# Presentation: 314954

## Population Health: Challenges for Science and Society

- David Mechanic, Ph.D.
- Institute for Health, Health Care Policy
- and Aging Research
- Rutgers, the State University of New Jersey

**1****st**** Matilda White Riley Annual Lecture**
**in the Behavioral and Social Sciences**
- National Institutes of Health
- Bethesda, MD
- May 22, 2006

## Exhibit 1

- Presentation Outline

-    The importance of social selection –
-      role of selection in shaping health outcomes
-    Early influences on later disease
-    Broad social factors affecting population health
-      and social disparities
-    Intervention strategies

## Exhibit 2

- Respondents’ Reports of WWII and Vietnam
- as Especially Important (By Age Group)

- (107)

- (182)

- (143)

- (171)

- (109)

- (91)

- (90)

- (77)

- (91)

- (76)

- (62)

- (49)

- Source:  Schumann and Scott, _American Sociological Review_, 54(3), June 1989

- %

## Exhibit 3

- Birth Weight and Coronary Heart Disease

- 				 **Death from Coronary Heart Disease**
- _Weight (pounds (kg))_		  _Before 65 Years_               _All Ages_
-      **Birthweight**
- ≤ 5.5 (2.5) (n=486)		  	  1.50 (0.98-2.31)          1.37 (1.00-1.86)
- 5.5-6.5 (2.9) (n=1385)		  1.27 (0.89-1.83)          1.29 (1.01-1.66)
- 6.5-7.5 (2.9-3.4) (n=3162)                	  1.17 (0.84-1.63)          1.14 (0.91-1.44)
- 7.5-8.5 (3.4-3.9) (n=3308)	                  1.07 (0.77-1.49)          1.12 (0.89-1.40)
- 8.5-9.5 (3.9-4.3) (n=1564)		  0.96 (0.66-1.39)          0.97 (0.75-1.25)
- >9.5 (4.3) (n=731)         		           1.00		 1.00
*p for trend*			          0.001		0.005
-      **1 year old**
- ≤ 18 (8.2) (n=715)                           	 2.22 (1.33-3.73)         1.89 (1.34-2.66)
- 18-20 (8.2-9.1) (n=1806)                   	 1.80 (1.11-2.93)         1.58 (1.15-2.16)
- 20-22 (9.1-10.0) (n=3404)		 1.96 (1.23-3.12)         1.66 (1.23-2.25)
- 22-24 (10.0-10.9) (n=2824)                	 1.52 (0.95-2.45)         1.36 (1.00-1.85)
- 24-26 (10.9-11.8) (n=1391)                	 1.36 (0.82-2.26)         1.29 (0.93-1.78)
- >26 (11.8) (n=496)                                             1.00                             1.00
*p for trend*			         <0.001                         <0.001

- Source:  Barker, _Philosophical Translations of the Royal Society of London_, 359(1449), September 29, 2004

- Hazard ratios (95% confidence intervals) for death from coronary heart disease according to birthweight and weight at 1 year in 10636 men born in Hertfordshire between 1911 and 1930, inclusive.

## Exhibit 4

- Growth Patterns and Coronary Heart Disease

- Mean Z scores for height, weight, and body-mass index in the first 11 years after birth among boys who had coronary heart disease as adults. The mean values for all boys are set at zero, with deviations from the mean expressed as a standard deviation (z scores).

- Adapted from Barker, et al., _New England Journal of Medicine_, 353(17): 1802-1809, 2005

## Exhibit 5

- Father’s Social Class, Educational Attainment, and Social Class
- in Adulthood are Associated with Coronary Heart Disease in Adult Men+

- 			**No of cases/****	****   Hazard ratios****	****          P value**
**	****	****	**** **_**No of men**_**	****       **_**(95% CI)**_**                    **_**for trend**_
**Infancy**
- Fathers’ social class:
-      Upper middle		   20/449		         1.00		           0.0006
-      Lower middle		   48/709	                1.44 (0.86 to 2.43)
-      Labourer		 202/2258                2.01 (1.27 to 3.18)
**Education**
- Level of Education:
-      High		  	  32/721		         1.00                           0.0001
-      Middle			111/1489	                1.87 (1.26 to 2.77)
-      Low 		                133/1373                 2.25 (1.53 to 3.30)
**Adult Life (1980)**
- Social class:
-      Higher official                       62/1247                          1.00                          <0.0001
-      Lower official                        69/888                    1.62 (1.15 to 2.28)
-      Self employed                      22/240	                 1.83 (1.12 to 2.97)
-      Labourer		132/1301                  2.15 (1.59 to 2.91)
- + Adapted from Barker et al., _British Medical Journal_,  323, no. 7324, December 1, 2001, page 1274

## Exhibit 6

- The Link-Phelan Hypothesis of
- Social Class as a Fundamental Cause

-    Risk factors change over time but the social
-      class/mortality association remains robust
-    Social class is primarily associated with
-     mortality from preventable disease
-    Social class more important than cognitive
-     capacity in explaining mortality/morbidity

## Exhibit 7

- National Longitudinal Mortality Study
- Percent Dying During 9 Year Follow-Up:
- Men and Women, 25-44

- 0.5

- 0.2

- 1

- 0.3

- 1.8

- 0.4

- 0

- 0.2

- 0.4

- 0.6

- 0.8

- 1

- 1.2

- 1.4

- 1.6

- 1.8

- 2

- High Preventability

- Low Preventability

- 16+ Years

- 12-15 Years

- <12 Years

- Source:  Phelan, Link, Diez-Roux, Kawachi and Levin, _Journal of Health and Social Behavior_, 45(3), 2004

## Exhibit 8

- National Longitudinal Mortality Study
- Percent Dying During 9 Year Follow-Up:
- Men and Women, 45-64

- 4.1

- 1.8

- 5

- 1.8

- 8.2

- 2.1

- 0

- 1

- 2

- 3

- 4

- 5

- 6

- 7

- 8

- 9

- High

- Preventability

- Low

- Preventability

- 16+ Years

- 12-15 Years

- <12 Years

- Source:  Phelan, Link, Diez-Roux, Kawachi and Levin, _Journal of Health and Social Behavior_, 45(3),  2004

## Exhibit 9

## Exhibit 10

- Motor Vehicle Fatalities
- United States, 1966-2004

- 			                      _Fatalities_
- 	1966 		        	50,894
- 	1970			52,627
- 	1975			44,525
- 	1980			51,091
- 	1985			43,825
- 	1990			44,599
- 	1995			41,817
- 	2000			41,945
- 	2004			42,636

- Adapted from Highway Traffic Safety Administration, National Center for Statistics and Analysis, _Traffic Safety Facts 2004_, Table 2 (January 2006).

## Exhibit 11

- Motor Vehicle Fatality Rates
- Per 100 Million Vehicle Miles Traveled
- United States, 1966-2004

- 			           **Fatality Rate                         VMT**
**                             **_**per 100 million VMT**_**             **_**(In Billions)**_
- 	1966 		      5.50		            926
- 	1970		      4.74		          1,110
- 	1975		      3.35		          1,328
- 	1980		      3.35		          1,527
- 	1985		      2.47		          1,775
- 	1990		      2.08		          2,144
- 	1995		      1.73		          2,423
- 	2000		      1.53		          2,747
- 	2004		      1.44		          2,963

- Adapted from Highway Traffic Safety Administration, National Center for Statistics and Analysis, _Traffic Safety Facts 2004_, Table 2 (January 2006).

## Exhibit 12

- International Comparison of Infant Mortality Rates - 2000

- 				                   **Infant Deaths/**
**	****	****                                                **_**1,000 Live Births**_
**United States – white**				5.7
**United States – total**				6.9
**Some Other Countries**
- 	Singapore				2.5
- 	Hong Kong				3.0
- 	Japan					3.2
- 	Sweden					3.4
- 	Finland					3.8
- 	Spain					3.9
- 	Czech Republic				4.1
- 	Germany					4.4
- 	France					4.6
**US Rank:     27**
- Adapted from _Health, United States, 2004_, Tables 19 and 25

## 	                            Absolute                          Absolute                                                                  	 	                Reduction                        Reduction         Percent                                                                                	            White          in Rate+         Black          in Rate+         Disparity

- Black-White Infant Mortality US, 1950-1995

- 	                            **Absolute                          Absolute                                                                  ****	**** ****	****                Reduction                        Reduction         Percent                                                                                ****	****            White          in Rate+         Black          in Rate+         Disparity**
- 1950                    26.8               ---                      43.9               ---                     64
- 1955                    23.6              3.2                     43.1                .8                     83
- 1960                    22.9                .7                     44.3           (+1.2)                    93
- 1965                    21.5              1.4                     41.7              2.6                     94
- 1970                    17.8              3.7                     32.6              9.1                     83
- 1975                    14.2              3.6                     26.2              6.4                     85
- 1983                      9.3              4.9                     19.2              7.0                   106
- 1985		 8.9                .4		   18.6                .6
- 1990                      7.3              1.6                     16.9              1.7                   132
- 1995                      6.3              1.0                     14.6              2.3                   132
- Total Absolute        20.5                                    29.3
- Reduction in
- Rate, 1950-1995

- + Per 1,000 Live Births
- Adapted from _Health, United States_

## Exhibit 14

- Black-White Infant Mortality US, 1950-1998
- Absolute Reductions in Rate per 1000 Live Births

**Absolute Reduction**
**in Rate**

**-2**

**0**

**2**

**4**

**6**

**8**

**10**

**1950**

**1955**

**1960**

**1965**

**1970**

**1975**

**1983**

**1985**

**1990**

**1995**

- White

- Black

## Slide 16