)
YLDi = Years of Life lived with Disability due to disease i
–
# incident cases x disability weight x average duration of disease case
until remission or death.
Estimating Years of Life Lost (YLL)
KCe ra (r  )(L  a)
1 K
(r  )a
rL
YLLs 
e

(r


)(L

a)

1


e

(r


)a

1


(1 e )


2
(r  )
r
Where:
r = discount rate (.03, rate used in GBD, 1997)
 = parameter from the age weighting function (.04)
K = age-weighting modulation factor (1)
C = constant (0.1658)
a = age at death
L = standard expectation of life at age “a”
Years Lived with Disability (YLDs)


 KCera (r  )(L  a)
1 K
(r  )a
rL 
YLDs  D
(r  )(L  a)  1  e
(r   )a  1
(1 e )
2 e


r
(r  )

Where:
a = onset of disability
L = duration of disability
r = discount rate (r = .03)
 = age-weighting parameter ( = 0.04)
K = age-weighting modulation factor (K = 1)
C = adjustment constant necessary because
of unequal age-weights = 0.1658
D = Disability weight
YLD
10000
Major Depression
8000
Alcoholism
Osteoarthritis
Dementia
6000
Schizophrenia
Bipolar disorder
4000
Cerebrovascular
COPD
2000
Car Accidents
Diabetes
0
Diseases
N
C
N
Disease Category
s
ef
cl
as
e
ud
in
g
es
is
s
H
IV
us
en
ci
m
el
lit
ici
s
ar
ia
ul
os
se
be
rc
di
et
es
ex
ia
b
ST
D
D
na
ld
Tu
e
M
al
nj
ur
ie
es
se
as
li
S
es
ea
s
is
IV
/A
ID
ns
rie
s
tio
fe
c
di
ld
H
in
ju
es
on
s
as
iti
l in
tio
na
st
iv
nd
di
se
na
to
ry
oe
a
en
ig
e
tio
D
tio
la
r
co
to
ry
ira
In
t
es
p
ut
ri
R
ira
te
n
ia
rrh
es
p
ni
n
D
R
U
cu
at
ric
as
io
v
ch
i
op
sy
ar
d
eu
r
DALYs
Millions
Global Disease-Adjusted Life Years (DALYs)
2002 Worldwide Disability Adjusted Life Years (DALYs)
180.00
160.00
140.00
120.00
100.00
80.00
60.00
40.00
20.00
0.00
Future projections of disease burden
ln M = C + b1lnY + b2lnHC + b3T
Where:
M = projected mortality level
C = constant term
Y = GDP per capita
HC = Human capital (including population growth)
T = Time
Estimating “Attributable Risk”
•
Attributable Risk is assessed, using published data on relative risks for each cause of
death and disability related to the exposure, levels of exposure (prevalence), and
burden of disease due to each cause of death and disability in the population:
• AB = ∑ AFj Bj = ∑Pj (RRj – 1) ÷ ∑Pj (RRj – 1) + 1
•
Where
– AB = Attributable Burden for a risk factor
– AFj = Fraction of Burden from cause j
– Bj = population level burden of cause j
– P = Prevalence of exposure
– RRj = Relative Risk of disease or injury for cause j in exposed versus unexposed
group.
– n = Maximum exposure level
Environmental burden of disease: Country profiles
•
http://www.who.int/quantifying_ehimpacts/national/countryprofile/intro/en/index.html
Burden of Disease Attribution to Environmental Factors in
the U.S.
Angola
Infant mortality
= 260/1000