Health and Wellbeing

Abigail Aiken • Elizabeth Armstrong • João Biehl • Jeanne Brooks-Gunn • Anne C. Case • Janet M. Currie • Sir Angus Deaton • Margaret Frye • Noreen Goldman • Bryan Grenfell • Sara F. McLanahan • C. Jessica E. Metcalf • Elizabeth Levy Paluck • Marta Tienda • James Trussell • Tom S. Vogl

Elizabeth Armstrong is working on a book manuscript, tentatively titled, How We Begin: The Origins of Fetal Personhood. The book explores the evolution of the belief that the fetus is a person in medicine, law, and popular culture. Armstrong is also interested in cultural attitudes and beliefs about risk during pregnancy and childbirth and policies related to maternity care in the United States. She is conducting research on medical professional attitudes towards home birth in the U.S. and on popular practices around childbirth. She has also investigated popular cultural practices regarding the placenta and is currently analyzing medical and scientific texts on placental form and function.

Elizabeth Armstrong anticipates continuing to work on reproduction from cultural and policy perspectives. She is beginning several smaller-scale research projects into various aspects of maternity care in the U.S. One of these is a history of policies and practices around pain relief during childbirth in the 20th century. Another investigates how negative birth experiences are framed in comparative perspective, whether as a form of PTSD in the U.S., as violence against women in Latin America, or as patient abuse in the U.K.

João Biehl’s main research centers on medical anthropology, the social studies of science and religion, global health, subjectivity, ethnography, and social and critical theory (with a regional focus on Latin America and Brazil). His present research explores the social impact of large-scale treatment programs in resource-poor settings and the role of the judiciary in administering public health in Brazil.

João Biehl is currently writing The Valley of Lamentation, a historical ethnography of the Mucker War, a religious war that shattered German-Brazilian communities in the 19th century. He is also working on a book titled, Anthropology of Becoming, and is collaborating on a book project on Oikographia, which foregrounds the house as a key site of empirical and conceptual analysis.

João Biehl’s present ethnographic research explores the social impact of large-scale treatment programs in resource-poor settings, the role of the judiciary in administering public health, and the emergence of the category of patient-citizen-consumers in Brazil. Biehl is also coordinating a research and teaching partnership between Princeton University and the University of São Paulo centered on medical anthropology, global health, and the social markers of difference, and is co-coordinating a collaborative network on Race and Citizenship in the Americas.

In the past two years, Anne Case’s research has focused on changing patterns of morbidity and mortality in midlife in the U.S., with a focus (to date) on white non-Hispanics in middle age. In academic year 2016-17, she plans to examine many of the questions that this research has brought to the fore. These will include differences in health and mortality between working class and wealthier Americans, differences between races and ethnicities, between men and women, between the U.S. and other OECD countries, and between age groups, to try to better understand the underlying causes of the reversal of mortality decline and of morbidity decline that is found among whites in middle-age in U.S.

Anne Case and co-author Angus Deaton, published a National Bureau of Economic Research (NBER) Working Paper titled, “Suicide, Age, and Wellbeing: An Empirical Investigation.” Together they found that suicide rates, life evaluation, and measures of affect are all plausible measures of the mental health and wellbeing of populations. Yet in the settings they examined, correlations between suicide and measured wellbeing are at best inconsistent. Differences in suicides between men and women, between Hispanics, blacks, and whites, between age groups for men, between countries or U.S. states, between calendar years, and between days of the week, do not match differences in life evaluation. By contrast, reports of physical pain are strongly predictive of suicide in many contexts. The prevalence of pain is increasing among middle-aged Americans, and is accompanied by a substantial increase in suicides and deaths from drug and alcohol poisoning. Their measure of pain is now highest in middle age—when life evaluation and positive affect are at a minimum. In the absence of the pain epidemic, suicide and life evaluation are likely unrelated, leaving unresolved whether either one is a useful overall measure of population wellbeing.

Anne Case and Angus Deaton’s paper, “Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century,” published in Proceedings of the National Academy of Sciences, documents a marked increase in the all-cause mortality of middle-aged white, non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population. The authors comment on potential economic causes and consequences of this deterioration.

Janet Currie’s work continues to follow several threads. First, she is concerned with investigating the fetal origins hypothesis, and examining the long-term impacts of health shocks in utero. Second, the evaluation (and sometimes unintended consequences) of programs or initiatives aimed at improving child health. Third, work on pollution and health, generally investigating the effect of low-level exposures. Fourth, the organization of medical care and what determines small-area (and even within hospital) differences in the ways that similar patients are treated.

In“Is there a Link Between Foreclosure and Health?” published in the American Economic Journal: Economic Policy, Janet Currie and Erdal Tekin (Georgia State University) investigate the relationship between foreclosures and hospital visits using data on all foreclosures and all hospital and emergency room visits from four states that were among the hardest hit by the foreclosure crisis. Together they found that living in a neighborhood with a spike in foreclosures is associated with significant increases in urgent unscheduled visits, including increases in visits for preventable conditions. The estimated relationships cannot be accounted for by increasing unemployment, declines in housing prices, migration, or by people switching from out-patient providers to hospitals.

Angus Deaton enthusiastically reviewed, “On Tyrannical Experts and Expert Tyrants,” for the Review of Austrian Economics in July 2015. He described William Easterly’s Tyranny of Experts as a paean to freedom, democracy, and the rights of the poor. It rightly damns the “technological illusion” that development is an engineering problem, not a political problem that cannot be solved by experts, particularly not by outside experts. Deaton went on to say that “it is too optimistic to believe that rights and democracy by themselves will guarantee growth and prosperity, and the argument that rights and democracy are both necessary and sufficient for population health is largely wishful thinking.”

Margaret Frye’s research focuses on a fundamental problem at the intersection of demography and cultural sociology: how does culture influence the plans and choices of individuals, producing the patterned behavior that one observes? She examines how socially structured standards of morality influence life course decision-making in contexts undergoing rapid cultural change. At each milestone on the transition to adulthood–continuing in school, starting a serious relationship, and having sex– her work demonstrates that individuals shape and reshape their life trajectories in accordance with these moral frames. Frye’s empirical research has primarily been based in Malawi, where she has looked at the influence of culture on educational choices, romantic experiences, and, most recently, men’s evaluations of women’s sexual desirability.

In a manuscript entitled, “Ideals as Anchors for Relationship Experiences,” published in American Sociological Review, Margaret Frye along with Jenny Trinitapoli (Pennsylvania State University) conducted research on young-adult sexuality in sub-Saharan Africa which typically conceptualizes sex as an individual-level risk behavior. They introduced a new approach that connects the conditions surrounding the initiation of sex with subsequent relationship wellbeing, examines relationships as sequences of interdependent events, and indexes relationship experiences to individually held ideals. New card-sort data from southern Malawi capture young women’s relationship experiences and their ideals in a sequential framework. Using optimal matching, they measured the distance between ideal and experienced relationship sequences to (1) assess the associations between ideological congruence and perceived relationship well-being, (2) compare this ideal-based approach to other experience-based alternatives, and (3) identify individual- and couple-level correlates of congruence between ideals and experiences in the romantic realm. Their research showed that congruence between ideals and experiences conveys relationship wellbeing along four dimensions: expressions of love and support, robust communication habits, perceived biological safety, and perceived relationship stability. They further showed that congruence is patterned by socioeconomic status and supported by shared ideals within romantic dyads. They argue that conceiving of ideals as anchors for how sexual experiences are manifest advances current understandings of romantic relationships, and suggest that this approach has applications for other domains of life.

Noreen Goldman, in collaboration with Andrea Graham (Princeton University, Department of Ecology and Evolutionary Biology) who has conducted assays of immune markers derived from frozen specimens in the Taiwan survey, has just begun to explore linkages between immune senescence, inflammation and the health and survival of older adults. Together with Dan Notterman (Princeton University, Molecular Biology Department), she will be using genetic information to explore determinants of depression and cognitive function of older adults in this survey.

In a separate project, Noreen Goldman has been examining the health of Mexicans both in the U.S. and in Mexico. Recent papers evaluate whether the survival advantage of Mexican Americans (relative to whites) is likely to endure in coming decades, whether there is evidence that less healthy Mexican immigrants in the U.S. are more likely to return to Mexico than their healthier counterparts, and whether older Mexicans whose children reside in the U.S. experience less social support and poorer health than those whose children remain in Mexico.

Bryan Grenfell co-authored a paper with Huaiyu Tian (Beijing Normal University), Sen Zhoub (Tsinghua University), Lu Dong (Beijing Normal University), Thomas P. Van Boeckel (Princeton University, Department of Ecology and Evolutionary Biology) et al. entitled, “Avian Influenza H5N1 Viral and Bird Migration Networks in Asia,” which was published in the Proceedings of the National Academy of Sciences. This paper reports that the spatial spread of the highly pathogenic avian influenza virus H5N1 and its long-term persistence in Asia have resulted in avian influenza panzootics and enormous economic losses in the poultry sector. However, an understanding of the regional long-distance transmission and seasonal patterns of the virus is still lacking. In this study, the authors present a phylogeographic approach to reconstruct the viral migration network. They show that within each wild fowl migratory flyway, the timing of H5N1 outbreaks and viral migrations are closely associated, but little viral transmission was observed between the flyways. The bird migration network is shown to better reflect the observed viral gene sequence data than other networks and contributes to seasonal H5N1 epidemics in local regions and its large-scale transmission along flyways. These findings have potentially far-reaching consequences, improving their understanding of how bird migration drives the periodic reemergence of H5N1 in Asia.

Bryan Grenfell along with Takahashi, S. (Princeton University, Department of Ecology and Evolutionary Biology) and C. Jessica Metcalf, Ferrari, M. J. (Pennsylvania State University), Truelove, S. A. (Johns Hopkins Bloomberg School of Public Health) et al. continue to analyze vaccination strategies for measles and rubella in Africa and other endemic countries. The major application this year was a novel assessment of the potential consequences of the West African Ebola epidemic on vaccination rates and epidemic potential of measles, published in Science, in a paper entitled, “Reduced Vaccination and the Risk of Measles and Other Childhood Infections post-Ebola.” This article states that the Ebola epidemic in West Africa has caused substantial morbidity and mortality. The outbreak has also disrupted health care services, including childhood vaccinations, creating a second public health crisis. They project that after six to 18 months of disruptions, a large connected cluster of children unvaccinated for measles would accumulate across Guinea, Liberia, and Sierra Leone. This pool of susceptibility increases the expected size of a regional measles outbreak from 127,000 to 227,000 cases after 18 months, resulting in 2000 to 16,000 additional deaths (comparable to the numbers of Ebola deaths reported thus far). There is a clear path to avoiding outbreaks of childhood vaccine-preventable diseases once the threat of Ebola begins to recede: an aggressive regional vaccination campaign aimed at age groups left unprotected because of health care disruptions.

Bryan Grenfell has generated the first major model of the spatiotemporal dynamics and control of Hand, Foot and Mouth Disease in China, on the eve of vaccine deployment. Grenfell has generated a major study on the dynamics of morbilivirus infections of cetaceans, in the face of a major epidemic. Other work this year explored the dynamics of malaria, chikungunya virus and other infections.

Antibiotic resistance is a major threat to humanity. Bryan Grenfell has published the first major study of the global distribution of antibiotic use in the meat and dairy industries, as well as a detailed review of the impact of coinfection on resistance.

In “Variation in Child Body Mass Patterns by Race/Ethnicity and Maternal Nativity Status in the United States and England,” published in Maternal and Child Health, Sara McLanahan, Melissa Martinson (University of Washington) and Jeanne Brooks-Gunn (Columbia University) conducted a cross-national comparison of children’s body mass patterns by race/ethnicity and mothers’ nativity status. The study was the first to examine race/ethnic and maternal nativity differences in BMI trajectories in both countries. Using data from the Fragile Families and Child Wellbeing Study and England’s Millennium Cohort Study, the researchers documented significant race/ethnic differences in initial BMI and BMI trajectories among children in both countries, with all non-white groups having significantly steeper BMI growth trajectories than whites. Nativity differences in BMI trajectories varied by race/ethnic group and were only statistically significantly higher for children of foreign-born blacks in England.

C. Jessica Metcalf’s research over the past two years has centered on the within-host demography of pathogens, or pathogen population growth, spread, and clearance within our bodies, shapes their ecology and evolution, driving outcomes of public health relevance such as the emergence of drug resistance. She has worked to articulate the core issues in a range of perspective papers, and via empirical work. The cross-scale dynamics of infectious disease drives its impact on human health, yet empirical studies tend to either focus on the within-host aspect, or the between-host aspect (transmission). She has also developed methods to bridge this gap. Both within-host and between-host dynamics will contribute to defining landscapes of immunity, a continuing focus of her work, and one that she has tackled in contexts of immediate public health relevance, such as in the wake of the Ebola outbreak. Overall her research blends basic ecological research and important applications. The underlying synthesis of demography and disease dynamics, across scales ranging from within host to across and between countries is a distinguishing feature of her work.

Over the next two years C. Jessica Metcalf will continue to focus on quantifying disease in motion as a core question in public health, and one that is often predicated on human migration and movement. She is leveraging novel data streams such as mobile phone call data records to capture both the patterns of seasonal human aggregation and its effects on transmission for directly transmitted pathogens (measles, rubella), but also patterns of local introduction for a broader range of infections (measles to malaria) for a range of countries and contexts. Patterns of re-introduction, in particular, are of increasing relevance in a public health landscape where disease elimination and eradication remain a central concern. Climatic drivers may shape both human movement and also pathogen ecology. Metcalf is also collaborating with researchers at NOAA/GFDL to describe climate influences on human movement at a range of scales, and to titrate the relative importance of these direct and indirect effects for a range of pathogens. This will open the way to longer term predictions of the outcome of climate change on human movement and the burden of infectious disease.

Two basic ideas motivate Elizabeth Paluck’s research. The first idea is that social psychological theory offers potentially useful tools for changing society in constructive ways. The second idea is that studying attempts to change society is one of the most fruitful ways to develop and assess social psychological theory. Much of Paluck’s work has focused on prejudice and conflict reduction, using large-scale field experiments to test theoretically driven interventions.

Despite a surge in policy and research attention to conflict and bullying among adolescents, Elizabeth Paluck finds little evidence to suggest that current interventions reduce school conflict. Using a large-scale field experiment in Changing Climates of Conflict: A Social Network Experiment in 56 Schools Paluck shows that it is possible to reduce conflict with a student-driven intervention. By encouraging a small set of students to take a public stance against typical forms of conflict at their school, Paluck’s intervention reduced overall levels of conflict by an estimated 30%. Network analyses reveal that certain kinds of students (called “social referents”) have an outsized influence over social norms and behavior at the school. The study demonstrates the power of peer influence for changing climates of conflict, and suggests which students to involve in those efforts.

In their study titled, “Birthing, Nativity and Maternal Depression: Australia and the United States” published in International Migration Review. Melissa Martinson (University of Washington) and Marta Tienda analyzes two birth cohort surveys, the Longitudinal Study of Australian Children and Early Childhood Longitudinal Study, to examine variation in maternal depression by nativity, duration of residence, age at migration, and English pro?ciency in Australia and the U.S. Both countries have long immigrant traditions and a common language. The results demonstrate that U.S. immigrant mothers are signi?cantly less depressed than native-born mothers, but maternal depression does not differ by nativity in Australia. Moreover, the association between duration of residence and maternal depression is not linear: Recent arrivals and long-term residents exhibit the highest depression levels. Lack of English pro?ciency exacerbates maternal depression in Australia, but protects against depression in the U.S. Differences in immigration regimes and welfare systems likely contribute to the differing salience of nativity for maternal depression.

Abigail Aiken and James Trussell’s report “Recent Advances in Contraception”, in the F100Prime Reports, focused on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives. Together, they reviewed recent advances in contraceptive development and discussed progress in policies to improve access to the most effective methods. They report on the shift in practice towards routinely providing IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of the insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, they describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, which comes with a preloaded inserter. They also discuss the efficacy of ulipristal acetate versus levonorgestrel for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of the increasing interest in providing IUCs and implants to women in the immediate postpartum and post abortion periods, they consider the rationale for this change in practice and review the progress that has been made so far in the U.S.

The commentary, “Immediate Postpartum Provision of Highly Effective Reversible Contraception” by Abigail Aiken, Catherine Aiken (University of Cambridge, UK), James Trussell, and Katherine Guthrie (Sexual and Reproductive Healthcare Partnership, Hull, UK) was published in An International Journal of Obstetrics & Gynaecology. This commentary notes that unintended pregnancies are associated with a higher risk of adverse maternal and neonatal outcomes, particularly when they occur within a short time interval from a previous birth. Early access to highly effective reversible intrauterine contraceptives (IUCs) and contraceptive implants in the postpartum period has been demonstrated to help women prevent unintended and rapid-repeat pregnancies. The authors discuss several compelling reasons for the immediate postpartum provision of such methods to women who desire them.

Intrauterine contraceptives (both copper intrauterine devices and levonorgestrel-releasing intrauterine systems) and implants are in the highest tier of contraceptive effectiveness because they require no active adherence on the part of the user. The provision of these methods in hospital following delivery is particularly attractive because it is convenient for women who may be highly motivated to prevent another pregnancy, and is logistically optimal in that health professionals trained in placement could be readily available. Despite previous concerns, the immediate postpartum placement of IUCs and implants is also extremely safe. There is no increased risk of pain, bleeding, infection, or uterine perforation for IUCs placed immediately (within 10 minutes of placental delivery), compared with delayed placement (weeks later).

The safety of immediate post-delivery placement of IUCs and implants is reflected in the World Health Organization Medical Eligibility Criteria for Contraceptive Use (WHO MEC), which provides evidence-based guidance regarding medical eligibility for specific contraceptive methods. This guidance is used by specialists in sexual and reproductive health worldwide to ensure that women are not exposed to inappropriate risk, while at the same time are not denied access to methods that are medically appropriate. It has been adapted for use in several countries, including the UK and the U.S.

In light of the Millennium Development Goal of reducing the worldwide maternal mortality ratio by three-quarters by 2015, and the resolution of the Parliamentary Assembly of the Council of Europe to reduce unintended pregnancy among EU member states, policies promoting the widespread availability of immediate postpartum IUCs and implants represent an important step towards improving women’s reproductive health worldwide.

The Health Grand Challenge funded by the Woodrow Wilson School has awarded Tom Vogl a Seed Grant for the 2015-2016 proposal, “Pollution, Early-Life Health, and Child Development in Developing Countries.” This proposal seeks to launch a research agenda that examines environmental influences on early-life health and child development in developing countries. Funding from an HGC small seed grant will enable the completion of the agenda’s first study, on the health consequences of air pollution from the harvesting of sugarcane, an important global energy source. Three new studies will examine the effects of agricultural air pollution, urban water pollution, and slum conditions on child health and development.

Much of the proposed research focuses on Brazil, so a key component of the proposal is its funding of undergraduate summer field research abroad. On campus, undergraduate and graduate students will have opportunities to collaborate on the proposed research, and findings will be incorporated into a range of interdisciplinary teaching activities. Beyond this educational use, the findings of the proposed research will have important implications for policymakers in developing countries seeking to balance population health with energy sustainability, agricultural livelihood, and rapid urbanization.