Key Determinants

When analyzing a public health problem, it is important to consider the key determinants that cause the issue. In the case of my final paper, which examines racial disparities in infant mortality rates, it is especially important to consider the wide array of factors that could cause infant mortality to occur so much more frequently in the black population than in the white. In this blog, I will discuss many of the factors that may contribute to this disparity. Since this blog is mostly a thinking exercise, meant to provide many possible intervention points, I will not fully describe to what extent each factor contributes to the problem. This will be done in my final paper. Key determinants can be divided into many categories. I will describe the determinants of racial infant mortality disparities in terms of these categories.

Biological Determinants: Genetics, body type, age

Developmental Determinants: conditions of both mother and child's development, was mother educated about safe sex practices? did mother's first sexual contact occur at a young age? did child progress to developmental goals in a timely manner (both in utero and after birth)?

Environmental Determinants: pollution, exposures in urban areas vs. suburban vs. rural, access to affordable health care, distance from closest health care center

Social and Cultural Determinants: cultural beliefs about where children should sleep, cultural customs regarding the necessity of childcare, age of first child, education

Economic Determinants: Socioeconomic status, hospital conditions, affordability of health care, affordability of cribs, proper nutrition, and vitamins

Political Determinants: availability of services, resources allocated to prevent disparities

Behavioral Determinants: Crib use, pre-natal doctor's visits, pre-natal vitamin use, child's sleep customs, healthy eating habits

All of these determinants are a very good point from which to design the intervention I will be discussing in my paper. Now its time for me to get back to my paper! It's due next week.

How bad is it?

This week, we were asked to further analyze the problem that is the focus of our final papers. This week's theme is "magnitude and indicators." In order to effectively tackle a public health problem, it is necessary to understand the magnitude of the problem. You need to know how many people are affects, to what degree, and what the costs of the problem are. Also, in order to track the problem (before, during and after intervention) you need to identify which variables serve as indicators. These indicator variables show whether the situation is improving, worsening, or staying the same.


Surveillance is used to keep track of indicators and determine the magnitude of the problem. In this case, hospital surveillance can be used to track the total # of live births and the # of infant deaths. Since the problem I am focusing on is a health disparity, the data collection would also have to include race and/or ethnicity.

I have collected some data that outlines the magnitude of this problem.
According to the Annie E. Casey Foundation: African-American infants in Baltimore City are 2.8 times more likely to die than white infants from 2006-2008.
According to the Maryland Babies Born Health Initiative: The percent of women receiving prenatal care in the first trimester of pregnancy has been dropping since 2000, reaching a low of 79.5% in 2007. Among white women in the state, 82% received early prenatal care, compared with 73.5% of Black women and only 63% of Hispanic women.
Also According to the Maryland Babies Born Health Initiative: African-American infants are at greater risk of poor infant health, with a disparity of nearly to 2:1 in prematurity rates, and over 2:1 in infant death rates. Between 2006 and 2007 the disparity in infant deaths increased to 3:1.
According to the Baltimore City Health Department: Short gestation and low birth weight are most responsible for the elevated infant mortality rate in Baltimore.
Also according to the Baltimore City Health Department: The infant mortality rate in Baltimore City is 11.3 deaths per 1000 live births. This is much higher than the US and Maryland averages. Much of this rate is driven by an even higher rate among African Americans.

In my paper, I will need to focus both on direct and indirect indicators. For example, low birth weight is a direct indicator of a high risk for infant mortality. Lack of prenatal care also contributes directly to a higher risk of infant mortality. On the other hand, SES may make a person less likely to receive prenatal care or have prenatal vitamins or sufficient food. Therefore, SES is an indirect indicator of infant mortality rate.

In order to write a strong research paper, it is important to evaluate the strength of your sources and consider any biases they may have. The Annie E. Casey foundation is a charity that seeks to improve health conditions for kids. In order to receive more funding it is in their best interest to use the rates that make the problem seem the most severe. The Maryland Babies Born Health Initiative probably uses fairly accurate numbers because they need to both give an accurate picture of the extent of the problem and continue to collect data that shows that their initiative is succeeding. The Baltimore City Health Department would probably like to minimize the problem in order to make it look like their department is doing a good job.

That's it for this week. Check back next week for more about infant mortality.

Defining the Problem

This week we were asked to develop a problem definition for our final paper. A good public health problem definition targets a population and is very specific. It is important to create a good problem definition in order to have a solid starting point from which to develop the rest of the paper.

My problem definition: From 2006-2008 African-American infants were 2.8 times more likely to die than white infants in Baltimore City.
Information from Annie E. Casey Kids Count Data Center http://datacenter.kidscount.org/data/bystate/Rankings.aspx?state=MD&ind=4514

I chose this topic because, in my opinion, health disparities are one of the largest problems with the current American health care system. Infant mortality rate has traditionally been considered a reliable indicator of overall population health. Therefore, if the African-American community experiences significantly worse infant mortality, this is a good predictor that the overall community experiences poor health.

I chose to focus on Baltimore because the city has historically tense race-relations which have resulted in large differences in living conditions between black and white Baltimoreans. These differences have resulted in particularly drastic health disparities. Also, in my volunteer experiences I have seen firsthand the campaigns to improve infant mortality rates and am surprised they have not had more success. I would like to analyze the true cause of this problem and brainstorm possible effective solutions.

I chose to focus on the years 2006-2008 because I wanted to focus on a problem that was still relevant but also wanted to ensure that enough data would be available. By focusing on the years 2006-2008, I can address a problem which is still a significant issue in Baltimore while using reliable information.

Beginning of the end...

This week, we were asked to start thinking about our final paper. The assignment is to choose a public health issue and write a term paper which assesses the problem and designs an intervention. I will be writing about infant mortality rates among the urban African-American population in Baltimore. In Maryland, the total infant mortality rate is about 7.4 deaths per 1000 live births. However, the infant mortality rate for African Americans is almost twice that (13.1 deaths per 1000 live births). Within Baltimore City, the disparity is even more severe. African American infants are almost three times as likely to die as white infants.

One of the goals of public health is to diminish health disparities. It is unjust that within Baltimore City, the African American community faces an infant mortality rate similar to many developing nations. Infant mortality rates are a very important indicator of overall health and if the health system is failing to provide adequate pre and post natal services, the health of the entire community suffers. There are many programs within Baltimore that seek to address this problem but so far there has not been much significant improvement. I think that this will be an interesting topic to examine deeper due to the complex factors that cause the disparity. It is also socially relevant since, as our country begins to implement health reform and works to improve overall population health, it will become extremely important to improve the health of underserved population groups. Until these disparities are addressed, it will be impossible for the overall health of the population to improve significantly.

Yesterday...

It's hard to believe that spring semester is already halfway done! Since most of the lectures in the class are over, this is a good time to look back on the semester and consider what has changed since I wrote my first blog. This semester's lecture topics have covered a huge area of information. It is extremely impressive to consider how far public health reaches. From chronic and infectious disease, to injury prevention, to statistics, and even to matters of national security like bioterrorism prevention, public health professionals work every day to promote the health of the population.

One of the lectures I found most interesting was the one that focused on injury prevention. It was really amazing to see the impact of increased speed (even of just 10 more miles per hour) has on injury. Also, I had previously kind of considered injuries to be accidents and had not thought of all the resources that can be used to prevent them. When the lecturer described the Haddon Matrix, I was blown away by all of the variables that can be assessed when considering what factors cause an injury. The focus on texting while driving was also very interesting and made the lecture seem more compelling since this is an issue which is currently up for debate in many state legislatures.

Some of the course material was very surprising. Specifically, I found the surveillance responsibility aspect of public health shocking. It is amazing the number of things public health professionals track very closely. To think that even purchases of over-the-counter drugs are tracked in order to identify trends and possible outbreaks is an awe inspiring glimpse into the amount of data that must be collected, organized, and analyzed. The bioterrorism lecture was also surprising to me. I had not previously considered the role of public health in national safety. However, when you think about it, one of the most effective ways to cripple a country would be to cause widespread health issues.

One of the main reasons I took this course was because I will be attending medical school in the fall and think that public health knowledge will help me be a more well rounded physician. I am still confident that this is true. Without a working knowledge of the US health system and the ongoing reform movement, it would be very difficult to navigate the field. Also, the information we have learned about vulnerable populations and health disparities will help me to better serve my patient population.

At the start of the course, I was most interested in the health reform movement and issues of global maternal and child health. Now, after the signing of the health reform bill, I am more interested in evaluating the strengths and weaknesses of the changes than in researching other reform possibilities. However, I remain deeply interested in global maternal and child health. The information given in the lecture about international health supported this interest and detailed many of the factors that contribute to inflated maternal mortality and other poor health outcomes among women and children in the developing world. I especially found it interesting that education and contraceptive availability were so highly correlated with improving health.

That's all for this week, I'm ready to get back to enjoying the beautiful spring weather!

Yes We Can Reform Healthcare

This Sunday the US Congress passed a groundbreaking health reform bill. The reform bill seeks to extend health insurance coverage and control medical costs. Firstly, the bill includes an expansion of Medicaid and SCHIP. This means that more severly impoverished families will receive goverment health insurance. The bill also hopes to improve options for people looking to purchase health insurance individually. The bill established a cooperative where consumers can go to purchase health insurance. This is especially important for people that are unemployed, self-employed or do not work full-time. Also, health insurance companies will no longer be able to deny anyone insurance because of a pre-existing condition or high-risk situation. In order to create an insurance group that reflects the population (both high and low risk), the bill also requires that everyone purchase insurance. Those who choose not to follow this mandate will pay extra taxes. In order to help people afford insurance plans the government plans to subsidize insurance payments for low-income families and individuals. There will also be employer "pay or play" provisions which means that an insurer will either have to provide insurance for its employees or pay into a government pool. In addition, there will be tax increases for high income (above $250,000 per year) individuals.

The bill was passed with no republican support. The republican party takes issue with this reform both because it generally opposes big government and because opposition is a good way to undermine President Obama's efforts as a reformer. Although some democrats felt that this bill was not radical enough, most supported the effort to reduce the number of uninsured people and the efficacy of our health care system. Although many insurance companies do not like the government interfering in their business and not allowing them to refuse consumers with pre-exisiting conditions, the mandate to buy health insurance does greatly increase their consumer population. Health care providers are an important stakeholder group that has a somewhat complex view of this bill. On one hand, expanding insurance coverage helps doctors be able to provide quality care. However, there is some discomfort with government setting limits on how they care for their patients (i.e. prescriptions, expensive diagnostic tests). The US population can be broken down into many small interest groups. However, generally uninsured people should welcome a solution to their problem. Most Americans should recognize the overall good this will bring the country. Also, there will be some opposition from people who are already well-insured and those in high-income groups.

Overall, I think this is a very important bill. The healthcare system in this country has been struggling and changes were definitely necessary. This reform may help to lower the huge number of uninsured people in this country and to increase the quality of health outcomes for every dollar spent. Personally, I would have liked to see some more radical reforms (i.e. the inclusion of a public option or a larger emphasis on reducing administrative costs). However, I recognize that these would have been politically unpallatable and therefore were not an option this time. I think that this bill is definitely a step in the right direction. Hopefully the bill will lead to health improvements and the public will form a more positive opinion of government involvement in healthcare. The provision in this bill that allows children to stay on their parents insurance until 26 will most likely effect me. Also, the fines for those who choose not to buy insurance would definitely persuade me to stay insured through my 20s.

Dollars and Sense: The US Healthcare Debate

Okay, it's time for another blog. This week, we read an article outlining the impact of the recession on health economics. As we've learned in the course, health spending in the US makes up an enormous percentage of GDP. According to this article, that number will only continue to increase. An interesting point made in the article was that although overall spending may be decreasing, health care spending most likely will slow, but not decrease. Health care spending is usually effected by recessions over the long term (i.e. people will save less and thus spend less on health care in the next few years). Another interesting point is that as a result of the recession, more people are shifting from out-of-pocket payment plans to Medicaid. The government needs to plan to accomodate this extra cost.

This increase in health spending in the public sector has serious consequences. If health care spending continues to occupy more and more of the GDP, the nation is in essence spending all of its money on a service good, something that is not exportable or particularly profitable. And, as the proportion of the health spending that is done by the public sector increases, the US government (already in serious debt) continues to spend more and more money it does not have on an inefficient system. If the government is going to spend so much on health care, it makes sense to shift to a single payer system. At least that would eliminate the enormous administrative costs associated with the current system. As the government continues to shoulder more of the cost burden of the health care system, it seems they should be given the opportunity to have some administrative power in a system that is costing them so much.

Within the health care debate, there are many key issues. In many ways, the debate is rooted in the US value system. Our society values instant gratification and people feel they deserve immediate access to the best and newest technologies. The decision to shift to a government-run system would require an ideological shift. Another key issue is centered around reimbursement rates for physicians. In this country many medical students incur large debts to obtain a degree. It is important that these professionals are compensated appropriately for their efforts and advanced knowledge.

Although there are many more issues involved in the health care debate, if I had the ability to change one thing, it would be eliminating the uninsured portion of the American population. Sixteen percent of Americans are uninsured (more than 46 million people). This is not only a social injustice (in my opinion health care should be a human right) but it also has serious economic consequences. These people are highly unlikely to access primary care and thus receive little preventative care. Therefore, when they become ill, it is usually fairly serious, and many times could have been completely avoided. Then, when they finally seek help, it is usually in an emergency room. Visits to the emergency room cost the system many times more than visits to general practitioners. Finally, since these people often cannot pay the costs incurred during their visit, these costs are shifted to insured patients. It is through this system that the health care system accrues enormous extra costs.

That's all for this week. I will be back with more intro to public health blogs after Spring Break.