Dayna Long, MD San Francisco Asthma Network Forum 10/10/14

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Dayna Long, MDSan Francisco Asthma Network Forum10/10/14

Social Determinants of Health and Asthma

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Objectives

• 1. To define Social Determinants of Health and the relationship to health inequities

• 2. To understand Adversity and Toxic Stress

• 3. To discuss new research projects

• 4. How care health providers screen and offer anticipatory guidance

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Where children live, eat, sleep, play, pray and go to

school profoundly impacts their health

Social Determinants of Health

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Social Determinants of HealthAccording to WHO:

•“The circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”

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Health and Wealth

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Social Determinants of HealthAcross America, Differences in How Long, and How Well We Live

RWJF Commission to Build a Healthier America 2008

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Just a few miles = Over a decade difference in LE

Alameda County Public Health Department, 2013

Photo Source: The California Endowment, Health Happens Here

Compared to a White child born in the affluent Oakland Hills…

…an African American child born in West Oakland can expect to live 14 fewer years.

OOAKLAND HILLSLIFE EXPECTANCY 85

OWEST OAKLANDLIFE EXPECTANCY 71

Source: Alameda County Vital Statistics files, 2010-2012

Compared to a White child in the affluent Oakland Hills, an African American child born in West Oakland is…

2 times more likely to be born low birth weight

12 times less likely to have a mother who graduated from college

13 times more likely to live in poverty

4 times less likely to read at grade level

5 times more likelyto be unemployed

3 times more likely to die of stroke

INFANTINFANT CHILDCHILD ADULTADULT

Cumulative impact:14 year difference in life expectancy

Source: Alameda County Death files, 2010-2012; Alameda County Birth files, 2009-2011; American Community Survey, 2007-2011; California Dept of Education, 2012-2013

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Source: Alameda County OSHPD files, 2009-2011

Neighborhood Poverty Level

*ED rates and neighborhood poverty are at the zip code level

Diabetes

Asthma

Obesity

Assault

0

1,000

2,000

3,000

4,000

5,000

Rates of Visits to the Emergency Department for Select Conditions by Neighborhood Poverty Level*

<10% 10%-20% 20%+

Rat

e pe

r 10

0,00

0

(High Poverty)

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Adverse Childhood Experiences (ACES)

3 types• Abuse: phyical, emotional,

sexual

• Neglect: physical and emotional

• Household Dysfunction: mental illness (depression), domestic violence, divorce, drug use, prison

Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune disease External Web Site Icon. Psychom Med 2009;71, 243–250.

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ACES >4

• 12.2 times as likely to attempt suicide

• 10.3 times as likely to use drugs

• 7.4 times as likely to be alcoholic

• 2.4 times as likely to have heart disease

• 1.9 times as likely to have cancer

• 1.6 times as likley to have diabetes

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What is Stress? • Positive stress response

• Tolerable stress response 

• Toxic stress response 

Jack Shonkoff. Harvard University Center on the Developing Child

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Toxic Stress really gets under your Skin.

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EpiGenetics

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Hypothalamic-Pituitary Adrenal Axis

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INFLAMMATIONINFLAMMATION

Asthma

BronchialHyperresponsiveness

Airflow Obstruction

Risk Factors(for exacerbations)

Symptoms

Genetic Environmental

Inflammation

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Inflammation in Asthma

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Airway Inflammation

Allergen/Trigger

T-cell

B-cell

IgEEosinophil

Mast cell

CytokinesHistamineMacrophage

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Inflammation

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Aftermath of Inflammation• Reversibility • Remodeling

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In Alameda County

What % of kids in Alameda County have a diagnosis of asthma?

• A. 15%

• B. 25%

• C. 35%

• D. 45%

Over THREE TIMES the

national average!!

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Who gets Asthma?

Blacks experience

more urgent care visits than Caucasians

higher asthma attack prevalence rate (19.2%) than Caucasians

higher rates of hospitalizations, 2.5 times greater than in Caucasians (Akinbami 2006).

165 % higher death rates than Caucasians (Akinbami2006).

Blacks of the same socioeconomic status and access to care still experience higher asthma morbidity (Gold)

Blacks of the same socioeconomic status and access to care still experience higher asthma morbidity (Gold)

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Inflammation

Less Reversibility and Response to Bronchodilators In most asthmatics, 12%

reserversibility in FEV1 after treatment with albuterol

In AA, less than 5-8% response.

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BARDBest African American Response to

Asthma Drugs

The NHLBI’s AsthmaNet

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In Blacks with asthma >5 yrs, who are poorly controlled on low dose ICS, what is the preferred step-up therapy?

and

Does the degree of African ancestry affect preference for different therapies?

BARD Major Research Questions

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GISAncillary Geographic

Information System Protocol to Assess Environmental Effects on Drug Response for AsthmaNet

Studies

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GIS Objectives

• To examine whether pre-existing chronic social and environmental exposures impact asthma treatment response

• Look at air pollution, crime statistics, SE conditions and look at spatial correlations between exposures and asthma outcomes.

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• We see how early childhood experiences and stress are so important to lifelong outcomes and how the early social and environmental conditions literally becomes embedded in the brain, changes biologic function and then affect future generations.

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So What Do We Do About This?

Training/Education

Technology

Policy/Advocacy

Community Engagement

Research/Evaluation

Clinical Best Practices

Sc

reen

ing

Preve

ntio

n In

terv

entio

n/

Trea

tmen

t

Improved Health

Outcomes

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Social Determinants of Health Approach to Medicine

• 1. Improve population health

• 2. Decrease Health Care Costs

• 3. Improve health care efficiency

SFGate11.26.13

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Thank You