Upstream to the Headwaters

Working collaboratively to promote community health

Presentation to Hood River BusyTown group & guests August 20, 2013

Adapted from a presentation given at the 23rd Annual Kinsman Bioethics Conference,

April 2013 in Ashland, Oregon

Tina Castañares, MD

Assumptions about guiding principles;all of us in the room…

• …are motivated to help people to be as healthy as they can be.

• …are agents of change (citizens, voters, members of society, leaders, members of organizations).

• …believe that scientific knowledge is important in promoting health and behaving ethically.

Assumptions about guiding principles;all of us in the room…

• …know that the US healthcare system spends more per capita than in any other place in the world, but we have very poor health status to show for it.

• …know that our investments in public health are far lower than in most other nations.

Assumptions about guiding principles;all of us in the room…

• …know that we operate in silos – health care, public health, education, early learning, corrections, public safety, etc. – that don’t collaborate or plan together like we should.

Assumptions about guiding principles:all of us in the room….

• …believe that we must attain health equity:

“valuing everyone equally and making focused and ongoing societal efforts

to address avoidable inequalities, historical and contemporary injustices,

and the elimination of health and healthcare disparities.”

Assumptions about guiding principles:all of us in the room….

…know that

All policy is

health policy.

Data from NHANES, CDC 2009

Trends in Diabetes in USA

We know we’re in trouble. Just 2 examples…..

% Oregon Population Defined as Obese(BMI > 30)

1989 1996 2003 20070

10

20

30

Year Measured

% o

f P

op

ula

tio

n

As shared at 2010 state Health Care Ethics Conference:

Moving Upstream of the Rapids

Moving Upstream of the Rapids

CT image of coronary artery disease

“The best hospital bed is empty.

The best CT scan is the one we don’t need. The best doctor’s visit

is the one we don’t need.”

In the wise words of Dr. Don Berwick…

Health planning that goes “upstream”: we’re not talking about….

� …health care access…� …or safety net clinics…� …or personal health care services…� …or the health care delivery system…� …or insurance coverage.

Rather, what we need to focus on is:

� Population-based health promotion & protection� Focused on upstream determinants of health – biological and social� Dedicated to primary prevention & containment� Public health work, which is historically more than twice as responsible for health improvement than medical, nursing, oral health and mental health care (services) combined

Examples of traditional “upstream” public health work

� immunization, hygiene, community water f luoridation

� prevention of infectious i l lness, epidemics, dental caries� creating and protecting standards for

food, water, air, housing and workplaces, other types of safety� promoting healthy “built environments” and proper nutrit ion and activity

Overall, “upstream” public health work:

� Promotes wellness, prevents disease and improves health status

� Avoids “blame games” about individual responsibil i ty for health

� Reduces demand for health care (overall spending, workforce, infrastructure)

� Raises all boats at once: truly equitable because population- and

community- wide

The poor and minorities experience serious health disparities

….because of risk factors such as:

� barriers to physical activity in schools, workplaces, neighborhoods� food subsidies making fast and processed

foods cheaper� environmental contaminants� targeted tobacco & alcohol advertising� lack of access to fresh foods� crowding and substandard housing� many other well-documented social factors

Achieving social equity

• …is the only real answer to preventable health disparities.

• …is a goal we have an ethical responsibility to work toward

… as community members, voters, leaders, taxpayers, and part of the human commons.

So now let’s go much more upstream of the rapids….

TO THEHEADWATERS

ACES

Adverse Childhood Experiences Study

DOHaD research

Developmental Origins of Health and Disease

Early childhood, neonatal, fetal, embryonic…. transgenerational !

“The Adverse Childhood Experiences

Study -- The Largest Public Health Study You Never Heard Of”

Huffington Post October 2012 3 parts

So now, more upstream sti l l….

The Developmental Origins of Health and Disease (DOHaD)

www.dohadsoc.orgwww.dohadsoc.org

Low Birth Weight (LBW)

• US babies more likely to be LBW than in almost every other developed country.2

• LBW = 2nd leading cause of infant mortality in the US after birth defects.

• Surviving infants: at elevated risk for debilitating medical conditions and learning disorders.3

•LBW (8.1%);VLBW (1.5%) > Healthy People 2010 targets (LBW 5%, VLBW 0.9%)

•1995-2004: significant ↑ in LBW among white, American Indian/Alaska Native, and Asian/Pacific Islander mothers.

•2002-2004: LBW infants born to African American mothers at nearly twice the rate as among white or Hispanic mothers (10.7 vs. 5.9 & 5.3 %, resp.)

Oregon’s Birth Weights

5 6 7 8 9 10

Birthweight at Term Delivery (lb)

Relative Risk of Death from Heart DiseasePredicted from a Person’s Birth Weight

Dea

th R

isk

1

2

3

David JP Baker, MD, PhD

“Developmental Origins of Disease” or just “programming”

QuickStats: Percentage of Children Aged 6--17 Years with Learning Disabil i ty (LD) and Attention Deficit Hyperactivity Disorder (ADHD), by Birthweight * --- National Health Interview Survey, United States, 2004—2006; MMWR August 29, 2008 / 57(34);947

How can this be? Epigenetics is the key.

• Our GENES themselves aren’t all that different.

• People with identical genes turn out differently, get different diseases, etc.

• “Behavioral genetics” has long sought explanations.

• Epigenetics brings biological evidence.

What does epigenetics tel l us?

• Gene REGULATION and EXPRESSION are mostly in charge. “How our genes work.”

• Gene regulation is subject to many influences.

• “Social” influences : not so very separate from “biological” influences

• Amazing: some gene regulation and expression are heritable….trans-generational.

3 key epigenetic factors in the developmental origins of disease and

disabil i ty in later l i fe :

• Maternal and placental nutrition

• Maternal, embryonic, fetal and early childhood chronic stress – physiologically reflected by sustained elevated levels of stress hormones (serum cortisol)

• Maternal, embryonic, fetal and early childhood exposures to toxins

Poor nutrit ion or sustained stress hormones:

The developing embryo/fetus biochemically responds by

-- making sub-standard vital organs (mostly smaller ones)

-- favoring a bigger placenta, and a lower birthweight

Risk of chronic disease is predicted epigenetically, right from grandmother’s

preconception health, through grandchild’s

early life.

So EARLY prevention and corrections are

imperative.

Epigenetic risk factors are preventable and even reversible.

• The earlier, the better• First 1000 days post-conception • Pre-conception too

Interventions must improve maternal & newborn nutritional status, and prevent or reverse sustained stress hormone levels.

Do ACES and DOHaD fit together?

• Elevated serum cortisol levels in development change our stress responses later in life.

• Aggression? Other ACE-related behaviors?

This is good news, not bad news… and not “biological determinism”

• new scientific evidence to guide social policy, strategies, and investments ! And to guide community collaborations.

• hope for better health for our society – a reversal of the last 100 years of downward health trends!

An obsolete debate

We’ve gone way upstream

Montana: aerial view of the headwaters of the Missouri

River

What can hospitals and health care professionals do?

� Get outside the health care box� Be educated about DOHaD and ACES � Advocate for equity� Join with new partners and across sectors� Deploy new kinds of community needs

assessment� Develop new strategies for community

benefit spending

Why should we all work on this together?

The future of human health is at stake.

“Peace, order and good government”

“Life, liberty, and the pursuit of happiness”

Imagine that we live in a region….

…which is the best place in the world for every baby to be born

…which is the best place in the world for every child to grow up

“Epigenetics is one of the most scientif ical ly important, and legally

and ethically signif icant, cutt ing-

edge subjects of scientif ic discovery.”

“The Ghost in Our Genes: Legal and Ethical Implications of Epigenetics,” Rothstein et al, Health Matrix: Journal of Law and Medicine, Case Western Reserve,

http://www.law.yale.edu

Bringing it home to BusyTown

• What’s Going On • CCO, BusyTown• Other health-related collaborations &

integration (notably including CHWs)• Early Learning Hubs succeeding

Commissions on Children and Families• Social services -- involved with all of these

and more• Education at all levels – involved with all of

these and more. Government, business too.

Bringing it home to BusyTown

• What’s Going On

• Explicit attention to “The Five Sectors”• Social and human services• Business• Health• K-12 (education)• Early learning

Some of our ideals

• Living wage jobs, less income equality, no poverty

• No food insecurity, no hunger, great food system

• Affordable options for lifelong education• Affordable, good housing and health care for all• Environmental safety and justice for all• Social and financial supports for families• Great opportunities for all for high quality of life• Investments to improve other upstream

determinants

Some of our most attainable and pressing ideals

• Stronger investments in public health • Stronger investments in pre-conception,

pregnancy and early childhood• Every child a wanted child, every parent wanting

the child• Every community member (who wants it), esp.

parents, young children, and others at greatest risk, having a skilled person who cares about them – home visitor, care coordinator, CHW, health promoter – for advocacy, support, education, cultural bridging, health literacy assistance, navigation, empowerment

Child & adolescent health & well-being Adult

health & well-being

Infant & early

childhood health &

well-being

Pregnant woman

and embryo/

fetal health &

well-being

Pre-conception

& family health &

well-being

Community well-being;

social circum-stances;

“root causes”

Path to healthy communities & people

Child & adolescent health & well-being Adult

health & well-being

Infant & early

childhood health &

well-being

Pregnant woman

and embryo/

fetal health &

well-being

Pre-conception

& family health &

well-being

Community well-being;

social circum-stances;

“root causes”

Best places for CCO, ELH, all sectors to invest and collaborate right now

Infant & early

childhood health &

well-being

Pregnant woman

and embryo/

fetal health &

well-being

Pre-conception

& family health &

well-being

Best places for CCO, ELH, all sectors to invest and collaborate right now to promote healthy communities in the coming

generations (scientifically supported)

We should invest the most where it is needed the most … and wil l do the most

good.

• sometimes: demonstrable rapid return on investment

• sometimes: ROI will take a generation or more to demonstrate.

• not a leap of faith• rather, a logical application of

sound scientific findings

We should invest the most where it is needed the most … and wil l do the most

good.

• A young man has an ACES score of 7. He has known risky behaviors and an “anger management problem.”

• His wife is malnourished with an ACES score of 6.

We should invest the most where it is needed the most … and wil l do the most

good.Our mission, should we choose to accept it, is to work together so that they have a child together only if and when ready, and that child has a good birthweight , an ACES score of 0, and equitable opportunit ies for well-being.

The basic strategies should emanate from science and ethics….

…and some key tactics are close at hand if we invest in them:

•CCO•ELH•Public Health•Integrated health care and a focus on prevention•Cross-sector collaboration•the Collective Impact model•Community Health Workers/ health promoters

Thank you

I welcome your feedback.

tina.castanares@gorge.net