Module 4 - Lecture notes 12 PDF

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MODULE 4 Lecture 27: Think Globally… Act Locally Epidemiology: study of distribution and patterns of health- events, health-characteristics and their causes or influences in well-defined populations Global Burden of Disease Project (GBD) Why prioritise (Module 3)- reason for GBD also  Health resources are finite (limited)  Each has an opportunity cost  Rationing involves ethical as well as evidence-based judgement  Difficult to compare ‘apples and oranges’  Individual (easier to look at, clinical setting, might not see biggest issues) vs population needs Reasons for GBD project  Burden of disease (and injury) data from many countries were incomplete (if no data= no problem to tackle)  Available data (data is skewed) largely focused on deaths; little information on non-fatal outcomes  Lobby groups (advocating health issues) can give distorted image of which problems are most important  Unless same approach is used to estimate different conditions, it is difficult to decide conditions are most important and which strategies may be the most “best buys” GBD Project: Aims  Use a systematic approach to estimate burden of diseases and injury (-need to know what dealing with) based on epidemiological principles and data and best available evidence- used globally and nationally  Take account of deaths (fatal) as well as non-fatal outcomes (incl. disability)- not prioritising one over another. In the past, only focused on fatal (death) outcomes  Develop standard (common) measure Disablity Adjusted Life Years (DALYs) to achieve (1fatal) and (2- non fatal)- bring the two concepts together i.e. COMBINES and consider costeffective solutions to reduce burden. Sources of information used  Vital registration data (e.g. NZ’s national mortality and hospital discharge databases)  Sentinel surveillance systems, sample registration systems  Epidemiological studies and surveys  Statistical models developed to get best estimates (optimal connections) when data were incomplete (as can get lots of data saying wrong thing, did not blind you to other views) Disability-Adjusted Life Year (DALY) Summary measure of population health that combines data on mortality and non-fatal (disability) health outcomes to represent health of a particular population (must define population, can be of a city, country etc.) as a single number  Higher DALY= greater burden on population  Can calculate on global scale or in different countries and compare countries therefore per capita Why need DALYs? 1

Advantages  Describes global burden of disease  Can compare burden of disease between populations  Compare different disease types themselves and determine leading causes of disease burden and death  Know how many people die and how many have disease burden right now Disadvantages  Same disability will have different severities- cannot be accommodated by DALY  Takes a lot of time to sort diseases (give them different weightings) by WHO  Disease affects different people in different ways  Assumptions that people who are disabled are less happy, have increased burden on themmay be inaccurate.

DALY= YLL + YLD 

2 data inputs for DALY are YLL and YLD

YLL: Years of life lost to mortality (death) i.e. life expectancy  People die sooner than others= early/premature death, so need to know when they die  Area based, average measure YLL= Number of deaths x (average) years lost per death (up to arbitrary ideal age)  (Average) years lost per death- obtain by subtracting from average life expectancy age  2 data inputs for YLL are no. of deaths and (average) years lost per death YLD: Years (average years) lived with disability (disease)  May not have died but not in best state of health, will impact on burden of health YLD= Incidence of cases with their outcomes x average duration x disability weight  Average duration- how long people can get better from disability  Disability weight- different diseases given different weighting (by WHO) as extent of disability different e.g. some more depriving than others so will have greater weighting, based on no. of factors - If disease kills people at average age of 20 vs. 70, or if disease kills more young people than old= greater weighting, disease is worse  3 data inputs for YLD are incidence of cases with their outcomes, average duration and disability weight A year of life lost due to death= 1 A year in perfect health= 0 A year with disability= between 0 and 1 Percent distribution of age at death by region- TRENDS  Deaths at 60+ years of age- high income countries= largest proportion (most people die then), low income countries= smallest proportion  Similar proportions of ‘middle age death’ (15-60 years) in both high income and low income countries  Deaths at 0-15 years of age- low income countries e.g. Africa= largest proportion, high income countries= smallest proportion Child mortality rates (per head of population < 5 years of age) by cause & region Burden of disease by broad cause group & region- TRENDS 2

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Communicable diseases (CD)- low income countries= higher prevalence and CD also proportionally more than NCD, high income= lower prevalence Non- communicable disease (NCD)- similar prevalence and proportions in both low and high income countries, so effect/burden is similar Injuries/disability- high income countries= more prevalent than in low income= less prevalent

Transition  Demographic: term used to describe decline in fertility and mortality rates observed in most developed and several developing (middle-income) countries. - People living longer and having smaller families, as a result, aging population 

Epidemiologic: characteristic shift in common causes of death (and disability) from perinatal (childbirth) and communicable (infectious) diseases to non-communicable (chronic) diseases - Proportion of NCD and accidents (injury=area of danger) causing death are increasing compared to CD, due to our ability to treat CD with modern medicine e.g. vaccines, i.e. progressing well whereas NCD e.g. cancer, not much medical progress

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Risk: In many parts of world, especially middle-income countries, previously common risks for perinatal and communicable diseases now co-exist with increasing risks for noncommunicable diseases i.e. alongside. These countries face “double burden” of risks and consequent disease problems - As low income countries transition to become middle/higher income countries, CD risk was still high previously and NCD is on the rise so is a double burden, both contribute to deaths and DALY - Can’t forget one disease and focus on other- must do both= double burden

Major impacts of GBD approach  Informed priority-setting based on premature death AS WELL AS disability  Avioded biases due to missing information and dependency on mortality data  Methods used applicable to any population  NCD recognised as problem in low and middle-income (developing) countries (not just rich country problem)  Drew attention to previously hidden burden of mental health problems e.g. depression and injuries (an increasing health burden) as major public health problems,

LECTURE 28: Revisiting DALYs, Disability and Determinants of Health Impact of GBD Project  NCDs are a problem in developing (low- and middle- income) countries, not just a problem for rich nations)  Mental health issues as a major public health problem (not obvious when only counting deaths)  Injuries identified as neglected problem  More accurate estimations of mortality and disability burden of many health problems  DALY’s: used as measure to compare conditions (useful for priority setting) and to decide which strategies or treatment options should be funded (Ministry of Health, Finance) Conditions

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Group 1: Communicable disease (CD): contagious, infectious diseases e.g. diarrhoea, TB, measles, HIV/AIDS Maternal/ perinatal conditions: problems during pregnancy, childbirth, very early life e.g. malnutrition Group 2: Non- communicable disease (NCD): not contagious, infectious e.g. heart disease, strokes, cancer, diabetes, asthma Group 3: Injury Example: RCT- Out of Africa FEAST Trial Aim- Is it safe and effective to give IV fluid boluses (EGs) cf. maintenance= giving fluids slowly (CG) to critically ill children in shock (study population)  Randomisation controlled/ balanced sample in regards to factors –by age, how sick they are so blinding not essential as outcome was objective  Ethics of RCT- stopped study early, as unfair to know that boluses were causing deaths of some children  Risk Difference= 4% i.e. 4 per 100 children getting bolus, likely to die from treatment, not the from the actual shock (as randomised, same likelihood of dying from shock)  Large study- effect on random error low, so accurate. Findings not generalizable to wealthy countries as could be different risks and effects- children are healthier, better access to ICU, different diseases, therefore RCT done in Africa for Africa. DALYs are more meaningful than using deaths (or e.g. hospital discharge rates) to assess burden of a disease as can measure burden of premature deaths, as well as burden of disease in a single calculation. YLL, YLD, DALYs by region DALY ~ N in N/D/T From 2004 to 2010 within DALYs:  YLL proportion decreased- as life expectancy increasing in world,  YLD proportion increased – as people with disability increases as population ages Limitations/challenges of DALY approach to Disability- how define ‘disability’?  ‘Perfect health’- In DALY, either dead or not dead (quite negative measure)  Disability weights for specific health condition assumed to be same, regardless of where person lives, SES, and other life circumstances. - Think Context- e.g. attach same weight for blindness in PNG and NZ or amputation in Bangladesh and NZ… reasonable? Are access to resources, life opportunities same?  Disability weights in initial GBD project assigned by ‘expert panels’. Who should be ‘experts’? Assume clinicians?  Disability weights assumed to be reasonably stable over time. But can vary by day, circumstance, situation involved  Disability weights and GBD project viewed as seeing people with disabilities as ‘burden’- less valuable, assumption of burden on society TRENDS Life expectancy at birth (men) – huge range between countries, but also in different parts/ suburbs of same country i.e. in deprived suburbs, much lower life expectancy than in affluent suburb Life expectancy of indigenous people- indigenous (male) much lower than total (male), sizable age gap Under 5 mortality by wealth group- same patterns in each country, highest no. of mortality in poorest groups, and lowest mortality in richest groups. 4

What are social determinants of health? "The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally… with the consequent unfairness in the immediate, visible circumstances of people’s lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon…. Together, the structural determinants and conditions of daily life constitute the social determinants of health."  Not having level playing field has reason- due to structural determinants Commission on Social Determinants of Health (CSDH) Overarching Recommendations: 1. Improve daily living conditions 2. Tackle inequitable distribution of power, money and resources 3. Measure (quantitavely?) and understand problem (inequities) and assess impact of action Issues must address are upstream, downstream is treating people Lecture 29: Rights Based Approach to Maori Health From last lecture…  Maori Health exemplified by systematic disparities  Maori population aging- younger, but still starting to age  Maori have worst health statistics in health statuses- patterns change e.g. bowel cancer, melanoma  Ethnicity is social group we belong to thus how we go about life, the way we live- relates to how social determinants of health distributed. It is self- identified- must ask people or systems in place.  Ethnicity (ask ethnicity question) different to ancestry (familial, genetic, collect separately and differently)  Maori history becomes embedded physically- stressful history leads to traumatic physical health  Social and Economic Inequalities- levelling opportunities/ risks or privileging?- want to have same existing privileges as rich  Damp housing, living in polluted environments/next to motorways examples of differential access to health determinants/exposures. Are socially determined, ethnicity is social barrier  Minority/ “other” group e.g. depressed, mental health- usually make assumptions relating to differences of quality care received e.g. giving tablets assumes good compliance will occur Development of Human Rights Instruments  UN makes policies which different nations sign up and stick to it on domestic level  Separated social determinants of health to medical care 1. Universal Declaration of Human Rights- 1948, UN General Assembly, Art 25 - Right to “standard of living adequate for the health and wellbeing of himself and his family including… medical care and.. the right to security in the event of…” - Didn’t define parameters of right to health but noted they include and transcend medical care and security (as basic human rights) - Health determinants contextualised 2. International Covenant on Economic, Social and Cultural Rights (ICESCR)- 1966 UN 5

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Explicit “right to health” and steps states should take to “realise progressively” “the maximum available resources” to the “highest attainable standard of health” Examples of inclusions, able to evolve, “reasonableness” for different states and expectation of international co-operation

THE RIGHT TO HEALTH  Enshrined in International Law  Extends beyond health care to pre-conditions  States obliged to respect (people R2H, no discrimination against e.g. disabilities- getting rid of disabled carparks, have them able to participate in society, activities ), protect (e.g.no interference from 3rd parties, smoke free interventions- images on packets) and fulfil (e.g. adopt measures to achieve equity) - Roles of govt to achieve rights of health  Social epidemiology links health with social justice and thus links to good government- if no warnings on smoking packets, fast food packets… good govt? accused of being bad “Right to Health” in Human Rights Framework;  Health Inequities are evidence of laws, policies and practices that distribute resources and opportunities in a discriminatory manner and limit full participation  Health is acknowledged as political (power, social context and politics) and health policy decisions have legal dimension rather than purely political discretion Right to Health specifically mentioned in Art 5 of International Convention on the Elimination of all forms of Racial Discrimination (1965) Also noted in other ‘Elimination of Discrimination’ Conventions Scope and range broadened and made more explicit Implementation and enforcement critically dependent on legislative and judicial action at national level Right to Health vs Right to be Healthy A government cannot guarantee an individual the right to be healthy (e.g. individual the right to be healthy (e.g. individual may have an inherited disease or a gene that predisposes them to breast cancer or a gene that predisposes them to breast cancer) but a government On a population level, not everyone is healthy e.g. accidents, chronic diseases, premature mortality, cancers so not everyone is entitled to the right to health but securing best environment (legal, political, environmental) for you to be healthiest you can be is a right.    

Discrimination travels on various axes of identity Impacts on multiple layers of determinants Acts on access to and through care and quality of care Even if not intentional, if discrimination causes impairment of enjoyment of rights= violation e.g. 2nd grade services- not prescribing what should be prescribed, instead of packaging services to have best service  State has moral and legal obligation to prohibit and eliminate, including acting affirmatively (car parks) R2H framework goes beyond medical, ethical and quality issues to focus on accountability In NZ The Code of Health and Disability Service Consumer’s Rights  Outlines 10 rights e.g. freedom from discrimination and services of appropriate standard  Aligns with Human Rights Act, NZ Public Health and Disability Act, R2H not explicit 6

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Code in part a response to ethical issues in health services research

NZ Public Health and Disability Act  Reducing inequalities- one of purposes  No explicit mention of Right to Health but main purpose a DHB based health system to foster community participation  Has Treaty of Waitangi clause as well as clause noting that no- one will have special privileges on basis of ‘race’ Te Tiriti o Waitangi (Treaty of Waitangi)  Affirms indigenous rights as does 1835 Declaration of Independence  Various ways of using ToW as framework with different strengths and limitations  Good governance  Didn’t sign for bad deal  Active protection- Te Reo Claim  Napier Hospital Claim- Health as taonga  Ngati Porou Claim- inequalities as a breach UN Declaration on Rights of Indigenous People  Gathers existing rights from other conventions and highlights/ reiterates existing rights for indigenous people vulnerable to achieving it  Adopted by UN after 25 years of negotiations in 2007, by NZ on 20th April 2010  Introduction/ Preamble and 46 articles  Preamble states - Everyone has human rights - Indigenous people have not always been able to fully realize them - Declaration seeks to facilitate full realization of rights and stronger relationships between Indigenous people and states R2H Instruments 1. Universal Declaration of Human Rights 2. ICESCR 3. Other international rights covenants 4. Indigenous Rights - Treaty of Waitangi - UN Declaration on Rights of Indigenous Peoples 5. NZ legislation and policies - Human Rights - NZPHDS - Code of Patient Rights Lecture 30: Climate Change Causes of warming  Solar activity (amount of)  Planetary tilt and orbit  Volcanic activity  Dusts and aerosols  Albedo (reflectants from clouds, ice, snow)  Heat- trapping “greenhouse” gases (basis of climate change)

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Carbon dioxide levels are much greater than they have been at any time in the last 400,000 years – steepness of line on graph of atmospheric CO2 has increased. Temperatures for global land, global water and globally are going up. These patterns cannot be explained by changes in solar activity >4 degrees warming by 2100  Globally, emissions increase by 2-3% a year  Population pressures: 50% increase in the next 50 years as population increases from 7 billion to 9/10 billion  Development catch-up- 90% of growth in emissions in low and middle income states  No sign of leadership from high income countries responsible for 70% of carbon presently in atmosphere Risks associated  5- 6 degrees warming over land areas, 10 degrees or more in Arctic  Rain-fed agriculture not viable in many parts of sub- Saharan Africa  Possible loss of Himalayan glaciers  Catastrophic fires in Australia every second summer  Increased chance of irreversible changes in earth systems Why it matters  Variability and frequency of extreme events more important than conditions in health point of view - Mean temperature peaks have shifted to right by ~ 3 deg, only 3 deg increase but marked increase in frequency. Curve not same shape- more spread out so variability increased- extreme events increase disproportionally  Compared with human populations, physical and ecological systems relatively open (less buffered) to environmental change and may be sensitive to temperature rise- subtle changes in ecosystem (exposed) small but...