Foundations of Public Health PH-200 Fall 2008

1. Foundations of Public HealthPH-200 Fall 2008 Advances in Public Health Theories Maternal and Child Health Week 8

2. Outline • 9:30 AM – 9:45 AM : Questions and Review • 9:45 AM – 11:00 AM : Theoretical Foundations – Natural Sciences / Ethics • 11:00 AM – 11:15 AM : Recess • 11:15 AM – 12:15 PM : Milestones: Maternal and Child Health • 12:15 PM – 12:30 PM : Review

3. Pop-quiz • What is “Medical Geology” and how is it relevant to public health? Use examples to support your response. • UCI Professor Bruce Blumberg studies “Obesogens” or environmental chemicals, including tributyl-tin, that can make people gain weight. Discuss this finding with respect to public health strategies for the national incidence of obesity. • Grün F, Blumberg B (2006). "Environmental Obesogens: Organotins and Endocrine Disruption via Nuclear Receptor Signaling" (reprint). Endocrinology147 (6): s50–s55. doi:10.1210/en.2005-1129 • Last year, the Food and Drug Administration detained food imports from China for testing (http://www.nytimes.com/2008/11/14/business/worldbusiness/14fda.html?ref=worldbusiness). Discuss the public health significance of this event. • Which side are you on, regarding genetically-engineered foods? Why?

4. An Enquiry concerning the Principles of Morals Public Health Theory • “You cannot get an ought from an is” • David Hume (1711-1776): Empiricist • (Descriptive versus Prescriptive) • Causation “Shall we rest contented with these two relations of contiguity and succession, as affording a complete idea of causation? By no means ... there is a necessary connexion to be taken into consideration.” • Ethics Hume's views on human motivation and action formed the cornerstone of his ethical theory. He conceived moral or ethical sentiments to be intrinsically motivating, or the providers of reasons for action. Given that one cannot be motivated by reason alone, requiring the input of the passions, Hume argued that reason cannot be behind morality. “Morals excite passions, and produce or prevent actions. Reason itself is utterly impotent in this particular. The rules of morality, therefore, are not conclusions of our reason.” 1711– 1776

5. More public health theory please – but make it adequate • Jim Connelly’s article in Journal of Public Health • References 3, 4, 6, 8, 9, 12

6. Integrative Approaches to Public Health • Winslow, C.E.A. 1920. The Untilled Fields of Public Health. Science 51(1306): 23-33. • "public health is the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health."

7. Epidemiologic Transitions Borrowing from Demographic Transition • The Demographic transition model (DTM) represents the transformation of countries from highbirth rates and highdeath rates to low birth rates and low death rates as part of the economic development of a country from a pre-industrial to an industrialized economy.

8. Demographic Pyramids Across the Four Stages of Demographic Transition Thompson, Warren S. 1929. "Population". American Journal of Sociology 34(6): 959-975.

9. Intermediate Demographic Pyramids Young Old

10. Demographic Transition at the National Level • Thailand – It took 40 years to transition from early to intermediate demographic profile.

11. Epidemiological Transition • Phase of population development involving sudden increase in growth rates due to public health innovation in treating or preventing diseases, followed by a re-leveling of population growth from subsequent declines in procreation rates. • First phase: new vaccines and effective treatments of infectious diseases, leading to declines in death rates and in infant mortality rates • Second phase: Drop in birth rates, leveling overall population growth. Omran, A.R. (1971) 'The epidemiological transition: A theory of the epidemiology of population change', Milbank Memorial Fund Quarterly 49:509–538

12. Generic Epidemiologic Transition • Caveats: • Double burden / Stalled transitions / Globalization

13. Stages of the Epidemiological Transition • Pestilence and Famine • Receding Pandemics • Degenerative and man-made diseases

14. The Environmental Risk Transition Traditional Risk Risk Modern Risk Risk Overlap Development

15. The Kuznets Curve Pollution Inequity Increasing Wealth Increasing Wealth Simon Kuznets, Nobel Economist, writing circa 1960

16. The Full Environmental Risk Transition Household Sanitation Urban Pollution Severity Greenhouse- gas emissions Increasing Wealth Shifting Environmental Burdens Local Global Immediate Delayed Risks to Human Health Risks to Life Support Systems

17. Exceptions to the Epidemiological Transition Model

19. The Ecological Model of Public Health • Board on Health Promotion and Disease Prevention. 2003. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Institute of Medicine, National Academies of Sciences, The National Academies Press, Washington, DC. • The integrative (ecological) model of public health is defined as a model of health that emphasizes the linkages and relationships among multiple determinants affecting health. An integrative view of health is a perspective that involves knowledge of the ecological model of determinants of health, and an attempt to understand a specific problem or situation in terms of that model. An integrative approach to health is one in which multiple strategies are developed to impact determinants of health relevant to the desired health outcomes.

20. Public Health Ethics • Online resources and lectures: • http://www.ajph.org/cgi/collection/ethics • http://www2.sph.unc.edu/oce/phethics/ • http://www.pitt.edu/~super1/lecture/lec15911/index.htm • http://www.asph.org/document.cfm?page=782

21. Public Health Code of Ethics • Aspirational code versus code of conduct • Codes can help: • Define a field • Make agencies accountable • Create an ethical environment • Frame the discussion of ethical questions

22. 1. Fundamental Causes • Pubhealth should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

23. 2. Community Health • Public health should achieve community health in a way that respects the rights of individuals in the community.

24. 3. Participation • Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

25. 4. The Disenfranchised • Public health should advocate for, or work for the empowerment of, disenfranchised community members, ensuring that the basic resources and conditions necessary for health are accessible to all people in the community.

26. 5. Seek Information • Public health should seek the information needed to implement effective policies and programs that protect and promote health.

27. 6. Provide Information • Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and to obtain the community’s consent for their implementation.

28. 7. Responsiveness • Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

29. 8. Diversity • Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community.

30. 9. Enhancing the Environment • Public health programs and policies should be implemented in a manner that most enhances the physical and social environment.

31. 10. Confidentiality • Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

32. 11. Competence • Public health institutions should ensure the professional competence of their employees.

33. 12. Collaboration • Public health institutions and their employees should engage in collaborations and affiliations in such a way that they build the public’s trust and the institution’s effectiveness.

34. Research Ethics • Research is defined in the Code of Federal regulations as: • “A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge” • (45 CFR 46).

35. Public Health Research and Development • Public health research includes the study of: • Inanimate substances such as water and air quality. • Biological processes not involving humans (e.g., the natural history of arthropods that are disease vectors) and questions that involve humans. There are ethical concerns in each of these types of research, but the majority of ethical deliberation is about research involving humans.

36. Informed consent • A potential study participant’s voluntary consent to participate in research after having been adequately informed of the relevant risks and benefits of the research in a way that is understandable to the potential participant.

37. Confidential Data • A data set containing information identifying study participants; • information which the researchers are to conceal from others.

38. Anonymous Data • Data or samples for which identifying information, such as name, social security number, or address was either never collected or was not maintained and cannot be retrieved. Such data are referred to as “unidentified” by the National Bioethics Advisory Commission (NBAC, 2000). • When a data set has been made anonymous by the removal of identifiers and any hope of making a connection back to identifying information it is called an “anonymized” data set (or “unlinked” by NBAC).

39. Coded Data • A data set that lacks explicit identifiers of study participants, such as name, social security number, or address, but contains a code that links each observation to another data set with identifiers. Access to the code that links the data sets is limited to the smallest number of people feasible to aid in the protection of confidentiality.

40. Risks and Benefits • Risks in a study are the harms that may be experienced by a participant because of their participation. Examples are physical trauma and social embarrassment. • Examples of benefits from participating in a study are improved health and contributing to the betterment of society through the accrual of useful information.

41. Institutional Review Board(IRB) • A group of people, often affiliated with a research institution, who review scientific protocols for research involving humans and who decide whether the proposed study design is ethical. • Also known as a human subjects review committee. More detail on IRB purposes and procedures can be found in the Code of Federal Regulations (CFR), Title 45, Part 46.

42. UCI’s IRB • http://www.rgs.uci.edu/ora/rp/hrpp/

43. Exempt Research • Although the category is called "exempt," this type of research does require IRB review and registration. The exempt registration process is much less rigorous than an expedited or full-committee review. To qualify, research must fall into six (6) federally-defined exempt categories. These categories present the lowest amount of risk to potential subjects because, generally speaking, they involve either collection of anonymous or publicly-available data, or conduct of the least potentially-harmful research experiments. Some examples of Exempt research are: • anonymous surveys or interviews • passive observation of public behavior without collection of identifiers • retrospective chart reviews • analyses of discarded pathological specimens without patient identifiers.

44. Expedited Research • To qualify for an expedited review, research must fall into nine (9) federally-defined expedited categories. These categories involve collection of samples and data in a manner that is not anonymous and that involves no more than minimal risk to subjects. Some examples of expedited research are: • studies involving collection of hair, saliva or dental plaque samples, • studies of blood samples from healthy volunteers, • analyses of voice recordings • studies of existing pathological specimens with patient identifiers.

45. Full Committee Review • Proposed human subject research which does not fall into either the exempt or expedited review categories must be submitted for full committee review. This is the most rigorous level of review and, accordingly, is reserved for research projects that present more than minimal risks to subjects. • The majority of biomedical protocols submitted to the IRB require full Committee review.

46. Maternal Mortality

47. Old and New Challenges to M&C H • Since ~ 1982, U.S. Maternal Mortality has reached a plateau at 7 – 8 maternal deaths per 100,000 live births. • Twenty countries have reduced their maternal mortality rates below U.S. levels. • Legalization of induced abortions led to 89% reduction in deaths from septic processes between 1950 and 1973. • Insurance coverage of pre-natal care

48. Infant mortality Per 1,000 live births

49. Infant Mortality Challenges • 100 years ago, 1/6 live births • Today, < 1/100 live births in the U.S. • Low birth-weight • Vaccination / Autism • Sudden Infant Death Syndrome (Ethnic disparities) • Chinese experience with one-child per family, and gender selection. • Genetic Counseling • “Family Planning” and government support at the global level.

50. Population-Level Intervention • Multivitamins and birth defects • (Folic acid/Spinal bifida)