Medical Ethics Fall 2011 Philosophy 2440 Prof. Robert N. Johnson Sunday, June 12, 2016

The public health approach Populations (patterns) Prevention Assessment, Assurance and Policy Development

The Obesity epidemic Currently 66% of adults are overweight or obese 16% of children are overweight or obese Obesity increases risk for hypertension, heart disease, diabetes

There are huge gaps in health Life expectancy at birth ranges from 34 years in Sierra Leone to 81.9 years in Japan. In the United States, the life expectancy gap between the most advantaged and the least advantaged is 20 years.

What matters most in determining whether or not you will be healthy?

Determinants of Health

What are the social determinants? Socio-economic status (SES) which includes income, job status, education Access to health care and health care systems Social Support Minority status Gender Rural vs. Urban

Gender discrimination

The link between poverty and illness is not news

Understanding the link between poverty and disease. Poor sanitation Poor housing Unsafe working conditions Lack of access to health care (including vaccination) In 1964, sociologist Charles Kadushin predicted that, “as countries advance their standard of living, as sanitation improves, as mass immunization proceeds and as Dr. Spock becomes even more widely read, the gross factors which intervene between social class and exposure to disease will become more equal for all social classes.”

“Greater wealth is also associated with both never smoking and successfully quitting…education confers additional advantage.” Education and Smoking: Confounding or Effect Modification by Phenotypic Personality Traits? Benjamin Chapman, PhD,1 Kevin Fiscella, MD MPH,2 Paul Duberstein, PhD,1 and Ichiro Kawachi, MD, PhD3

Social gradient in emotional and behavioral problems by annual household income. Spencer N Pediatrics 2003;112: ©2003 by American Academy of Pediatrics

Absences due to illness according to position: The social gradient

Proportion of adults eating five or more portions of fruit and vegetables per day, by equivalised household income quintile Maggie Nash Vital 8, (2011) doi: /vital1371

Contextualizing Behavior “What causes the causes?”

Factors determining fruit and vegetable consumption? Cost? Availability? Time to cook? Advertising/Culture/Convenience

Public Health is about Prevention

Why a structural intervention? “(Among young women in South Africa)…”Relative economic disadvantage” significantly increases the likelihood of a variety of unsafe sexual behavior- Hallman KK “Economic independence and negotiating power are the strongest predictors of condom use.” Greig. F. Koopman C. Botswana 2003

Social Justice Continuum Safety Net/ Communicable diseases Prevention Conditions in which people can be healthy Controversy

Being poor shouldn't have to mean: No access to quality preschool Poor schools Housing that is prone to exacerbate things like allergies and asthma Crime-plagued neighborhoods Inadequate access to public transportation to get you to jobs and jobs that don't pay a living wage that lift people out of poverty. “The current social consequences of being poor in the United States are severe, and they tend to be associated with poor health outcomes.” Anthony Iton, M.D., is Alameda County Public Health Department Director and Health Officer.

Some ideas: Reduce inequalities in life circumstances (especially education, employment, and income) Focus interventions on the early years Address both health care and non health care solutions Remove barriers in access to health and non-health care goods and services Focus on structural and regulatory policies Recognize need for more intensive support among more socially disadvantaged groups Monitor the outcome of policies and interventions, both in terms of overall cost effectiveness and differential cost-effectiveness