1. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Early Life Lasts a Lifetime: INEQUALITY AND HEALTH Stephen Bezruchka MD, MPH Depts. of Health Services, & Global Health School of Public Health University of Washington

2. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Agenda US Vital Signs Explanations –Inequality –Early life Stress as mediator Socioeconomic Gradient: health & health care Social medicines

3. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 KEY MESSAGE All of us in the US have worse health than we should Early life & inequality are major reasons Issues of neglecting early life in US affect us all

4. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 US VITAL SIGNS Life expectancy at birth Infant Mortality Low Birth Weight, Pre-Term Birth Maternal Mortality Child Mortality Adult Mortality Life Expectancy at age 50 County life expectancy trends SCALE of health inequities

5. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 How Healthy is the US? Health Olympics Number one Gold 1-5 _______ 6-10 _______ 11-15 _______ 16-20 _______ 21-25 _______ 26-30 _______ 31+ _______

6. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

7. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Life Expectancy (years) restricted to UN Countries

8. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

9. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 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): 484-8.

10. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 MacDorman & Mathews 2009 PTB % Excluding <22wks Gestation (2004), US & EUROPE

11. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 MacDorman & Mathews 2009 PRETERM BIRTHS OUTCOMES, US & EUROPE

12. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Raphael 2010 %

13. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Australia, Canada, Japan, Sweden, US Under 5 Mortality 1970-2010 IHME 2011

14. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Australia, Canada, Japan, Sweden, US Maternal Mortality 1970-2010 IHME 2011

15. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Maternal Mortality Olympics (2008)

16. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

17. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 WHO 2009 10 20 5 15 25 30 years Health Olympics Age 50 (2006)

18. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 FEMALE Life Expectancy Age 50 Trends 1955-2007 Glei et al. 2010

19. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Kulkarni et al. 2011 FEMALEMALE County Life Expectancy 2007

20. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 County Life Expectancy 2007 YEARS BEHIND FRONTIER NATIONS FEMALEMALE Kulkarni et al. 2011

21. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 County Black Life Expectancy 2007 YEARS BEHIND FRONTIER NATIONS Kulkarni et al. 2011 FEMALEMALE

22. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Netherlands France Sweden USA HEALTH INEQUITIES OECD 2006

23. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Singh 2006 Gravlee 2009 66 million

24. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 WHY DO WE DIE SO YOUNG? Not personal health-related behaviors Not medical care

25. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Cancer 5 year Survival Rates (%) (dx 2000-2) United States Surveillance, Epidemiology, End Result Europe (47 cancer registries) Prostate99.377.5 Skin melanoma92.386.1 Breast90.1 79.0 Corpus uteri82.378.0 Colorectum65.556.2 Non-Hodgkin lymphoma 62.054.6 Stomach25.024.9 Lung15.710.9 Verdecchia et al. (2007).

26. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

27. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 "As dramatic and consequential as medical care is for individual cases and for specific conditions, much evidence suggests that such care is not and probably never has been the major determinant of levels or changes in population health." Pg 4.

28. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Life course CHRONIC DISEASE RISK HEALTH - Traditional Disease Approach medical intervention PREVENTION Primary Secondary tertiary

29. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 POPULATION HEALTH Health has been improving most of the last century, Health improvements are not shared equally Health Inequities (poorer people have poorer health) Early Life: critical for adult health

30. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

31. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 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) www.equalitytrust.org.uk

32. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Kondo et al. 2009 Deaths attributable to excess income inequality 1 / 3

33. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Wilkinson & Pickett 2009 Spirit Level Child Well-Being

34. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 DEVELOPMENTAL ORIGINS BIOLOGY Fetal and subsequent GROWTH Ovum made maternal grandmother’s womb Fertilized ovum (zygote) divides ~42 times to produce newborn Further ~5 cycles of cell division to produce adult

35. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 NormalSevere Maternal StressEnzyme Deficiency Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal 'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

36. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Early Life Natural Experiments Hurricane Katrina World Trade Center 911 Dutch Hunger Winter HIGH EXPOSURE: –Pre-term delivery, –Low Birth Weight Increase LBW exposure at periconception and first two trimesters & PTD

37. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Roseboom et al. 2006 Mental disorders November 1944-May 1945 Dutch hunger winter

38. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Poor Pregnancy Conditions Related to entire life history of woman before she become pregnant Impacted by parents Impacted by grandparents Impacted by previous generations

39. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Poor Pregnancy Conditions Increased Risk of –Pre-term Delivery –Low Birth Weight –Caesarian Section –Infant Mortality –Behavioral Problems –Poor School Performance Earlier reproduction Cardiovascular Disease Obesity Metabolic syndrome Diabetes Hypertension Common Cancers Early death EARLYLATER LIFE

40. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 CNS Stress-associated Hormone Response Z-Scores of Helskini Birth Cohort who had CAD as adults (tracking all hospital admissions 1971-98)

41. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 –Pre-term Delivery –Low Birth Weight –Caesarian Section –Infant Mortality –Behavioral Problems –Poor School Performance Earlier reproduction Cardiovascular Disease Obesity Metabolic syndrome Diabetes Hypertension Common Cancers Early death Poor Pregnancy Conditions Increased Risk of EARLYLATER LIFE

42. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 LBW Associated With Hypertension Type 2 diabetes Obesity, metabolic syndrome Coronary heart disease Stroke Osteoporosis Depression and psychoses (e.g. schizophrenia) Age-related cognitive impairments Chronic renal failure Altered gonadal responses Altered immune responses Overall reduced life expectancy Seckl, J. R. and M. C. Holmes (2007). "Mechanisms of Disease: glucocorticoids, their placental metabolism and fetal 'programming' of adult pathophysiology." Nature Clinical Practice Endocrinology & Metabolism 3(6): 479-488.

43. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 BIOLOGY of INEQUALITY

44. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 DO Poorer people have poorer outcomes with MEDICAL CARE?

45. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

46. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 pathway LATEN T cumulative Life Course Health Model Conception

47. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 PRENATAL & PARENTAL PAID LEAVE

48. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Trans-generational PRIMORDIAL PREVENTION CHRONIC DISEASE RISK Conception DEATH SOCIETAL HEALTH Approach

49. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 http:// www.dohad2011.org / GET INVOLVED IN EARLY LIFE ISSUES http:// www.msfhr.org/news/news_blog/2011/06/DOHaD

50. Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 SUMMARY We neglect early life for all at OUR peril (i.e. we all die young) Not a problem so long as an informed choice