Transcript Foundations of Public Health PH

Foundations of Public Health
PH-200 Fall 2008
Week 8
Advances in Public Health Theories
Maternal and Child Health
Outline
• 9:30 AM – 9:45 AM : Questions and Review
• 9:45 AM – 11:00 AM : Theoretical Foundations –
Natural Sciences / Ethics
• 11:00 AM – 11:15 AM : Recess
• 11:15 AM – 12:15 PM : Milestones: Maternal and
Child Health
• 12:15 PM – 12:30 PM : Review
Pop-quiz
• What is “Medical Geology” and how is it relevant to public health? Use
examples to support your response.
• UCI Professor Bruce Blumberg studies “Obesogens” or environmental
chemicals, including tributyl-tin, that can make people gain weight.
Discuss this finding with respect to public health strategies for the
national incidence of obesity.
– Grün F, Blumberg B (2006). "Environmental Obesogens: Organotins and Endocrine
Disruption via Nuclear Receptor Signaling" (reprint). Endocrinology 147 (6): s50–s55.
doi:10.1210/en.2005-1129
• Last year, the Food and Drug Administration detained food imports from
China for testing
(http://www.nytimes.com/2008/11/14/business/worldbusiness/14fda.html?ref=worldbusiness ).
Discuss the public health significance of this event.
• Which side are you on, regarding genetically-engineered foods? Why?
Public Health Theory
•
“You cannot get an ought from an is”
– David Hume (1711-1776): Empiricist
•
1711– 1776
(Descriptive versus Prescriptive)
•
Causation
“Shall we rest contented with these two relations of contiguity and succession, as
affording a complete idea of causation? By no means ... there is a necessary
connexion to be taken into consideration.”
•
Ethics
Hume's views on human motivation and action formed the cornerstone of his
ethical theory. He conceived moral or ethical sentiments to be intrinsically
motivating, or the providers of reasons for action. Given that one cannot be
motivated by reason alone, requiring the input of the passions, Hume argued that
reason cannot be behind morality.
“Morals excite passions, and produce or prevent actions. Reason itself is utterly
impotent in this particular. The rules of morality, therefore, are not conclusions of
our reason.”
More public health theory please – but make it adequate
• Jim Connelly’s article in Journal of Public
Health
• References 3, 4, 6, 8, 9, 12
Integrative Approaches to Public
Health
• Winslow, C.E.A. 1920. The Untilled Fields of Public
Health. Science 51(1306): 23-33.
– "public health is the science and the art of preventing
disease, prolonging life, and promoting physical health and
efficiency through organized community efforts for the
sanitation of the environment, the control of community
infections, the education of the individual in principles of
personal hygiene, the organization of medical and nursing
services for the early diagnosis and preventive treatment
of disease, and the development of the social machinery
which will ensure to every individual in the community a
standard of living adequate for the maintenance of
health."
Epidemiologic Transitions
Borrowing from Demographic Transition
•
The Demographic transition model (DTM) represents the transformation of countries from high birth
rates and high death rates to low birth rates and low death rates as part of the economic
development of a country from a pre-industrial to an industrialized economy.
Demographic Pyramids Across the Four Stages
of Demographic Transition
Thompson, Warren S. 1929. "Population". American Journal of Sociology 34(6): 959-975.
Demographic Pyramids
Intermediate
Young
Old
Demographic Transition at the National Level
•
Thailand –
It took 40 years to
transition from
early to
intermediate
demographic
profile.
Epidemiological Transition
•
Phase of population development involving sudden increase in growth rates due to public
health innovation in treating or preventing diseases, followed by a re-leveling of population
growth from subsequent declines in procreation rates.
– First phase: new vaccines and effective treatments of infectious diseases, leading to
declines in death rates and in infant mortality rates
– Second phase: Drop in birth rates, leveling overall population growth.
Omran, A.R. (1971) 'The epidemiological transition: A theory of the epidemiology of population change', Milbank Memorial Fund Quarterly 49:509–538
Generic Epidemiologic Transition
• Caveats:
– Double burden / Stalled transitions / Globalization
Stages of the Epidemiological
Transition
– Pestilence and
Famine
– Receding
Pandemics
– Degenerative and
man-made
diseases
The Environmental Risk Transition
Traditional Risk
Risk
Modern
Risk
Risk
Overlap
Development
The Kuznets Curve
Inequity
Increasing
Wealth
Pollution
Increasing
Wealth
Simon Kuznets, Nobel Economist, writing circa 1960
The Full Environmental Risk Transition
Household
Sanitation
Urban
Pollution
Severity
Greenhousegas emissions
Increasing Wealth
Shifting Environmental Burdens
Local
Immediate
Risks to Human
Health
Global
Delayed
Risks to Life Support
Systems
Exceptions to the Epidemiological
Transition Model
The Ecological Model of Public Health
• Board on Health Promotion and Disease Prevention. 2003.
Who Will Keep the Public Healthy? Educating Public Health
Professionals for the 21st Century. Institute of Medicine,
National Academies of Sciences, The National Academies
Press, Washington, DC.
– The integrative (ecological) model of public health is defined as a
model of health that emphasizes the linkages and relationships
among multiple determinants affecting health. An integrative
view of health is a perspective that involves knowledge of the
ecological model of determinants of health, and an attempt to
understand a specific problem or situation in terms of that model.
An integrative approach to health is one in which multiple
strategies are developed to impact determinants of health
relevant to the desired health outcomes.
Public Health Ethics
• Online resources and lectures:
• http://www.ajph.org/cgi/collection/ethics
• http://www2.sph.unc.edu/oce/phethics/
• http://www.pitt.edu/~super1/lecture/lec15911/index.htm
• http://www.asph.org/document.cfm?page=782
Public Health Code of Ethics
• Aspirational code versus code of conduct
• Codes can help:
– Define a field
– Make agencies accountable
– Create an ethical environment
– Frame the discussion of ethical questions
1. Fundamental Causes
• Pubhealth should address principally the
fundamental causes of disease and
requirements for health, aiming to prevent
adverse health outcomes.
2. Community Health
• Public health should achieve community
health in a way that respects the rights of
individuals in the community.
3. Participation
• Public health policies, programs, and
priorities should be developed and
evaluated through processes that ensure
an opportunity for input from community
members.
4. The Disenfranchised
• Public health should advocate for, or work
for the empowerment of, disenfranchised
community members, ensuring that the
basic resources and conditions necessary
for health are accessible to all people in the
community.
5. Seek Information
• Public health should seek the information
needed to implement effective policies and
programs that protect and promote health.
6. Provide Information
• Public health institutions should provide
communities with the information they
have that is needed for decisions on
policies or programs and to obtain the
community’s consent for their
implementation.
7. Responsiveness
• Public health institutions should act in a
timely manner on the information they have
within the resources and the mandate given
to them by the public.
8. Diversity
• Public health programs and policies should
incorporate a variety of approaches that
anticipate and respect diverse values,
beliefs, and cultures in the community.
9. Enhancing the Environment
• Public health programs and policies should
be implemented in a manner that most
enhances the physical and social
environment.
10. Confidentiality
• Public health institutions should protect
the confidentiality of information that can
bring harm to an individual or community if
made public. Exceptions must be justified
on the basis of the high likelihood of
significant harm to the individual or others.
11. Competence
• Public health institutions should ensure the
professional competence of their
employees.
12. Collaboration
• Public health institutions and their
employees should engage in collaborations
and affiliations in such a way that they
build the public’s trust and the institution’s
effectiveness.
Research Ethics
• Research is defined in the Code of Federal
regulations as:
• “A systematic investigation, including
research development, testing and
evaluation, designed to develop or contribute
to generalizable knowledge”
– (45 CFR 46).
Public Health Research and Development
•
Public health research includes the study of:
1. Inanimate substances such as water and air quality.
2. Biological processes not involving humans (e.g., the natural
history of arthropods that are disease vectors) and
questions that involve humans.
There are ethical concerns in each of these types of research,
but the majority of ethical deliberation is about research
involving humans.
Informed consent
• A potential study participant’s voluntary
consent to participate in research after having
been adequately informed of the relevant
risks and benefits of the research in a way
that is understandable to the potential
participant.
Confidential Data
• A data set containing information identifying
study participants;
• information which the researchers are to
conceal from others.
Anonymous Data
• Data or samples for which identifying information,
such as name, social security number, or address
was either never collected or was not maintained
and cannot be retrieved. Such data are referred to as
“unidentified” by the National Bioethics Advisory
Commission (NBAC, 2000).
• When a data set has been made anonymous by the
removal of identifiers and any hope of making a
connection back to identifying information it is
called an “anonymized” data set (or “unlinked” by
NBAC).
Coded Data
• A data set that lacks explicit identifiers of
study participants, such as name, social
security number, or address, but contains a
code that links each observation to another
data set with identifiers. Access to the code
that links the data sets is limited to the
smallest number of people feasible to aid in
the protection of confidentiality.
Risks and Benefits
• Risks in a study are the harms that may be
experienced by a participant because of their
participation. Examples are physical trauma
and social embarrassment.
• Examples of benefits from participating in a
study are improved health and contributing
to the betterment of society through the
accrual of useful information.
Institutional Review Board(IRB)
• A group of people, often affiliated with a research
institution, who review scientific protocols for
research involving humans and who decide whether
the proposed study design is ethical.
• Also known as a human subjects review committee.
More detail on IRB purposes and procedures can be
found in the Code of Federal Regulations (CFR), Title
45, Part 46.
UCI’s IRB
• http://www.rgs.uci.edu/ora/rp/hrpp/
Exempt Research
• Although the category is called "exempt," this type of research does
require IRB review and registration. The exempt registration process is
much less rigorous than an expedited or full-committee review. To
qualify, research must fall into six (6) federally-defined exempt
categories. These categories present the lowest amount of risk to
potential subjects because, generally speaking, they involve either
collection of anonymous or publicly-available data, or conduct of the
least potentially-harmful research experiments. Some examples of
Exempt research are:
•
•
•
•
anonymous surveys or interviews
passive observation of public behavior without collection of identifiers
retrospective chart reviews
analyses of discarded pathological specimens without patient identifiers.
Expedited Research
• To qualify for an expedited review, research must fall into
nine (9) federally-defined expedited categories. These
categories involve collection of samples and data in a
manner that is not anonymous and that involves no more
than minimal risk to subjects. Some examples of expedited
research are:
–
–
–
–
studies involving collection of hair, saliva or dental plaque samples,
studies of blood samples from healthy volunteers,
analyses of voice recordings
studies of existing pathological specimens with patient identifiers.
Full Committee Review
• Proposed human subject research which does not
fall into either the exempt or expedited review
categories must be submitted for full committee
review. This is the most rigorous level of review and,
accordingly, is reserved for research projects that
present more than minimal risks to subjects.
• The majority of biomedical protocols submitted to
the IRB require full Committee review.
Maternal Mortality
Old and New Challenges to M&C H
• Since ~ 1982, U.S. Maternal Mortality has reached a plateau
at 7 – 8 maternal deaths per 100,000 live births.
• Twenty countries have reduced their maternal mortality
rates below U.S. levels.
• Legalization of induced abortions led to 89% reduction in
deaths from septic processes between 1950 and 1973.
• Insurance coverage of pre-natal care
Infant mortality
Per 1,000
live births
Infant Mortality Challenges
•
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•
•
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•
100 years ago, 1/6 live births
Today, < 1/100 live births in the U.S.
Low birth-weight
Vaccination / Autism
Sudden Infant Death Syndrome (Ethnic disparities)
Chinese experience with one-child per family, and
gender selection.
• Genetic Counseling
• “Family Planning” and government support at the
global level.
Population-Level Intervention
• Multivitamins and birth defects
• (Folic acid/Spinal bifida)
Recommended Daily Intake (Folic Acid)
Men
Women
(19+)
(19+)
Pregnancy
Breast feeding
400 µg
400 µg
600 µg
500 µg
1 µg of food folate = 0.6 µg folic acid from supplements and fortified foods