Wider determinants of health 1 commodities

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Published on February 14, 2008

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Wider determinants of health: 1. Commodities and health:  Wider determinants of health: 1. Commodities and health MSt in Public Health, 2005 cohort John Powles ‘Wider determinants’ of health:  ‘Wider determinants’ of health Loss of health Disease & injury ‘Wider determinants’ of health:  ‘Wider determinants’ of health Loss of health Disease & injury Proximal determinants Eg Infection metabolic disturbance Energy transfer ‘Wider determinants’ of health:  ‘Wider determinants’ of health Loss of health Disease & injury Proximal determinants Intermediatedeterminants Eg Infection metabolic disturbance Energy transfer Eg Exposure to infection Diet Careless driving ‘Wider determinants’ of health:  ‘Wider determinants’ of health Loss of health Disease & injury Proximal determinants Intermediatedeterminants Wider determinants Eg Infection metabolic disturbance Energy transfer ??? (no agreed conceptual-isation) Eg Exposure to infection Diet Careless driving ‘Wider determinants’ mostly used in relation to:  ‘Wider determinants’ mostly used in relation to Social determinants of health inequalities However: Contemporary assessments of social influences may not throw much light on underlying determinants of long term health transitions in populations The ‘wider determinants’ of health transitions:  The ‘wider determinants’ of health transitions The idea of health transition:  The idea of health transition Demographic transition Epidemiologic transition Health transition The idea of ‘the’ health transition:  The idea of ‘the’ health transition The transition from health levels typical of premodern (‘late agrarian’) societies to those of late modern societies … with some emphasis on the social and institutional determinants of the transition eg changes in status of women …but why take agrarian societies as the baseline?:  …but why take agrarian societies as the baseline? Earlier transition from hunting and gathering to agriculture is also likely to have had profound health effects …better: ‘health transitions’ How should the ‘wider determinants’ of ‘health transitions’ to be conceptualised?:  How should the ‘wider determinants’ of ‘health transitions’ to be conceptualised? Proposed classification: Commodities (‘material life’) Institutions (‘social life’) Knowledge (‘intellectual life’) In reality these are meshed together:  In reality these are meshed together Eg Increase of knowledge Changed world views Institutional change Economic development … and can only be separated by ‘thought experiments’ Why bother?:  Why bother? To test the plausibility of competing claims for the primacy of: Material conditions of life, versus Social organisation, versus Knowledge … as determinants of long-term health trends Does one cog drive the others?:  Health Medical Non-medical Institutions Knowledge Commodities Does one cog drive the others? Part 1: Commodities and health transitions:  Part 1: Commodities and health transitions The ‘strong materialist’ interpretation Thomas McKeown Robert Fogel Slide19:  Fogel Escape from hunger Four survival patterns and transitions between them:  Four survival patterns and transitions between them The health transition in the Third World The first health transition Four survival patterns and transitions between them:  Four survival patterns and transitions between them How do we know about mortality and fertility levels in the past?:  How do we know about mortality and fertility levels in the past? Official systems for vital registration In the UK from 1837 ‘Family reconstitution’ from parish records In England from the 16th century Survival analysis using household registers Sweden/Belgium/Italy/Japan/NE China for late C18/C19 What is ‘family reconstitution’?:  What is ‘family reconstitution’? In eg early modern England, vital events were recorded by the established Church (baptisms, burials, marriages) Starting eg with a record of a baptism Back to marriage and baptism of parents Forward to death of subject, … and so ‘Reconstitute’ families and then estimate vital rates What are household registers?:  What are household registers? Updated records of who is living in each household Can use standard epidemiological techniques to estimate survival Associations with other characteristics can be explored Eg indices of social rank Comparing survival patterns:  Comparing survival patterns Summary measure = Life expectancy at birth = Mean of all life durations Or Mean age at death (in a life table population) But Mean does not convey distribution (ie survival patterns) well when many lives are very short So when considering transitions across a wide range of survival (e0) levels:  So when considering transitions across a wide range of survival (e0) levels It is more informative to consider separately, changes in Survival chances in childhood And Survival chances in adulthood Additionally because these have varied independently through time Mortality patterns are closely linked to fertility patterns:  Mortality patterns are closely linked to fertility patterns In the long run: death rate = birth rate Except in stationary populations The distribution of deaths by age at death, and The age structure of the population Are much more sensitive to the recent history of the birth rate than to the recent history of the death rate Population ‘aging’ has been much more powerfully influenced by the decline in fertility than the decline in mortality Summary measures of child survival:  Summary measures of child survival Infant mortality ‘rates’ Conceptually = probability of death by age 1 Operationally measured as = Drawback: Direct estimation requires vital statistical system ie not very practical in high mortality populations Under 5 mortality ‘rates’:  Under 5 mortality ‘rates’ Conceptually: probability of death before 5 Operational estimation: Indirect from survey Qs to women about Number of children born Number who have died? (Brass technique) Main measure now used for low and middle income countries (IMR estimates also derived this way, but less robustly) For an intuitive summary of population experience:  For an intuitive summary of population experience May use ‘chance of surviving to (or dying before) adulthood’ (taken as 15) Even at e0 = 35 corresponds closely to U5MR 93% of those surviving to 5 survive to 15 At e0 = 75 99.8% of those surviving to 5 survive to 15 Summary measures of adult survival:  Summary measures of adult survival Adult mortality ‘rate’ = probability of dying before 60 Given survival to 15 Most widely used measure eg by World Bank But 60 is rather low for low mortality countries (especially when you are my age!) I use probability of surviving/dying between 15 and 65 (difference will be small) Life expectancy in England since the C17*:  Life expectancy in England since the C17* Sweden: life expectancy since the mid C18:  Sweden: life expectancy since the mid C18 Changing survival chances: England C17 to late C18 - childhood:  Changing survival chances: England C17 to late C18 - childhood Changing survival chances: England C17 to late C18 - adulthood:  Changing survival chances: England C17 to late C18 - adulthood Changing survival chances: England since the late C18:  Changing survival chances: England since the late C18 Changing survival chances: England since the C17:  Changing survival chances: England since the C17 NB: In early modern times, 70% of those alive at 15 died before 65. The idea that that high mortality was concentrated in childhood is misleading. Slide40:  Risks of death per year lived were higher at the beginning of life But cumulative risks of dying over the 15 years of childhood were much lower than the cumulative risks of dying over the next 45 years (to age 60) Life expectancy in England since the C17*:  Life expectancy in England since the C17* Fogel: ‘techno-physio-revolution’:  Fogel: ‘techno-physio-revolution’ Hunger was not abolished in the West til the C20 Before then life was constrained by sub-optimal nutrition Adjustments included small body size Slide43:  Economic development Increased personal incomes Increased command over food Better nutrition Better health (especially because of increased resistance against infection) Advanced by Thomas McKeown Recently elaborated by Robert Fogel We are much taller than our ancestors:  We are much taller than our ancestors …and very much heavier:  …and very much heavier 50kg -> 75kg for males ‘Net nutrition’ and survival in adults:  ‘Net nutrition’ and survival in adults Height summarises net nutrition in childhood Weight for height summarises recent adequacy (or excess) of dietary energy (relative to expenditure) ‘Waaler surface’: Relationship between height, weight and risk of death based on follow-up of 309000 Norwegian males:  ‘Waaler surface’: Relationship between height, weight and risk of death based on follow-up of 309000 Norwegian males ‘Waaler surface’: Relationship between height, weight and risk of death based on follow-up of 309000 Norwegian males:  ‘Waaler surface’: Relationship between height, weight and risk of death based on follow-up of 309000 Norwegian males ‘Waaler surface’: Relationship between height, weight and risk of death based on follow-up of 309000 Norwegian males:  ‘Waaler surface’: Relationship between height, weight and risk of death based on follow-up of 309000 Norwegian males Slide51:  The available data suggest that the average efficiency of the human engine in Britain increased by about 53 percent between 1790 and 1980. The combined effect of the increase in dietary energy available for work, and of the increased human efficiency in transforming dietary energy into work output, appears to account for about 50 percent of the British economic growth since 1790 Fogel, 2004 Four survival patterns and transitions between them:  Four survival patterns and transitions between them The health transition in the Third World The health transition in the ‘Third World’:  The health transition in the ‘Third World’ Sources for early phase: India: censuses from 1881 Japan/China: household registers from later C18 Picture of India:  Picture of India Differences with West:  Differences with West Timing: C20, mainly second half Implication: Bigger stock of knowledge available Starting point: higher mortality/fertility levels (in some populations) Speed: Mortality decline much faster India: the demographic transition since late C19:  India: the demographic transition since late C19 India: the demographic transition since late C19, with projections to 2050:  India: the demographic transition since late C19, with projections to 2050 Life expectancy in India since the 1880s*:  Life expectancy in India since the 1880s* * estimates are for decades and do not show short term deviations Episodes of catastrophic mortality in India since the C18:  Episodes of catastrophic mortality in India since the C18 Life expectancy in India since the 1880s*:  Life expectancy in India since the 1880s* * estimates to the 1950s are for decades and do not show short term deviations 1940s History of mortality decline in India:  History of mortality decline in India C19 to WWII Immediate post WWII How is life expectancy calculated from census returns?:  How is life expectancy calculated from census returns? Those aged x at a decennial census are the survivors of those aged x-10 at the previous census But Survivorship in the first decade still needs to be reliably estimated Problems of data quality especially mis-statement of ages Survival trends in childhood, India late C19 to 1940s:  Survival trends in childhood, India late C19 to 1940s Survival trends in adulthood, India late C19 to 1940s:  Survival trends in adulthood, India late C19 to 1940s NB: 5 out of 6 15yr olds died before reaching 65 Mortality risks were NOT concentrated in childhood. Survival trends in childhood, India since late C19:  Survival trends in childhood, India since late C19 Survival trends in adulthood, India since late C19:  Survival trends in adulthood, India since late C19 Why was pre-transition mortality so much more severe in eg India?:  Why was pre-transition mortality so much more severe in eg India? Except in what are necessarily periods of transition, the death rate approximates the birth rate. This allows 2 main possibilities in pre-modern societies very high mortality in balance with very high fertility 'sub-maximal' mortality in balance with ‘sub-maximal’ fertility Why was pre-transition mortality so much more severe in eg India?:  Why was pre-transition mortality so much more severe in eg India? In Europe north and west of a line joining St Petersburg and Trieste the 'European marriage pattern' moderated fertility and thereby allowed moderated mortality Fertility levels in (some) poor agrarian societies:  Fertility levels in (some) poor agrarian societies The combination of universal early marriage and a sedentary / agrarian mode of life was associated with subtantially higher fertility than observed in Undisrupted hunter-gatherer societies Free-living great apes Demographers refer to it as ‘natural fertility’ but this is clearly a misnomer … in Chinese extended households (effective) fertility was also controlled :  … in Chinese extended households (effective) fertility was also controlled …partly by (mainly female) infanticide Infant weight and survival, India, 1970s:  Infant weight and survival, India, 1970s Relative risk of dying in the next 6 months by % of the Harvard weight for age norm:  Relative risk of dying in the next 6 months by % of the Harvard weight for age norm Indian infants aged 1 to 36 months Field studies of poor agrarian populations with high burdens of infection:  Field studies of poor agrarian populations with high burdens of infection Slide74:  1978 Slide78:  3 boys born Feb 64 at 10 years of age Similar height to 7 year olds in US Conclusion of Narangwal Study, Punjab, India, 1968-72:  Conclusion of Narangwal Study, Punjab, India, 1968-72 ' If [the infection-malnutrition-infection] sequence moves rapidly, the child dies - although neither malnutrition nor infections by themselves would have caused death.' Ie. Net nutritional status is a critical determinant of survival, but:  Ie. Net nutritional status is a critical determinant of survival, but It depends not only on Food consumed But also on Burden of infection … and this is subject to social (institutional) influences Eg literacy of the mother cleanliness Four survival patterns and transitions between them:  Four survival patterns and transitions between them The first health transition Evidence on survival (and fertility) in hunter-gatherers:  Evidence on survival (and fertility) in hunter-gatherers Best for: Ache of Paraguay !Kung (or San) of the Kalahari Slide87:  e0 similar to early modern N-W Europe Fertility moderate 4-5 year birth spacing TFR 4-5 This contrast throws light on sources of NCDs under the material conditions of late modernity:  This contrast throws light on sources of NCDs under the material conditions of late modernity The first health transition Greater command over commodities is not uniformly favourable to health:  Greater command over commodities is not uniformly favourable to health Tobacco Alcohol Saturated fat Sugar Salt Reduced need to expend energy (Deferred (and reduced) childbearing) These actual or potential harms from affluence also need to be contained:  These actual or potential harms from affluence also need to be contained Does one cog drive the others?:  Health Medical Non-medical Institutions Knowledge Commodities Does one cog drive the others?

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