Reclaiming the Commons: Our Health and Our Education Stephen Bezruchka, MD, MPH Departments of Global Health & Health Services School of Public Health University of Washington

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years Maternal mortality in the US has increased 50% over the last 15 years According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years Maternal mortality in the US has increased 50% over the last 15 years According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

Sri Lanka US Adult Female Mortality

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years Maternal mortality in the US has increased 50% over the last 15 years According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years Maternal mortality in the US has increased 50% over the last 15 years According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

Ezzati et. al 2008 Female Male US County Life Expectancy Trends

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

Australia, Canada, Japan, Sweden US Maternal Mortality

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years X According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years X According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years X According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. X A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years X According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. X A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations.

1st & 4th yr US medical student knowledge of Population Health (2002) QuestionINCORRECT US has higher life expectancy than any other nation? 32% US has lower infant mortality than any other nation? 34% Agrawal, J. R., J. Huebner, et al. (2005). "Medical students' knowledge of the U.S. health care system and their preferences for curricular change: a national survey." Acad Med 80(5):

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years X According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. X A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations. X

POP HEALTH QUIZ TrueFalse A 15 year old girl in the US a smaller chance of dying before reaching age 60 than a similarly aged girl in Sri Lanka. X During the period of 1987 to 2007 life expectancy for women declined in about 30% of US counties (which was not so for the previous 20 years X Maternal mortality in the US has increased 50% over the last 15 years X According to the Central Intelligence Agency, Bosnia and Herzegovina has a longer life expectancy than the United States of America. X A survey in US medical students in 2002 found that one third of them thought the US had the lowest infant mortality of all nations. X

Playing Game of Health without a scoreboard

Measures of health of populations?

How healthy is the US? Health Olympics Number one Gold 1-5 _______ 6-10 _______ _______ _______ _______ _______ 31+ _______

HEALTH OLYMPICS 2011 Life expectancy United Nations Human Development Report 2011

Ezzati et. al 2008 US County Life Expectancy Trends Female Male

Ezzati et. al 2008 Female Male US County Life Expectancy Trends

Trends FEMALE life expectancy age 50 from Glei et al. 2010

SCF State of the World's Mothers 2004 A fifth of 20-yr old women in the US gave birth in their teens In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 w omen aged 15 to 19 - a rate higher than in 94 developing countries.

*Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore rates were not calculated. Youth violence Olympics—Homicide rates among youth aged (most recent year available) from the World Health Organizations’ World Report on Violence and Health, 2002* checking indicators

Population Health Concepts Health has been improving most of the last century Health improvements are not shared equally Poorer people have poorer health Early life is most critical period for health

Population Health Concepts Health has been improving most of the last century Health improvements are not shared equally Poorer people have poorer health Early life is most critical period for health

Wilkinson & Pickett 2009 Spirit Level US MORTALITY RATES BY ZIP CODE INCOME

Survival Rate on the Titanic 60 % 40 % 25 % 24 %

Index of: Life expectancy Math & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness – incl. drug & alcohol addiction Social mobility Health and Social Problems are Worse in More Unequal Countries Source: Wilkinson & Pickett, The Spirit Level (2009)

"more egalitarian societies (i.e., those with a less steep differential between the richest and the poorest) have better average health" pg. 59

Kondo et al Deaths attributable to excess income inequality 1 / 3

Health and Education Education –an epiphenomenon, not root cause –(we have most education of all countries) –Marsh, J. (2011). Class dismissed : why we cannot teach or learn our way out of inequality. New York, N.Y., Monthly Review Press. Introduction Unintended Consequences: 9-23

World Bank WDR 2006 Data are for 2000 and line tracks changes BETTER HEALTH

World Bank WDR 2006 Data are for 2000 and line tracks changes BETTER HEALTH