• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/132

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

132 Cards in this Set

  • Front
  • Back
Intersectoral Action for Health
Promotion of health thru involvement of actors in other sectors (ie transport, housing, education)
Libertarianism
Philosophical approach that favors individualism w/ free market economic policy and non-intervention by govt.
Public Health
Science and art of promoting health and preventing disease thru organized efforts of society
Development of ideas on role of public health
-Sanitary movement with contagion concept (idea- communism, or dz-cholera)
-Preventative medicine w/ increased scientifica medicine w/ focus on hygiene (also genetic/racial hygiene)
-Health Field Concept 1974: move away from medicalization of PH to policy (HFA),
-Inclusion of mental health in PH
2 reasons historical development of PH relevant today
1. In some countries PH has still to emerge from telling people what to/not do with little understanding of why
2. PH is political and not value free and assumes acceptance for society as not just group of individuals therefore justifies constraint on freedom to benefit population as a whole
Discuss for/against societal interventions for promotion of health
(Exp junk food, firearms, speed camera, public smoking)
1. Skrabanek: unjustified interventions b/c don't know enough about determinants of dz and use inappropriate use of epidemiology seizing on chance associations b/t dz and RF.
2. Heath Fascism: PH imposes lifestyle on others; nico nazis and nanny state
3. Health Imperalism: heath equated to happiness or wellbeing to justify involvement in many issues
4. Patronizing: do not respect individual autonomy
5. Liberty depriving: common in past w/ contagion/psych illness (criminal for psych and drugs and DOT)
Beaglehole and Bonita Paper
PH multidiciplinary, intersectoral, inc political process, global and perspective broad and PH responsible for pop health na dshould be closer relationship b/t PH practioners and society. Focus on health inequalities
Rothman Paper
Epidemiologists aren't social engineers/economists and scientists have right to specialize. PH accomplishments won slowly over time (Vit A and malnutrition) and specific causes of dz essential for foundation of effective PH actions. Work in epi into specific causes of dz essential to lay good foundation for effective PH actions
Criteria to consider CDC involvement in an issue
1. How much death and disability does issue cause and what is current burden of disease
2. Scope for preventing burden
3. Future consequences of failing to act
4. Cost of acting
5. Feasibility of acting
6. Here are you b/t libertarianism and collective action
7. Are these legitimate areas for state involvement
Etoh abuse policies
Need policies BOTH toward whole drinking population and risk drinkers
Age standardization
A way of controlling for age that we can compare rates of deaths or disease in populations w/ different age structures.
Life expectancy
Avg number of yrs a person can expect to live in a given population. Expressed as life expectancy at birth or at a particular age. Based on current patterns of mortality, so technically not measure of how long child born today can expect to live as can't yet know death rates that will apply at different ages in future. Most widely used summary of mortality in a population.
Survival rate
Proportion of population who survives a dz for a specified time period (~5yrs)
Main sources of data on population and mortality and describe strengths/weaknesses
1. Census: rapidly out of date, some subgroups hard to reach, susceptible to misreporting by respondents (heaping age by 5yrs, inc SES, single vs divorced), time and E intensive
2. Population registry (register when move houses)
3. Population estimates (back adjust censuses)
4. Death certificates with ICD (can be multiple but only state 1, interphysician variability, dx inexact science
5. Demography and Health Surveys (childhood and maternal events by "sisterhood" method, and "verbal autopsy", cross-sectionaly; recall bias, requires identification of clearly distinguishable sx complexes
5. Modeling: apply data from surveys of childhood mortality to standard life tables or developing equations from available data (ie economic measures) to predict mortality using info from large number of countries
Crude Death Rate=
number of deaths/mid year population
x1000
Cause specific mortality rate=
deaths by cause z / mid year population
x 1000
Age specific mortality rate=
deaths to persons aged z / mid year population of persons aged z
x 1000
Infant mortality rate=
number of deaths <1 yo in year z / number live births in year z
x 1000
Perinatal mortality rate
stillbirths + deaths <1wk in year z / number live births in year z
x 1000
2 techniques for standardizing age
Direct and Indirect
1. Direct Age-Standardization: need age-specific mortality rates from population interested in and defined standard population with known age structure (# persons in each age category). Calculate age-standardized mortality or death rate (SDR) or directly standardized rate (DSR).
2. Indirect Age Standardization: used when no info on age-specific mortaliyt rates; calculate SMR (standardized mortality ratio). SMR= ratio (x100) of observed to expected deaths in a study population. Often used to look at district data or specific population groups. B/c smaller geography or small populations have sm numbers of deaths per age group, use of SMRs use std population death rates from a larger sample to decrease error of small sample.
Direct Age Standardization
Direct Age-Standardization: need age-specific mortality rates from population interested in and defined standard population with known age structure (# persons in each age category). Calculate age-standardized mortality or death rate (SDR) or directly standardized rate (DSR).

Commonly use standard populations
1) Segi "world" population (intermediate world std b/t European std and std w/ high proportion of young people for making comparisons w/ populations in Africa)
2) European std population: higher number of elderly to reflect Western Europe
Indirect Age Standardization
Indirect Age Standardization: used when no info on age-specific mortaliyt rates; calculate SMR (standardized mortality ratio). SMR= ratio (x100) of observed to expected deaths in a study population. Often used to look at district data or specific population groups. B/c smaller geography or small populations have sm numbers of deaths per age group, use of SMRs use std population death rates from a larger sample to decrease error of small sample.
SMR
Measure of indirect age standardization

=observed deaths/expected deaths x100 = SMR %
Survival rates
Depends on accuracy of registries and are dependent on dx practices, existence of screening programs, stage of disease at presentation, incidence and mortality rates;
Morbidity measurements
~self reported health surveys about lifestyle and SES indicators
Burden of disease
Measure of the physical, emotional, social, and financial impact that a particular dz has on health and functioning of a population
Disability Adjusted Life Year (DALY)
estimates the equivalent years of healthy life lost by being in a state of poor health/disability
Health Adjusted Life Expectancy (HALE)
estimates equivalent of healthy expected number of years of life for a newborn in a given population, if current disability adn mortality conditions in that population continue to apply
Health Expectancy
Summary measure of population health that estimates the expectation of yrs of life lived in various health states
Health gap
summary measures of population health that estimates the gap b/t current population health and the normative goal for population health
Summary Measures of Population Health (SMPH)
Indicators that combine information about mortality and health to summarize the health of a population in a single number

2 categories: health expectancies (estimate avg time person could expect to live in various states of health) and health gaps (quantify the difference b/t actual health of a population and some stated norm/goal for population health)

Better than mortality rates b/c say more about the health of those still alive and include prevalent conditions causing disability and use of HC resources.

HALE (Health Adjusted Life Expectancy) is #1 SMPH
Uses of SMPH
1) Compare health of 1 population w/ that of another
2) Monitoring time trends in health of a given population
3) Assessing overall health inequalities w/i populations
4) Providing appropriate and balanced attention to effects of non-fatal health outcomes on overall population health
5) Informing debates on priorities for HC delivery, planning, research, and development
6) Improving curricula for professional training in PH
7) Analyzing the benefits of health interventions for use in cost-effectiveness analysis
Limitations of SMPH
GBD (global burden of disease) project
1. How to define and measure disability and then select weight to particular health state.
2. Value placed on a life at different stages of life (GBD decided there was a difference in younger life)
3. How to obtain SMPH in countries from which data is unavailable (data applied to model life tables or by SES/level of female education)
Methods used to assess burden of dz in a population and major contributors to it
Burden of dz can be seen as a measurement in gap b/t current health of population and ideal situation where everyone lives to old age in full health.

DALY determined by mobility, self care, pain, cognition, interpersonal activities, vision, sleep and energy, affect weighted values.
GBD (Global Burden of Disease)
Disproportionate dz burden in LICs and MICs
Non-communicable dz large part of DALYs in HIC
Communicable, maternal/perinatal conditions, and nutrition large part of DALYs in LIC/MIC.
Risk Factor Transition
Several differences among 3 mortality groups suggest demographic changes and better economic environment accompany a reduction in relative importance of communicable disease RF's and inc in noncommunicable dz RF's. (LIC-underwt, unsafe water/sanitation/hygiene, Fe defic, indoor smoke from solid fuels vs HIC- bp, high chol, smoking, overwt, low fruit and veg intake)
How do nutritional diseases create a dual burden of disease?
Problems with malnutrition and micronutrient deficiencies and the chronic, non-communicable diseases of adults. Rapidity of the nutritional transition means that many low- and MIC's now respond to both sets of diseases
The Risk Transition (aka epidemiological transition)
As a country develops, the types of diseases that affect a population shift from primarily infectious (diarrhea/pneumonia) to primarily non-communicable (CV disease and cancer)

Caused by improvement in medical care, aging population (where non-communicable dz affect more), public health interventions (vaccines and clean water and sanitation) reduce infectious dz
Direct vs Indirect Discrimination
Direct discrimination: 1 person treated <favourably than another is, has been, or would be treated in a comparable situation based on race, ethnic origin, other factor.

Indirect discrimination: apparently neutral provision, criterion, or practice would put persons w/ a give trait (for example racial/ethnic origin) at a particular disadvantage compared with other persons, unless that provision, criterion, or practice is objectively justified by a legitimate aim and means of achieving that aim are appropriate and necessary.
Health Inequalities
Differences in health status or in distribution of health determinants b/t different population groups.

Thought unfair and could be remedied
Life course epidemiology
study of long-term effects on later health or disease risk of physical or social exposures during gestation, childhood, adolescence, young adulthood, or later adult life
Regeneration
Reviving run-down or deprived areas, for example providing employment and training schemes, improving housing, developing transport links, offering local health services, landscaping and creating green spaces from derelict areas.
Main developments in debate about inequalities in health over 150yrs
Industrial revolution
Stevenson linked occupation with mortality
1970's economic boom but health gap larger than ever
1979 Black Report inequalities were not narrowing possibly due to:
1. artefact: biases arose form death certificates, shrinking lower class, changing in social class over time; later disproved
2. social selection: healthy people promoted vs unhealthy lose jobs; later disproved--retired did not change position from last position
3. behaviour: indulge in health damaging behavior by poorest people.
4. material circumstances: poverty leads to poor health
*Many aspects of health are determined by social class.
-Emerging theories: life course epidemiology (disease result of conditions inutero and throughout life), monotonous conditions assoc w/ higher mortality from CV disease -->need broader measures of wellbeing.
Barker hypothesis and Life course epidemiology
not just ones circumstances that determine one's health but accumulated experience thru life--link conditions in early childhood, in-utero, etc with later disease.

Policy implication: to tackle inequalities, interventions should primarily focus on circumstances of kids and those with young families
Apply framework for action on health inequalities to the development of a health strategy
1. strengthen individuals: knowledge
2. strengthen communities: a) community development; b) community regeneration. Success if strong citizen groups and integrated programs and priority to employment and alleviating povert and LT; familure most likely if mainly physical refurbishment;
3. Improve access to services (groceries--food deserts, clinics--inverse car law, internet)
4. Encourage macroeconomic and social change: 1. fairness of resources; 2. countries w/ lg income inequalities experience lower rates economic growth, higher rates crime, greater social disorder
Focus on children to improve health gap
-give every child best start in life
-give every child, young person, and adult to maximize capabilities and have control over their lives
-create fair employment and good work for all
-ensure healthy std of living for all
-create and develop healthy and sustainable places and communities
-strengthen role and impact of ill-health prevention
Trickle down theory
Theory that as wealthy became richer, lger amts wealth trickle down to poor to benefit everyone.

Inequality is actually more important than absolute income and challenges this theory
Gini coefficient
measure of income inequality; express as percentage or proportion
What are main challenges in describing patterns of income inequality in a country
Current indicators of income inequalities are of limited value. Doubt accuracy for international comparison as difficult to assess household income (sensitive), different tools used in different countries, difficulty with sampling, measurement bias, etc). Methods may be too simplistic and don't take act other important factors on health (ie hx, culture, politics, economics, gender and ethnic minorities)
Describe social capital
mix of relationships individuals have; network of social relations characterized by norms of trust and reciprocity
Strong correlation found b/t Gini coefficient and life expectancy for 22 countries--explain why?
Largely due to data from Russia as level of income inequality largely exceeded that of other countries. 1 country can have important effect on correlation coefficient.
Black box epidemiology
Although we seen an association b/t given RF (ie ethnicity) and an outcome, we can't explain it, we don't understand mechanism behind it. (exp. health differences b/t ethnic groups and don't know what factors explain them)
What are the potential pitfalls of research on ethnicity and health and how can they be avoided
-ethnicity hard to define
-its underlying concepts are poorly understood
-it is hard to measure w/ accuracy or validity
-there are inconsistent and non-specific meanings used
-there are problems in recruiting representative and comparable population samples
-adjustment for confounding factors and interactions isn't always done
-differences are rarely studied in details in an attempt to explain them (going beyond the black box)
-research on ethnicity and health can be harmful (ie if ethnic groups perceived unhealthy, if conclusions focus on a few ethnic problems, if they minimize importance of some problems, if importance of the quality of care is forgotten, if it fuels racial prejudice)
How to avoid pitfalls in ethnic research and health
-understand hx of misuse of studies in past
-ethnicity is different than race
-complex and fluid nature of ethnicity appreciated
-limitations in classifying ethnic groups appreciated
-better describe characteristics of their study and comparison populations with explicit description of ethnic coding used
-research on methods for ethnic classification should be given higher priority
-realize pot bias by personal values
-analysis should include confounders (SES)
-results shouldn't be generalized except w caution & should be applied to planning of health services
-ethnic minorities should be involved in research, policy, dev of services
3 Ways to tackle health inequalities
1. improve daily living conditions
2. tackle inequitable distribution of power, money, resources
3. measure and understand the problem and assess the impact of action
Avoidable mortality
premature deaths that shouldn't occur in presence of timely and effective HC
Health System
Health system includes all activities whose primary purpose is to promote, restore, or maintain health
Health System Goals
Improving health of the population they serve, responding to people's expectations, providing financial protection against the cost of ill health
Discuss changing views on contribution of HC to population health
Clinical iatrogenesis: Harm done to patients by unnecessary risks of investigations and treatments.

Social iatrogenesis: diminution of autonomy for patients causing harm by physicians.
Discuss ways of assessing the contribution of HC to health (ie avoidable mortality) and the use of specific indicators
Inf disease rates, diabetes registries, vacine preventable disease, occupational injuries
Describe ways in which health provision can be used to promote health
Improving conditions for those hospitalized
Making areas assessable (ie disability act)
Send consistent messages (nutrition, activity, not just better HC methods)
Bans and action to help smoking cessagion
Handwashing and reduction of infection--do no harm
HC needs of staff
Unnecessary untimely deaths
aka avoidable mortality

deaths from certain conditions that should be avoidable, on basis of current medical knowledge, by timely intervention and that could therefore serve as an indicator for quality of medical care.
Beaglehole Vs Yusuf views on CV disease funding
Beaglehole: Already known RF's and now divert efforts away from aetiology studies to primary prevention to inc low risk population rather than ID and treating high risk.

Yusuf: early detection and tx reduce occurence of and establishment of chronicity; priority should be secondary prevention interventions making them affordable, accesible, and convenient to ensure worldwide benefit from tx.
+/- using Infant mortality as indicator of population health
Traditional key measure of population health as sensitive indicator of living conditions and coverage/quality of HC.

May conceal different trends in neonatal and postneonatal mortality since postneonatal mortality strongly related to SES factors while neonatal mortality more closely reflect quality of medical care.

Thus, infant mortality is useful indicator in quality of medical care but should be
1) looked at in assoc w/ other measures, such as avoidable mortality and
2) you should ideally, take account of differences in underlying factors that inc risk of death in infancy (ie differences in birth weight with LBW assoc with low SES)
9 criteria of causality
RF's cluster making causality hard to prove
1. strength of association
2. consistency (association seen in diff circumstances)
3 specificity (cause leads to single outcome, not multiple)
4. temporality (exposure b/f outcome)
5. biological gradient (dose-response curve (>exposure related to >risk disease)
6. biological plausibility
7. coherence (consistent with common sense)
8. experimental evidence (animal studies support)
9. analogy (if 1 drug causes birth defects, plausible that another does)
Health inequalities
Differences in health experience and health status b/t countries, regions, and socioeconomic groups
Health Impact Assessment (HIA)
means of assessing the health impacts of policies, plans, and projects in diverse economic sectors using quantitative, qualitative and participatory techniques

combination of procedures, methods, and tools by which policy/program/project judged to potential effects on population health and distribution of those effects w/i the population

concerned w/ population health and attempts to predict future consequences in health decisions

flexible, adaptable, intended to influence decision-makers, improve PH or do no harm to population health

HIA rooted in promotion of healthy pubic policy and in environmental impact assessments (HIA similar to social impact assessment and EIA)

Make recommendations with constraints of time and resource limitation w/ evidence that can be mixed, contradictory, or limited; imp to involve key stakeholders w/ clear understanding of diff perspectives and reached by consensus.
4 ways HIA can influence decisions
1. raise awareness among decision-makers of relationship b/t health and other factors (physical, social, economic environ)
2. help decision-makers ID and assess potential impact proposal on population health and wellbeing and o n distribution of those effects w/i population (consider inequalities)
3. ID practical ways to improve and optimize outcome of proposals
4. help stakeholders affected by policies participate and contribute to decision-making
Ultimate purpose of HIA
to informa nd influence subsequent decision-making and not merely research tool; it is a polical tool to aid in decision-making
What are the broad determinants of human health
personal, social, cultural, economic, environmental

Include pre-conceptual/in utero, behavior/lifestyle, psychosocial (religion/culture), physical envir, SES, provision of/access public services (transport, shops, health, etc), public policy global policy

Greatest scope for improving PH often lies out of control of health services (economic, housing, agriculture, transport, education)
What are the 5 stages of HIA process
Multidisciplinary, intersectoral process includes (SSARM)
1. screening: establishes health relevance of the policy/program; decide whether there is a need for more detailed assessment
2. scoping: ID questions the appraisal needs to ask and scope of HIA (ie geographical area, population, timescales)
3. appraisal: assessment of health impacts using available evidence (rapid/in-depth; ;quantitative and/or qualitative)
4. Reporting: conclusion/recommendations to remove/mitigate negative impacts or enhance positive aspects on health; important to meet political timeframes
5. Monitoring: monitor actual impact where appropriate
Difficulties in methology of HIA
1) Hard to get data and may need qualitative over quantitative; limits of time and available resources
2) Shared defn of health is needed (perceived determinants of health as markers: ie employment)
3) Methods are no sufficiently rigorous to w/stand scruity and challenge. Principal sources of evidence from lit reviews and qualitative methods; better to use range of data (economic, epidemiology, quant, qual). However, most useful info is not routinely collected due to time/money. Qualitative measures may limit strength of recommendations.
4. Balance objective evidence and subjective opinion
5. limited HIA by finance and time
6. May not be discrete activity but cont over long time, evolving (ie gentrification)
Benefits of using HIA
provide mechanism for health to inform decision-making
improve intersectoral working
create structure approach for demonstrating broad health agenda to other agencies/policy sectors
raise community awareness of health
encourage and enable public participation
increase transparency of some aspects of decision-making
Germ theory
theory that all contagious disease are caused by microorganisms
Addiction:
dependence on s/t that is psychological/physically habit forming
Globalization
sest of processes that are changing nature of human interaction by intensifying interactions across certain boundaries that have hitherto served to separate individuals and population groups. These spatial, temporal, and cognitive boundaries have been increasingly eroded, resulting in new forms of social organization and interaction across boundaries
International vs Transnational
International: Cross-border flows that are, in principle, possible to regulate by natl govt

Transnational: transborder flow that largely circumvent national borders and can thus be beyond the control of national govts alone
Tort
Legal term to describe wrongful act, resulting in harm/loss to another person or their property, on which a civil action for damages may be brought
Human rights
all human beings are born free and equal in dignity and rights
Food miles
distance that foods travel from where grown to where purchased/consumed by end user
Food security
physical and economic access for everyone and at all times to enough foods that are nutritious, safe, personally acceptable, and culturally appropriate, produced, and distributed in ways that are environmentally sound and just
Nutrition transition
process of change in which populations shift diet from restricted diet to one higher in saturated fat, sugar, and refined foods and low in fiber as result diet related ill health previously assoc w/ affluent Western societies takes root in developing countries
Ecological footprint
accounting tool for ecological resources; sustainable is 2hectares/per capita; recycling alone not sufficient and waste minimization essential w/ energy reduction, reduction waste and water. Domestic waste only 10% vs industry.

Corresponds to the area of productive land and aquatic ecosystem required to produce the resources used and to assimilate the wastes produced by a defined population at a specified material standard of living, wherever on Earth that land may be located
Environmental/Occupational Exposure
any contact b/t substance in environmental medium (ie H2O, air, soil) and surface of human body (ie skin/resp tract); after uptake into body referred as dose

Outdoor air pollution: CV,
Exposure assessment
Study of distribution and determinants of substances/factors affecting human health
Precautionary Principle
When there is reasonable suspicion of harm, lack of scientific certainty or consensus must not be used to postpone preventative action to avoid serious/irreversible harm
Adaptation
ST adjustment in natural/human systems in reseponse to actual/expected climatic events to reduce the impact of climate change.
Carbon footprint
measure of impact of human activities on the environment and in particular on climate change. It relates to the amount of greenhouse gases produced, measured in units of tonnes (or kg) of CO2 equivalent

Use transition initiative for projects to dec carbon load
Climate change
LT (minimum 1 decade) change in statistical distribution of weather patterns over periods of time; usually now refers to changes in modern climate due to human activities
Co-benefits
Results of action likely to impact favourably on climate change which also are likely to reduce M&M due to other causes or to improve the health of a population
Contraction and Convergence
Model that sets out a global framework for reducing greenhouse gas emissions to safe levels in a socially just way

Global carbon budget with annual reduction targets limit temp rise to 2C, shared commitment , LT individual use same personal budget and choices regarding its use; dev countries allowed initial inc to UTD cost and carbon-efficiency lessons
Ecological PH
integration of ecological and environmental issues w/i PH research and practice to seek to benefit both human and environmental health.
Mitigation
A human intervention over the LT to reduce concentrations of greenhouse gases, so reducing the severity of climate change.
Sustainable development
Development that uses resources to meet present day needs, while not compromising the ability of future generations to meet their own needs.
Global warming from
1) greenhouse gases
2) inc CO2 productino in soil organisms from warmth
3) deforestation
4) relentless population growth
Why climate change is important to PH
Patterns of disease and mortality
Food security
Water and sanitation
Shelter and human settlements
Extreme climatic events
Population migration
Direct impact of climate change on health
infectious diseases, heatstroke, mortality by unstable weather (ie floods)
famine (from failed crops/floods)
Inc skin cancers and sunburn
Inc prevalence cataracts
Impact of climate change on wider determinants of health
access food/clean water
living conditions & overcrowding
hygiene/sanitation
infectious disease and vaccinations
access to health services and essential medicines
economic instability
civil unrest/war
Methods of tackling climate change
1) mitigation: human intervention to reduce sources/enhance sinks of greenhouse gases; reduces severity of climate change (ie dec fossil fuel use)
2) adaptation: adjustment in natural/human systems in response to actual/expected climatic stimuli/their effects which moderates harm/exploits beneficial opportunities; reduces impact of climate change
3) resilience: capacity of system to absorb distrubance and reorganize while undergoing change as to still retain essentially the same function, structure, identity, and feedbacks; through adaptation we develop resilience.
Livestock farming remains the greatest contributor to methane and CO2 production--even more than transport and other uses of fossil fuels; consumption of meat imp factor in climate change. Why
pasture/livestock deforestation
Grain E-intensive nitrogenous fertilizers
Methane released from animal manure and from enteric fermentation34x potential of CO2
Nitrous oxide 300x greater than global warming potential of CO2.
Suggest limit of 100gm of meat/day and 1 meat-free day/week.
Examples of co-benefit
1) inc price petrol (less cars on road, less accidents, less congestion/pollution/stress
2) active travel: dec noise, improve health, dec pollution
3) insulation of homes
4) Breastfeeding
5) reducing food waste
Risks/benefits carbon pricing
harm poorest in society if safeguards not placed, some E efficiency can dec ventilation impacting indoor air quality/radon, buying local foods may prevent adequate intact or impair nutrition in some people
Areas of global damage
-climate change
-oxygen dead zones in seas/oceans->acidic, decline fish stock and coral reefs
-3 species/hr in dec biodiversity
-loss fertile land (esp africa from pollution, erosion, nutrient depletion, water scarcity and salinity
-dec fresh water for humans/animals
Factors that contribute to global spread of infectious dz
-Demographic changes and human behaviors (pop growth, poverty, pop movements, human behaviors with sex/drug use/noncompliance
-Tech development (A/C, BSE, TSS, nosocomial)
-Economic development and land use (lyme, malaria)
-microbial adaptation and change
-b/d health infrastructure or PH policy (soviet union)
-climate change (flood, loss land and contaminated water)
-warfare, terrorism, conflict (bio warfare, dec hygiene, movement people)
Legal measures used to control infectious disease
-tax and spend
-direct regulation individuals (removal freedom if decline tx, ie TB)
-indirect regulation thru litigation/tort (sue hospital for failure inf control)
-deregulation (ie brothels)
-alter how info received (health promotion)
Armed conflict
over 1000 battle-related deaths in 1 yr
Household surveys
collection info from representative sample of households on health events
Mortality rate
# deaths in given pop at risk during specified time.

Usually expressed in deaths per 10,000 persons per day in conflict-settings.
Surveillance
systematic collection and analysis of info over time to regularly monitor changes in health
Armed conflict today
>civil conflicts that international

deliberate targeting of civilians and humanitarian organizations (kill, rape, maim, abduct) and civilian populations forcibly displaced by violence/insecurity w/ 27 millinon internally displaced persons (IDPs)--w/i natl border and 15 million refugees

IDPs and refugees commonly lived in camps but now in urban settings

Those not displaced have low access to essential HC, food, basic needs due to surrounding insecurity

Little adherence to human rights principles

Refugees may move into areas where support services not yet available (cholera and Rwandan Hutu refugees in Zaire)

Conflicts usually last avg 10yrs
Pre-conflict RF's
poverty, SES vulnerability, often affect younger populations w/ high burden communicable disease
Conflicted induced RF's to health
reduced HC access
disrupted vaccine and dz control programs
reduced food/nutrition
dec hygiene, water, sanitation
overcrowding/inadeq shelter
stress
poverty

Causes direct heath effects (immediate): poor mental health, mortality, injuries

Causes indirect health effects (higher amt): M&M, malnutrition, poor mental health

Affecs reproductive health
Ways PH can guide decision-making in conflict--methods
1. rapid assessments (trade off rapid vs quality; unlikely accurate on mortality rates, prevalence/incidence of dz/malnutrition or impact of interventions); use health profiles and available data on population
2. surveillance: trend mortality, prevalence dz, and impact interventions by demographic survellance (death/birth from households or specialized systems surveying risk behaviors, food insecurity, malnutrition prevalence;
-surveillance establish ASAP in affected areas
3. household surveys: single point in time crude and <5yo mortality rate; doubling of pre-conflict mortality is considered emergency situation

Challenges to getting this info: insecurity, logistics, donars favor process over impact indicators,
Complex disease:
Conditions occurring freq in population, often multi-factorial aetiologies (genes and environment)
Genome
sume of all an individual's genetic info
Genome-Wide Association Study (GWAS)
large epi sutdy comparing frequencies of SNPs across entire genome b/t groups w/ and w/o particular phenotype (ie DM2)

Natural selection on genome; therefore variants causing lg differences in dz susceptibility are unlikely to be found commonly in population and most likely variants are common ones w/ modest effects.
Genotype
composition of DNA in person at particular point/locus
Linkage study
epi study to ID sequences of DNA shared by people w/ common phenotype/dz
Locus
defined point in genome (single base or whole gene, or clusters of genes
Mendelian dz
dz where single mutation gives rise to major, deleterious phenotype and is inherited in Mendelian pattern thru a family (ie Duchenne muscular dystrophy, familial HLD)
Mutation
larger change in genotype with more substancial phenotype consequences (lg insertion/deletion of nucleotide bases)
Phenotype
physical, biological manifestation of a gene (simple or complex. Determined by environment as well.
Polymorphism
small change in individual's DNA sequence, ~ limited to few nucleotide bases that may/may not influence phenotype
SNP (single nucleotide polymorphism)
Change from 1 nucleotide base to another at particular location in genome; accts for majority of genetic variation b/t individuals
Advantages of Mendelian randomization studies over non-genetic observational research
MR minimizes confounding and can eliminate referse confounding factors; exposures in observation can be difficult to measure vs MR easy to characterize.
Advantages of Mendelian randomization studies over randomized control trials
cost less, less time, easily performed on very large scale, may prevent exposure to potential drug/therapy, allow investigation of range of phenotypic associations, avoid ethical difficulties of exposing people to potential harmful exposures, reflects lifetime exposure to phenotyp vs RCT wk/mon or rarely yr exposure.
Prevention Paradox
Most individuals w/ common dz ie CHD) exposed to avg and not markedly unusual risk alleles
Ideal characteristics in predictive test for chronic disease
cost-effective, marker by test not changed markedly w/ time, marker not operator-dependent, accurately designate people as high/low risk, tx for condition available, tx of those at risk reduces risk tof dz to nil, test acceptable to pt, dz has major impact on PH, natural course of dz well understood
Key benefits to pop health of effective pharmacogenetic test
-substantial reduction in drug SE's
-optimize intended effects of treatment
-inc drug concordance (personalized drug to individual may inc compliance)
Advantages/Disadvantages to direct-to-consumer genetic testing
1. knowledge of genome aids motivation in risk reduction behaviors vs genomic futility
2. incorporated into prediction models and can aid in research; widen inequality in health care as only inc SES will pay for genome
3. cost low and decreasing; is info value-for-money
4. rapid, low cost testing may yeild more info quickly than conventional tests and are not time-limited; HC workers need training on interpretation/application; superiority over conventional testing may take time to prove
Ways to combat worsening nutrition in food
-Make healthy choices easy
-Evidence of harm necessary but not sufficient to motivate policy change
-Decisions to act need not wait for evidence of effectiveness--precautionary principle
-Look at wider issues in food production (farmers)
-The more comprehensive the pkg of measures considered, the greater the impact
-media savvy leadership important
-do not expect immediate results (ie tobacco)
modest, well-spent funds can have massive effects
4 foci in modern thinking in diet on health
food safety, nutrition, sustainable development, food security