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Public Health & Health Disparities/Health JusticeJeffrey R. Backstrand, Ph.D.Chair, Department of Urban Public AdministrationRutgers School of Public HealthAssociate Research ProfessorRutgers School of Public Affairs & Administration
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What is Public Health? “Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease.” - The World Health Organization
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http://iom.edu/Reports/1988/The-Future-of-Public-Health.aspxhttp://www.health.gov/phfunctions/public.htm
Core Functions of Public Health Assessment Policy development Assurance
Purpose of Public Health Prevent epidemics and spread of disease Protect against environmental hazards Prevent injuries Promote and encourage healthy behaviors Respond to disasters and assist communities in recovery Assure the quality and accessibility of services
Core Functions of Public Health Steering Committee:”Public Health in America”
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Some Public Health Headlines
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Origins of Public Health
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Cholera (1827-1835; 1839-1856)
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John Snow & the Broad St Pump, London 1854
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American Water Systems
Fairmount Water Works, Philadelphia , 1812
Croton Water System, New York City, 1842
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Public Health & Health Disparities
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Disparities In US Life Expectancy At Age 25, By Income And Race Or Ethnicity
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Disparities In Health Status Of US Adults Ages 25–74, By Educational Attainment And Race Or Ethnicity
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Growing Disparities in Life Expectancy
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Income Growth in U.S.
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Income Disparities
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Change in Median Net Worth
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Eight America: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States
Murray CJ, Kulkarni S, Ezzati M. Eight Americas: new perspectives on U.S. health disparities. Am J Prev Med. 29 (5 Suppl 1):4-10, 2005.
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The Eight Americas
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Sick Individuals & Sick Populations
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Sir Geoffrey Rose1926-1993
• 1985: seminal article "Sick Individuals and Sick Populations“
• 1992: Book The Strategy of Preventive Medicine
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Sick Individuals and Sick Populations
Some Epidemiological Concepts:
• Incidence• Prevalence• Relative risk• Exposure
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Causes of Individual Cases vs.Causes of Incidence
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Distributions of BMI
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Genes and Environment
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Predicting Heart Disease (1950s)
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Causes of Incidence: Two factors
1. The Exposure-Risk relationship2. Distribution of the Risk Factor
in the population
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LDL Cholesterol & Heart Attack
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Incidence of Down’s Syndrome
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Population vs High Risk Strategies
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Rose: “seek the causes of incidence, not just the causes of cases.”
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Understanding Social Causation
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Model to achieve Healthy People 2020 overarching goals
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Important Concepts• Chain of Causation
• Upsteam (distal) vs Downstream (proximal)• Multicausality• Life-Course Perspective
• Conceptual issues• Period Effect: time• Cohort Effect: group• Age Effect: aging
• Epigenetics• Some important factors
• Allostatic Load• Chronic stress
• Race• Social construction vs biological
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Prevalence of AtherosclerosisAutopsies of U.S. GIs
Korea Vietnam Iraq/Afghanistan0
10
20
30
40
50
60
70
80
90
100
% o
f sol
dier
s
Source: New York Times
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Upstream and Downstream
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Upstream-Midstream-Downstream
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Life Course Perspective
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Some Important Concepts• Many diseases are developed over long
periods of time• Fetal programing• Critical or sensitive periods• Cumulative Impact (“weathering”)
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Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Matern Child Health J. 2003;7:13-30.
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Developmental Programming
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David Barker & Fetal Origins
“More than 25 years ago, he started an investigation into why historically poorer areas of England had disproportionately high death rates from coronary heart disease than other areas. He showed that people who had low birth weight have a greater risk of developing coronary heart disease and diabetes, demonstrating a relationship between a mother's nutrition and the health of her children as adults.” - Oregon State Univ
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Coronary heart disease death rates, expressed as standardized mortality ratios, in 10,141 men and 5585 women born in Hertfordshire, United Kingdom, from 1911 to 1930, according to birth weight
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Age-adjusted Relative Risk of Non- fatal Coronary Heart Disease and Stroke
121,700 American Nurses, self report study BMJ 315:396,1997
5.0 7.5 10.00.50
0.75
1.00
1.25
1.50
Birthweight
Rela
tive
Risk
Mean ± 95% CL
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Environment & Genes: Epigenetics
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A brief introduction to EPIGENETICS…
What is epigenetics?The study of heritable changes in gene function that occur without a change in the sequence of nuclear DNA. This includes the study of how environmental factors affecting a parent can result in changes in the way genes are expressed in the offspring.The idea has been around since 1942, but only in the last few years has it been observed directly…
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Hongerwinter 1944German’s blocked food to the Dutch in the winter of 1944.Calorie consumption dropped from 2,000 to 500 per day for 4.5 million.Children born or raised in this time were small, short in stature and had many diseases including, edema, anemia, diabetes and depression.The Dutch Famine Birth Cohort study showed that women living during this time had children 20-30 years later with the same problems despite being conceived and born during a normal dietary state.
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Stress and Allostasis
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Allostasis: Maintain Stability through Change
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
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Allostastic Load:Wear and Tear from Chronic Stress
McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med. 1998;338:171-9.
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Stressed vs. Stressed OutStressed
Increased cardiac output
Increased available glucose
Enhanced immune functions
Growth of neurons in hippocampus & prefrontal cortex
Stressed Out
Hypertension & cardiovascular diseases
Glucose intolerance & insulin resistance
Infection & inflammation
Atrophy & death of neurons in hippocampus & prefrontal cortex
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The End