we may be rough, and we have to be tough. healthier, longer lives

We may be rough, and we have to be tough

Healthier, Longer Lives

Healthiest State in Nation

Where Have We Been?

100 years ago, how many babies born

in Maine died before their 5th birthday?

1 in 5 , 1 in 8 before their 1st birthday

Where Have We Been?

Where Have We Been?

Today, how many babies born in Maine die before their 5th birthday?

1 in 800

Or, 1 in 1,000 not counting prematurity

Where Have We Been?

Aren’t these successes due to advances in health care and education of mothers?

What did Maine children diefrom 100 years ago?

1. Diarrhea

2. Vaccine-Preventable Infections: Influenza, Diphtheria, Pertussis, Meningitis, Measles, Tetanus, Polio, Smallpox

3. TB

4. Pneumonia

INFANT DEATHS PER 1,000 LIVE BIRTHSMaine, 1892-2007

0

20

40

60

80

100

120

140

1892 1897 1902 1907 1912 1917 1922 1927 1932 1937 1942 1947 1952 1957 1962 1967 1972 1977 1982 1987 1992 1997 2002 2007

YEAR

Where Have We Been?

Top Reasons for Infant MortalityDecline:

• Sanitary conditions during birth and perinatal period

• Safe drinking water

• Vaccines

Where Have We Been?

What were the top causes of death among adults 100 years ago in Maine?

Where Have We Been?

Tuberculosis Deaths per 100,000 Population Maine, 1892-2007

0

50

100

150

200

250

1892 1897 1902 1907 1912 1917 1922 1927 1932 1937 1942 1947 1952 1957 1962 1967 1972 1977 1982 1987 1992 1997 2002 2007

Year

Where Have We Been?

My Own Journey to Public Health

Shirati, Tanzania

Shirati Tanzania

Where Are We Now?

Chronic Diseases

• Leading causes of death and disability

• ~75% of Mainers will die from 1 of 4 diseases – CVD, Cancer, Diabetes, Chronic Lung Disease

• Mostly preventable – Tobacco and Obesity

• Direct health care costs = 40% of Maine’s Health Care Budget

Cardiovascular Disease

• #1 cause of death and disability

• 40% of all deaths

• 25% of all hospital costs

Cancer

• #2 cause of death

• 65% due to Tobacco or Obesity

• Most are curable if screened, detected, and treated early

Lung Cancer Deaths per 100,000 Population Maine, 1900-2007

0

10

20

30

40

50

60

70

80

1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

Rat

e p

er 1

00,0

00 P

op

ula

tio

n

1918-1936 data unavailable

Leading 4 Cancers That Kill Maine PeopleIncidence And Mortality Rates

Age-Adjusted Rate Per 100,000 Population

Maine 2001-2003

76.9

131.1

167.7

56.961.4

24.329.1

20.7

15

35

55

75

95

115

135

155

175

Lung Cancer (both sexes) Female Breast Cancer Prostate Cancer (males) Colorectal Cancer (bothsexes)

Incidence Mortality

Note: Mortality rates would be expected to decline only if incidence and/or percentage of late-stage disease declines (treatment advances have not recently been responsible for dramatic changes in survival.)

Diabetes

• 8% of adult Mainers now have diabetes; - 3% did 10 years ago.

• 11% of pregnant Maine women have diabetes; - less than 2% did 20 years ago.

Mainers with Diabetes1988-2007

42,355

38,179

42,211

37,927

34,11432,331

39,449

45,848

33,495

50,415

56,449

64,931

71,557

74,67376,683 77,219

72,667

82,709

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

No data available for

1992 and 1993

Lung Disease

• Asthma

• Emphysema, Chronic Obstructive Pulmonary Disease

Proportion of Adults With AsthmaMaine and U.S. - 2007

8.4%

10.3%

0%

5%

10%

15%

Maine U.S.

Proportion of Children With Asthma2004

11.6%

15.8%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Maine U.S.

Dental Disease

• 1 in 3 Mainers over age 65 have lost all their teeth

• 40% of Maine 3rd graders have tooth decay

• Highly associated with other chronic diseases

Mainers suffering from frequentmental distress are twicetwice as likely to:

• Have Diabetes

• Be Tobacco Addicted

• Have Asthma

What Are Two Big Factors Associated with Poor Health?Poverty

Racial Discrimination

What Are Effective What Are Effective Strategies?Strategies?

Tertiary Prevention Strategies – Treating Illness

Secondary Prevention Strategies – Reducing Risks

Primary Prevention Strategies – Preventing Risks

• State and Community Interventions

• Health Communication

• Surveillance and Evaluation

Primary Prevention Strategies

Statewide Intervention:

Tobacco Tax

1991 $0.37

1997 $0.74

2001 $1.00

2004 $2.00

Statewide Intervention:Laws Banning Smoking

1981 Public meetings

1983 Court houses

1985 Stores

1986 Most workplaces

1989 Hospitals, except psychiatric patients and hospitals

1999 Restaurants

2003 Bars

2005 All loopholes closed2007 School grounds2009? Public beaches, outdoor eating

Community Intervention - Healthy Maine Partnerships

• 28 Comprehensive Community Health Coalitions

• Cover all of Maine

• Funded with Tobacco Settlement andFederal Funds

• Tobacco, Obesity, Substance Abuse community interventions

Smoke Free Parks

City/Town ordinances for walkable communities

Food policies for organizations

X

Health Communication Goals

• Change culture

– Secondhand smoke

– Children watching TV

– Walking

– Portion Sizes

• Support community and statewide interventions

• Promote quitting Tobacco

Secondary Prevention

Motivate Tobacco Users to Quit

Improved TreatmentImproved Treatmentof Chronic Diseasesof Chronic Diseases

Tertiary PreventionTertiary Prevention

Care Model

• Decision Support

• Information Systems

• Self-Management Support

Decision Support & Information Systems- Diabetes

• Diabetes Registries

• Learning Collaboratives

Self-Management Support

• Diabetes Educators

• Diabetes Support Groups

Examples of SuccessExamples of Success

Coronary Heart Disease DeathsAge-Adjusted Rate Per 100,000 PopulationMaine And US Selected Years 1990-2004

177.4

129.9143.4

150.8160.9

169.7176.7

187.5199.7195.5

207.3212.1220.8

212.7

238.6242.4

192.7183.8

200.3205.0

211.4220.3

227.2232.0

240.1239.6247.5

257.2

100

120

140

160

180

200

220

240

260

280

300

1990 1992 1994 1996 1998 2000* 2002 2004

Maine Coronary Heart Disease Deaths US Coronary Heart Disease Deaths

* Indicates preliminary data

Note: Coronary Heart Disease = ICD-9 Codes 402, 410-414, 429.2; and for years 1999 and 2000, ICD-10/11, I20-I25.

166.0

Stroke DeathsAge-Adjusted Rate Per 100,000 Population

Maine And US 1990-2005

60.9

56.6

59.6

53.6

58.6 58.0 58.0

55.754.2

57.055.5 55.6

50.9

51.8

53.7

51.4

54.255.8

62.9

60.759.8

60.9 60.9 61.5 61.059.8

57.659.8

58.7

40

45

50

55

60

65

70

1990 1992 1994 1996 1998 2000* 2002 2004

Maine Stroke Deaths US Stroke Deaths

51.0

* Indicates preliminary data

Note: Stroke = ICD-9 Codes 430-438; and for years 1999 and 2000, ICD-10 I60-I69.

Overall Cancer Incidence RatesAge-Adjusted Rate Per 100,000 Population

Maine And US 1990-2003

490.7

500.8

474.3 471.6

498.2

515.1

474.2465.8

458.5

449.0456.3456.3

446.0

419.5

467.7

487.5495.1

487.7494.5492.0

487.9480.8480.1

486.8

496.9

517.3510.8

489.5

400

420

440

460

480

500

520

540

1990 1992 1994 1996 1998 2000 2002 HealthyMaine2010

Target

Cas

es P

er 1

00,0

00

All Cancers, Total Maine All Cancers, Total US

Source: Maine Department of Human Services, Bureau of Health, Maine Cancer Registry.SEER (Surveillance Epidemiology and End Results) - whites only, NCHS (National Center for Health Statistics) - for Maine and for US whites at http://wonder.cdc.gov; Age-adjusted rate per 100,000.

Slightly Lower

Incidence Rate

Overall Cancer DeathsAge-Adjusted Rate Per 100,000 Population

Maine And US 1990-2003

204.1

212.5207.5

213.9

226.3

234.5230.7

233.6

227.1 227.2

218.9 217.5

210.2214.4

188.3191.8

193.6196.3

210.4 210.6 209.2 209.2 207.8206.1

203.4199.9

197.6 197.8

180

190

200

210

220

230

240

250

1990 1992 1994 1996 1998 2000* 2002 HealthyMaine2010

Target

Maine Overall Cancer Deaths US Overall Cancer Deaths

*Note: Because 1999 data is coded according to ICD-10 Coding rules and 1990-1998 is coded using ICD-9 coding rules,

comparisons between 1998 and 1999 may not be accurate. Mortality rates would be expected to decline only if incidence

and/or percentage of late-stage disease declines (treatment advances have not recently been responsible for dramatic

changes in survival).

Slight

Decrease

in Mortality

Smoking Rates - High School Students Maine & US, 1993-2007

14

28.5

23

16.2

20.5

25

28.6

39.237.8

32.6

30.5

34.836

34.6

21.9

0

50

1993 1995 1997 1999 2001 2003 2005 2007

Per

cen

t

Maine High School Students

US High School Students

Smoking Rates - High School Students, Maine & US, 1993-2007Source: Maine Department of Education, Youth Risk Behavior Survey, 1993, 1995, 1997, 1999, 2001, 2003, 2005, 2007 1999 data is unw eighted .

64%

Drop!

Smoking Rates - Middle School Students Maine 1997-2007

21.0

7.5

5.7

8.79.9

0

25

1999 2001 2003 2005 2007

Per

cen

t

Smoking Rates, Middle School Students, Maine 1997-2007Source: Maine Department of Education, Youth Risk Behavior Survey, 1997, 2001, 2003, 2005, 2007

73%

Drop!

Cigarette Consumption - Packs Sold Per Capita Maine and US 1990-2006

60

70

80

90

100

110

120

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Pac

ks p

er C

apit

a

Packs per capita Maine

Packs per capita US

Source: The Burden on Tobacco, Orzechowski and Walker

Maine Consumption of CigarettesPacks per Capita Sold

116.1114.5

108.5

101.6 102.3100 101.1

94.5

85.582.9

81.279.6

74.672.4 71.5

64.8

117.5

60

70

80

90

100

110

120

130

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Nu

mb

er

of

packs s

old

per

cap

ita

**

** Excise Tax Increases

*

Maine Revenue Service, published in The Tax Burden On Tobacco, Orzechowski and Walker

Cigarette Smoking AdultsMaine And US 1990-2005

27.0%

26.1%

23.3%

24.7%

23.6%

25.0%25.3%

22.7%22.4%

23.3%23.8%

23.8%

23.2%22.0%

20.9% 20.6%

23.0%

23.1%

22.2%

22.6% 22.7%22.4%

23.4%

23.2%22.9%

22.6%23.2%

23.9%23.6% 23.7%

21.0%20.8%

15%

20%

25%

30%

1990 1992 1994 1996 1998Baseline

2000 2002 2004 HealthyMaine2010

Target

Maine Adults US Adults

19%

Where Are We Going?

Patient Centered Medical Home

Public Health Infrastructure

Existing players, newmodel for coordination

• 8 DHHS Districts

• Strengthened Local Health Officer system

• Some core public health functions carried out by Healthy Maine Partnerships

• 8 District Coordinating Councils (DCCs)

• District Public Health Units

• MCDC Office of Local Public Health

Goals of thePublic Health System:

• helping Maine become the healthiest state in the nation;

• readying and maintaining the state public health system for national federally-recognized public health accreditation;

• assuring the effectiveness, efficiencies, and evidence-based delivery of the essential public health services.

Healthy Communities

But the cause for which we fought was higher; our thought wider... That thought was our power.

- Joshua Chamberlain- Joshua Chamberlain

If facts are the seeds that later produce knowledge and wisdom, then the emotions and the impressions of the senses are the fertile soil in which the seeds must grow.

- Rachel CarsonRachel Carson