Kansas Public Health: There and Back Again

Healthy Kansans 2010 as a Common Language for Todays Public Health ImprovementsKansas Public Health Association, Inc. 2006 Fall Conference

First Official Public Health Body in Kansas:Kansas State Board, 1885State and Local Boards of HealthChapter 129, Laws 1885An Act to create a State and local boards of health, and to regulate the practice of medicine in the State of Kansas.

Sec 4. The state board of health shall supervise the health interests of the people of this state.

Board was charged tomake careful inquiry in respect to the cause of disease, and especially of epidemics, and investigate the sources of mortality, and the effects of localities, employments, conditions; ingesta, habits and surroundings on the health of the people.

Establish environmental policyadvise officers of government, or other state boards, in regard to location, drainage, water supply, disposal of excreta, heating, and ventilation of public buildings.

Establish vital statistics tracking systemcollect and preserve such information relating to forms of disease and death as may be useful in the discharge of the duties of said board.

Become the states health data and information repositoryreceive reports and publications from all health officers of local boards of health in the state, and such sanitary information as may be useful to people of the state.

Oversee the registration vital statistics, and track reportable diseasessupervise the registration of marriages, births, and deaths, and also the registration of forms of disease prevalent in the state; and the secretary of said board shall superintend the registration of the vital statistics of the state.

Create mortuary policy and proceduresprepare the forms and establish the rules by which permits for transporting the dead bodies of persons for burial beyond the county where the death occurs;

Conduct public health research and appoint special research committeesappoint committees, or engage suitable persons to render special sanitary service, to make or supervise practical or scientific investigations and examinations, requiring expert skill, and to prepare plans and report thereon.

Board was charged to improve the health of Kansanswith limited resources

Need for accurate statisticsAccurate and reliable compilation of vital statistics is of paramount importance and of inestimable value. We have inaugurated a system which is meeting with general approval, and promises, during the year 1886, to be very reliable and complete.

And then there are the doctors

In Osage City, Kansas, a physician urged the local school board to refuse to carry out the vaccination order of the Kansas State Board of Health:

Personally, I cannot comply with such an order; experience has taught me better. They cannot disease my child with the pus of a brute, while God sees fit to make its check bloom with health, if I can prevent it.

What would a Healthy Kansans 1890 planning process have looked like?

1880 Kansas Population by Age

U.S. and Kansas in 18801880 U.S. Vital Statistics showedNation struggling with infectious, preventable diseasesMore than one in ten infants died before their first birthday9 out of the top 10 ten causes of death were infectious diseasesThere were no official vital statistic records for Kansas in 1880 (no data)

Actions of First State Board of Health focused onSetting up appropriate systems and tools to allow them to identify health problems, track improvements, and set priorities Created first vital statistics forms, which included marriage, birth, still-birth, death, and vaccination formsPromoting prevention policies specifically, sanitation and hygiene Included rules for appropriate sewer drainage, keeping water supplies clean, quarantining infectious diseases, disinfecting areas where disease had been present, and vaccination

ProgressEfforts of first public health officials in state provided a foundation for Dr. Crumbine, appointed Secretary in 1904.Dr. Crumbines efforts resulted in rapid advancements in public health policy and health education in Kansas during his tenure (1904 1923).

Leading Causes of Death in U.S., 1920

Leading Causes of Death in U.S., 1950

Leading Causes of Death in U.S., 1970

Fast Forward

just a century or so!Phones, lights, and motor carsWho are we now?

Understanding our Population allows for good decisions on priority setting

1920 Population by County

2000 Population by County

2000 Kansas Population by Age

Projected 2030 Kansas Population by Age

2000 Hispanic Population by Age

Health Problems in the U.S., 2000Leading Causes of Death*United States, 2000Actual Causes of Death United States, 2000TobaccoDiet / Physical InactivityAlcohol consumptionMicrobial agents(e.g., influenza, pneumonia)Motor vehiclesToxic agents(e.g., pollutants, asbestos)FirearmsSexual behaviorIllicit drug usePercentage (of all deaths)*Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-20.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291 (10): 1238-1246. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Correction: Actual Causes of Death in the United States, 2000. JAMA. 2005;293 (3): 293.

TodayChronic disease are the new frontierHave enjoyed rapid advancements in medical technologies, pharmaceuticals but these have not solved the chronic disease problemMany chronic diseases share common risk factorsBehavioral changes are key to reducing premature deathChronic diseases present complex, long-term challenge

Healthy Kansans 2010Learning from the past preparing for the future Encouraging change for healthier Kansans

ProcessGroup of Kansans representing multiple decisions participated in priority-setting processBuilds on comprehensive, nationwide health promotion and disease prevention agenda, Healthy People 2010

Healthy People 2010 GoalsIncrease quality and years of healthy life. The first goal is to increase our populations life expectancy and improve their quality of life.Eliminate health disparities. The second goal is to eliminate health disparities among different segments of the population by specifically targeting the segments that need to improve the most.

Healthy Kansans 2010 Health Focus Areas

10 Leading Health IndicatorsPhysical ActivityOverweight and ObesityTobacco UseSubstance AbuseResponsible Sexual BehaviorMental HealthInjury and ViolenceEnvironmental QualityImmunizationAccess to Health Care

PrioritiesReducing and Eliminating Health and Disease Disparities Systemic Interventions to Address Social Determinants of Health Early Disease Prevention, Risk Identification, and Intervention for Women, Children and Adolescents

Reducing and Eliminating Health and Disease Disparities

Scope of Healthy Kansans 2010 DisparitiesRacial/ethnicDisabilityAge (particularly senior adults)GenderGeography (rural/urban)Socioeconomic status (education, income, insurance/health benefit coverage)

Percent of Self-Reported Fair or Poor Health Status by Selected Population Groups

System Interventions to Address Social Determinants of Health Social determinants can be summarized by two variablesClassSocial supports and social connectednessDisparities related to Social DeterminantsIncomeEducationSocial Determinants

Four Points of Opportunity Where Policy or Systems Can Intervene to Affect Social Determinants of HealthDecrease social stratificationDecrease specific exposure to health-damaging factors suffered by people in disadvantaged positionsSeek to lessen the vulnerability of disadvantaged people to the health-damaging conditions they faceIntervene through healthcare to reduce the unequal consequences of ill-health and prevent further socio-economic degradation among disadvantaged people who become ill

Early Disease Prevention, Risk Identification, and Intervention for Women, Children and Adolescents Issues considered: Interventions with pregnant women;Interventions for pre-conceptional health;Screening programs;Substance abuse interventions during and immediately following pregnancy;Early childhood interventions (0-5 years);School-based initiatives (6-18 years);After-school programs (6-18 years);Chronic disease risk factors including tobacco use, physical inactivity and poor nutrition;Disease prevention and management programs for asthma, cancer, diabetes, cardiovascular disease, etc.; Immunization programs;Injury prevention programs intentional and unintentional; andOral health interventions

Early Intervention Progress

Growing Threat of Chronic Disease and Associated Risk Factors

Early Intervention RecommendationsAssure access to health care and preventive services for children and parents. Integrate efforts to affect the whole childs emotional and social well-being.Promote the development and adoption of healthy lifestyles

Action Steps Selected for Immediate Action Based on Three Cross-Cutting PrioritiesTobaccoDisparities DataCultural CompetencyOverweight and ObesityAccess

Tobacco#1 preventable cause of death in Kansas17% of adults smokeResults in more than 3,800 deaths per yearCigarette use costs Kansas $724 million in direct medical costsIf current trends continue, 54,000 children alive today will die of tobacco-related causes

Disparities DataRecommendation: Routinely collect and report data on all segments of the population (race/ethnicity, gender, rural/urban, economic status, disability status) to identify where improvements are most needed.

Cultural CompetencyDefinition: Cultural competence: Having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and communities. An ability to relate to others in a trustworthy manner, with respect for individual cultural differences.Achieving cultural competency is a process rather than an outcome.

Adult Overweight/Obesity Trend

Overweight/ObesityFive national overweight/obesity prevention goals:Increase fruit and vegetable consumptionIncrease physical activityDecrease screen time (TV, leisure computer, video games)Increase breastfeedingBalance caloric intake with expenditure

Access

What will we do to make a difference in Kansas future?

The time is nowthe place is here

and its up to us.

Not comprehensive. Listing key duties from the regulation.Not comprehensive. Listing key duties from the regulation.The Board did create the first vital statistics collection forms and establish a system in 1885, to be implemented in 1886. In the report presented to the Governor, they explain, Accurate and reliable compilation of vital statistics is of paramount importance and of inestimable value. We have inaugurated a system which is meeting with general approval, and promises, during the year 1886, to be very reliable and complete. And when we remember that no other State department has ever attempted to compile it, we may reasonably conclude that it will be more fully appreciated for its intrinsic value and incalculable importance.

Portions of above quote are included later in the presentation.Not comprehensive. Listing key duties from the regulation.Not comprehensive. Listing key duties from the regulation.Not comprehensive. Listing key duties from the regulation.

Picture is an ambulance from Ft. Riley hospital around 1900.Not comprehensive. Listing key duties from the regulation.This is just an introductory slide. Examples of limited resources given in following slidesBest available data for priority setting was 1880 national vital statistics records (through Census Bureau no NCHS at that time).Board Health passed regulation for compulsory small-pox vaccination on school entry.

More complete quote argument against vaccination is for individual versus population health: Despite statistics and the authority of the best medical authors, teachers, and practitioners, there are some doctors (?) who seem determined to keep disease in the field. There is a method in their madness. They prescribe for the patient, while the true physician prescribes for the disease, and they too often do for the patient what the physician would do for the disease. There are others who seem incapable of grasping the truth, however clearly demonstrated.

More complete quote for the bottom section. We find another sample of this class in Osage City, Kansas, who, at a meeting of its school board, urged it to refuse to carry out the vaccination order of the Kansas State Board of Health, informing it that many of the most enlightened physicians considered vaccination useless and injurious; that to insert diseased pus in the arm could not do other than injury; and warning them that if they attempted to execute the order of the board, they might expect the same mob law that ruled the neighboring city of Montreal.

There is a time to keep silent, and a time when a citizen should speak. The performance of that duty is the only apology offered for objecting to the order issued by the Kansas State Board of Health that all parents who do not submit their children to compulsory vaccination, must have them expelled from our public schools. That there may be no mistake that such an order has been made, permit me to clip it from Topeka Daily Capital of September 12, 1885, the official organ of the Kansas State Board of Health, I presume:

Personally, I cannot comply with such an order; experience has taught me better. They cannot disease my child with the pus of a brute, while God sees fit to make its check bloom with health, if I can prevent it. Yours, in the interest of humanity, T. Arthur Wright, MD

Then young population due to premature death.

According to the 1880 Census, less than 2% of the population was 65 years or older compared to 13% in 2000. An even smaller fraction of the population, 0.04% (4 in 10000 rare to have friends or family age 85 or older!) versus 1.93% (2 per 100 we all probably have friends or family age 85 or older) in 2000.4 out of 10 of the nations deaths in 1880 were to children under age 5.Progress was made

Rates are crude death rates.

Pneumonia is #1Tuberculosis has fallen to #3Heart disease is #2 (up from #4 in 1880, 1890, and 1900)

Still dominated by infectious causes

More progress.

Still crude death rates.

Chronic disease is becoming a bigger player.

TB is #7Heart disease has been #1 since 1930.Diabetes emerges in the top 10.

More progress.

Crude death rates.

Infectious diseases are very small player

Chronic disease is becoming a bigger player.

Diabetes is #7. Top 3 causes are chronicKansas became a state in 1861. Rapid increase in population between 1860 and 1880.

In 1880, Kansas was the 20th most populous of 47 states and territories, larger than California by 130,000 people.

Today, Kansas is 33rd in size by population.In early 1900s, eastern Kansas was more densely populated than western Kansas (as today), but population was more evenly distributed.

In 1890, Jewell County (now one of the smallest) had approximately 2,000 more people than Johnson County.Today, population more concentrated in urban areas and regional centers (e.g., Garden City, Hays, Salina).The 2000 Kansas population is more evenly distributed across the age groups, indicating increased longevity

The bump in the middle of the 2000 graph represents the Baby Boomer generation. In 2030, the population will be even more flatly distributed across the age groups with projected increases in life expectancies and the Baby Boomer generation well into their senior years. An estimated one in five Kansans will be aged 65 years or older, and one in ten will be 75 or older.Understanding the characteristics of our population not only age, but also race/ethnicity, socioeconomic status and more will help us appropriately target each population group for greatest gains in quality and years of healthy life.

For example, racial and ethnic minorities in Kansas have younger population distributions than Whites. This is particularly true of the Hispanic/Latino population (2000 Census, Figure 12), due the immigration of young adults and families and higher-than-average birth rates. In 2000, 43% of Hispanic/Latinos were under age 20 years, while only 3% were 65 years or older.

Hispanic population distribution more similar to 1880 Kansas distributionNo quick-fix with todays chronic diseases (e.g., antibiotics, childhood immunization)Cross-cutting priorities identified by the Steering Committee to impact MULTIPLE 10 leading health indicatorsContext: Kansas is becoming Increasingly racially & ethnically diverse

In 1880, Kansas was a land of immigrants (Figure 13). Twelve percent were foreign-born, compared to 5% of the population in 2000. Most of 1880-Kansas was White (96%). Over the past 120 years, Kansas has become increasingly racially and ethnically diverse. In 2000, 13.9% of Kansans were a racial/ethnic minority; this has increased to nearly one in five Kansans (18.4%) for 2005. In both Kansas and the United States, Hispanics surpassed Blacks in the 2000 Census as the largest minority group (Figure 14). From 1980 to 2005, Hispanics in Kansas increased over three-fold from 63,339 to 228,250. The 2000 Census was also the first time residents could select multiple races to describe themselves. Healthy Kansans 2010 adopted a comprehensive view of health disparities, with the intention of elevating the priority status of health disparities. Health disparities are not only a function of race and ethnicity, but are influenced by other factors, such as disability, age (particularly senior adults), gender, geography, and socioeconomic status. The term underrepresented groups represents all of these population segments. Example of disproportionate health outcomes

Just one example do you want more??In this country, class is largely determined by income and education.Shows scope of workgroup chargeIn the late 1800s, more than one in ten U.S. infants died before their first birthday, and one in five children born died before reaching the age of 6. Due to preventive efforts, early intervention strategies, and improved medical treatments and technologies (e.g., immunizations, improved sanitation, prenatal care, antibiotics), infant mortality and child death rates plummeted in the last 120 years, though there is still room for improvement (Figure 25). Add examples of specific action steps??

Photo is of Kansas Mission of MercySimilarly, tobacco use remains the number one preventable cause of death in Kansas, resulting in more than 3,800 deaths per year. Early intervention is crucial, as almost all smokers begin smoking by age 18. While only 17% of Kansas adults are current smokers (Behavioral Risk Factor Surveillance System, 2005), the negative health impact of tobacco use is much more widespread, particularly as it affects the health of children. Approximately two-thirds of Kansas High School students and 48% of Middle School students report being exposed to tobacco smoke on a regular basis (Kansas Youth Tobacco Survey, 2002). The health costs of tobacco are enormous. Cigarette use alone currently costs Kansas $724 million in direct medical costs, plus another $897 million in indirect (lost productivity) costs per year (Smoking-Attributable Mortality, Morbidity, and Economic Costs [SAMMEC], Centers for Disease Control and Prevention). This includes $153 million in Medicaid program expenditures. These costs will undoubtedly rise year by year if we fail to take action to reduce tobacco use and exposure. If current trends continue, 54,000 children alive today will die of tobacco related causes (Campaign for Tobacco Free Kids). Improved cultural competency: Promote cultural sensitivity, specificity, and competency through adoption of policies and actions at multiple levels, including professional, organizational, and system-wide.

Cultural sensitivity: The ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic or cultural heritage.

Cultural specificity: The creation of an environment where the identity and experiences of people in a specific group or culture are recognized, explored, and accepted. Related to health promotion and prevention, participants see their culture and images of themselves represented in the messages.From final report

Advancements in technology, health care and public health have all been built on the dedication of those who have gone before us. Looking back 120 years, we can see the vision and wisdom of the inaugural Kansas State Board of Health. In recommendations put forward in the late 1880's, the Board recognized the need for sound strategies to curb the growth in infectious disease. While it took decades before some of their recommendations were fully accepted, today we enjoy the fruits of their work and take pride in their commitment to keeping past and future Kansans healthy. What will we leave for future generations? We have the recommendations of experts, leaders, health providers, health educators, and community members before us. If we have the foresight to act on these recommendations and implement system wide change, we can reap the benefits of a healthy life for us, our children, and future generations.Healthy Kansans 2010 is a call for all Kansans individuals, health professionals, communities, businesses, state and local organizations to partner together in implementing community-wide and systems-wide changes for improving our health.