Epidemiology, Economics, Evolution, and Enlightenment by Victor J. Schoenbach

Epidemiology, Economics, Evolution, and Enlightenment Victor J. Schoenbach, http://go.unc.edu/vjs April 17, 2017

Outline Epidemiology what it is, what it has shown Economics power and resources, the basis of public health Evolution everything is evolving Enlightenment humanity could manage much better than we do

Epidemiology

What is epidemiology? Classic: Epidemiology is the science devoted to the systematic study of the natural history of disease its distribution in populations and the factors which determine distribution . . . The basic science of public health work and of preventive medicine. (Higher Education for Public Health. Report of the Milbank Memorial Fund Commissions, Cecil G. Sheps, Chairman. 1976, pg 60-61) Dictionary: The study of the distribution and determinants of health related states and events in populations, and the application of this study to control health problems (John Last, Dictionary of Epidemiology) Operational: Epidemiology is what people who fund research, edit journals, certify and hire epidemiologists, and/or write qualifying examinations decide epidemiology is.

What is John Cassels epidemiology? Epidemiology is fundamentally engaged in the broader quest for social justice and equality. (per Sherman James, 1/20/1999)

What is John Cassels epidemiology? One of my father s qualities and methods of investigation was that he cast a wide net over a problem, without preconceived notion of what he would find. He gathered all sorts of information whether it was potentially valuable or not. He dissected out the variables and discarded the ones that were the same. He took careful note of ones that were different. From there he would examine what it was about the different variable(s) that might influence the problem he was investigating. He gave my UNC nursing class commencement address and emphasized that searching for answers required critical and clear thinking without bias. Gillian Cassel Wolfe, 1/22/2014

Excerpt from John Cassel, EPID160 Fall 1972, Lecture I: (from EPID160 lecture handout) In summary then, fifty years ago community health programs were dealing with a population in which the most vulnerable segment was the woman and her young child. This was where most of the emphasis of the health programs [was], as is true in most parts of the world today. Secondly, they dealt with the problem of acute infectious diseases. And thirdly, the goal of the health programs [was] the saving of lives. For these reasons the success of the programs could be measured in changing mortality rates (changing death rates). Finally, this was a time where the knowledge necessary to save lives was contained in the professions of medicine and dentistry, nursing, and engineering . "Contrast that with the situation today. In a vastly expanding and mobile population we are dealing with a situation in which our most vulnerable segment is no longer only the mother and her child, but includes the increased risk in the males from a point of view of dying, and in elderly females from the point of view of the consequences of isolation and loneliness. There are vulnerable segments of the population in which a major threat to health is no longer the acute communicable diseases but the chronic, long-term disorders. Our objectives are no longer restricted to saving lives but must somehow include making life more livable. "The body of knowledge necessary for this must come not only from medicine, dentistry, nursing, engineering, but must come also from sociology, anthropology, psychology, psychiatry, nutrition, statistics, chemistry, biology and education. This knowledge must come from a whole host of disciplines that have a contribution to make to the development of intelligent health programs. And we must devise ways in which to synthesize the contributions of these disciplines in terms of the problems that we see today. "The questions then are how can we plan so as to develop intelligent approaches to these problems? How will we know if our attempts are effective or need to be modified? Can we learn from our attempts more about the determinants of disease and disorder? These and similar questions are ones to which epidemiology addresses itself."

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) the first prerequisite for any intelligent public health program is knowledge of the extent and distribution of the problem under consideration. Traditionally this has meant a study of the extent, and the distribution of, various diseases in any given community. This study of the distribution of, and extent of, diseases in communities has been, and will continue to be, one of the essential functions of epidemiology . While there are numerous other definitions of epidemiology which are variations on this same theme, [none of the definitions makes] explicit what is meant by determinants of disease nor which of these determinants are amenable to epidemiological studies. Neither do they define any more clearly what is included In the term environment. This can be interpreted to mean the physical environment (which is the usual concept) or more broadly the human environment as well .

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) In order to develop information concerning the distribution and extent of diseases in a community, that is to provide knowledge of the extent and scope of the health problems, three things have to be understood. First, the investigator must know something about the indicators of the health problem - that is how the condition that he is studying will be measured. In other words, there must be a clear definition of who shall be counted as a case and who shall not be counted as a case... The way in which the cases are labeled becomes a crucial point and one must know for any given study the advantages and disadvantages of various ways of indicating or labelling cases and what sort of inferences are, and are not, possible, depending upon how the cases are labelled .

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) The second point is that the investigator needs to know some of the methods for describing the frequency of occurrence of the characteristics and/or the condition in the population or group being studied . Thirdly, one must know the peculiarity, advantages, and disadvantages of the sources from which the data come. Each particular source of data has its own set of built-in errors and built- in biases which will determine what and how much one can infer and interpret from that particular data. The investigator must know for each condition that he is studying the particular attributes of the source of data .

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) Although such information on the distribution of diseases and the extent of these diseases in populations is still essential for the careful development of programs, and forms the essential core of information that should be constantly available to all operating health agencies, it is now recognized that such information alone is insufficient for epidemiologic needs and the needs of developing relevant programs. It is insufficient in two respects. First, the concept of disease needs broadening to include a wider range of human problems. It should include such things as how many premature births are occurring, whether there are too many births occurring, (the population explosion), the occurrence of drug addiction, the problems of industrial growth in rural areas, to name but a few. In other words, the human problems which are meaningful, and for which we need to find answers, are not restricted to the occurrence of narrowly defined medical conditions but include a whole host of social problems that may be associated with medical problems. These social problems are sometimes indistinguishable from the medical problems and need to be included in our epidemiologic surveillance system.

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) Secondly, not only should the extent and distribution of these problems be known by any adequate epidemiologic surveillance system but the community diagnosis should include information on what is being done about the problems, how it is being done, and what is the readiness of the community for new or additional services. One needs to know not only the extent of the problems but also what attempts are being made to remedy them; how well the attempts are succeeding; and how ready the community is for innovations or changes. This aspect of community diagnosis or surveillance, i.e., the application of epidemiology to defining the problems is difficult to come by. It cannot be obtained in a short period of time and requires a deliberate and conscious effort to develop the machinery to obtain, to interpret, and to act upon such information. In other words, there is no point in collecting such information purely for the sake of collecting data. This is an area which is almost totally unexplored. The understanding of what is being done, how well it is being done, and how ready the community is to act upon it, is not currently available in any textbook, nor is it linked together in any systematic fashion....

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) What kinds of data can and should be gathered, what should be the indicators or the measurement tools used in a particular community is a complex matter . Some of Cassel s examples: What is the pattern of utilization of existing health services? Who uses what health services and for what purposes? How many people take their complaints to the druggist, or to the faith healer, or to the grandmother? How many people take them to doctors, to the nurse, to the hospital? What determines where people take their complaints? Who are the decision-makers in any community? How do you determine who the decision-makers are in any community?

Excerpt from John Cassel, EPID160 Fall 1972, Lecture II: Role of Epidemiology in Scientifically Based Practice: Epidemiologic Surveillance and Community Diagnosis (from EPID160 lecture handout) More of Cassel s examples: What is the network of relationships that occur in a community that lead people to selecting a particular source of health services? How does a newcomer to a city or to a community find out about the available health services? Is it by word of mouth and if so from whom? If there is a social service or public health nursing service available, are they being used? What is the relationship between the hospitals and the community services? Are patients being discharged from hospitals to communities without any adequate preparation for them within the communities? The physician would never dream of admitting a patient to a hospital ward if there were no staff available for that ward; if the nurses were not available the hospital would close the ward. Yet we think nothing of admitting patients back to the community without any services at all even though they need continuing services.

The Essence of Epidemiology (what Vic learned) Epidemiology studies populations diversity, distributions, dynamics. Thoughtful comparison within and across populations is key strategy. Premium on empirical observation data with emphasis on careful definition, accurate measurement, painstaking collection. Question(s) and their rationale should be clearly articulated. Diseases are processes that unfold over through stages. Broad perspective knowledge from any discipline should be considered, critically evaluated, synthesized, including influence of error and extraneous.

What has epidemiology taught us about health equity? Immediate essentials for health are air, water, food, clothing, shelter, security, etc. Populations without these are not healthy! Broader essentials are some degree of personal autonomy, access to resources and services, knowledge and information (education). Preponderance of health problems occur to people with limited resources. Power begets resources; resources beget power.

Equity and power What is health equity? Health equity is what people say it is. People are diverse and will have different judgments. Judgments about equity reflect power. Actions speak louder than words; influencing actions requires more power than does influencing words. Equity requires modest differentials in power and resources.

Economics

Economics Sources of power and resources: physical force ( barrel of a gun Mao Tse Tung), knowledge and skill, land and natural resources, technology, organization, discipline, creativity, ideology, dedication, cooperation (family, tribe, friends), health, In 21stcentury US, continuing from 20thcentury, income and especially wealth are key determinants of individuals and groups power and access to resources. Longevity of wealthy health care, knowledge, choices, influence, control, decision-making, autonomy, support Income and especially wealth are very unequally distributed. Natural tendency of market capitalism winners and lowers. Winners get to shape rules. These influences are not absolute, since there are some conflicts and contradictions. There are various sources of power that compete with economic power. Consider the fate of millionaires in Russia. Also, political movements are not entirely under the control of money. But in U.S. democracy, money has considerable access to power. Two major contrasting philosophies of equity 1) people deserve what they can get versus 2) everyone should have what they need. Each philosophy has pros and cons, with the balance constantly shifting. The former philosophy has strategic advantages because it requires less cooperation and less enforcement. The latter philosophy may produce more harmony.

Economics Every process needs resources, so every agent and every organization needs resources. Resources are needed for current consumption and for investment to increase future capabilities and productivity. Resources can be garnered by force, by exchange, by gift, by taxation, etc. Private enterprise has most direct access to resources, especially in democracies. Government programs need agreement on revenue, which means political support and compliant taxpayers. Consumers may willingly provide revenue, and both government and, especially business, have found ways to entice people to give over money (e.g., Powerball, reward cards; what would happen if the IRS provided a lottery ticket to people who pay their taxes early?).

Economics More knowledge, more technology, more global, more - those with $$$ have more opportunities, and not only under capitalism. Though power is contested, so relative power is a dynamic situation. Markets ration, convey incentives, promote efficiencies , enable marshaling huge resources, and manipulation of political process, opinion, education, - But market capitalism promotes growth, though indicators of growth (e.g., GNP) are quite imperfect so much of that growth may be illusory. Freedom enables some to take advantage and forces others to compete with larger aggregations. WTO, NAFTA, immigrants, unions, Capitalism is an institution and corporate behavior reflects institutional dynamics. Consider retirement savings. Where should you invest? What do you want your investments to do? Corporate governance designed to push toward expansion, growth in profits,

John Bogle John Bogle Enough: The True Measure of Money, Business and Life Enough: The True Measure of Money, Business and Life There's a sign in Einstein's office that I describe in the book that says there are some things that count that can't be counted and some things that can be counted that don't count. And that really summarizes it up. We've got this counting society, and we rely on numbers to give us facts that are really not facts. If someone's corporation, for example, says their earnings were $1.32 per share, the amount of financial engineering that's gone into that number is usually rather breathtaking. It's an engineered number. And the idea that you think you know something when you see a number is just greatly overdone. We think we can count everything that's important, and we can't do that. You can't measure character, you can't measure integrity, you can't measure moral conduct, you can't measure love, the things that are really important in our lives, in our society. (From NPR interview with Alison Stewart, Nov 1, 2008, http://www.npr.org/templates/story/story.php?storyId=96432098)

David Callahan, David Callahan, The Givers: Money, Power and Philanthropy in a The Givers: Money, Power and Philanthropy in a New Gilded Age New Gilded Age https://www.nytimes.com/2017/04/14/your-money/wealth-matters- philanthropy-david-callahan.html?_r=0 John Kenneth Galbraith: Under capitalism, man exploits man. Under communism, it's just the opposite.

Thoughts Thoughts Adam Smith - The Invisible Hand (The Wealth of Nations) and The Impartial Spectator (Theory of Moral Sentiments) Idea? - capitation funding for youth, comprising early childhood development, school, and criminal justice, so if spend less on criminal justice have more for education End of history illusion, end of evolution illusion Theories - Out of Asia vs. Out of Africa , particle vs. wave How can know what is right action? The effects of action are unfathomable.

Evolution

Evolution Every organism, every process even, needs inputs and produces outputs. Inputs (resources need to be acquired, outputs need to be removed how manage? E.g., chemical reactions, factories, body, society. One major strategic advantage of market capitalism is that it mirrors evolution, the process through which we along with everything else in the universe have come to be here. Key principle of evolution what exists has, for the most part, survived from yesterday (and the day before). So strategies, reason, values, etc. all stand or fall based on whether they survive over extended periods (or if not too complex can resurface, which these can do). Evolutionary time scale is very long. What survives? Our perspective is retrospective: over very long times, environments change; adaptability, reproduction, diversity are key need to cover all contingencies (portfolio) a species that loses once is gone. Inheritance but imperfect. Cycle of birth and death more adaptable, more diversity Safety in numbers, portfolio theory Because of growth, reproduction competition is inherent in existence. Not just among people, everything that has value and limits (economics). E.g., attentional resources. Along with competition comes cooperation (e.g., M vs F, M and F) because can compete more effectively if cooperate. Cooperation requires trust which also opens door to cheating. So need sanctions, fairness , justice .

Evolution Enduring processes New influences Cycles Change is more rapid Competition and cooperation Internet, information availability Trade-offs (e.g., central vs. delegated) Social media Human tendencies Mobility Religion Fertility control Economic impacts Technology, industrialization, impact Public health Use it or lose it (e.g., syphilis control) SAIPG Wealth explosion

Enlightenment

Enlightenment Business as usual won t survive environmental degradation. There is no shortage of wealth we waste a great deal and promote unnecessary, harmful consumption conflict, security, spam, excess consumption. The environment dictates the need for a more enlightened approach to human living. What can epidemiology contribute to achievement of enlightenment? Epidemiology is transdisciplinary, integrates across all fields, purposeful, goal directed, practically-oriented, wholistic, systems thinking approach. Epidemiology should devote more attention to studying how the nervous system works thinking, noncognitive processes, biological influences, feedbacks, environmental, including behavioral environment influences, evolution, economics, decision-making (loss aversion) fundamental, neuroeconomics. (Examples: NIH BRAIN initiative, Science, 10 May 2013). Tversky and Kahneman, Dan Ariely (Predictably Irrational), Jonah Lehrer (www.jonahlehrer.com/). Human nervous system creates new possibilities if we can manage it well. What influences consciousness, breadth of awareness, drivers of philanthropy. Leverage current knowledge and resources to broaden awareness See notes at www.unc.edu/epid600/modules/130roleOfEPID/ and www.unc.edu/epid600/modules/130roleOfEPID/morethoughts.htm

Fred Travis talk States of consciousness, types of meditation - 8 min www.epidemiolog.net/video/epid799c_2016/03-20160426/Excerpt-1018-1804.mp4 Brain diagrams of blood flow, EEG patterns - 5 min www.epidemiolog.net/video/epid799c_2016/03-20160426/Excerpt-1945-2445.mp4 TC to CC, brain waves in 4-month vs. 8-year meditators - 4+ min www.epidemiolog.net/video/epid799c_2016/03-20160426/Excerpt-3153-3642.mp4 * Brain integration correlations - TM - 1+ min www.epidemiolog.net/video/epid799c_2016/03-20160426/Excerpt-5434-5541.mp4 * Brain integration correlations - not TM - 2.5 min www.epidemiolog.net/video/epid799c_2016/03-20160426/Excerpt-5700-5928.mp4 TM and brain integration - conclusion - 2 min www.epidemiolog.net/video/epid799c_2016/03-20160426/Excerpt-6062-6228.mp4 [If only the audio plays, try copying-and-pasting the link into Chrome]

What do you think? Student presentations next week!