Wider determinants of health: 1' Commodities and health

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Wider determinants of health1. Commodities and
health

• MSt in Public Health, 2005 cohort
• John Powles

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Wider determinants of health
Disease injury
Loss of health
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Wider determinants of health
Proximal determinants

• Eg
• Infection
• metabolic disturbance
• Energy transfer

Disease injury
Loss of health
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Wider determinants of health
Intermediatedeterminants
Proximal determinants

• Eg
• Exposure to infection
• Diet
• Careless driving

• Eg
• Infection
• metabolic disturbance
• Energy transfer

Disease injury
Loss of health
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Wider determinants of health
Widerdeterminants
Intermediatedeterminants
??? (no agreed conceptual-isation)
Proximal determinants

• Eg
• Exposure to infection
• Diet
• Careless driving

• Eg
• Infection
• metabolic disturbance
• Energy transfer

Disease injury
Loss of health
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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

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The wider determinants of health transitions
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The idea of health transition

• Demographic transition
• Epidemiologic transition
• Health transition

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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

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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

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How should the wider determinants of health
transitions to be conceptualised?

• Proposed classification
• Commodities (material life)
• Institutions (social life)
• Knowledge (intellectual life)

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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

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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

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Does one cog drive the others?
Non-medical
Medical
Commodities
Institutions
Health
Knowledge
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Part 1 Commodities and health transitions

• The strong materialist interpretation
• Thomas McKeown
• Robert Fogel

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Fogel Escape from hunger
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Four survival patterns and transitions between
them
The health transition in the Third World
The firsthealth transition
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Four survival patterns and transitions between
them
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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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)

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Life expectancy in England since the C17
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Sweden life expectancy since the mid C18
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Changing survival chances England C17 to late
C18 - childhood
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Changing survival chances England C17 to late
C18 - adulthood
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Changing survival chances England since the late
C18
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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.
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• 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)

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Life expectancy in England since the C17
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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

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• 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

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We are much taller than our ancestors
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and very much heavier

• 50kg -gt 75kg for males

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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)

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Waaler surface Relationship between height,
weight and risk of death based on follow-up of
309000 Norwegian males
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Waaler surface Relationship between height,
weight and risk of death based on follow-up of
309000 Norwegian males
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Waaler surface Relationship between height,
weight and risk of death based on follow-up of
309000 Norwegian males
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• 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

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Four survival patterns and transitions between
them
The health transition in the Third World
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The health transition in the Third World

• Sources for early phase
• India censuses from 1881
• Japan/China household registers from later C18

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Picture of India
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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

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India the demographic transition since late C19
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India the demographic transition since late C19,
with projections to 2050
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Life expectancy in India since the 1880s
estimates are for decades and do not show short
term deviations
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Episodes of catastrophic mortality in India since
the C18
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Life expectancy in India since the 1880s
1940s
estimates to the 1950s are for decades and do
not show short term deviations
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History of mortality decline in India

• C19 to WWII
• Immediate post WWII

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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

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Survival trends in childhood, India late C19 to
1940s
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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.
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Survival trends in childhood, India since late C19
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Survival trends in adulthood, India since late C19
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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

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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

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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

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in Chinese extended households (effective)
fertility was also controlled

• partly by (mainly female) infanticide

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Infant weight and survival, India, 1970s
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Relative risk of dying in the next 6 months by
of the Harvard weight for age norm
Indian infants aged 1 to 36 months
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Field studies of poor agrarian populations with
high burdens of infection
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1978
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• 3 boys born Feb 64 at 10 years of age
• Similar height to 7 year olds in US

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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.'

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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

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Four survival patterns and transitions between
them
The firsthealth transition
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Evidence on survival (and fertility) in
hunter-gatherers

• Best for
• Ache of Paraguay
• !Kung (or San) of the Kalahari

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• e0 similar to early modern N-W Europe
• Fertility moderate
• 4-5 year birth spacing
• TFR 4-5

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This contrast throws light on sources of NCDs
under the material conditions of late modernity
The firsthealth transition
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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)

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These actual or potential harms from affluence
also need to be contained
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Does one cog drive the others?
Non-medical
Medical
Commodities
Institutions
Health
Knowledge