Partnering for Community Health 2013 Hood River Oregon


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Presentation to regional health policy planning group ("Hood River Busytown") about upstream public health, determinants of health, community health workers, cross-sector collaboration, developmental origins and ACES study elements.

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  • Good morning. I’m reallygrateful to be here. I hope I bring us to a fully awakened mental state this morning so there will be lots of photos, lots of colors, and maybe even a controversial assertion or two. Let’s get to it….
  • I’m going to start by asserting a number of things that I IMAGINE are guiding principles or values or frameworks for all of us. I might be wrong about some of them, but I want in this hour to get to some other points that to me feel more important than establishing evidence for these first few. So I’m taking the liberty of just assuming some things. (point to slide)
  • Here, I’m assuming we know we spend way too much on health care to get way too little…
    ..and that we’re miserly with our investments in population health.
  • I’ll be talking more about sectors and silos later.
  • And here I assume we believe in health equity….which means that we or our neighbors aren’t left out or left behind due to social status, race, ethnicity, nationality, immigration status, income, religion, sexual orientation, age, genes, diagnosis, disability, gender.
  • I would dare someone to name a social policy that doesn’t affect our health and the health of our communities, be the policy about education or health care or guns or the water table or prisons or roads or climate change or campaign financing. All social policy is health policy, at least indirectly. And that’s very important to remember, because typically we elect the policy makers.
    So okay, I’m proceeding from the idea that we at least more or less agree to these shared understandings and values….
  • …Which is important, because it gives us a platform from which to reflect and act upon the deep trouble we’re in when it comes to America’s health, which is far worse overall than it’s been in 100 years, despite longer life expectancy.
    These sorts of trend lines and bar graphs and CDC maps and the like are probably familiar to most of us. At the top, a bar graph showing the rising rate in this century of adult obesity. On the bottom, trend lines showing the rise of diabetes, such that there are reasonable forecasts today of type 2 diabetes affecting 1 in 3 American adults by the year 2050. It’s a catastrophe and the implications are profound.
  • At the state ethics Conference in 2010, I shared a commonly heard, and useful, metaphor of public health – about the rapids and going upstream. If the two of us are standing on the banks of a river and notice a person struggling and drowning as she is swept down from the rapids we can hear behind us, we’re going to try to jump in and save her. But probably while we’re doing that….
  • …we spot someone else, calling for help as he’s swept down, too. So we split up and try to save them both, but then more and more people come hurtling down from the rapids and we’re scrambling to save them all…
  • Until it’s endless….more and more rescues attempted , and a never-ending supply of people needing rescue….
  • …just like it is in health care, where one personal health disaster after another is what we’re responding to, whether in our clinics, our ERs, our dental chairs, or our hospital beds and ICUs.
    It’s like customized disaster relief. And, of course, lots of people have meantime not gotten rescued at all, and those who have will often slip back into the water again as soon as we give them a green light to get back on their feet.
  • By the time we find someone nearly drowned after their excursion through the rapids, it’s like the proverbial horse out of the barn. In medical terms, for example, the heart (or the brain, or the kidney, or the lung, let’s say) , is already compromised…..
  • …yes, we’re doing what we can, downstream of the perilous rapids, pulling people out of the water….and we’re so busy doing that, that some people get drowned because we couldn’t reach them or didn’t hear them…and some even slip out of our hands when we’re trying to pull them to shore….
  • That’s largely our world of responsive health care, which would be better called SICK CARE. Very important, sometimes very successful and sometimes not.
    But what if we went upstream from the rapids, and noticed how just some actions on our part to keep people from falling into the river up there might save the most lives of all??? After all, -
  • *(President Obama’s first director of Medicare and Medicaid)
    So we need to do the things upstream that will empty those hospital beds, make doctors’ and dentists’ and behavioral health visits less needed and less desperate, and prevent the need as many of those tests and treatments we possibly can. And if we take our cue from history and the scientific evidence, a lot of the heavy lifting will best be done by Population Health, creative, public efforts and policies that address – across sectors -- why people get sick or injured or disabled in the first place.
  • It’s NOT (read quickly the bullet points)…
    Though those are all worthy things.
  • IT IS
    (read quickly the bullet points)
    (don’t read!) go on quickly ---
    (don’t read! Go on quickly! -)
  • But I do want to take a moment to call out the matter of HEALTH EQUITY as I referred to earlier, and how poverty, minority status and other elements of disadvantage in this society of ours result in disparities and health inequity, that is, relative lack of opportunity to pursue and enjoy good health….
  • And again, your handout names some reasons why these disparities arise.
    (don’t read….Go on quickly!)
  • So here’s a pitch for our responsibility to strive for social and health equity….
    And I want us to keep this in mind as we talk about going much farther upstream now.
  • So three years after I first pitched public health or upstream population health to Oregon’s ethics community, I was surprised and honored to be invited back to their 2013 conference on the topic. And I wanted to share with them what I’d been learning about more upstream elements still – and most of all, about the SCIENTIFIC EVIDENCE regarding these elements.
  • I want to focus on two areas of research with profound, paradigm-shifting implications for us all….as scientists, ethicists, health care and public health professionals, and members of the human community.
    The first is the ACES, the Adverse Childhood Experiences Study. As I’ll talk about briefly, we have very, very solid evidence that certain adverse experiences during early childhood are strong predictors of learning disabilities, some mental illness, and numerous other chronic illnesses during later childhood and throughout adult life. Many of the correlated conditions don’t appear until decades after the childhood traumas -- in other words, the horse has long ago left the barn. So I’ll speak more about that first.
    But my great passion, recent, life-changing new information for me, is even more involved with DOHaD, a very rapidly emerging field of research, and I’ll want to spend even more time on that today.
    So get ready, because here we go upstream, to learn about causes, and more causes, and to reflect together, I hope, about the implications.
  • The ACES was started at Kaiser Permanente in the 1990s though a suggestive predecessor study was conducted earlier in the Kaiser system. Dr. Vincent Felitti looked at 18,00 adults in ACES, asking them to answer a very simple survey – 10 simple questions – about their early childhoods. He was then able to demonstrate a significant correlation between early childhood trauma experiences and severe obesity, heart disease, depression and other psychiatric disorders, diabetes and many other ailments later in life. According to the Oregon Public Health Division, 16% of adult Oregonians had an ACE score of 4 or higher…16% (you get one point for every answer “yes” in the questionnaire). Compared to people with ACE scores of 0, those with an ACE score or 4 or higher are now known to be twice as likely to smoke, 7 times more likely to have alcoholism, 10 times more likely to inject street drugs, and 12 times more likely to commit suicide. But that’s not all – you see other chronic diseases in this very dramatic bar graph (above)
  • And more illnesses and disabilities continue to be associated with ACES scores…COPD, GI disorders, GU disorders, STIs, sexual dysfunction, and pre-term delivery….
  • The original ACES work has its own CDC website now, has been internationally received, validated and applied, and the data from the original as well as newer cohorts are behind very robustly studied to see if there are even more chronic health and social conditions that appear after, and correlate with, adverse childhood experiences. I urge you to research ACES for yourself if it’s new to you – the CDC website is a fine place to start.
    This slide shows a headline from the online newspaper The Huffington Post, which ran a good series of 3 articles for the general public last fall about ACES.
    But while it’s true that ACES may be the largest public health study you never heard of, I would argue that this is even more true of DOHaD research – it’s just that DOHaD work hasn’t come as closely under the umbrella of public health OR social science research yet….so it’s even less widely known.
  • So let’s go to DOHaD. If there’s one thing I hope you’ll take away from this morning plenary, it’s that the Developmental Origins of Health and Disease – and more broadly, the field and discoveries of epigenetics that relate to DOHaD, are standing on its head our former knowledge of genetics, nature and nurture. As I said, it’s paradigm-shifting, and it has profound implications for healthcare, public health, the law, social policy and ethics.
  • DOHaD research is scarcely 25 years young, and most of the exploding amount of research has come about only in the past 10 years. OHSU is now possibly the preeminent research institution for DOHaD in the US, but the field was launched in Europe by Dr. David Barker and is very global today….with its next international conference scheduled next fall in Singapore, taking as its theme FROM SCIENCE, TO POLICY AND ACTION.
  • [3. T. J. Matthews, Fay Menacker, and Marian F. MacDorman, “Infant Mortality Statistics from the 2001 Period:
    Linked Birth/Infant Death Data Set,” National Vital Statistics Reports 52, no. 2. (Hyattsville, Md.: National
    Center for Health Statistics, September 15, 2003); Maureen Hack, Nancy K. Klein, and H. Gerry
    Taylor, “Long-Term Developmental Outcomes of Low Birth Weight Infants,” The Future of Children 5, no.
    1 (1995), 176–96.
    Full Term Low Birthweight (CDC Definition)
    37 or more weeks gestation and <2500 g
    Women with valid data on born alive or dead, infant birthweight, infant's date of birth, and date of LMP or EDC. Include live born infants only. Complete and postpartum only records.]
    LET’S JUMP RIGHT TO THE SEMINAL FINDINGS IN DOHaD WORK, which center around Low Birth Weight. Now, for context (point to the first two bullets here)…we have a disproportionate share of LBW babies in our nation, and this has big consequences.
  • Oregon Perinatal Data Book, 2007,,Oregon Public Health Division; (background if needed:)
    {Compared to infants of normal weight, low birth weight (LBW) and very low birth weight (VLBW) infants are at increased risk for impaired development and infant death.4,5 VLBW infants’ risk of dying in the first year of life is 100 times that of normal birth weight infants.6 LBW infants who survive are more likely to suffer from long-term disabilities such as cerebral palsy, blindness or other chronic conditions.4 In 2004, 6.1 percent of Oregon infants were LBW and 1.1 percent • were VLBW compared to 8.1 percent and 1.5 percent for the U.S.8 Although Oregon is consistently below the U.S. average for these measures, both rates are above the Healthy People 2010 targets of 5 percent for LBW and 0.9 percent for VLBW.
    From 1995-2004, Oregon’s rates of LBW and VLBW births have • significantly increased. From 1995-2004, rates of LBW significantly increased for infants • born to white, American Indian/Alaska Native, and Asian/Pacific Islander mothers, while the LBW rate among Hispanic infants significantly decreased. (Data in Appendix D)
    There was no significant change in the LBW rate for black/African • American infants from 1995-2004. (Data in Appendix D)
    During 2002-2004, infants born to black/African American • mothers were almost twice as likely to be LBW as those born to white or Hispanic mothers (10.7 versus 5.9 and 5.3 percent, respectively). VLBW <1500 gm]
    You can read this slide in your handout at your leisure, but I’ll point out that in Oregon, where most of us hail from, we have increasing rates of LBW among minority groups, and African-American women, as is true nationally, are around twice as likely as white women to give birth to a LBW infant.
  • So DOHaD theories and research were launched when British researcher Dr David J. Barker found that rather than smoking, dietary fat or some other lifestyle cause, the factor that was most predictive of whether an individual would develop and die from premature heart disease (before the age of 65) was their birth weight. He looked only at Full Term infants and found that those weighing between 8.5 and 9.5 pounds had a 45 percent lower risk of developing heart disease later in life than infants born at 5.5 pounds. (They also had a lower risk of stroke, a 70% lower risk of insulin resistance and a slightly lower risk of blood pressure later in life.) The risk declined in a linear fashion between 5.5 and 9.5 pounds, but started to increase again as birth weight rose above 9.5 pounds. Over the last 25 years, Barker’s original work has been replicated internationally and greatly expanded to include evidence demonstrating that embryonic, fetal and neonatal health, and even mothers’ and grandmothers’ preconception health, are predictors not only of the risk or propensity of adult heart disease but also of several adult cancers, diabetes, obesity, renal disease, and possibly immune and autoimmune diseases, osteoporosis, degenerative conditions, neurological diseases, mental illness, learning disabilities, and addictions.
  • THIS CURVE, DISPLAYED SLIGHTLY DIFFERENTLY BY DR> BARKER AND BY DR KENT THORNBURG AT OHSU, IS A REMARKABLE ONE TO JUST GAZE AT AND REFLECT ON THE PROFUNDITY OF WHAT IT TELLS US….again, not just about premature heart disease, but by the many serious chronic illnesses and conditions I just named.
  • So it’s remarkable how LBW clearly represents such a propensity and a greater risk of these chronic conditions later in life than the risk for the normal BW infant. But some of the conditions appear even earlier, as in this one example about learning disabilities at ADHD in children as reported by the CDC from the National Health Interview Survey.
    I could share with you slides showing equally, or even more dramatic, comparisons associating LBW with quite a number of other conditions, but I chose Dr Barker’s original, plus this slide, merely as important examples.
  • (pointing to the bullet points as I say:)
    --Yes, really, my genes are not so different from yours, even though we’re not twins or even siblings or any kind of relatives. But
    --(second bullet) Even those who have identical genes within their chromosomes very often turn out quite differently – that’s what’s meant by the PHENOTYPE – what we look like on the outside, and what diseases we might develop, and so on.
    --(third bullet) So the field of “behavioral genetics” which many ethicists also know about has long sought explanations. Why do identical twins raised apart have so much in common as adults, or why do they NOT? And so forth. We really haven’t had much to go on there.
    --(fourth bullet) So along comes EPIGENETICS – which I’ll explain in a second – and finally we have hard science, strong evidence, to help us understand.
  • It turns out that it’s not so much the genes we inherited from our parents that create our phenotype, as the way those genes turn on and off – the way they express themselves. Genes, after all, make proteins. And if they do their particular jobs right, things will go, well, as designed. But if they don’t do their particular jobs right, let’s say they shut off when they should be on, or they fail to turn on when they should….well, what happens to the body after that will be different from what was designed in that system. // The field of epigenetics has already identified and demonstrated at least two major biochemical mechanisms by which gene expression is regulated in these ways…and can be, let’s say, corrupted. Today, some are saying that the human genome, the DNA strands that make up our chromosomes that contain our genes, is the “hardware” of the body like a mother board or the chips and processors and circuits are the hardware of a computer….and that the genes and what they accomplish are the software – the operating system, the programs and apps. And I’ll go farther and say that the files are the products of gene translation and expression and creation of proteins and building blocks of our bodies. When the genes ---the software – are modified or tweaked, you’ve got epigenetics --- something laid on top of the genes – and the files might come out differently…. Our most vital organs themselves will be constructed differently during our early development. // And what would modify the genes? As we’ll see, there are biological things that do, but they aren’t so different or separate from social forces. Stay with me. AND what’s also profound is that epigenetic changes can be inherited.
  • Three really key epigenetic influences on the embryo and developing fetus – going to the heart of what DOHaD stands for, Developmental Origins of Health and Disease – are PLACENTAL NUTRITION, CHRONIC STRESS, and TOXIC EXPOSURES. // Today I’ll confine myself to speaking only about the first two. // Placental nutrition is about the proper mix of protein, fat, and other nutrients – biochemistry, yes? And chronic stress is reflected in circulating stress hormones – biochemistry again, yes? But can any of us doubt that both nutrition and chronic stress are socially influenced, even predicted? // So DOHaD is where biological evidence meets the social determinants, and fills in many of the blanks. It’s exciting new science that shows us the platform on which we need to act. Epigenetic changes to gene expression, caused by poor placental nutrition (first and foremost) and sustained maternal stress, are associated with LBW which in turn creates huge health risks and propensities. // The main kinds of stressors studied so far in this arena involve family disruption and conflict, domestic violence, parental mental health, financial strain, and discrimination or persecution. Other elements of social disadvantage are undergoing study as well. Both neuroendocrine and immune processes are centrally involved in the stress response.
  • Yes! When the developing embryo, even before it implants in the uterus, and later the fetus, is exposed to poor placental nutrition, its biochemical response is to be thrifty. To “make organs on the cheap” as Dr. Kent Thornburg at OHSU explains it. Epigenetic changes to the genes are made, regulating the genes so that they make smaller or substandard organs and resulting in lower birth weight, while putting more energy into forming a bigger placenta. So if I, for example, have only a few hundred thousand nephrons in each of my kidneys (or filtering units) but you have over a million of them, first of all you’re likelier to have a better-functioning set of kidneys than I do – and I formed my less functional kidney in utero, probably due to epigenetic regulation of my genes because I lacked good placental nutrition and perhaps was overwhelmed by serum cortisol levels that reached me because they were so high. It all happened a long time, but by the time my kidney trouble is discovered, perhaps I have HTN and heart disease already as a result. //
    DOHaD findings and implications like these are hugely important. And please don’t think that they’re fringey or radical. These findings have been recognized by seven of the national institutes of health, and the litreature, as I mentioned, is exploding. If you’d like me to send you a selective bibliography of recommended reading, please let me know later today.
  • Now let’s turn to the transgenerational aspects of epigenetics. Here’s the deal: modifying the expression or proper regulation of my genes ---remember, this isn’t about mutations changing the genes themselves, (we’ve always known that those are inherited) – but ACQUIRED changes in gene regulation, acquired because of my environment – can be passed along to a biological child or grandchild in my life. Yes! If you remember learning, like I did, about Darwin and Lamarck and the disputes in evolutionary biology’s earliest decades, you’ll be as surprised as I was by this knowledge. But it’s true. Let’s remember that my mom, while developing in my grandmother’s uterus, had all the eggs she was going to have in her lifetime already fully formed. If my mom’s fetal environment was such that she made epigenetic changes to those ova, she changed ME…. The environment in which my grandma, my fetal mom, and the ovum which would later produce me, all existed, affected how my genes wuld be expressed and the phenotype I’d have later in life.
  • As I’ve said, over the last 25 years, Barker’s original work has been replicated internationally and greatly expanded to include evidence demonstrating that embryonic, fetal and neonatal health, and even the preconception health of women who later become mothers and grandmothers, are predictors not only of the risk or propensity of adult heart disease but also of certain adult cancers, diabetes, obesity, renal disease, osteoporosis, and possibly immune and autoimmune diseases,, degenerative conditions, neurological diseases, mental illness, learning disabilities, and addictions.
    The importance of learning about the Developmental Origins of Health and Disease can’t be overstated. Because although actual changes to GENES –their structure, their alleles – are irreversible, EPIGENETIC CHANGES ARE REVERSIBLE.
    There is very good evidence that proper nutrition introduced or re-introduced within the first 1,000 days after conception – in other words, up to about the age of 2 years in childhood – can normalize or reverse epigenetic changes and restore a young child to normal risk or propensity for these chronic diseases I’ve mentioned. The case is also emerging for the value of reversing or reducing chronically elevated stress hormone levels in pregnant women and young children, measured in terms of the later development of chronic disabiiltiies and propensities.”
  • So VERY UPSTREAM STRATEGIES to PREVENT, MINIMIZE, OR CORRECT the exposure of developing fetuses and young children to poor nutrition or chronic stress --- those drivers of adverse epigenetic effect – are vital.
    IMAGINE if instead of 1 in 3 American adults developing Type 2 diabetes, we could reduce that figure and all its implications for costs of care and complications, to 1 in 10 or 1 in 50, by working on the developmental origins of Type 2 diabetes! Or heart disease, HTN, or the rest!
  • Children who were exposed to chronically elevated stress hormone levels in fetal life are turning out to be abnormal in their response to acute stress later in life. The body’s ability to appropriately “switch off” the fight-or-flight stress response later in life appears to be impaired, and several biological markers have been studied that suggest or demonstrate this association.
    So here we have to reflect on the transgenerational effects of chronic stress in the sense even of contributing, perhaps, to the very actions that cause adverse childhood experiences to the next generation…and so it might continue to proceed.
  • We can stop talking so much about nature vs. nurture. Shakespeare, Darwin, John Locke – they all liked to compare the two and puzzle out their different influences. Today, I think it’s fair to say we’ve learned, especially powerfully through the findings of epigenetics and the Developmental Origins of Health and Disease research, that they are not so separate and that we were asking the wrong question
    Similarly, I wonder if we’ll soon stop separating biological from social determinants of health.
  • And most importantly, just as those elements of the origins of the problem –the biological and the social -- are clearly intertwined now, so must our solutions and approaches be intertwined – the biological and the social approaches. The strictly technologic approach – say, taking a pill to reverse unwanted epigenetic change -- for my values, isn’t the right answer --- though no doubt we’ll see plenty of those technological “solutions” commercially pursued, and rolled out once again within our comfort zone, where we provide care to identified, individual patients – at least to those who can afford us. But isn’t it obvious that the bang for the buck will come from population-based, cross-sector policy and programs that create the CONDITIONS for the best lifelong health for everyone at once? At the headwaters?
    looks like a placenta, huh? Or the coronary aa? ☺
  • So when the ethicists last April asked themselves, as expressed in their conference title: Health and Well-Being: Who Is Responsible? ,
    my own answer to the question was an impassioned one – WE are collectively responsible. And we have to be rational agents of change, and leaders in our organizations, as well as strong members of the larger community, to achieve health equity and promote the best possible health for all our neighbors – for all of US – through creative, cross-sector policy and action…. Creating the best conditions for all members of all our communities to develop at an early age in the ways that promise the best possible health throughout our lives.
  • With the ethics group, I was speaking solely with health care professionals, and I wanted to make a strong pitch for these activities on their part. (just read the bullets quickly) But here at BusyTown, we’re more eclectic, more diverse, and already engaged in creative collaboration across sectors. Why should we ALL pay attention to all this? Then to next slide -
    (background only about public health investment) Therefore, TFAH concludes that an investment of $10 per person per year in proven community-based disease prevention programs
    could yield net savings of more than $2.8 billion annually in health care costs in one to 2 years, more than $16 billion annually within
    5 years, and nearly $18 billion annually in 10 to 20 years (in 2004 dollars). With this level of investment, the country could recoup nearly $1 over and above the cost of the program for every $1 invested in the first one to 2 years of these programs, a return on investment (ROI) of 0.96. Within 5 years, the ROI could rise to 5.6 for every $1 invested and rise to 6.2 within
    10 to 20 years. This return on investment represents medical cost savings only and does not include the significant gains that could be achieved in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.
  • We shouldn’t fool ourselves. The future of human health really is at stake. Throwing more, and more costly, health care services at an American public whose health is demonstrably worsening isn’t going to change our outcomes.
    Going upstream to the origins of health – and disease – through public policy is what can. And LOCALLY, working collectively for the most impact on future generations is what can.
  • There is more going on in Canada around health promotion of this sort, but values are a little different…and I know values matter to ethicists.
    Ronald Klaboute, a Canadian health promotion expert, has been quoted as pointing out that our individualistic approach in the US represents a very different worldview than that of Canada, which calls for something rather different as a culture. “As a consequence, when the notion of public or community good is invoked in the United States (fr example, around motorcycle helmet laws)…public or private god is defined as my right not to pay for your foolish or risky behaviors. Broadening our concept of the common good to embrace a sense of our intimate interdependnce – a notion that we are indeed ‘all in this together’ – is just one of the ways in which the worldview of Americans would need to change….”
    Dr. Meredith Minkler of UC Berkely School of Public Health
    HEALTH EDUCATION & BEHAVIOR, 1999, “Personal Responsibility for Health?...”
  • I want us to imagine that…and I want us to step up and imagine the opposite, as well.
    There are some interesting ethical issues related to justice across generations. As C.S. Lewis wrote, “Every generation exerts power over its successors,” and as was expressed in a very fine recent health law and ethics journal article I’ll cite in a moment, “Any current generation…that alters the biological inheritance of its successors has ‘pre-ordained’ the lives of future generations in meaningful ways. The current generation will have weakened future generations, limited their options, and required them to pay with their health or their lives for the environmental misdeeds of their forebears.”
  • (Marvin Gaye reference)
    We have a lot going on here already. We’re doing a lot to support and spread the model of Community Health Workers or health promoters, and other home visitors and lay educators and advocates. BusyTown and now the CCO is bringing together partners in some very concrete health systems analysis and planning, and in a parallel way the ELH is doing the same with early childhood advocates and workers and agencies. Social services like The Next Door and its programs are involved with all of these and much more, just as the education sector is, K-12 but also right up through the Community College level and even the new rural residency track for family doctors. Health care itself is becoming more integrated, mental, dental, and medical, and all three are working harder than ever on prevention strategies.
  • Several people, esp. Karen Enns at the Next Door, have been kind enough to help me learn more about the Early Learning Hub, and I’ve appreciated the explicit calling out there of the differing sectors that need to work better together for collective impact to benefit young children and future generations.
  • When it comes to what most of us would like to see, there are ideals we can work on immediately and some which we will always work on, as voters and activists, but which will require social policy beyond the changes and investments we can make in our own communities. For example, read bullet points quickly…. These can be considered relevant to Root Causes of health and wellbeing or, conversely, disease, disability and poor quality of life.
  • But what we can work on most immediately and locally, right here and now, and that the growing scientific evidence really compels us to do, are these sorts of things (read bullet points quickly).
  • Partnering for Community Health 2013 Hood River Oregon

    1. 1. Tina Castañares, MD Upstream to the Headwaters Working collaboratively to promote community health Presentation to Hood River BusyTown group & guests August 20, 2013 Adapted from a presentation given at the 23rd Annual Kinsman Bioethics Conference, April 2013 in Ashland, Oregon
    2. 2. Assumptions about guiding principles; all of us in the room… • …are motivated to help people to be as healthy as they can be. • …are agents of change (citizens, voters, members of society, leaders, members of organizations). • …believe that scientific knowledge is important in promoting health and behaving ethically.
    3. 3. Assumptions about guiding principles; all of us in the room… • …know that the US healthcare system spends more per capita than in any other place in the world, but we have very poor health status to show for it. • …know that our investments in public health are far lower than in most other nations.
    4. 4. Assumptions about guiding principles; all of us in the room… • …know that we operate in silos – health care, public health, education, early learning, corrections, public safety, etc. – that don’t collaborate or plan together like we should.
    5. 5. Assumptions about guiding principles: all of us in the room…. • …believe that we must attain health equity: “valuing everyone equally and making focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”
    6. 6. Assumptions about guiding principles: all of us in the room…. …know that All policy is health policy.
    7. 7. % Oregon Population Defined as Obese (BMI > 30) % of Population 30 20 We know we’re in trouble. Just 2 examples….. 10 0 1989 1996 2003 Year Measured Data from NHANES, CDC 2009 2007 Trends in Diabetes in USA
    8. 8. As shared at 2010 state Health Care Ethics Conference: Moving Upstream of the Rapids Moving Upstream of the Rapids
    9. 9. CT image of coronary artery disease
    10. 10. In the wise words of Dr. Don Berwick… “The best hospital bed is empty. The best CT scan is the one we don’t need. The best doctor’s visit is the one we don’t need.”
    11. 11. Health planning that goes “upstream”: we’re not talking about…. …health care access… …or safety net clinics… …or personal health care services… …or the health care delivery system… …or insurance coverage.
    12. 12. Rather, what we need to focus on is: Population-based health promotion & protection Focused on upstream determinants of health – biological and social Dedicated to primary prevention & containment Public health work, which is historically more than twice as responsible for health improvement than medical, nursing, oral health and mental health care (services) combined
    13. 13. Examples of traditional “upstream” public health work immunization, hygiene, community water fluoridation prevention of infectious illness, epidemics, dental caries creating and protecting standards for food, water, air, housing and workplaces, other types of safety promoting healthy “built environments” and proper nutrition and activity
    14. 14. Overall, “upstream” public health work: Promotes wellness, prevents disease and improves health status Avoids “blame games” about individual responsibility for health Reduces demand for health care (overall spending, workforce, infrastructure) Raises all boats at once: truly equitable because population- and communitywide
    15. 15. The poor and minorities experience serious health disparities
    16. 16. ….because of risk factors such as: barriers to physical activity in schools, workplaces, neighborhoods food subsidies making fast and processed foods cheaper environmental contaminants targeted tobacco & alcohol advertising lack of access to fresh foods crowding and substandard housing many other well-documented social factors
    17. 17. Achieving social equity • …is the only real answer to preventable health disparities. • …is a goal we have an ethical responsibility to work toward … as community members, voters, leaders, taxpayers, and part of the human commons.
    18. 18. So now let’s go much more upstream of the rapids…. TO TH E H EADW ATERS
    19. 19. Early childhood, neonatal, fetal, embryonic…. transgenerational ! ACES DOHaD research Adverse Childhood Experiences Study Developmental Origins of Health and Disease
    20. 20. “The Adverse Childhood Experiences Study -- The Largest Public Health Study You Never Heard Of” Huffington Post October 2012 3 parts
    21. 21. So now, more upstream still…. The Developmental Origins of Health and Disease (DOHaD)
    22. 22.
    23. 23. Low Birth Weight (LBW) • US babies more likely to be LBW than in almost every other developed country. 2 • LBW = 2nd leading cause of infant mortality in the US after birth defects. • Surviving infants: at elevated risk for debilitating medical conditions and learning disorders. 3
    24. 24. Oregon’s Birth Weights • LBW (8.1%);VLBW (1.5%) > Healthy People 2010 targets (LBW 5%, VLBW 0.9%) • 1995-2004: significant ↑ in LBW among white, American Indian/Alaska Native, and Asian/Pacific Islander mothers. • 2002-2004: LBW infants born to African American mothers at nearly twice the rate as among white or Hispanic mothers (10.7 vs. 5.9 & 5.3 %, resp.)
    25. 25. 3 Relative Risk of Death from Heart Disease Predicted from a Person’s Birth Weight 2 1 Death Risk David JP Baker, MD, PhD 5 6 7 8 9 10 Birthweight at Term Delivery (lb) “Developmental Origins of Disease” or just “programming”
    26. 26. QuickStats: Percentage of Children Aged 6--17 Years with Learning Disability (LD) and Attention Deficit Hyperactivity Disorder (ADHD), by Birthweight * --- National Health Interview Survey, United States, 2004—2006; MMWR August 29, 2008 / 57(34);947
    27. 27. How can this be? Epigenetics is the key. • Our GENES themselves aren’t all that different. • People with identical genes turn out differently, get different diseases, etc. • “Behavioral genetics” has long sought explanations. • Epigenetics brings biological evidence.
    28. 28. What does epigenetics tell us? • Gene REGULATION and EXPRESSION are mostly in charge. “How our genes work.” • Gene regulation is subject to many influences. • “Social” influences : not so very separate from “biological” influences • Amazing: some gene regulation and expression are heritable….trans-generational.
    29. 29. 3 key epigenetic factors in the developmental origins of disease and disability in later life : • Maternal and placental nutrition • Maternal, embryonic, fetal and early childhood chronic stress – physiologically reflected by sustained elevated levels of stress hormones (serum cortisol) • Maternal, embryonic, fetal and early childhood exposures to toxins
    30. 30. Poor nutrition or sustained stress hormones: The developing embryo/fetus biochemically responds by -- making sub-standard vital organs (mostly smaller ones) -- favoring a bigger placenta, and a lower birthweight
    31. 31. Risk of chronic disease is predicted epigenetically, right from grandmother’s preconception health, through grandchild’s early life. So EARLY prevention and corrections are imperative.
    32. 32. Epigenetic risk factors are preventable and even reversible. • The earlier, the better • First 1000 days post-conception • Pre-conception too Interventions must improve maternal & newborn nutritional status, and prevent or reverse sustained stress hormone levels.
    33. 33. Do ACES and DOHaD fit together? • Elevated serum cortisol levels in development change our stress responses later in life. • Aggression? Other ACE-related behaviors?
    34. 34. This is good news, not bad news… and not “biological determinism” • new scientific evidence to guide social policy, strategies, and investments ! And to guide community collaborations. • hope for better health for our society – a reversal of the last 100 years of downward health trends!
    35. 35. An obsolete debate
    36. 36. Montana: aerial view of the headwaters of the Missouri River  We’ve gone way upstream
    37. 37. What can hospitals and health care professionals do? Get outside the health care box Be educated about DOHaD and ACES Advocate for equity Join with new partners and across sectors Deploy new kinds of community needs assessment Develop new strategies for community benefit spending
    38. 38. Why should we all work on this together? The future of human health is at stake.
    39. 39. “Peace, order and good government” “Life, liberty, and the pursuit of happiness”
    40. 40. Imagine that we live in a region…. …which is the best place in the world for every baby to be born …which is the best place in the world for every child to grow up
    41. 41. “Epigenetics is one of the most scientifically important, and legally and ethically significant, cuttingedge subjects of scientific discovery.” “The Ghost in Our Genes: Legal and Ethical Implications of Epigenetics,” Rothstein et al, Health Matrix: Journal of Law and Medicine, Case Western Reserve,
    42. 42. Bringing it home to BusyTown • What’s Going On • • • • • CCO, BusyTown Other health-related collaborations & integration (notably including CHWs) Early Learning Hubs succeeding Commissions on Children and Families Social services -- involved with all of these and more Education at all levels – involved with all of these and more. Government, business too.
    43. 43. Bringing it home to BusyTown • What’s Going On • Explicit attention to “The Five Sectors” • Social and human services • Business • Health • K-12 (education) • Early learning
    44. 44. Some of our ideals • Living wage jobs, less income equality, no poverty • No food insecurity, no hunger, great food system • Affordable options for lifelong education • Affordable, good housing and health care for all • Environmental safety and justice for all • Social and financial supports for families • Great opportunities for all for high quality of life • Investments to improve other upstream determinants
    45. 45. Some of our most attainable and pressing ideals • Stronger investments in public health • Stronger investments in pre-conception, pregnancy and early childhood • Every child a wanted child, every parent wanting the child • Every community member (who wants it), esp. parents, young children, and others at greatest risk, having a skilled person who cares about them – home visitor, care coordinator, CHW, health promoter – for advocacy, support, education, cultural bridging, health literacy assistance, navigation, empowerment
    46. 46. Path to healthy communities & people Community Prewell-being; conception & family social health & circumstances; well-being “root causes” Pregnant woman and embryo/ fetal health & wellbeing Infant & early childhood health & wellbeing Child & adolescent health & well-being Adult health & wellbeing
    47. 47. Best places for CCO, ELH, all sectors to invest and collaborate right now Community Prewell-being; conception & family social health & circumwell-being stances; “root causes” Pregnant woman and embryo/ fetal health & wellbeing Infant & early childhood health & wellbeing Child & adolescent health & well-being Adult health & wellbeing
    48. 48. Best places for CCO, ELH, all sectors to invest and collaborate right now to promote healthy communities in the coming generations (scientifically supported) Preconception & family health & well-being Pregnant woman and embryo/ fetal health & wellbeing Infant & early childhood health & wellbeing
    49. 49. We should invest the most where it is needed the most … and will do the most good. • sometimes: demonstrable rapid return on investment • sometimes: ROI will take a generation or more to demonstrate. • not a leap of faith • rather, a logical application of sound scientific findings
    50. 50. We should invest the most where it is needed the most … and will do the most good. • A young man has an ACES score of 7. He has known risky behaviors and an “anger management problem.” • His wife is malnourished with an ACES score of 6.
    51. 51. We should invest the most where it is needed the most … and will do the most good. Our mission, should we choose to accept it, is to work together so that they have a child together only if and when ready, and that child has a good birthweight , an ACES score of 0, and equitable opportunities for well-being.
    52. 52. The basic strategies should emanate from science and ethics…. …and some key tactics are close at hand if we invest in them: •CCO •ELH •Public Health •Integrated health care and a focus on prevention •Cross-sector collaboration •the Collective Impact model •Community Health Workers/ health promoters
    53. 53. Thank you I welcome your feedback.