Public Health Final

Heritage Foundation

"Free-riders" who don't buy insurance and cannot afford to pay out of pocket cost tax payers a lot of money Mandating some level of health insurance for all should reduce some of the subsidizing middle/upper classes do for the poor/free riders Downside - individual mandate on some road as universal coverage Massachusetts passed a law w similar components in 2006 - gov Mitt Romney (R) championed the reform Provisions: Health insurance mandate, employer coverage mandate, free health insurance for low income, subsidized insurance for other, Health Insurance Connector Romney - should be left to states, not mandated by federal gov

Carrying Capacity: sustainability

"Number of organisms that can be supported in an environ without degrading it" "The max population size of the species that the environ can sustain indefinitely, given the food, habitat, water, and other necessities available in the environ - added complexity w humans where sanitation, health care, technology creativity, etc are important

Paul Erlich - Malthus's modern day intellectual descendent

"The general public, businessmen, governments, and many business economists appear to believe that population and per capita consumption can grow indefinitely, and that eventually all economic inequities can be eliminated by growth itself.. This is an entirely unwarranted assumption - and debunking it may be the single most important task of environmental and resource economists" Malhtusian - end of world

Aging and Social Security

$888B in 2015 (24% of fed budget) Will increase with baby boomers retirements peaking around 2030 Current annual cash-flow deficits Reserves exhausted by 2033

Foodborne Illness

1 in 6 Americans have a foodborne illness - any illness resulting from ingestion of food 128,000 are hospitalized/year 3,000 die Foodborne illness costs about 15.6 bill per year

Measures to improve pop control

1. Media campaigns to restrict family size e.g., China's one-child policy 2. Family planning programs Education Provision of (subsidized) birth control 3. Address basic conditions to improve infants' and children's chances of survival Basic education, especially of girls Health care access & quality Improve agricultural outputs

Negative Media Portrayals of Mental Illness

1. People w mental illness are *criminal or violent* -Studies show that not only are individuals w mental illness less likely to commit violent crimes, they're actually more likely to be victimized (victim of crime) 2. People with mental illness *look dif* than others - People with mental illness look like everyone else - not like their media stereotypes 3. People with mental illnesses are *childish and silly* - These portrayals don't convey the way most people with serious mental illnesses are in pain and struggling 4. Mentally illnesses are *all severe - or all alike* - Most rare disorders are over-represented on TV, more common disorders (depression) are less represented 5. *Psychiatric hospitals cause more harm than good* - Med facilities differ in quality BUT today's hospitals are dif than those in movies 6. People with mental illness can *never recover* - Not only do patients often recover from psychiatric illnesses, but they can live healthy lives with the help of therapy

Top 5 pathogens resulting in hospitalization

1. Salmonella Norovirus

Cultural Factors in Diagnosing and Treating Psychiatric Disorders

1. Symptoms, Presentation, and Meaning 2. Causation and Prevalence 3. Family Factors 4. Coping Styles 5. Treatment seeking 6. Mistrust 7. Stigma 8. Immigration 9. Overall Health Status

Tuberculosis

1/3 of world's population has latent TB of which there is 10% lifetime risk of developing active TB TB is top 10 cause of death worldwide 10.4 million new cases and 1.8m deaths in 2015 Six countries account for 60% of total TB is leading killer of HIV positive people Treatable and curable Rapid testing, effective multidrug treatment is essential MDR-TB resistant to anti - 5% of cases XDR-TB strains also resistance Prevention

Global death toll due to tobacco

100 mil deaths in 20th c WHO predicts 1 billion deaths in 21st century 6 million per year now, 8.6 in 2030 By 2030 tobacco = leading cause of death worldwide Most of tobacco deaths in LMIC

Teens w/o contraception use

18,1% Detroit no use 11.4% no use in MI

Detroits population 1840 to 2012

1840 to 1950 increased Peak - 1,800,000 million 1950 to 2012 decreased to 700,000

Origins of Gov Regulation

1862 - Lincoln formed Department of Agricult 1879 - First USDA investigation into food adulteration practices 1883 - 1886 - 100 food and drug bills introduced by congress 1898 - Pure Food Congress; focused national attention to enact federal legislation against misbranding and adulteration of foods Public Outrage over: Unhygienic conditions in meatpacking plants (Upton SInclairs The Jungle) Adulteration of foods with cheaper ingrediented Toxic additives to improve appearance/color and cover up spoilage Similar abuses in sale of medicines - unknown mix of substances, wild claims regarding beneficial effects, adverse side effects

Pure Food and Drug Act AND Meat Inspection Act

1906 passage Food and Drug - prohibited interstate commerce in misbranded and adulterated foods, beverages, and drugs Meat - Regulation of meat quality and safety

Growth in U.S. Eldery

1935 - 6.1% over 65 -- 1.9% over 75 2010 - 13% over 65 -- 6% over 75 2030 - 20% over 65 -- 9.3% over 75

Logic of 65 as retirement age today

1940 - % surviving age 21-65 = 57%, LE at 65 is 13.7 2009 - 79 % 21-65, 19.2 LE --- People are living longer after 65, more money you make longer you live after 65

Policies in EHS

1970 - Lead Based Paint Poisoning Prevention Act 1975 - Hazardous Materials Transpotation Act 1969 to 1976 lots passed for EHS 25% of global burden of disease due to environmental factors

ACA details

2,400 pages long 10 Titles, each dedicated to different parts of the health care system Subsequent creation of hundreds of regulations and administrative rules by various agencies within the DHHS

Organics

2000, federal standards regulated what foods could be labeled organic Food product labels - organic meat - raised w/o antibiotics or GH Organic produce - no fert, pesticide Advantage - fewer pesticide residues, may activate moe natural pesticides, may have more nutrients Dis - cost, feeding poor, organic and carbon footprint (eat local)

Local legislation to protect breastfeeding in public

2005, Michigan exempts breast-feeding from its public nudity statute, but it does not protect a woman's right to breast-feed in public places 2006 Ann Arbor City Code 2014 Michigan legislation to protect a woman's right to breastfeed in a public place 49 states now have this legislation

Nutrition Labels

2006 - nutrition labels were required to list trans fats 2020 - New nutrition facts labels and serving size reqs

Malaria

212M cases and 429,000 deaths in 2015 Most cases/deaths in children 92% in Africa Mortality rates decreased 62% 2000-2015 Prevention/Control Methods - Vector control --> eliminate standing water, insecticide treated nets, indoor residual spraying Intermittent preventive therapy (infants, pregnant women) Rapid diagnostic tests Vaccines? - none yet

Physicians per 100,000

271,9 per 100, 000in MI 97 per 100,000 in Wayne county

Summary of Global HIV Epidemic

36.7 million now estimated to live w HIV 1.8 mil newly infected 1 million related deaths Infections is exceeding deaths Disease is increasing, not going away

Growing up LGBT in America is difficult

4 in 10 youth say the community in which they live is not accepting of LGBT 26% of LGBT youth say their biggest probs are not feeling accepted by their fam, trouble at school, and a fear to be ou 22% of non-LGBT say their biggest problems are trouble w class, exams, and grades 92% of LGBT youth say they hear negative messages about being LGBT, top sources are school, internet, and their peers 2/3 of hs say they are out to classmates

Globally, water bodies that serve ___ million people are polluted by chemical, biological, and physical stressors?

5 Billion

Severe Maternal Morbidity During Delivery Hospitalizations 1998-2011

60 to 160

Tackling Lead Exposure in DET

7x chances of dropping out of HS 1.5x risk of arrest for violent crime 7 years lifetime income loss due to reduced IQ

Health of eldery

80% have 1 chronic 68% have 2 or more chronic Common ones are: Hypertension High cholesterol Arthritis Heart Disease Diabetes --- High prevalence of heart disease - 30% of all death vs. 22% for cancer For all ages less than 65, cancer kills more than heart disease Alzheimers and dementia Osteoprosis Macular degeneration and cataracts Arthritis Falls and sequelae Multiple prescriptions and drug interactions Social isolation, loss of professional identity

How many chemicals are there in U.S. commerce?

85,000

How many LGBT adults in U.S.

9 million adults 1.3 million if high school Most are white, 18% hispanic, 15% black, 2% asian

Two major trends

95% of births in next 25-50 years will be in world's poorest countries Urban migration - majority of world's people live in cities (1st time) - adverse implications overcrowding, sanitation, infectious disease increase, violence/crime, prostitution, HIV/AIDS, children w/o homes, families, death rates increases

% deaths among young and old in low and high

<15 years - 40% LI, 1% HI >70 years - 20% LI, 70% HI

Population growth and global climate change

A central challenge of climate change: How can we at the same time: 1. maintain high living standards in developing countries 2. improve living standards in less developed countries 3. reduce overall greenhouse gas emissions to levels that are compatible w a stable and sustainable environ

AIDS Facts

ART treatment rising due to international aid Gov, especially PEPFAR - $72.7 bil, treatment, testing, counseling, training, also provides funding for TB and Malaria Non-gov - 2.5 bil to HIB research and organizations 1.4 bil to Global Fund to fight AIDS, TB, and malaria Yet, in 2016 only 53% living with HIV received ART

Preconception Health

Access to care Managing health issues (diabetes, hypertension, thyroid....) Screening and treatment for STIs (HIV, chlamydia, gonorrhea, syphilis) Promoting optimal health- stress reduction, smoking cessation, exercise and diet

Pregnancy related deaths in MI

Accident Medical not obstetric All obstetric causes Assaults Suicide

Assurance/Oversight

Accreditation of training programs Licensure/professional standards Laboratory safety/quality standards Quality of care protocols and systems Radiation safety standards FDA: Drug regulations Facility safety regulations Certificate of need laws

Mental Health Promotion and Protection

Actions to create living conditions/environments that support mental health Environment that respects and protects basic civil, political, socio-economic and cultural rights (security and freedom from rights allows for health mind) National mental health policies should not be solely concerned w mental disorders, also recognize broader issues which promote MH - policies, programs

AIDS race

Africa has 25.6 mil, 2/3 of all ppl 3.3 mil in Americas and SE Asia

Regulation of Dietary Supplements

After hearings on vitamin fortification of foods and dietary supplements, FDA issued regulations on them Public and industry response led Congress to ban FDA from regulating supplements Dietary Supplement Health and Education Act of 1994 Prohibits FDA from regulating herbs and supplements, despite risk of several supplements Manufacturers not required to alert FDA to adverse side effects of supplements Requires FDA to provoke "signif and unreasonable risk to health" before removing supplement from stores

Alcohol

Alcohol-attributable deaths cover many diagnostic categories (CVD, DM, cancers, GI, ID, injuries, neonatal conditions) Alcohol results in ~3.3 million deaths per year (5.9% of all deaths) Alcohol use disorders (ICD-10): 4.1%

Facilities

Ambulatory care clinics (outpatient) Emergency departments/urgent care clinics Hospitals (3 types: private for profit; private non-profit; public) Long-term care/nursing homes Community health centers School-based clinics Family planning clinics Local health departments Retail clinics Mobile vans Dialysis centers

Maternal Mortality ratio

Amount died per 100,000 live births

Income among elderly

Amount in poverty has decreased 35% in 1960 to 10% in 2015 -- Amount in Labor forced decreased from 1945 to 1990 then increased to now (19.4%) --- Lowest income get most of income from social security

Dose

Amount of agent actually deposited within or imparted onto the body

Dose

Amount of agent actually desposited within or imparted onto the body

Exposure

Amount of contact w hazard

Intersection of Mental Illness and Other Social Issues

An estimated 26% of homeless adults staying in shelters live with serious mental illness and an estimated 46% live with severe mental illness and/or substance use disorders Approx 20% of state prisoners and 21% of local jail prisoners have a "recent history" of a mental health condition 70% of youth in juvenile justice systems have at least one mental health condition and at least 20% live with a serious mental illness Only 41% of adults in US with a mental health condition received mental health services in past year Among adults w a serious mental illness, 62.9% received help in past year

What is foodborne illness

Any ilness resulting from ingestion of food 3 hazards Biological - bacteria, mold, viruses, parasites, toxins Chemical - substances added to foods, cleaners, sanitizers, lubricants, drug residues in food of animal origin Physical - bone, metal, plastic, glass, woodchips

Gini Coefficient

Area between line of equality and Lorenze Curve divided by total area under line of equality 0 = perfect equality of income 100 = perfect inequality of income Higher numbers = more inequality G = A/(A+B)

GDP per capita and life expectancy

As GDP Increases life expectancy increases Levels out around 6,000 LE increases steeply then levels 3,200 in 1860 got you 60 years, now it gets 70 LE has improved over time

As GINI goes up

As GINI goes up, life expectancy decreases

Does a country's level of spending on health care matter?

As Per cap HC spending increases LE increases At around 1,000 levels off We spend about 4500

Obesity and Built Environ

As amenities of environ increase, obesity decreases

Human-made causes of climate change

Atmospheric pollution due to - industrial activity - urban/suburban sprawl and dependence on cars - affluence --> increased consumption per person - waste disposal Clear cutting and logging for agricultural and land use

Who is LGBT?

Attempts to classify people by sexual orientation have been around ~70 years *Kinsey Scale of Sexual Behavior* Scale between exclusively heterosexual and exclusively homosexual Exclusively hetero, incidental homo, more than incidental homo, equal hetero and homo, more than incidental hetero, incidental hetero, exclusively homo

Behavioral Health vs. Mental Health

BH is scientific study of emotions, behaviors, and biology relating to a person's mental well-being, their ability to function in every day life and their self concept BH includes ways or promoting well-being and prevention/intervention substance abuse and addiction MH covers many of same issues as BH but MH only encompasses biological component of this aspect of wellness (BH looks at behavior too) The term "behavioral health" encompasses all contributions to mental wellness including substances and their abuse, behavior, habits, and other external forces

What is "aging"

Becoming old; showing the effects or characteristics of increasing age

Medicaid Expansion under ACA

Before ACA, very few states offered Medicaid coverage to ppl without extremely low incomes AND categorical qualifications (cognitive or physical disability, certain disease, pregnancy) Mandated Expansion: Medicaid will cover everyone under 133% of FPL. including childless adults Feds cover costs for newly eligible (2014-17), then 95%(2018-19), then 90% of costs after 2020 Reauthorized Children's Health Insurance Plan (CHIP) until

City level built environ issues

Beneficial exposures - health food, health care services, recreational facilities, nature

Prevention Strategies for prematurity

Birth Spacing Progesterone Preconception health

Birth spacing

Birth spacing is good for health of mothers and children >18 months birth spacing Decreased prematurity rate Decreased perinatal and infant mortality Decreased maternal mortality risk Decreased pregnancy complications

Origin of 65 as retirement age

Bismarck: German social insurance at age 70, adopted 1889 Lowed to 65 in 1916 FDR: Social Security Act of 1935 Elderly dependency ratio then v. now

Racial disparity in maternal mortality

Black 42.8 per 100,000 Other 17.3 White 12

Detroit Infant Mortality Rate

Black babies in Detroit are twice as likely to die as babies in MI overall Detroit - 14.5/1000 MI - 7/1,000 14.9% of Detroit's black babies born at low weight (8.4 MI) 19.3 BB born preterm (12.3 MI)

Michigan racial disparity

Blacks are much higher than other races Around 15-20% Others are between 5-10

Three examples of improving MCH

Breastfeeding Birth spacing and intended pregnancies Pre-conception health and preventing premature birth

LGB are less safe than hetero peers

Bullying, E bullying, forced sex, dating violence, dating sexual violence all elevated as compared to hetero

Disparity reduction efforts

Can be effective All races stay level around 10 Black increased from 1999 to 2005 then decreased back to level in 1999 in 2013

Detroit Population

Can fit Sand Fran, Boston, and Manhatten together into Detroit No public transportation system --> people are isolated Redlining - fed gov wanted to help ppl get housing by giving loans but didn't want to lose $$ so didn't want to loan to AA specifically -- encouraged movement to suburbs Gave $ access to white wealthy, only gave econ prosperity to whites Prices of those homes increased giving whites more money Left AA intercity in poverty

Projected global deaths 2004-2030

Cancers, heart disease, cerebrovascular, road traffic increases Acute resp infection, perinatal, HIV, malaria, TB - decline Chronic dis increase, ID decrease

No rescission

Cannot kick sick people off of their plans

Population pressures

Carrying capacity - 2-40 billion depends on need Loss of tropical rain forest Fishery exploitation Temperature increase

Patterns/causes of death now and in future Leading causes of death, high and low income countries

Cause in low 1. Lower respiratory dis 2. Diarrhea 3. Stroke 4. Heart dis 5. HIV/AIDS Infectious Cause in high 1. Heart dis 2. Stroke 3. Alzheimers 4. COPD 5. Lower resp Chronic EPIDEMIOLOGICAL TRANSITION Non-communicable disease = 37% of deaths in low-income countries 88% of deaths in high-income

Vulnerable Populations World Map

Central Africa, India, Middle East

Economics of EHS

Change lead paint $1 spent = $17-221 saved (EHP: 117: 1162-67)

Percent of Nonelderly Adults and Children w usual source of care other than ER

Children - all races are really high Adults - all races much lower than kids, hispanic is lowest at 73% Hispanic lowest access to something besides ED

Fertility by Major Region

Children per women has dropped a TON Used to be about 6, African highest Now all around the same level of 2.1

Primary cause of preg related deaths

Chronic disease Non-cardiovascular highest, cardiovascular, infection

Impact of change in smoking on Medicaid

Clear savings due to reduced smoking among medical care beneficiaries Nursing home support - elderly smokers more likely to need nursing home care, but reduction in smoking means more older seniors and therefore more nursing home care, unknown net effect Costs may decrease

Potential Effects on Health

Climat Changes - temp rise, hydrologic extremes Environ changes - heat, severe weather, air pollution, allergies, vector-borne diseases, water-borne diseases, water and food supply, mental health, eviron refugees Health changes - Heat Stress, Cardiovascular Failure Injuries, Fatalities Asthma, Cardiovascular Disease Respiratory Allergies, Poison Ivy Malaria, Dengue, Encephalitis, Hantavirus, Rift Valley Fever Cholera, Cryptosporidiosis, Campylobacter, Leptospirosis Malnutrition, Diarrhea, Harmful Algal Blooms Anxiety, Despair, Depression, Post-Traumatic Stress Forced Migration, Civil Conflict

A Collaborative Approach

Clinician engagement - increase number of clinicians who are offer LARCs through med ed,forums, tech support Public Awareness - engage comm in candid discussion on teen preg to develop a target public relations campaign Improved Access - build network of clinical providers and innovative access points Work on program to decrease rates of preterm birth by supplying "sisters" - mentors in the area and certain classes Unintended teen preg - increases access to LARCs by building clinics in neighborhoods, education for providers public awareness campaigns

Characteristics of human aging

Collective effects of physical, psychological and social changes over the lifespan Some characteristics improve w aging - knowledge wisdom Others decline - reaction time Some improve then decline - muscle

LARCs are effective in reducing unplanned pregnancies - Colorado Study

Colorado study (2014) Low income young women age 15-24 Had increased access to LARC products Decreased pregnancy rates (29% in 15-19yo, 14% in 20-24yo) Decreased abortion rates (34% in 15-19yo, 18% in 20-24yo)

Breast Milk - the perfect food

Colostrum Antibodies, immune cells Milk Fats, carbohydrates, protein, minerals, antibodies, immune cells Changes with needs of babies More digestible than cow's milk

Points of Contamination - Processing

Contaminated water used to wash, pack, chill fruits/veggies Slaughtering of animals Contaminated surfaces of equipment used for processing spread to foods

Determinants of Birth

Culture and religion economics social change war politics and policy health care technology (birth control, NICU)

Medicare Dilemma

Current system unsustainable financially 15% of Federal Budget, $540 billion in 2015 Number of beneficiaries projected to rise from 53 million to about 78 million in 2030 Covers only half of beneficiaries health care costs Expenditures are greater than revenue in 2009 Hospital Trust Fund exhausted in 2026 % scheduled benefits payable from current tax income: 81% in 2017; 50% in 2035; 30% in 2080

Community Health Assessment

DHD goals Asking ppl what they think is wrong and focus on PH involving the community To work in partnership with Detroiters to protect and promote their health, well-being, safety, and resilience, and to respond to every public health need with exceptional leadership, policies, programs and services.

Infant Mortality

Death of a baby who was alive at birth but died before reaching his or her first birthday Infant morality rate: number of deaths of infants under one year old per 1,000 live births

Maternal Death

Death of a woman while pregnant or within 42 days of termination of a pregnancy from *any cause related to or aggravated by pregnancy*, not from accidental or incidental causes

Prenancy-related death

Death of a woman while pregnant or within 42 days of termination of pregnancy (irrespective of cause)

Climate Change

Debate is over Intergov Panel on Climate Change Time for doubt has passed Warning of our climate system has been unequivocally confirmed and linked directly to human activity

Prenatal Progesterone

Decreases preterm birth risk (RR .58-.66) Decreased preterm complications Makena - (17-OHP) weekly injection Orphan drug was $15 to make, FDA approved in 2011, priced at $1500/dose, not all insurance covers Logistical issues Access to medication Recommendation in 2011- still only 10-15% of candidates receive

Prematurity

Definition: baby born live before 37 weeks (3 or more weeks before due date) Extremely preterm <28 wks Early preterm 28-<34 wks Late preterm 34-36 wks Primary cause of infant death Most preme in south

Population: Is the challenge too great?

Despite improvements, population growing rapidly in many (poor) countries - many countries appear to be reaching limits of carrying capactiy - wars and violence sometimes related to resources scarcity Population shrinking in others

Detroit Pop 2000 to 2010

Detroit saw its population drop by 25%, some areas saw far greater drops and some stayed stable

Poverty

Discussed previously, but consider linkages to others Hunger, population, sanitation, literacy, health behaviors,fam planny, lack of health services, crime violence

We need to pay attention to LB health

Disparities in utilization of sexual health services exist between heterosexual and sexual minority women (SMW) These disparities vary across a number of demographic characteristics, including age, race/ethnicity Increased risky sexual behavior + reduced are utilization = higher vulnerability for negative health outcomes

Coming out to providers: questions

Does being "out" to your health care provider influence whether or not sexual minority women receive sexual health services? Is there a decrease, increase, or no effect in clinical recommendations for sexual health services among "out" SMW patients? Is there a decrease, increase or no effect in receipt of sexual health services among "out" SMW patients? Sexual health services: STI testing Papanicolaou (Pap) testing Human papillomavirus (HPV) vaccination STI testing and PAP test are similar levels to receipt and recommended but HPV vaccine is a lot lower than recommended

Indicators of mental health and social determinants of MH

Domains of MH - *Emotional well-being* --> life satisfaction, happiness, cheerfulness, peacefulness - *Psychological well-being* --> self-acceptance, personal growth including openness to new experiences, optimism, hopefulness, control, spirituality, self-direction - *Social well-being* --> social acceptance, beliefs in potential of people and society, personal self-worth, sense of community Social Determinants of MH: Adequate housing, safe neighborhoods, equitable jobs and wages, quality education, equity in access to quality health care

Food, Drug, and Cosmetic Act of 1938

Drug requirements Pre-market approval of new drugs - FDA does not test drugs, reviews company tests and evidence Accurate labes Drugs to be labeled w instructions for safe use - however, advertising by the Federal Trade Commission Prohibits false therapeutic claims Many subsequent amendments

Examples of Mental Health Promotion Programs and Interventions in PH

Early childhood interventions Support to children Socio-econ empowerment of women Social support for elderly pop Mental health promotional activities in schools Mental health interventions at work Care for ppl w chronic illness Housing policies Violence prevention programs Community development programs Poverty reduction and social protection for the poor Anti-discrimination laws and campaigns Promotion of the rights, opportunities and care of individuals w mental disorders

Pollution

Econ dev in larger LMIC will exacerbate pollution probs Clean water may be most important scare resource of future

Food Safety Modernization Act 2011

Emphasizes prevention rather than responding to contamination Requires increased plant inspections - every 3 years for high-risk Food companies to establish written plans for safe manufacture Mandatory recalls of contaminated foods More frequent inspection of foreign food manufacturing facilities But congress may not grant budget needed

Private Insurance

Employer-Sponsored Individual Market Health Savings Account

Need for support for public health

Est. state, local, and federal direct PH expenditures: ~$80B (in 2015) ~2.5% of national health expenditures ~$250 of total of ~$10,000 per person Likely OVER-estimated! PH is underfunded, imbalance between spending on clinical care but not on population-based actions that influence health more profoundly than medical services Structural and workforce issues How to create more demand for funding PH - ppl/legislators don't want to increase any public spending, public supports in emergency and that's it, clash of econ, politics disfavor

Hazardous Waste: Global

Estonia, South Korea, China, and Netherlands produce most hazardous waste Ship it to poorer countries

Governance

Executive and administrative leadership Boards of directors/trustees

Exposure equation

Exposure = magnitude x frequency x duration

Built Environ Issues

Exposures to hazards Air contaminants Waste contaminants Noise Heat Crime Pests Traffic

What's next?

Extensive support and outreach to women during pregnancy and especially in the first week postpartum Improve education for health professionals Legislate increased maternity care leave to 12 weeks National legislation to protect woman's right to breastfeed in public Make baby friendly hospitals a priority!

Insurance Industry Reform

Federal gov can regulate insurance company rate increases and unfair practices Health insurance companies must 80-85% of premiums on health care (medical loss ratio) Insurance companies are already sending rebates to consumers when they fail to meet these standards

Justice and Climate change

Few are driving the prob for many Poor and disadvantaged bear brunt of climate change Moral obligation to future generations reverse climate change

Foods Associated w Outbreaks

Fish and Shellfish cause about 26% of all outbreaks; more than any other food except produce Difficult to regulate Contamination

What is Global Health

Focus on worldwide health issues, rather than country-specific Interconnectedness of countries regarding health How transportation, commerce, communications, economics, & politics influence health around the world Infectious disease communicability through air & other travel Chronic disease communicability through media & commerce Climate change Addressing health disparities across and within countries

Regulatory Challenges

Food and drug regulation for safety = basic function of gov High politicized - big $$ at stake Food industry wants to make health claims yet avoid new labeling rqs Drug industry wants quick drug approval, consumer advocates claim FDA too readily approves new drugs Tobacco industry wants to minimize reuglation Supplements industry wants to avoid regulation altogether Hundreds of thousands of food processing plants and service outlets Global prep and distribution Resources needed to fin sources of or better to prevent probs Coordination of gov agencies

Effective global tobacco control

Framework Convention on Tobacco Control World's first global health treaty Adopted in 2003; ratified by 180 countries Now dev specific protocol

Relationship between econ dev and health con

General conclusions ↑ in per capita income has huge impact on pop. health to a point (≈ $6K in 1990 $); thereafter, more modest (but real) effect Additionally, for a given level of income, life expectancy has risen over time Also very important: Education (especially of women) Empowerment of women Country's equality of income distribution

Why study population growth?

Generate ciritical info to understand health implications (and other consequences) of pop growth - size of pop - pop distribution (age, sex, race) - births and deaths - marriages and divorces - each of these has health implications Planning for services and resources - schools/hospitals/other services - Roads and other infrastructure - disaster preparedness - gov spending Environmental protection efforts - laws and regulations Planning to control population size, density, etc

Globalization and health

Globalization good for econ dev; essential to get poor ppl in LMICs out of poverty Transfers high-paying jobs to impoverished countries where wages are lower Good for innovation and modernization

CO2 levels over all history

Goes up and down Spiked after 1950, way higher than longer Every year amount of CO2 is highest ever

Income inequality

Great variation in income inequality across countries Income inequalities greatest in poor countries Income inequalities greatest in Africa and through South and Central America Income inequalities least in affluent countries w most homogenous population U.S. and a few other developed countries have substantial inequality (but usually lower than poor)

Population growth and global climate change

Greenhouse effect - CO2 - fluorinated gases - methane - nitrous oxide

World population growth 1750-2100

Growth peaked in 1970, now decreasing a ton, the population looks like S shape now

HIV epidemic

HIV epidemic is patterned by sexual behavior, race/ethnicity age, and geography 8,807 total HIV diagnoses among young people --> 81% of all diagnoses in youth were among young gay or bisexual men 55% black, 24% hispanic, 16% white

"Big Three" Infectious dis

HIV/AIDS TB Malaria

Maternal Mortality rate recently

Has increased recently All other countries decreased 1990 - 2013 gone from 12 to 18

U.S. women's use of LARC over last decade

Have increased 2.4 in 2002 to 11.6 in 2012 Most get IUD some get implant

Support and LGBT

Having supportive parents improves health outcomes for LGB youth LGBT youth out to their immediate families are more likely to report being happy than those who are not out

HACCP "hassip"

Hazard Analysis Critical Control Point Food safety protocol for food processors/manufacturers based upon the principles of hazard analysis and risk assessment Intended to prevent hazards rather than reliance on inspection of finished problems, identifies probs throughout food handling Introduced by Clinton Admin for seafood and meat safety 96% of meat and poultry plants regulated by USDA use system

Why care about aging?

Health Overall costs of health care and opportunity costs Financial support for health care (medicare) Financial support for nursing home care (medicaid) Financial support for income (social security) -- Adjustment over time in care providers/facilities/systems Social support systems Politics - old ppl vote

Medicaid's Role in Our Health Care System

Health Insurance Coverage Assistance to Medicaid Beneficiaries Long-Term Care Assistance Support for Health-Care System and Safety-Net State Capacity for Health Coverage Reagan expanded Medicaid to assist near-poor women in gaining financial access to prenatal care, labor/delivery, and post-natal care

Admin/Other Staff component of HS

Health care executive leaders Admin Board members/trustees Lab staff Diagnostic services staff clerical and patient support staff facilities staff food service staff consultants

Coming out to providers: findings

Health inequities exist in receipt of sexual health care services between SMW (sexual minority women) (in this study) and the general population Lower HPV vaccine rates, Pap testing, and STI testing Among sexual minority women, being "out" is associated with a positive (or no) effect on sexual health care

Perfect Storm

High and rising costs of care Aging population Increasing Elderly Dependence ratio [EDR = (# >65 not in labor force) / (total labor force)]

Infant mortality rate by statw

High in south and midwest

Global burden of pollution

High income - air pollution Lower - water pollution major role Lowest - water and air evenly split

Alc-related deaths and Disability Adjusted Life Year

Higher income countries have highest rate Low income - lower rate, less disposable income Alcohol probs come along w development

Michigan geographic disparities in infant mortality

Highest in Detroit 13% Then Wayne County 11% Michigan 2013 7% Health people 2020 goal is lowest

Road Traffic Deaths

Highest in Middle IC Low income don't really have cars 1% of vehicles in LI but 16% of deaths HI has lower death rate but much higher reg vehicles HI more rules, safety, dif in vehicles and roads Low income have highest road traffic deaths per 100,000 More wealth - risk of MV accident goes down

Anti-retroviral Therapy (ART) coverage over time 2000 - 2017

Huge increase Started to grow in early 2000s

"New" global health (GH) vs. "Old" international health (IH)

IH focused primarily on health in developing countries, not on interconnectedness among countries IH unidirectional: transfer of knowledge/ technology from rich north to poor south Contrast with GH: bidirectional learning/training Still, line between GH & IH blurred

Case Management Coordinates Response

Identification - home visit - referrals - abatement - enforcement

Breastfeeding - children's health

If 90% women breastfeed exclusively for first six months and continue until 1 year of age.... Would prevent 721 deaths >600,000 ear infections 2,500,000 GI infections 20,900 severe lower respiratory infections 45,298 cases of childhood obesity

Breastfeeding - mother's health

If 90% women breastfeed exclusively for first six months and continue until 1 year of age.... would prevent 2619 maternal deaths and avoid many disease diagnoses Breast cancer Type 2 diabetes Hypertension Heart attacks

Advances in Mental Health Related Services and Care

Implementation of *Patient Protection and Affordable Care Act* and the *Mental Health Parity and Addiction Equity Act* more than 60 mil Americans will gain access to new or expanded coverage for mental health and substance abuse services Broadening of health system accomplishes some wide-ranging goals in providing services for individuals w behavioral health conditions that previously were much harder to obtain Enactment of these laws has prompted largest expansion of MH and addiction coverage and potential reimbursement in a generation, creating path to better treatment of mental/substance disorders It also means that many health plans must cover preventive services (depression screenings and behavioral assessments for kids at no cost to insured) Insurance plans can't deny coverage or charge more due to preexisting health conditions

Effective Use of Contraception

In 2008, two-thirds of women at risk of preg who used contraceptives consistently accounted for only 5% of unintended pregs

National Health Interview Survey: Serious Psychological Distress

In 2016, 3.35-3.88% of adults aged 18 and over had experienced serious psychological distress during the past 30 days From 2014 through 2016, the percentage of adults who had experienced serious psychological distress during the past 30 days increased from 3.1% to 3.6%

Possible Medicare Solutions

Increase age of eligibility Increase premiums for high-income beneficiaries; increase co-pays Decrease benefits Negotiate drug prices for part d Means-test Increase payroll taxes Medical practice changes

Consequences of climate change

Increase and variability in global temps Rising oceans More intense storms Heat waves Threats to agriculture More disease-carrying insects w temp increases

Impact of change in smoking on Medicare

Increased # of beneficiaries because of decreased smoking, costs increase Healthier on average by age - per person per age, less expensive However, more old-old and therefore costs increase Net effect: Medicare expenditures increase

Unintended Teen Preg in Detroit

Infant Mortality Rate Teen moms - 14.1% All mom - 6.8% A teenage living in D is 2.5 times as likely to get preg than typical MI teen HS Graduation rate - 50% teen mom, 90% 1st child after adolescence

Infant mortality over last 70 years

Infant mortality has decreased in the last 70 years

Infant mortality measures

Infant mortality is a sensitive measure of the overall health and wellbeing Women Communities Nations

Spectrum of Intervention Pyramid

Influencing policy and legislation Changing organizational practices Fostering coalitions and networks Educating Providers Promoting community education Strengthening indiv knowledge and skills

Ready2Learn

Integrated Service Delivery Universal intake and referrals Medicaid Outreach Home visitation and clinical opportunities Mental and Behavioral Health Screening

2016 JAMA Article by Obama

Key points: ACA has made significant progress towards solving long-standing challenges in US health care system: •Uninsurance dropped by 43% (16% in 2010 to 9.1% in 2015) •Improvements in access to care •Improvements in affordability of care •Slowed growth in health care costs •Improvements in quality of care•ACA provides important lessons for policymakers

Irradiation

Kills microbial food contaminants, widespread use could greatly increase safety of food supply Currently in use - pests in herbs, spices, tea, insects in wheat and flour, some treatment of meats, veggies, fruit No evidence of harm to humans leaves no radioactive residue, over 40 years of research Still fear-inducing in many countries

Legislating a solution - little success

Kyoto protocol (1997) - Mandatory reductions in greenhouse emissions according to timetable - In 2006, 121 countries participating, covering majority of emission, US never ratified Copenhagen Climate Conference (2009) - Largely a failure, although general statement signed at end by most participants

Progress in PH in 20th c

LE increased 2/3 --> 47 to 79 years Infant mortality down 94% (100 per 1000 in 1900 to 5.82 in 2014) Maternal mortality rate down 99% Much of LE increase due to decrease in IMR, but LE at age 65 increased by 50% Decrease in death from heart disease and stroke (less smoking, more exercise, screening and treatment for HBP, better acute and post MI care) Vaccinations against crippling and fatal ilness Infectious disease control also through sanitation, cleaner water, safer foods Antibiotics Major decline in smoking Improvements in MV safety, safer cars, safer roads, better law enforcement Decrease in occupational injuries and death Better family planning (smaller families) Better dental health Air and water pollution decrease Nutritional diseases decrease due to better diets and vitamin fortification of selected foods

LBG youth have more health threats to their health than heterosexual youth

LGB youth are at increased risk of negative health behaviors and decreased positive/promotive factors Substance use, psychological distress (ED, suicidality), sexual behavrios (*HIV/STI*s, Pregnancy), *Violence and Victimization*, Homelessness, *Access to Health Care*

LGBT youths are targets of violence

LGBT are twice as likely to say they have been physically assaulted, kicked, or shoved at

Medicaid Eligibility

LOW INCOME Pregnant women Children under 19 People who are 65+ People who are blind People who are disabled People who need nursing home care

Breastfeeding recs

Length of nursing - at least 1 year as recommended by the American Academy of Pediatrics Exclusively breast milk - 6 months World Health Organization recommends two years

Sexual Orientation and Gender Identity

Lesbian, gay, bisexual, queer, questioning GI - transgender, genderqueer, cisgender These terms perpetually shift and are context specific Identity is mental, expression is outward, attraction is person you're attracted to, sex is biological

Compression of Morbidity

Life extension, shift to right, window of morbidity is moved and shortened Affecting people later in life and for not as long Disability rates decreasing

2016 E. coli Outbreak

Linked to raw flour

Genetically Modified Foods

Living organisms whose genetic material has been artificially manipulated in a lab through genetic engineering Highly controversial, large differences in how countries treat them, labeling not require in US, req in other countries Benefits - higher crop yields, potentially less expensive, improved quality, longer shelf life, higher nutrient content Risks - modified w bacteria or viruses --> new diseases without resistance, allergic response, take over of similar crops through cross-pollination, messing w nature, market domination by a few firms

Who investigates an outbreak?

Local Health dep Most foodborne outbreaks are local events Public health officials in just one city or county health dep investigate these outbreaks State dep Investigates outbreaks across several cities or counties This department often works with state dep of agriculture with fed food safety agencies CDC State may ask for help from CDC for outbreaks that involve large numbers of people or severe or unusual illness. CDC usually leads investigations of widespread outbreaks

Local Regulation

Local health departments conduct inspections of restaurants, food carts, institutions

Public Policy

Local, state, and federal policy and regulation impact all aspects of the health care system Public policy often intervenes when there are "market failures" or market inefficiencies, negative outcomes Of particular importance is public policy that addresses the "triple aim"

Detroit Black Bottom Neighborhood

Lots of AA businesses prosperous BUT econ downturn affected them AND gov thought they could by building highway through town Detroit - spreadout, lots of houses, no public transport, poverty isolation, nice and not nice areas

Dual Eligibility

Low income people who are disabled and cannot work Low income 65+

Nomenclature used by PH

MSM - men sex w men MSWM - men sex w women and men WSW - women sex w women WSWM - women sex w men and women SOGI - sexual orientation and gender identity

Urbanization

Majority of humans in urban settings for first time In poorer countries, equiv of our industrial rev - econ progress but.. Serious sanitation probs, housing crises, shortages of clean water, occupational hazards and child labor, traffic dangers, greenhouse gases, crime violence

The population "pie"

Make a bigger pie: Increase production through technology & innovation Put fewer forks on the table: Family planning & vegetarian diets Teach better manners: Enhance social justice

ACA

March 23, 2010 The ACA is historic legislation that ranks w Social Security, Medicare, and Civil Rights Act in creating social change Makes significant reforms to health insurance industry and health care system but leaves overall structure in place Primarily, intrusion of federal gov into health insurance markey

Historical EHS: Lake Erie

Massive contamination prior to 1960s Industrial waster, Cuyahoga River caught fire >12 times Cleaned up in 1970s Blue-green algae, summer 2014, fertilizer runoff from farming City of Toledo forced to close water treatment plant -> harmful cyanobacteria blooms, no water supply/sanitation for 500K people, water unsafe to drink even after boiling

Maternal mortality rates over last 100 years

Maternal mortality rates have decreased significantly in the last 100 years Used to be 1,000 per 100,000 in 1920 but now around 10

Per capita health care spending among countries

Mean per capita health care expenditures Low income - $37 Low mid - $93 Upper mid - $519 High - $5,266

Exposure Assessment

Measurement or estimation of human exposure Key components - magnitude - how much agent is there - frequency - how often does contact occur - duration - how long does contact last much, long, often

Public Insurance

Medicaid Medicare SCHIP Veteran's Health System State/Local Plans

Detroit Suffer More from Lead

Medicaid-enrolled children <6 with EBLL 56% live in Det 7.5% children <6 with EBLL in DET 3.4% children <6 with EBLL in MI average

"Coming out" advocated

Medical and public health organizations advocate "coming out" to health care providers "Coming out" is viewed as a lynch pin to reducing sexuality-based disparities & improving patient and population level health Benefits and risks to coming out to provider

Net financial impact of reduction in smoking

Medicare increase Medicaid unsure SS increase Aggregate social support costs increase

WHO: Key facts about mental health promotion

Mental health is more than the absence of mental disorders Mental health is an integral part of health; indeed, there is no health without mental health Mental health is determined by a range of socioeconomic, biological, and environ factors Cost-effective public health and inter-sectoral strategies and interventions exist to promote, protect, and restore mental health

Mental Illness, Chronic Disease, and Co-Morbidity

Mental illness is associated w increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer Mental illness is associated w lower use of med care, reduced adherence to treatment therapies for chronic diseases and higher risks of adverse health outcomes Many people suffer from more than one mental disorder at a given time. Nearly half (45%) of those w any mental disorder meet criteria for two or more disorders w severity strongly related to comorbidity Over 8.9 million personas have co-occurring disorders - that is, they have both a mental and substance use disorder

Prevalence of any mental illness in the US

Mental illnesses are more common in US The data presented here from HSDUH which defines any mental illness (AMI) as - a mental, behavioral, or emotional disorder - diagnosable currently or within the past year - of sufficient duration to meet diagnostic criteria specified in DSM 4 In 2015, there was an estimated 43.4 million adults aged 18 or older in US with AMI within past year This number represented 17.9% of all U.S. adults Race: white and asian highest Female higher than male Young adult higher than low adult

Numerous frameworks exist for studying LGBT health

Minority stress, life course, intersectionality, social ecology Demographic research, social influences, health care inequities, intervention research, transgender-specific health needs Lead to more complete understanding of LGBT health

Community Health Assessment: DHD goals

Mobilizing for Action through Planning and Partnership A community-driven strategic planning framework for improving community health. Goal 1: Prioritize public health issues. Goal 2: Identify resources to address public health issues. Goal 3: Implement locally-relevant strategies. Public Health Belongs to the Community

Impact on change in smoking on SS

More beneficiaries, living longer Financial impact unambiguously negative 1987, estimated each smoking male subsidizes SS 20,000 and female, 10,000

Modern understanding of sexuality

More expansive than earlier models Triadic understanding of human sexuality -attractionality, identity, behavior Emphasis on fluidity

Black babies

More likely to die Black children are more likely than white children: To be born small (low birth weight) To be born early (premature) To die before reaching one year of age (infant mortality)

Public and occupational health hierarchy of controls

Most effective ------- Elimination/Substitution Engineering Controls Warnings Training and Procedures Personal Protective Equipment -------- Least Effective EEWTP

Prevention and the elderly

Most important = same advice as for young Exercise, no tobacco/alc, control HBP, proper diet, weight control Vaccination against pneumonia and flu, physical environ adjustments to prevent falls, avoid social isolation

Sacred Hour - case study

Mothers and infants skin to skin until after first breastfeeding Rates of exclusive breastfeeding at time of discharge: 28% before intervention to 55% one year later 2 years after the program started, rate of exclusive breastfeeding at time of discharge: 82% For vaginal and Cesarean births

Environmental Fate

Movement of pollutatns Exposure routes Route is how hazard gets into your body once it reaches you Think of an example of an exposure you have by each route in your daily life -ingestion, initiation, skin contact, skin absorption

3. Improving Quality and Efficiency of Health Care

Moves health care financing away from fee-for-service to value-based payments based on quality and efficiency

Multiple National efforts to improve MM rates

National commitment and approach to decrease maternal mortality and morbidity in the US Define and monitor morbidity Bundles: Hemorrhage, Htn, VTE prevention, cardiac and infection, obesity Equip all obstetric care providers with education and resources needed (58% of births in US occur in hospitals with fewer than 1000 deliveries) Identify women at highest risk for maternal morbidity and ensure access to risk appropriate care

4. Prevention of Chronic Disease and Improving Health

National prevention plan, community grants

Determinants of carrying capacity of human population

Nature - weather, fertility of land, water Humans themselves - urbanization, agricultural practices, pollution, resource consumption/conservation practices, technology

Increase in behavior-related probs around the globe

Nearly all LMICs experiencing increase in smoking, alc consumption, and fat in diet growth in cig consumption in LMIC offsetting decline in dev nations Fat in diet increasing in asian countries Chronic dis now = 2/3 of all global-deaths

Michigan breastfeeding rates

Need to improve 75.3% currently, want to be at 82% Many people stop too soon

Hazardous Waste: Love Canal, NY

Neighborhood in Niagara Falls Company buried chemicals, built neighborhood over it Hooker Chemical People got sick, weren't told about chemicals, EPA bought and destroyed homes in superfund site Superfund site - any land in the United States that has been contaminated by hazardous waste and identified by the EPA as a candidate for cleanup because it poses a risk to human health and/or the environment

Decline in HIV incidence and mortality over time

Newly infected decreasing, peak in 1995 People dying peaking in 2000s now decreasing

Housing level built environ issues

Noise and light pollution Temperature (mold) Humidity Indoor air quality Question: What's the 2nd leading cause of lung cancer in US? Environmental tobacco smoke Biomass smoke Pests and sanitation Building condition / safety Toxins

Top 5 Pathogens contributing to domestically acquire foodborne illnesses

Norovirus Salmonella Clostridium Campylobacter Staphylocacchus

Water usage by region of world

North america uses a ton, almost double world average West Asia next highest Asia and Pacific, Europe = world average Latin American and Caribbean a bit below average Africa, half world average

Disease vs. Disorder

Not complete agreement among MH prof about what MH conditions constitute a disorder v. disease Some psychological disorders fit the def of "disease", a prob that impairs functioning and that mostly stems from biological causes Common ex: bipolar and schizo Other "disorders" impair functioning but are determined by a more diverse array of causes, some of which are psychological and social/cultural in nature In this sense, these conditions are not true "diseases" Ex: anxiety, depression, addictive disorders, eating disorders

Diagnosing MH Conditions

Not like diagnosing other health issues - classifying psychiatric disorder is more subjective Defining symptoms for MI are is DSM-5 published by American Psychiatric Association Manual is used by MH providers to diagnose mental conditions and by insurance companies to reimburse for treatment Diagnoses are usually determined through clinical interviews. May involve questionnaires Provider may rule out physical probs that could cause symptoms by having a physician conduct and examination/run lab

Occupational Health

Number of people who die each year (and estimated $ cost) in the US... Heart disease: 599K, $444B Cancer: 567K, $104B Stroke: 129K, $43B Influenza: 54K, $87B US annual occupational deaths: 4-6k from injuries, 49-60K from illness, $51B Globally, about 2 million die per year Number of fatal work injuries - transportation and warehousing, construction, agriculture/forestry/fishing Rate - forestry, mining, transportation

Examples ofeffects from environmental hazards

Obesity (built environment) Asphyxiation (carbon monoxide) Asthma (air pollution) Death (poisoning) Gastrointestinal illness (waterborne and foodborne pathogens) Hearing loss (noise) Injuries (motor vehicles) Lung cancer (radon) Reproductive effects (mercury) Skin cancer (ultraviolet radiation) Skin rash (poison ivy) Thyroid cancer (nuclear radiation) Zika virus (mosquitoes)

Risk assessment - battle w Gelman

Ongoing legal battle by Gelman about inclusion of local jurisdictions in negotiations (vs only MI Dept of Environ Quality, MDEQ) Ann Arbor, Washtenaw County Public Health, and Huron River Watershed Council added to negotiations 2016 Ongoing debate over management of risks vs. cleanup of contamination

Obama 2016 ACA Challenges

Ongoing political and substantive challenges "Repeal and Replace" platform of many Republicans Patience: Many ACA reforms are years away from maximum effect Additional attention to prescriptive drug coverage and cost control is needed Enhanced competition needed in Marketplace Additional work needs to be done on affordability

Foodborne Illness Outbreak What does the size of an outbreak depend on?

Only 2 people need to be sick for outbreak Size of an outbreak depends on 5 factors 1. Pathogen that caused the illness 2. Contaminated food 3. Where contamination occurred 4. How food was prepared 5. Number of people who ate it FPPWN

Pesticides/Herbicides

Only a fraction of food supply is tested Imported foods may contain residues of pesticides that are banned in US, 25% of incoming fruit has been reported to have higher residue levels than allowed by the FDA "Dirty Dozen" and "Clean Fifteen" Created life-saving benefits during Green Revolution post WW2 Use of then-modern age techniques to dramatically increase crop yields in low-income countries Yields increase 3 fold, price decrease Avert deaths Chemicals used to prevent, control, eliminate insects/unwanted plants Could pose some risk (cancers, birth defects, dev issues) Pesticide Chemical Act Integrated Pest Management - 50% reduction in conventional pesticides Pesticide Law

Sexual minorities must weight these benefits and risks/barriers BENEFITS

Open comm Partner inclusion Patient-provider relationship

A new Public Health in Detroit

Our PH system is diverse and interconnected, need to work in partnerships to promote community health and make a ROBUST system Use 1,2,3 prevention and attack at levels in ecological model Community health improvement matrix - collectively summarized in prevent pyramid

Uninsured Health Insurance

Out of pocket Health care safety net

Aging and medicaid

Out of pocket health care expenditures for Medicare beneficiaries >15% of income - can bankrupt many elderly, many turn to medicaid Nursing home care - pay down to poverty, medicaid covers almost half of nursing home costs Medicaid = 21% of state budget, 9% federal

Food and oceans

Over fishing Pollution - declining fish populations Fish farming increases but creates problems/risks

Nutrition Labeling

Overall, dietary behavior has a bigger impact on health than food contamination Nutrition labeling first established by FDA in 973 - voluntary, micronutrients Nutrition Labeling and Education Act of 1990 - required labeling for almost all foods regulated by FDA Concurrently, USDA developed a parallel regulations for meat and poultry Federal Trade Commission regulates advetising

Impact of smoking on societal costs: A case study from the Czech Republic

Overall, net gain Reduced hc costs, savings on pensions and housing for elderly all related to early mortality of smokers

Federal Food Safety Regulation

Patchwork system Institute of Med and General Accountability Office --> repeated calls to establish a single, independent agency that would admin a unified science-based food safety syste Resistance from the food industry - heavily influences congress Obama proposed consolidating food safety components of USDA and FDA into new agency Need heightening by risk of bioterrorism Bioterrorists spread Salmonella in Oregon, deliberate attack by local commune, infected salad bars with salmonella at local restuarants

Federal Leg

Patient Protection and Affordable Care Act: employers must provide space that is not a bathroom for breastmilk expression for the first year after birth No nationwide protection against breastfeeding discrimination

Sexual minorities must weight these benefits and risks/barriers BARRIERS

Patient fears - ill-treatment, discrimination, worse care Provider deficits - embarrassment, discomfort, lack of knowledge

Person-centric language guide from "Stamp Out Stigma"

People should never be referred to as "schizophrenics" "alcoholics" "anorexics" etc... people *have* disorders, they do not become a disorder Instead, use such phrases as "people with schizo" or "indivs who have anorexia" Be sensitive to the use of words that connote negativity such as "problem" to describe a medical condition Do not describe an individual as "mentally ill" Avoid descriptions that connote pity, such as "afflicted with" "suffers from" or "victim of" Do not use derogatory terms such as insane, crazy, crazed

Clinical Work Force component of HS

Physicians Nurses Dentists Pharmacists Pscyhologist

Rapidly declining birth rates in some areas of world due to

Policies - especially China's one child policy - Policy support of birth control (but political battles) Changing expectations and norms - how does infant and child survival increase affect fertility rate? - with increasing affluence, child labor laws, etc., people want fewer children

Barriers to population control

Political Economic value of children (as workers and caretakers) Cultural/religious Personal Restrictions on individual liberty

Inequities in access to water

Poorer countries suffer more pollution (hence polluted water supplies) Low SES pay 5-10 times more per liter than high SES An American's 5-min shower uses more water than an average person in a poor, developing country uses in a day for all purposes

Population growth equation

Pop growth = birth rate - death rate For individual countries, includes in- and out-migration Generally smalle

Triple Aim

Population Health Cost of Care Care Experience CEPHCC

Conclusions

Population growth is a serious public health challenge, in addition to having important economic, social, and political ramifications. Addressing the problem satisfactorily will require Continuing economic/technological development Continuing improvements in child health & survival Creativity re pop planning Sustained, energetic, committed leadership Talented leadership able to work effectively in environment of political & religious obstacles

Population

Population of poor countries growing rapidly Rate of growth slowing Fertility rates decreases as child survival increases and as econ dev increases Fam planning increases dramatically in many countries

What is worlds biggest killer?

Poverty

Issues for global health for future

Poverty, population, urbanization, global warming, water, hunger, obesity, literacy, tobacoo

Future of Climate Change

Preventing climate change very unlikely - implies need to develop adaptive strategies, while trying to minimize extent of change Developed nations contribute disproportionately to greenhouse emissions - largest developing nations contributing more each year People in poorer countries will suffer most

PH Labor Intensity Problem

Price of labor increases faster than price of technology Cost of labor intensive services increases faster than cost of technology intensive services and products Gov is labor intensive, cost of providing fixed set of PH services increases over time, to get that unchanging set of services, public must pay more each year

Public Policy

Primary - lead inspection requirement Secondary - mandated physician testing

Lead - Individual

Primary - safe, health home (abatement, relocation) Secondary - screening Tertiary - med treatment

Points of Contamination - Production

Production - infected reproductive organs of hens, contaminated yolk, shell Fields sprayed w contaminated water Animal fecal matter contamination during growing season Human fecal matter contamination during harvest

Barriers to LARC

Provider education myths Training for post-placental or post-abortion LARC use Information Side effects and risks Access- currently covered in ACA

Treating Mental Health Conditions

Psychiatric hospitalization. Inpatient or residential mental health treatment. Outpatient mental health treatment. Dual diagnosis treatment. Psychotherapy. Medication. 12-step programs and support groups. Complementary and alternative treatments.

Coming out to providers: conclusions

Public health efforts should: Focus on sexual health promotion Support development and evaluation of provider-focused educational and cultural humility interventions Clinicians should: Ensure practice meets clinical guidelines on sexual health service recommendations Increase efforts to solicit sexual orientation disclosure ("coming out") Create clinical environments that recognize the concerns of multiply marginalized young adult SMW

Public health and population growth

Public health is responsible for the growth

Food Additives

Purpose - prevent nutrient deficiencies, preservative, aesthetics (improve color, enhance flavor/texture) Food Additives Amendment (1958) - requires FDa approval for any proposed food additive, manufacturers must first petition the FDA for its approval, studies must show that the additive performs as intended and no harm Two major exceptions - additives already in use before 1958 and GRAS "Generally recognize as safe" substances

Trauma Impacts Health Pyramid

Pyramid Early Death Disease, disability, social probs Adoption of health-risk behaviors Social, emotional, and CI Adverse childhood experiences (violence, moving) All affect upwards to help outcomes need community involvement A, S/E/C, R, D, D

Outbreak Containment

Quickly Detect the outbreak Gather evidence Take action - health officials warn the public, companies recall contaminated products, restaurants/food production facilities are temp close Sometimes outbreaks end before source is identified

What matters besides being "out"?

Race/ethnicity Where you live Sexual identity Lifetime number of sexual partners

Foods Associated w Illness

Raw foods of animal origin - raw undercooked meat and poultry, raw or lightly cooked eggs, unpasteurized milk, raw shellfish Fruits and Vegitables - field contamination, processing, cross-contamination Fish, Dairy, Chicken, Beef

Possible fixes

Recent phased-in increased in regular age from 65 to 67 Percentage of high-income recipients benefits subject to tax Means test receipt of benefits 16% of SS tax increase would solve next 75 years or decrease benefits by 13%

Overdose Prevention Proposal

Reduce opioid fatalities by 10% before 2021 Clinician Education ---> 150 naloxone access points, 250 clinicians receive opioid education Public Education Campaign ---> 20,000 online impressions, 5,000 shares/interactions Community Empowerment ---> 1,000 layperson interventionists trained

Points of Contamination - Distribution

Refrigerated food left on loading dock for a long time in warm weather Fresh produce loaded into truck not properly cleaned after transporting animals/animal products

Water

Renewable resources but - rate of renewal fixed - limited by capacity of desalination, purification Availability variable, depending on land, and precipitation patterns Source of significant political issues/conflict - certain to grow in coming decades - rich vs. poor

Role of PH in improvements

Research credits PH w majority of improvements in health According to CDC and NAM only 10% of potential future gains in health can come from medical care

Barriers to Treatment for MI: National Comorbidity Survey-Replication

Respondents with common 12-month DSM-IV mood, anxiety, substance, impulse control and childhood disorders 1. Low perceived need for treatment 2. Financial 3. Availability 4. Transportation 5. Inconvenient 6. Wanted to handle on own 7. Perceived ineffectiveness 8. Stigma 9. Thought would get better 10. Problem was not severe

CDC

Responsible for epidemiological surveillance (collection, analysis, and reporting of foodborne illness data) and promote follow-up of any foodborne outbreak Passive surveillance system (surveillance that occurs after the fact, look at data after ppl are sick) and active surveillance (find outbreaks that haven't been reported yet, find people as they become sick)

Prevalence of serious mental illness (SMI) in the US

SMI = a mental, behavioral, or emotional disorder, diagnosable currently or in past year, of sufficient duration to meet diagnostic criteria of DSM 4, resulting in serious functional impairment which substantially interferes with or limits one or more major life activities In 2015, there were an estimated 9.8 million adults aged 18 or oder with SMI 4.0% of US adults Female higher Young adult high White and asian high

Top 5 resulting in death

Salmonella Taxoplasma gondii Listeria Noro Campylobacter

Why is U.S. population health so poor given how much we spend on health care

Schroeder: Reasons are "Deceptively Simple" Many Americans do not receive health care when needed, receive it too late, or receive poor quality care. Pathways to better population health do not generally depend on better health care, yet 95% of health investments in the U.S. are spent on personal health services. SOCIAL DETERMINANTS OF HEALTH

Lead - Interpersonal

Secondary Educating parents

Organizational

Secondary Lead testing in clinics

What PH must do to meet these challenges?

Sell Ph to "powers that be" --> journalists, public, medical profession, legislators Difficult to: explain PH, sell abstract future benefit for real cost Hard to convince audience that benefits for unknown masses should trump costs for known people Econ forces in opposition Work harder and smarter to use resources efficiently Goal setting - Health People Select foci of work rationally Recognize that PH is much more than what formal PH departments do; extend reach of PH agencies by enlisting non-PH resources (= PH's assurance function) Work w medical professional groups

Primary Care shortage

Shortage of primary care physicians

Compression of mortality

Shorter window where people die Start of window is getting later, more people are living to be older

Points of Contamination - Preparation

Sick food worker, doesn't wash hands Cross-contamination - contamination surfaces of equipment used for prep, refrigerator - meat juices contaminate items that will be eat raw Undercooking animal products Mishandling at multiple points

Food and Land

Since 1961, arable land per capita has declined 47% world-wide "Green revolution" dramatically increased food production but also damaged land Improvements in agricultural yields at risk due to - water shortages - soil depletion - pesticide resistance Declines in arable land due to - urban sprawl - erosion from overgrazing Deforestation modestly increase land available for crops but creates other problems

Exposure and dose - Simple exposure

Single, short-duration, known exposure, well-documented one medical x-ray

World population over last 12,000 years

Skyrocketed, around 1850 is when exponential curve goes up

Aging, health behavior, and costs of social supports

Smoking among adults over 65 has decreased (17.9% in 1965 to 8.5% in 2014) Contributor to - larger number of seniors, healthier on average, longer survival post-65

Health Behaviors

Smoking, Alc, Obesity, Unsafe Sex, MV accidents The developed world's gifts to LMIC (low and middle-income countries)

What happens to the health of population with strategic and intentional disinvestment?

Social Determinants and health --> poverty, unemployment, education, $ for doc, obesity, tobacco use, diabetes, HIV incidence, cancer, homicide, infant mortality, stress

Social acceptance

Social acceptance for LGB indivs is increasing Roughly 3/4 of LGBT youth say they are more honest about themselves in online world than real world Over 3/4 of LGBT youth say things will get better 75% of LGBT youth say most of their peers do not have a prob with their identity 9 in 10 youth are out to their close friends

Maternal Mortality and Morbidity

Social loss - motherless children, productive years Measures overall effectiveness of health care systems Identifies gaps in health care system

Greenhouse Gases and climate change

Solar radiation powers the climate system, some radiation is reflected by earth and atmosphere, about half of solar radiation is absorbed by the Earth's surface and warms it Infrared radiation, some of the infrared radiation passes through the atmosphere, but most is absorbed and re-emitted in all directions by greenhouse gas molecules, and clouds Effect is a warming of the earths surface and the lower atmosphere Infrared radiation is emitted from the Earth's surface

Negative population growth - another trend

Some counties face decreases in population - AIDS (Low-income countries) - War and famine - Reduced fertility Contribute to population aging

Hazard

Something capable of harming human heath

Exposure Disease Model

Source --> Movement of Pollutants --> Human Exposure --> Dose --> Adverse Health Effect SMEDE

Health Care spending as % of GDP

Spend a lot of GDP is spent on HC, keeps increasing, U.S. is outlier compared to other countries Spend most on HC, not healthiest, high rates of infant mortality High rate of ppl without health insurance

Globalization and health - negative consequences

Spread of infectious and chronic dis Transfers high-paying jobs out of affluent countries Inevitable: increasing affluence in LMICs plus spread of techno and commerce

Current Status of State Medicaid Expansion Decision

States decide if they want to expand medicaid Michigan - 3rd republican state to do it 600,000 to 700,000 people on new expansion in MI

Relationship between health care expenditure and LE

Strong correlation for most countries reflects econ dev and health Among richest countries, marginal benefit small, if anything Other factors more important

Research question: Does being "out" to your health care provider influence whether or not sexual minority women receive sexual health services?

Study design: Michigan Smoking and Sexuality Survey (M-SASS) Web-based, cross-sectional survey; recruitment via Facebook Eligibility criteria: 21 - 24 years old, identify as sexual identity other than heterosexual or same-sex sexual experience in last 12 months Study Sample = 285 sexual minority women Sample: Age: 22 Sexual identity: Lesbian/gay 59% Bisexual 31% Other 10% Race/Ethnicity: White 66% Black 15% Hispanic/Latina 12% Insured - 88%, Recent med care - 69%, *out to provider 35%*

GRAS

Substances recognized by experts as safe, based on their extensive use in food or based on published scientific evidence Do NOT need to be approved by FDA, NOT tested by FDa Food manufacturers no longer need to tell the FDA which substances they certified as GRAS Controversy over industry-approved GRAS list

Overall goals/outcomes of 6 building blocks of a health system

System inputs + access, coverage, quality, safety = Improved Health Responsiveness Social and financial risk protection Improved Efficiency

U.S. Health Care System Has Several Structural Flaws

System of Financing Care - Fee-for-service, fragmented payments Organization of Services - A paradox of excess and deprivation Insurance Coverage of the Population - health insurance is connected with unemployment, health insurance is still not available to everyone, v political Health care systems exacerbates and create social inequities in health U.S. ranked 7 on ranking, 7 is worst score -- U.S. spends more on health care than any other nation, yet ranks poorly on most population health measures

Maternal Morbidity

Temporary or permanent disability

Burden of maternal morbidity and maternal morality

The burden of maternal morbidity is much larger than maternal mortality Severe morbidity 12.9 per 1000 deliveries Increased by 75% and 114% for delivery and postpartum from 1998/99 to 2008/09 Increase in shock, ARF, PE, RDS, Acute MI, blood transfusion, aneurysm, cardiac surgery Overall mortality in postpartum period increased by 66% Impacts >50,000 women each year

Putting Off Treatment for a serious vs non-serious condition

These percentages of p much increased since 2001, Less people are uninsured but they don't use it

Dose-response assessment

Toxicology involves characterizing relationship between varying exposures and adverse effects in exposed populations

Foodborne Illness Pathogens

Two main groups 1. Known foodborne pathogens 2. Unspecified agents 31 Known foodborne pathogens - 21 bacteria, 5 parasites, 5 viruses EIGHT known pathogens are the majority of domestically acquired foodborne illness, hospitalizations, and death

Aging around the world

U.S. baby boomers (1946-64) 14% of today's population 20% in 2030 Europe senior pop 18-22% in 2014 (20-35% in 2030 Japan is highest at 26%! China one-child policy - pop >65 will triple to 24% by 2050 -- China and India have 1/3 of the world population over 65 20 countries have negative population growth (i.e. deaths are greater than births) Ukraine, Russia Belarus, Japan

1800, 1850, 1900, 1950, 2000, 2016 us pop

U.S. population, added population, % growth 1800 5 million 1850 23 mil, 18 mil, 360% 1900 76 mil, 54 mil, 235% 1950 282 mil, 130 mil, 86% 2000 324 mil, 42 mil, 15% This pattern parallels growth pattern of world (extreme growth then decline)

U.S. infant mortality rank since 1960

U.S. ranking of infant mortality has been getting worse since 1960 11 in 1960 27 in 2000 28 in 2002 31 in 2008 50 in 2013 Many other countries, including Cuba, Japan, & Hong Kong, do a better job at saving their babies.

Legislating a solution - Promise?

US - China non-binding agreement (2013) UN Paris Climate Change Conference (2015) - 195 countries - Goal: Legally binding universal agreement - US has withdrawn

Health Care Spending as Percentage of GDP 1980-2013

US is 17%, all other countries are signif lower

Food Safety Regulation - Federal

USDA - Food Safety and Inspection Services Regulates animal products (meat, poultry, eggs) Daily inspection of processing plans 8,200 in plant-employees 20% of federally regulated foods 17% of foodborne illnesses 1 billion budget ----- FDA - Agency within US DHHS All other foods Plant inspections very 10 years, more under Food Safety Modernization act, seafood annually 800 employees 80% of federally regulated foods 67% of foodborne illnesses 1.5 bil budget

State Regulation

USDA and FDA also issue reccomendations that state and local gov use to regulate food/retail establishments High variably, responsibility generally within state health dep

Consequences of water scarcity

Unclean water for drinking/bathing/washing clothes (sometimes same source for all 3) Hence risk of water-borne diseases Water storage in homes increases risk of mosquito breeding Waste water for agriculture War??

Uncompensated care in 2015 dropped nearly half in MI hospitals

Uncompensated care - don't have to pay for care Uncompensated care costs decrease from 5.2% in FY13 to 2.9% in FY15 Average annual uncompensated care decreased from $7.2 million to $3.8 million Large Detroit hospital $35.8 to $19.5 million

Why lower breastfeeding rates?

Undermining of women's confidence that they can breastfeed Loss of knowledge between generations Birthing practices Medical and nursing education Early hospital discharge Free diaper bags... Limited support at home Access to lactation support (IBCLC, CLC) formula companies Maternity leave and return to work

Population growth in selected countries 2000-2005

United Arab Emerites is super high Some have negative growth rate (Ukraine, Russia)

Contemporary and future PH challenges

Unknown HIV/AIDS, 9/11, Zika Most important: obesity and lack of exercise and their sequelae Aging of population Residual smoking Dealing w racial and ethnic and SES disparities Infant mortality, maternal mortality With current trends in smoking and obesity, typical 18 yo will lose 0.7 years of LE If by 2020 all adults had normal weight and didn't smoke, 18 yo would gain 3.76 years of LE Novel infectious disease (AIDS) Antibiotic resistance w known disease (TB) Relationship between infectious and chronic dis Food-borne pathogens Climate change - heat waves, coastal storms, rising sea level, air pollution and lung disease, aging instrastructure Terrorism - 9/11 and anthrax, emergency preparedness, nuclear threats Revolution in techno - EHR (electronic health records), genetics knowledge More equitable and efficient HC, insurance for all, cost control, access to care

Growth hormones

Used to increase feed efficiency, promote growth in farm animals, increase milk production in cows Main concerns - ability of steroidal compounds to enhance effects of estrogen, promote early puberty Some cancers

Antibiotics

Used to treat or eliminate infectious agents of signif to animal health, also given to healthy animals to encourage growth 80% of all anti in US are used on livestock Believed to have led to increased anti resistance in bac

What is globalization

Usually considered in context of econ Development of an increasingly integrated global econ marked esp by free trade, free flow of capital and the tapping of cheaper foreign labor markets

Rapidly declining death rates due to

Vaccinations Reduction in infectious disease Sanitation Clean water Pest control Disease treatment Reductions in warfare and genocide

Nutrient Additives

Vitamin D - milk, rickets Folic Acid - flour and rice, neural tube defects Iodine - table salt, goiter Niacin - bread, pellagra Vitamin A - golden rice, blindness

Vulnerable Populations are a key focus in risk assessment

Vulnerable due to Differences in exposure Differences in susceptibility to disease Both Examples Fetuses and children Pregnant women Elderly People with preexisting disease Disabled people Low income communities People with genetic predisposition towards certain diseases

this is already occurring...

WHO estimates that the global burden of diseases from climate in 2--- already exceeded 150,000 excess deaths/year Estimate did not even include weather disasters that were probs associated w climate Climate change may have affected 1/2 of extreme weather events in 2012

Mental Illness/Psychiatric or Psychological Disorders

WHO: Mental disorders comprise a broad range of problems, with different symptoms. However, they are generally characterized by some combination of abnormal thoughts, emotions, behavior and relationships with others. Examples are schizophrenia, depression, intellectual disabilities and disorders due to drug abuse. Most of these disorders can be successfully treated. CDC: Mental illness is defined as "collectively all diagnosable mental disorders" or "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning." American Psychiatric Association: Mental illnesses are health conditions involving changes in thinking, emotion or behavior (or a combination of these). Mental illnesses are associated with distress and/or problems functioning in social, work or family activities. MI: Large collection of dif diagnoses, related to how we think, how we feel, what we do

Mental Health/Mental Well-being Definition

WHO: Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. CDC: Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. HHS: Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood. MH: Cope w stress, state of wellbeing, expanded, holistic health, how we deal with life

Impact of population growth for resources

Water Land, sea, food Air - climate change

Conclusions - progress

We are making progress, some impressive Life expectancies rising dramatically In some countries, LE ↑ >1 yr. for every yr. that passes Birth rates declining Infectious disease toll declining International community responding

Conclusions - tools

We have tools to combat problems Vaccines for some infectious diseases Effective treatments (e.g., ORT, HIV/AIDS drugs) (Some) knowledge about how to avoid or reverse behavior-related problems FCTC for tobacco & as model for other issues Large number of well-educated people committed to improving the condition of their less fortunate fellow human beings 4. Further progress faces challenges Politics Religion Resources Slow-moving bureaucracies Etc.

Promoting well-being in PH

Well-being integrate MH and physical health (body and mind) resulting in more holistic approaches to disease prevention and health promotion Well-being is a valid population outcome measure beyond morbidity, mortality, and econ status that tells us how people perceive their life if going from their perspective Results from cross-sectional, longitudinal, and experimental studies find that well-being is associated with - self-perceived health - longevity - health behaviors - mental and physical illness - social connectedness - productivity

Climate Change

Will create world-wide probs but worst in least dev countries Populations often concentrated near oceans Potential for more natural disasters Heating up environ can breed/spread more infectious dis Damage to fresh water supplies, agriculture Rapid dev of China, India Implies growing prob, unwilling to forgo growth for long-term climate gain Will affluent nations subsidize poorer countries transition to sustainable production

Aging by function

Wisdom increases, peaks in 70s then drops a bit Vision, social science reasoning, muscle mass, math reasoning, sexual potency all peak in 20s then decline Vision levels off around 50 Caveat: Graph is not precise, much individual variance Physiological peak is NOT psychological peak Reduction in some functions can be slowed

Typical Use Failure Rates

Withdrawal Condoms POP CHC Ring Depo Implananon most effective

Who is least likely to breastfeed?

Women from rural areas Women under age 20 Women who only have a high school education Women living below the poverty line African American women We must work for social change to challenge the intersections of poverty/race/gender

Energy in tonnes of oil used

World average is 2 US is at 7 China, India low Australia, Canada also high

Relationship between econ dev and health

World bank: 10.7% of global population lived on less than $1.90 per day Decreased from 35% in 1990 WHO: Under-nutrition contributes to 4% of all deaths per year among kids <5

Concluding Observations - world PH probs

World plagued with huge number of PH problems Premier among them = poverty & inequality Age-old problems persist: unclean water, lack of sanitation, malnutrition Infectious diseases continue to take their toll, especially AIDS, malaria, & TB "Modern" problems (smoking, obesity, alcohol, motor vehicles) spreading from rich countries to LMICs New problems, notably global climate change

Malthus's predictions, 1798

World would experience overpopulation and outgrow the food supply, resulting in war, famine, overall destruction -- huge increase, then crash, not slow like model His theories disregarded His predictions have not (yet) come true die to improvements in technology and population expansion from Europe to Americas and Africa

Obesity

World-wide prevalence of obesity more than doubled from 1980 to 2014 Overweight and obesity are linked to more deaths world-wide than underweight Impacts adults and children Increasing in LMICs, particularly in urban settings; often co-exists with undernutrition in the same country/community/household

Greatest risk for HIV infection

Youth living in the South Many youth aren't receiving quality HIV care or don't know they are infected 51% of youth 13-24 living with HIV don't know it LGB youth are less likely to know their HIV status than hetero peers

J and S shaped curves of population growth

a. exponential growth (unrestricted) The growth rate of the population accelerates b. logistic growth (restricted) looks exponential at first (rate accelerates), reaches point of maximum growth (where curve of S is), then rate slows down

Title 1 - Health Insurance Industry Reforms Guaranteed issue

cannot exclude people with pre-existing conditions No annual or lifetime caps Can cover dependents up to 26 years old Effective clinical preventative services must be offered at no charge to patients No rescission Most of these features are designed to end insurance company efforts to avoid "adverse selection" CDPPR

Determinants of Death

disease, famine culture and religion economics social change war health care technology

Exposure and dose

exposure leads to dose No exposure = no does

Source

location or point from which hazard originates

Complex exposure

mixture of agents, high variability 1 yr of exposure to urban air pollution

Exposome

totality of environmental exposures from conception onwards

What's driving environmental health issues?

Population is expanding rapidly Population pressures

Population Pyramid of U.S. in 2015

1. Bulge at 50-60 and 20-30 2. More females at older age Large aging population, and shortage of physicians to take on responsibility Demand for family physician grows, and people aren't choosing fam medicine

6 Dimensions of Quality of Care

1. Effective 2. Efficient 3. Safe 4. Timely 5. Patient-centered 6. Equitable STEEEP

10 Essential Public Health Services

1. Monitor population health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. *** 3. Inform and educate people about health issues. *** 4. Mobilize community partnerships and action to identify and solve health problems. *** 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. *** 8. Assure competent public and personal health care workforce. *** 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. *** 10.Conduct research for new insights and innovative solutions to health problems.

Six Building Blocks of a Health System (inputs)

1. Service Delivery 2. Health workforce 3. Information 4. Medical products, vaccines, technologies 5. Financing 6. Leadership/governance WIPDFL

Trump Actions on ACA

1.Weaken enforcement of individual mandate 2.Fail to advertise open enrollment 3.Cut funding for promotion/navigators 4.Make tax credits for premiums less generous 5.Defund Cost Sharing Reductions or subsidies that limit out-of-pocket costs 1.Impose work requirements for Medicaid beneficiaries 2.Redefine essential health benefits Number of uninsured has increased

What % of global death/disease is due to environmental hazards?

1/4 global disease burden due to modifiable environmental factors (1/3 in kids) 1 billion lack safe water 2.5 billion lack sanitation

How many liters of air do you inhale per day?

11,000 liters of air per day 1-2 Liters H2O per day 2 kg food/day

Medicare as a Share of the Federal Budget

15%

Medicare

1965 amendment to the Social Security Act of 1935 (Title XVIII) Social Insurance for the elderly and disabled. Nationwide eligibility and benefits A defined benefit plan with no limit to annual spending Covers 55 million people Age 65 and older Under age 65 if disabled by - End stage renal disease (kidney failure) or ALS

Life Expectancy

2015 life expectancy = 78.8 years Males 76.3 years Females 81.2 years Ranked 53 worldwide Below developed country average of 80.1 years Significant differences by race, ethnicity, SES, geography Racial/ethnic disparities (White=79.0; Black=75.5) Disturbing trends: Gains among women stalled Decreasing life expectancy in some populations

Section 5, 6, 7, 8, 9, 10

5. Health Care Workforce Increasing primary care providers and emergency preparedness 6. Transparency and Program Integrity Fraud and Abuse 7. Improving access to innovative therapy Focus is on access to generic drugs for seniors -8. Community living assistance and supports -- major provision for subsidizing long-term care insurance program which has been quashed- 9. Revenue Provisions How to pay for everything 10. Strengthening Quality Affordable Health Care for All americans Bucket list of other provisions

Global burden of population

9 million premature deaths caused by pollution in 2015 16% of all deaths worldwide 3X deaths than from AIDS, tuberculosis, and malaria combined 15X deaths from all wars and other forms of violence In most severely affected countries, pollution-related disease responsible for more than one death in four 92% of pollution-related deaths occur in low- and middle-income countries Disease caused by pollution most prevalent among minorities and marginalized

5 A's of Access

Affordability - Prices of services meet client's income and availability to pay Accessibility - Location of supply aligns w location of clients/demand Availability - Size of volume of supply meets need Accommodation - Delivery of healthcare accommodates client's needs Acceptability - Healthcare providers accept all clients regardless of characteristics

How many Americans live in areas that > National Ambient Air Quality Standard (NAAQS)?

Approximately 127 million people in the U.S> live in counties that exceed national air quality standards

WHO Definition of environmental health

Aspects of human health, including quality of life, determined by factors in the environment -physical, biological, social, psychosocial Also theory and practice of assessing, correcting, controlling, and preventing factors in environment that can potentially affect current and future health Basically: discover how environment affects people in order to promote healthier lives

Nursing Shortage

Average age of nursing workforce is getting older (44 years) 20,000 retire per year After 2020, that number will be 80,000 Supply is projected to increase after 2020, but shortage is forecasted through baby boom years

Examples of Hazards - biological, chemical, physical

Biological - tuberculosis, zika, influenza, salmonella, animals Chemical - Cleaning products, cig smoking, lead in h2o, bpa, carbon monoxide Physical- UV radiation, musculoskeletal, noise, vibration, cell phone radiation All stressors

Response

Biological response to agent

Mortality Age 45-54 by race (1999 - 2014)

Black decreased a lot White Stayed increased slightly Hispanic decreased som

Current EHS Issues

Climate Change, water pollution, solid waste, air pollution, nanotechnology, built environments, injuries, pesticides, sustainability, occupational health

Individual Mandate

Combo of Individual mandate and gov assistance in affording health insurance through expanding public programs and also a new "marketplace" for purchasing publicly subsidized private insurance Based on ideas first introduced by Republicans

Benefits of ACA

Coverage for young adults under 26 Coverage for pre-existing companies Free preventive care No cancellations or lifetime limits on care Lower cost coverage

Social Determinants of Health

Econ stability - employment, income, expenses, debt, med bills, support Neighborhood and Physical Environ - housing, transportation, safety, parks, playgrounds, walkability Education - literacy, language, early childhood education, vocational training, higher education Food - hunger, access to health options Community and Social Context - social integration, support systems, community engagement, discrimination Health Care System - health coverage, provider availability, provider linguistic and cultural competency, quality of care -- GDP is spent of health expenditures and not social services, most other countries spend a lot more on social services

ACA Individual Mandate - penalty

Everyone must have insurance or face a penalty if they don't purchase a plan $695 or 2.5% of income Exemptions: financial hardship, those who don't pay Social Security for religious reasons, Indian tribes, unauthorized immigrants, uninsured for period of less than 3 months, etc.In June 2012, Supreme Court ruled this is a TAX and constitutionalSubsidies and tax credits to households below 250% of FPL and premium tax credits for households between 251% and 400% FPL

DDT and Silent Spring (diet)

High efficiency contact poison for insect Malaria in Taiwan in 1945 - 1 million 1969 - 9 deaths DDT went up food chain, killed birds Direct effects vs. indirect

Infant Mortality U.S.

Higher than other comparable countries 6 died per 1,000 Comparable country average is 3.5

Pathways

How hazards travels from source to humans

Putting it all together EHS

Hypothesis - scientific evidence - synthesizing process - decision-making process - policy

Access: Health Care "Safety Net"

Includes publicly-funded insurance Local public health clinics - immunization and other preventive services, aging services/home health care Family Planning clinics Community health centers - Federally Qualified Health Centers, Community Clinics School-based health centers Prescription drug assistance programs Charity care/uncompensated care Long-term payment plans/bad debt

Medicaid Expansion increased jobs, income, and tax revenue for MI economy

Increased employment Increased personal income Increased econ activity

1. Quality, Affordable Health Care for All Americans

Insurance industry reforms Employer mandates Individual mandates Insurance subsidies for low-income persons through Exchanges

Great London Fog

London in early 20th c., used coal for heat, so much pollution, 1952 spike in December, people who died spiked too

Medicaid and Births

Medicaid Covers 50% of births Most in southern states and Maine

2. Role of Public Programs

Medicaid, indian health service, community health centers

Essential Health Benefits Package

Minimum required set of services to be covered Includes: Outpatient care, hospitalization, emergency services, maternity and newborn care, pediatric care, mental health and addiction treatment, prescription drugs, rehab services and devices, lab services, clinical preventive services Limit on Annual Out-of-Pocket Spending Individual - $6,600 Family - $13,200

What do people hate about the ACA?

Misinformation: That "Obamacare" is public insurance plan -- socialized medicine That the ACA takes away consumer choice of plan/provider That ACA is bad for doctors, hospitals, health care ACA is "big government" at its worst, intruding into a free market Individual mandate: Federal government is intruding upon personal freedom/liberty Essential benefits: Makes people pay for health care they will never use - unfair subsidy Expansion of the welfare state we cannot afford Taxes that support ACA are unfair Attempts to coverage contraception Premiums remain high; plans are leaving the marketplace

EHS risk in our backyard

Organic solvent, 1,4 dioxane, detected in surface water, wells near Ann Arbor 1984-5 Source was Gelman Industries facility Used ~60,000 lbs/yr 1,4 dioxane 1966-1986 to make filters to measure pollution (irony!) Disposal via unlined lagoons, sprinklers Discharges often > permitted amounts Post-1982 discharge through injection well Contamination of Ann Arbor aquifers

Basic Components of US Health Care System

Patients Services Providers Admin/Staff Facilities (clinics, hospitals, pharmacies, etc) Assurance/Oversight Governance Public Policy --> Access to care, coverage/financing, quality of care/safety

Patients - component of health system

Patients - people receiving indiv services Individuals who live in contexts: Family and relationships Socioecon Occupation Phys Environ Cultural Political Types of services - primary care, specialty services, treatment, dental, vision, rehab, end of life care

Medicare Eligibility

People 65 and older People of any age who have kidney failure or long term kidney disease People who are currently disabled and cannot work

Mortality by Cause for Whites aged 45-54 (1999 - 2014)

Poisonings have increased A LOT Suicide and Liver Disease increased too Lung cancer decreased Diabetes stayed same

Risk assessment for plume

Prohibition zone has been established within which extraction of ground water is illegal Plume continues to spread Since 1997, remediation system cleaning groundwater Contamination far exceeds generic cleanup criterion for groundwater of 85 ppb Gelman has treated billions of gallons of groundwater, recovered >110,000 lbs of 1,4-dioxane But 850,000 lbs were discharged Can treat 1300 gallons/min, but only doing ~½ that Cleaned water discharged at ~8 ppb New concern: vapor intrusion 2016 testing to evaluate 1,4 dioxane in shallow groundwater in Ann Arbor <20 ft below ground level 1,4 dioxane detected at 2 of 16 sampling locations Well below vapor intrusion screening criteria But shows dioxane close to surface in some areas

Percent uninsure 2008-2016

Slow increase from 2008 to 2013 then sharp decline

State of Population Health

Steven Schroeder, MD, Shattuck Lecture, NEJM, 2007 "We Can Do Better—Improving the Health of the American People" U.S. spends more on health care than any other nation, yet ranks poorly on most population health measures: Life expectancy Infant and child mortality rates Premature mortality rate Incidence and prevalence rates of specific diseases Suicide, firearms injuries, homicides Foregoing needed health care because of costs

Of 3,000 high production volume what % have basic risk info?

U.S. produces or imports close to 3,000 chemicals (excluding polymers and inorganic chemicals) at >1 million pounds per year (e.g., High Production Volume, HPV) Most Americans assume basic toxicity testing is available and that all chemicals in commerce today are safe. A recent EPA study has found that this is not a prudent assumption EPA reviewed publicly available data on these chemicals, and found most were never tested to determine how toxic they are to humans or the environment International authorities agree six basic tests necessary for minimum understanding of chemical's toxicity. These tests, called the Screening Information Data Set (or SIDS), cover: acute toxicity; chronic toxicity, developmental and reproductive toxicity; mutagenicity; ecotoxicity; evironmental fate 93% of 3,000 HPV chemicals missing one or more basic tests 43% of HPV chemicals missing ALL tests. *Only 7% of HPV chemicals have all six basic screening tests*