Kansas Public Health: There and Back AgainKansas Public Health: There and Back Again

Healthy Kansans 2010 as a Healthy Kansans 2010 as a Common Language for Common Language for

Today’s Public Health ImprovementsToday’s Public Health Improvements

Kansas Public Health Association, Inc. 2006 Fall Conference

First Official Public Health Body First Official Public Health Body in Kansas:in Kansas:

Kansas State Board, 1885Kansas State Board, 1885

State and Local Boards of HealthChapter 129, Laws 1885

An 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 to…Board was charged to…

“…make 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 policy…Establish environmental policy…

“…advise 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 Establish vital statistics tracking system…system…

“…collect 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 state’s health data Become the state’s health data and information repository…and information repository…

…receive 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 Oversee the registration vital statistics, and track reportable statistics, and track reportable

diseasesdiseases

“…supervise 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 Create mortuary policy and proceduresprocedures

…prepare 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 Conduct public health research and appoint special research and appoint special research

committeescommittees

“…appoint 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 Board was charged to improve the health of Kansans…the health of Kansans…with limited resourceswith limited resources

Need for accurate statisticsNeed for accurate statistics

“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 then there are the doctors…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 What would a “Healthy Kansans 1890” planning Kansans 1890” planning

process have looked like?process have looked like?

1880 Kansas Population by Age1880 Kansas Population by AgeFigure 9. 1880 Kansas Population

20% 15% 10% 5% 0% 5% 10% 15% 20%

< 55-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Male FemaleU.S. Census Bureau

U.S. and Kansas in 1880U.S. and Kansas in 1880

• 1880 U.S. Vital Statistics showed…– Nation struggling with infectious, preventable

diseases– More than one in ten infants died before their

first birthday– 9 out of the top 10 ten causes of death were

infectious diseases

• There were no official vital statistic records for Kansas in 1880 (no data)

Table 1. United States Leading Causes of Death, 1880

CauseNumber of Deaths

(Registered States)

Percent of Known Causes of

Death

Consumption (Tuberculosis) 91,270 13.1%

Pneumonia 63,053 9.1%

Diphtheria 38,143 5.5%

Heart disease 26,068 3.8%

Cholera infantum 24,983 3.6%

Typhoid fever 22,854 3.3%

Malarial fever 20,231 2.9%

Croup 17,966 2.6%

Convulsions 17,844 2.6%

Scarlet fever 16,388 2.4%

Actions of First State Board of Actions of First State Board of Health focused on…Health focused on…

• Setting 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 forms

• Promoting 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

ProgressProgress

• Efforts of first public health officials in state provided a foundation for Dr. Crumbine, appointed Secretary in 1904.

• Dr. Crumbine’s 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., 1920Leading Causes of Death in U.S., 1920

Cause Deaths Rate

Pneumonia (all forms) and influenza 178,438 207.3

Diseases of the heart 137,374 159.6

Tuberculosis (all forms) 97,366 113.1

Intracranial lesions of vascular origin 80,019 93.0

Nephritis (all forms) 76,410 88.8

Cancer and other malignant tumors 71,756 83.4

Accidents excluding motor-vehicle 52,255 60.7

Diarrhea, enteritis, and ulceration of the intestines 46,266 53.7

Premature birth 37,564 43.6

Puerperal causes (total) 16,320 19.0

Leading Causes of Death in U.S., 1950Leading Causes of Death in U.S., 1950Cause Number Rate

Diseases of the heart535,70

5 355.5

Malignant neoplasms (cancer)210,73

3 139.8

Vascular lesions affecting central nervous system

156,751 104.0

Accidents 91,249 60.6

Certain diseases of early infancy 60,989 40.5

Influenza and pneumonia, except pneumonia of newborn 47,120 31.3

Tuberculosis, all forms 33,959 22.5

General arteriosclerosis 30,734 20.4

Chronic and unspecified nephritis and other renal sclerosis 24,677 16.4

Diabetes mellitus 24,419 16.2

Leading Causes of Death in U.S., 1970Leading Causes of Death in U.S., 1970

Cause Number Rate

Diseases of heart 735,542 362.0

Malignant neoplasms (cancer) 330,730 162.8

Cerebrovascular diseases 207,166 101.9

Accidents 114,638 56.4

Influenza and pneumonia 62,739 30.9

Certain causes of mortality in early infancy 43,205 21.3

Diabetes mellitus 38,324 18.9

Arteriosclerosis 31,682 15.6

Cirrhosis of liver 31,399 15.5

Bronchitis, emphysema, and asthma 30,889 15.2

Fast Forward…Fast Forward…

• …just a century or so!

• Phones, lights, and motor cars

• Who are we now?

Understanding our Population allows Understanding our Population allows for good decisions on priority settingfor good decisions on priority setting

Figure 6. Kansas Population, 1860 - 2000

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

U.S. Census Bureau

1920 Population by County1920 Population by County

2000 Population by County2000 Population by County

2000 Kansas Population by Age2000 Kansas Population by AgeFigure 10. 2000 Kansas Population

20% 15% 10% 5% 0% 5% 10% 15% 20%

< 55-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Male FemaleU.S. Census Bureau

Projected 2030 Kansas Population by AgeProjected 2030 Kansas Population by Age

Figure 11. Projected 2030 Kansas Population

20% 15% 10% 5% 0% 5% 10% 15% 20%

< 55-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Male FemaleU.S. Census Bureau

2000 Hispanic Population by Age2000 Hispanic Population by AgeFigure 12. 2000 Kansas Hispanic Population

20% 15% 10% 5% 0% 5% 10% 15% 20%

< 55-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Male FemaleU.S. Census Bureau

Health Problems in the U.S., 2000Health Problems in the U.S., 2000

Leading Causes of Death*United States, 2000

Actual Causes of Death† United States, 2000

0 5 10 15 20 25 30 35

Percentage (of all deaths)

Heart Disease

Cancer

StrokeChronic Lower

Respiratory DiseaseUnintentional injuries

Diabetes

Pneumonia / influenza

Alzheimer’s disease

Kidney disease 0 5 10 15 20

TobaccoDiet / Physical Inactivity

Alcohol consumptionMicrobial agents

(e.g., influenza, pneumonia)

Motor vehiclesToxic agents

(e.g., pollutants, asbestos)

FirearmsSexual behavior

Illicit drug use

Percentage (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.

TodayToday

• Chronic disease are the new frontier• Have enjoyed rapid advancements in medical

technologies, pharmaceuticals but these have not solved the chronic disease problem

• Many chronic diseases share common risk factors

• Behavioral changes are key to reducing premature death

• Chronic diseases present complex, long-term challenge

Healthy Kansans 2010Healthy Kansans 2010

Learning from the past…

preparing for the future

Encouraging change for healthier Kansans

ProcessProcess

• Group of Kansans representing multiple

decisions participated in priority-setting

process

• Builds on comprehensive, nationwide

health promotion and disease prevention

agenda, Healthy People 2010

Healthy People 2010 GoalsHealthy People 2010 Goals

• Increase quality and years of healthy life. The first goal is to increase our population’s 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 Healthy Kansans 2010 Health Focus AreasFocus Areas

Maternal Infant Child Health Oral Health Hearing HIV & STD Family Planning Arthritis Childhood & Adult

Immunization Disability Environmental Health Nutrition and Physical Activity Respiratory Health

Occupational Health Vision Heart Disease and Stroke Diabetes Mental Health Substance Abuse Injury and Violence Cancer Tobacco Chronic Kidney Disease Public Health Infrastructure Access to Care

10 Leading Health Indicators10 Leading Health Indicators

• Physical Activity• Overweight and Obesity• Tobacco Use• Substance Abuse• Responsible Sexual Behavior• Mental Health• Injury and Violence• Environmental Quality• Immunization• Access to Health Care

PrioritiesPriorities

• Reducing 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

Figure 14. Population by Race/Ethnicity (Excluding White)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

1860

1870

1880

1890

1900

1910

1920

1930

1940

1950

1960

1970

1980

1990

2000

Black/African Amer.

Amer. Indian/Native Amer.

Asian/PacificIslander

Other Race

Two Or MoreRaces

Hispanic

U.S. Census Bureau

Reducing and Eliminating Health Reducing and Eliminating Health and Disease Disparitiesand Disease Disparities

Scope of Healthy Kansans 2010 DisparitiesScope of Healthy Kansans 2010 Disparities

• Racial/ethnic

• Disability

• Age (particularly senior adults)

• Gender

• Geography (rural/urban)

• Socioeconomic status (education, income, insurance/health benefit coverage)

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

Figure 19. 2005 Percent Self-Reported "Fair" or "Poor" Health Statusby Selected Population Groups

0

5

10

15

20

25

30

35

40

18-2

4 yea

rs

25-3

4 yea

rs

35-4

4 yea

rs

45-5

4 yea

rs

55-6

4 yea

rs

65+ ye

ars

White

Onl

y

Blac

k Onl

y

Less

than

Hig

h Sc

hool

College G

radu

ate

Less

than

$15,00

0

$15,00

0 - $2

4,99

9

$25,00

0 - $3

4,99

9

$35,00

0 - $4

9,99

9

$50,00

0+

Emplo

yed

Out of

Wor

k

Kansas Behavioral Risk Factor Surveillance System

• Social determinants can be summarized by two variables– Class– Social supports and social connectedness

• Disparities related to

Social Determinants– Income– Education– Social Determinants

System Interventions to Address Social System Interventions to Address Social Determinants of Health Determinants of Health

Four Points of Opportunity Where Policy or Four Points of Opportunity Where Policy or Systems Can Intervene to Affect Social Systems Can Intervene to Affect Social

Determinants of HealthDeterminants of Health

• Decrease social stratification• Decrease specific exposure to health-damaging

factors suffered by people in disadvantaged positions

• Seek to lessen the vulnerability of disadvantaged people to the health-damaging conditions they face

• Intervene 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, Early Disease Prevention, Risk Identification, and Intervention for Women, Children and and Intervention for Women, Children and

Adolescents 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; and– Oral health interventions

Early Intervention ProgressEarly Intervention Progress

Figure 25. Infant Mortality Rate for U.S. (1880-2000)

0

20

40

60

80

100

120

140

1880 1890 1900 1915-1919

1920-1924

1930-1934

1940 1950 1960 1970 1980 1990 2000

U.S. Census BureauDeaths per 1,000 births

Growing Threat of Chronic Disease Growing Threat of Chronic Disease and Associated Risk Factorsand Associated Risk Factors

Figure 27 . Kansas Obesity and Diabetes Prevalence (1992-2005)

0%

5%

10%

15%

20%

25%

30%

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Obesity Diabetes

Kansas Behavioral Risk Factor Surveillance

Early Intervention Early Intervention RecommendationsRecommendations

• Assure access to health care and preventive services for children and parents.

• Integrate efforts to affect the whole child’s emotional and social well-being.

• Promote the development and adoption of healthy lifestyles

Action Steps Selected for Action Steps Selected for Immediate Action Based on Immediate Action Based on

Three Cross-Cutting PrioritiesThree Cross-Cutting Priorities

• Tobacco

• Disparities Data

• Cultural Competency

• Overweight and Obesity

• Access

TobaccoTobacco

• #1 preventable cause of death in Kansas

• 17% of adults smoke

• Results in more than 3,800 deaths per year

• Cigarette use costs Kansas $724 million in direct medical costs

• If current trends continue, 54,000 children alive today will die of tobacco-related causes

Disparities DataDisparities Data• Recommendation: 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 CompetencyCultural Competency

• Definition: 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 TrendAdult Overweight/Obesity TrendFigure 30. Adult Obesity (BMI >=30) and Overweight (BMI >=25) by Year

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

1990 1992 1994 1996 1998 2000 2002 2004

Kansas Obesity U.S. ObesityKansas Overweight U.S. Overweight

Healthy People 2010 Obesity Target

Kansas Behavioral Risk Factor Surveillance System

Overweight/ObesityOverweight/Obesity

• Five national overweight/obesity prevention goals:1. Increase fruit and vegetable

consumption

2. Increase physical activity

3. Decrease “screen” time (TV, leisure computer, video games)

4. Increase breastfeeding

5. Balance caloric intake with expenditure

AccessAccessFigure 31. Percentage of Adults Who Lacked Health

Care Coverage

10.4 10.7 10.1 11.113.1 13.2

13.0

15.615.3

45.2

36.2

26.8

31.5

25.9

33.6

30.0

0

5

10

15

20

25

30

35

40

45

50

1999 2000 2001 2002 2003 2004 2005

Year

Per

cent

All Adults

Adults 18-64

Hispanic

Kansas Behavioral Risk Factor Surveillance System

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

The time is now…The time is now…

…the place is here…

…and it’s up to us.