Comments on Public Health and Mortality : What Can We Learn from the Past? Berkeley Symposium on Poverty the Distribution of Income and Public Policy Barbara Wolfe

How do you define public health? A Little Perspective on the paper “the science and art of preventing disease, prolonging life and promoting health…through organized community effort” (Winslow 1920) “Fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM 1988)

Major Public Health Eras Prior to 1850 –Epidemics –Sanitary reform through state and local infrastructure present –Gaps in medical care and expanding agenda

A Simple Epidemiology Model of Human-environmental interactions: Or, where does the analysis of this paper fit more broadly? Physical environment = water, heat, air whose quality is influenced by sanitation, water purification, control of temp. Biological environment = infectious agents, vectors that transmit disease (flies), reservoirs of infection (animals, soil), food, medicine SES environment= quality of housing, nutrition, income, income certainty, income inequality, stress,

A Newer Production function Model Components of Paper’s Model are in purple. Health Status Medical Care Endowment Behavior Physical Environment Knowledge Income (Poverty) Health Insurance Supply medical care Public Sector Race/ethnicity

Issues of Measurement that raise concern with analysis –Relation of severity of illness to statistics –_ not apparent ___mild____Moderate_____Severe _______Fatal___________ │Likely to be seen by a doctor; recorded?│ │Likely to be hospitalized and recorded│ So how accurate are data? –Role of Herd Immunity (pre vaccinations) – Persons with the disease develop immunity which stops the spread of the disease. Measles is most commonly used example. (Hedrich 1933.) So there should be a natural pattern of decline and subsequent increase of measles cases without any public health interventions. Is credit given appropriate? –Accuracy of Information on Death Certificate: registration complete only for about last 50 years; disease incomplete and inaccurate. Change in composition of population. So, even with data on death’s are they sufficiently accurate? –Breadth of Measures: Mortality an extreme measure. Quality of life, disabilities also relevant. Are measures used sufficently broad?

Does paper capture causality correctly? Could better record keeping go together with improved public health measures? Role of education Role of income

Does Paper Include major Diseases of the time?

Causes of Death, 1900

Does it help us to understand public health interventions and causes of disparities today?

Causes of Death 2000

What worked? According to the paper Environmental approaches –e.g., fluoridation, sanitation, infect. Control But also Health policy changes –e.g., school vaccination, seat belt laws, worker safety Preventive services –e.g., high blood pressure rx. Public education –e.g., schooling, food labels, smoking and health Income Transfer Policies –e.g., Income, housing, food stamps, SSI

Preventable Causes of Death, 2000, or what are opportunities today to improve population health? McGinnis and Foege

Today’s Public Health Challenges and Ties to Health Disparities Smoking – advertising and marketing Food Consumption – everything now giant sized Use of time – too little exercise Access to care Low cost housing, etc.

Who is targeted by tobacco ads?

Trends in Smoking by Education U.S., Percent Year Health U.S., 1998 (1966 from SGR 1989)

Probit on Obesity (=1 if BMI ≥ 30), NHANES IV data Female0.257(0.000)** Black0.226(0.000)** Hispanic Poor0.244(0.000)** Near Poor0.272(0.000)** Moderate Income0.223(0.000)** Observations3918 p values in parentheses ** significant at 1% age and other race also included Obesity is an increasing problem especially for Black women with low incomes

Risk Factors and SES Well-known today Smoking: Higher smoking rates among the poor and less educated Diet and obesity: Higher fat diets, lower consumption of fruits and vegetables among the poor Health care: Less access to and use of clinical preventive services

Can we learn from Other countries experiences today? Think of more universal access to care and greater equality of income Think of less work Less obesity (but indications of catching up) Perhaps it is time for observational study – Gene?

Geno’s Public Finance Travel: Focus on the economy, eating and drinking and the implications for health. Lessons for U.S. policy?

Where is red wine consumption in our models? Surely a neccessity for maintaining health

So Gene …. We see you have much research (and travel) to do. To improve health of the population you need to travel far and wide, sample food and wine, engage in leisure activities and then write up your Advice for The Elderly on How to Stay Healthy though Travel and Campaign for part F of Medicare –needed travel vouchers for health! We are counting on you.