Health and Wellbeing

Elizabeth Armstrong • João Biehl • Anne C. Case • Janet M. Currie • Angus S. Deaton • Thomas J. Espenshade • Noreen Goldman • Bryan Grenfell • Chioun Lee • Germán Rodríguez • Nicole K. Smith • Sarinnapha Vasunilashorn • Tom S. Vogl • Brandon G. Wagner • Charles F. Westoff

Elizabeth Armstrong has been researching the origins and consequences of the idea of fetal personhood, tracing the evolution of the belief that the fetus is a person in medicine, law and popular culture. She is planning on publishing a book tentatively titled How We Begin: The Origins of Fetal Personhood.

Collaborating with postdoctoral fellows, Elizabeth Armstrong is working on sexist attitudes and gender equity at the societal level, the cultural backlash against breastfeeding and the political economy of infant feeding, and ideas about fetal origins of adult health and disease and the phenomenon of fetal microchimerism. With collaborators Dan Carpenter (Harvard) and Marie Hojnacki (Penn State), Armstrong continues to collect and analyze data on public attention to disease. With data on attention to 40 diseases over a 25-year time period in multiple arenas collected, they have recently begun conducting a series of analyses. They will begin work on a book tentatively titled Disease Wars about competition among disease advocates for attention and resources in the public arena.

João Biehl’s main research and teaching interests center on medical anthropology, the social studies of science and religion, global health, subjectivity, ethnography and social theory (with a regional focus on Latin America and Brazil). Biehl is the co-editor of the books When People Come First: Critical Studies in Global Health (Princeton University Press) and Subjectivity: Ethnographic Investigations (University of California Press). He is also co-editor of the book series Critical Global Health: Evidence, Efficacy, Ethnography (Duke University Press).

In 2013, João Biehl and Adriana Petryna (University of Pennsylvania) edited, When People Come First: Critical Studies in Global Health. This book assesses the expanding field of global health. It brings together an international and interdisciplinary group of scholars to address the medical, social, political, and economic dimensions of the global health enterprise through vivid case studies and bold conceptual work. The book demonstrates the crucial role of ethnography as an empirical lantern in global health, arguing for a more comprehensive, people-centered approach. Topics include the limits of technological quick fixes in disease control, the moral economy of global health science, the unexpected effects of massive treatment rollouts in resource-poor contexts, and how right-to-health activism coalesces with the increased influence of the pharmaceutical industry on health care. The contributors explore the altered landscapes left behind after programs scale up, break down, or move on. They learn that disease is really never just one thing, technology delivery does not equate with care, and biology and technology interact in ways they cannot always predict. The most effective solutions may well be found in people themselves, who consistently exceed the projections of experts and the medical-scientific, political, and humanitarian frameworks in which they are cast.

An updated edition of João Biehl’s Vita: Life in a Zone of Social Abandonment, Updated with a New Afterword and Photo Essay was published by the University of California Press in 2013. This book along with Biehl’s, Will to Live: AIDS Therapies and the Politics of Survival, published by Princeton University Press are ethnographic studies of the experience and treatment of mental illness and AIDS, respectively. Both Vita and Will to Live explore new geographies of access and marginalization that have emerged alongside pharmaceutical globalization. They also elaborate on networks of care that poor urban patients create in their daily struggles to survive.

Vita looks at zones of social abandonment that are emerging everywhere in Brazil’s big cities—places like Vita, where the unwanted, the mentally ill, the sick, and the homeless are left to die. This story centers on a young woman named Catarina, increasingly paralyzed and said to be mad, living out her time at Vita. Biehl leads a detective-like journey to know Catarina; to unravel the cryptic, poetic words that are part of the “dictionary” she is compiling; and to trace the complex network of family, medicine, state, and economy in which her abandonment and pathology took form.

Vita garnered six major book awards, including the Margaret Mead Award of the American Anthropological Association and the 2013 J.I. Staley Prize. Will to Live received the Wellcome Medal of Britain’s Royal Anthropological Society and the Diana Forsythe Prize of the American Anthropological Association. Biehl received the Rudolph Virchow Award for his articles “The Activist State” and “Pharmaceuticalization.”

João Biehl’s research in 2013 also included exploring consequences of Brazil’s constitutional right to health. He has documented the emergence of right-to-health litigation in that country over the past decade. Information gathered through visits to courtrooms and clinics to meet patients and record their stories, combined with rigorous evaluation of medical and legal data, was used by Biehl, a native of Brazil, and his research team to create a detailed picture of who sues for treatment and why in this country with a population of about 200 million people and a rising economy.

His work has helped dispel myths that Brazil's universal healthcare and judicial system are being largely misused by well-off individuals to gain access to expensive and unnecessary medications, and has led to a broader debate about social justice and access to medical technologies.

Biehl’s research has been supported by grants from the John Simon Guggenheim Memorial Foundation, the John D. and Catherine T. MacArthur Foundation, the Wenner-Gren Foundation, the Ford Foundation, Princeton’s Health Grand Challenges Initiative, and Princeton’s Council of International Teaching and Research.

For the past four years Anne Case’s work has been focused in two areas. The first documents the impact of early-life health and circumstance on health, cognitive function and economic status over the life-course, in both developed and developing countries, and investigating the mechanisms through which early-life circumstances matter. The second investigates the impact of the AIDS pandemic on several dimensions of life in Africa.

Janet Currie’s research explores two main questions. The first focuses on determinants of fetal health, and its long term consequences for human capital formation. She investigates pollution, stress, and nutrition during pregnancy as factors that affect infant health. The second line of research focuses on factors related to the inefficient provision of medical care (either over-provision or under-provision). Papers in this line of work look at factors such as the tort system and incentives facing providers.

Childhood obesity has both immediate and long-term effects on health. In her recent paper with David Ludwig (Boston Children’s Hospital) and Heather Rouse (University of Arkansas for Medical Sciences), “Pregnancy Weight Gain and Childhood Body Weight: A Within-Family Comparison,” Janet Currie found that the initial problems are usually psychological. Obese children often experience discrimination, leading to low self-esteem and depression. Their physical health also suffers. They are more likely to be at risk of cardiovascular disease from high cholesterol and high blood pressure. They may also develop pre-diabetes or diabetes type II. In the long-term, obese children tend to become obese adults, putting them at risk of premature death from stroke, heart disease, or cancer.

In Janet Currie’s paper with Maya Rossin-Slater (Columbia University), “Weathering the Storm: Hurricanes and Birth Outcomes,” they looked at the growing literature suggesting that stressful events in pregnancy can have negative effects on birth outcomes. Using millions of individual birth records, they found that exposure to hurricane during pregnancy increases the probability of abnormal conditions of the newborn such as being on a ventilator more than 30 minutes and meconium aspiration syndrome (MAS). Their results suggest that measured effects of stressful events on these outcomes are sensitive to specification and it is preferable to use more sensitive indicators of newborn health.

Angus Deaton’s current research focuses on the determinants of health and well-being, particularly on relationships with income (both domestically and internationally), the determinants of health in rich and poor countries, and on the measurement of poverty in India and around the world. He also maintains a long-standing interest in the analysis of household surveys.

Angus Deaton’s research on wellbeing continues with several papers co-authored with Arthur A. Stone (Stony Brook). These papers include: “Subjective Wellbeing, Health, and Ageing,” with Andrew Steptoe (University College London) and Arthur A. Stone, The Lancet, forthcoming; “Two happiness puzzles,” with Arthur A. Stone published in the American Economic Review, Papers and Proceedings; “Grandpa and the Snapper: The Wellbeing of the Elderly Who Live with Children,” with Arthur A. Stone, NBER Working Paper 19100, 2013 and forthcoming in David A. Wise, Editor, Discoveries in the Economics of Aging, Chicago University Press; “Do Context Effects Limit the Usefulness of self-reported wellbeing measures?” with Arthur A. Stone and “Evaluative and Hedonic Wellbeing of Those with and Without Children at Home,” also written with Arthur A. Stone, and both submitted.

Angus Deaton’s health status and economics work is concerned with the "social" determinants of health, how people's incomes, their education, and the characteristics of the societies in which they live, affect their health status and their life chances. It is also concerned with how the findings affect the way that researchers think about wellbeing and about policy towards health and poverty.

For the U.S., recent work has focused on the effects of income inequality on health, and on the finding that the racial composition of states and cities affects the mortality rates of the people who live there. Angus Deaton has also looked at the policy implications of the relationship between socioeconomic status and health. For developing countries, work on India and South Africa has looked at how one might measure wellbeing, taking into account economic and health status. The Udaipur Health Survey is one of Deaton’s current research projects in India.

Thomas Espenshade and researchers at Princeton University are looking for new ways to measure a person’s sense of wellbeing with mobile devices. To gain a better understanding of how cellphones and other mobile devices can gauge our sense of happiness, the research team conducted a study that was published recently in the journal Demography. In their article “New Approaches to Human Mobility: Using Mobile Phones for Demographic Research,” John R. B. Palmer (Ph.D. Candidate), Thomas J. Espenshade, Frederic Bartumeus (Movement Ecology, the Center for Advanced Studies of Blanes, Spain), Chang Y. Chung (Statistical Programmer, Princeton University), Necati Ercan Ozgencil (Professional Specialist at Princeton University), and Kathleen Li (Princeton University, Undergraduate Class of 2010) explore new methods for gathering and analyzing spatially rich demographic data using mobile phones. The article describes a pilot study, “The Human Mobility Project,” in which volunteers around the world were successfully recruited to share GPS and cellular tower information on their trajectories and respond to dynamic, location-based surveys using an open-source Android application. The pilot study illustrates the great potential of mobile phone methodology for moving spatial measures beyond residential census units and investigating a range of important social phenomena, including the heterogeneity of activity spaces, the dynamic nature of spatial segregation, and the contextual dependence of subjective well-being.

This collaborative research project involves faculty, graduate students, and undergraduates in Computer Science, Electrical Engineering, OPR, Sociology, and the WWS. Its broad aim is to extend a pilot study on the use of T-Mobile’s G1 phone and Google’s Android platform to track human location and movement. The objectives are to (1) develop an Android-based application for recording and transmitting data from the phone’s internal GPS receiver, wireless network interface, compass, and accelerometer, (2) develop a central system for collecting and analyzing such data, (3) evaluate the strengths and limitations of both the G1 hardware and the Android platform through a small scale, campus-based trial, and (4) develop a strategy for large scale testing and research.

As part of the Taiwan project, Noreen Goldman will be using genetic information (e.g., telomere length, and genetic markers related to depressive symptoms and cognitive function) to explore links among stressful experience, physiological measures and mental, physical and cognitive health. This past year, she began a collaboration with Andrea Graham in the EEB department to assay additional markers related to inflammation and infection from frozen Taiwan blood samples in an effort to explore recent hypotheses regarding immune senescence and auto-immunity among older adults. She submitted a grant proposal to NIA to extend the Taiwan project to use newly collected data and biological assays to further their understanding of linkages among the social environment, biomarkers of health, and survival, including the influence of childhood exposure to disease in later life. In the coming months, she is planning to submit a proposal to NICHD to extend the Hispanic health project to evaluate the consequences of the migration of adults in Mexico (to other locations within Mexico and to the U.S.) on their children and older parents who remain at home.

Bryan Grenfell is a population biologist, working at the interface between theoretical models and empirical data with particular interest in the dynamics and control of infectious diseases in space and time. He combines the development of theory with analyses of empirical data sets from a range of diseases, including measles, rotavirus and influenza. His recent focus has been on combining basic developments in infectious disease dynamics with application to public health as well as on investigating how the interaction of noise and non-linear density-dependent feedback drive population processes at different scales. Other areas of study include understanding the spatiotemporal dynamics of infectious disease and how these are affected by control strategies and Phylodynamics, the exploration of how pathogen phylogenies are affected by host immunity, transmission bottlenecks and epidemic dynamics — at scales from individual host to population.

In 2013 Bryan Grenfell’s work on the dynamics of measles in developed and developing countries and control implications of vaccine refusal resulted in several publications including “Think globally, act locally: the role of local demographics and vaccination coverage in the dynamic response of measles infection to control,” written with Ferrari Matthew J. Ferrari (Penn State) and Peter M. Strebel (WHO, Geneva) and published in Philosophical Transactions of the Royal Society. Other areas of focus this past year include: spatiotemporal dynamics of human influenza in the United States; linking within-host and population dynamics of human, equine and avian influenza; exploring epidemiological and evolutionary implications of novel broad spectrum influenza vaccines; the dynamics of Hand, Foot and Mouth Disease, a major infection of children in SE Asia and the impact of new, cross protective influenza vaccines; population dynamics and control of rotavirus; research on the nonlinear dynamics and control of rotavirus, norovirus and typhoid fever. Grenfell is also working on developing new, publically available platforms for inferring epidemic parameters for all these infections from noisy epidemiological data.

In a paper forthcoming in Journal of Aging and Health, Chioun Lee, Germán Rodríguez, Dana Glei (Georgetown University), Maxine Weinstein (Georgetown University), and Noreen Goldman have examined the extent to which the death or illness of a spouse—a stressful life transition in old age—affects the blood glucose levels of older Taiwanese. They found that women whose husbands suffer a decline in health experienced an increase in blood glucose levels, but a decline in wives’ health does not significantly change husbands’ glucose levels. The death of a healthy spouse—an unexpected life event—is associated with a substantial increase in blood glucose levels for both genders, but losing a spouse in very poor health—a more predictable event—is associated with a relatively small increase in glucose levels for women. These findings underscore, that stressful life transitions may compromise the blood glucose levels of older adults. Taking on a caregiving role may erode some of the benefits of marriage and interfere with women’s maintenance of their own health. Health educators and medical professionals should know that older adults who experience such stressful life transitions may be at high risk for developing diabetes.

In an effort to prospectively study how women perceive changes in their sexual health and functioning upon initiating a contraceptive method, Nicole Smith is leading a research initiative called “The Birth Control Project: A Longitudinal Study of Women’s Contraception Use and Sexual Health.” One of the sad ironies of contraception is that once a woman begins using a method for non-procreative sex she may be less inclined to desire, initiate, engage in or feel pleasure during sexual activity. The Birth Control Project is an online longitudinal study of women’s contraception use and related sexual health outcomes. Funded by a grant from the Patty Brisben Foundation for Women’s Sexual Health, participants are actively being recruited in family planning clinics and student health centers in four states across the U.S. including Montana, Indiana, New Jersey and Utah. Women between the ages of 14 and 45 who are initiating a new contraceptive method and who have not used a hormonal method for at least two months are eligible to enroll. Women using non-hormonal methods exclusively are being recruited for comparison purposes. Follow-up surveys are emailed after 3, 6, and 9 months to assess: 1) rates of method continuation; 2) reasons for switching or discontinuing contraception; 3) experiences with a wide range of side effects; 4) perceived changes in sexual function and 5) sexual behaviors and relationship dynamics over time. Participants receive $10 for each survey completed. To date, approximately 260 women are participating in the study and recruitment is ongoing. Initial findings indicate that over 12% of women have switched methods and an additional 12% have discontinued the use of contraception within the nine-month timeframe. Findings from this study will provide much-needed context and a better understanding of how reproductive behaviors and contraception use fit into a larger sexual health framework.

In “Weight Status in Adolescence is Associated with Later Life Functional Limitation,” published in the Journal of Aging Health, Sarinnapha Vasunilashorn and Melissa Martinson (University of Washington) examine the relationship between weight status in adolescence and later life functional limitations. They used the Wisconsin Longitudinal Study to characterize the relationship between standardized relative body mass ascertained from high school photograph portraits in 1957 and self-reported functional imitations in 2004. Compared to individuals with normal body mass, participants who were overweight in high school had poorer later life physical function, with observed gender differences. Women who were underweight in adolescence had better functioning in older adulthood than their normal weight counterpart. This relationship, however, was not found among men.

In “Perceived stress and mortality in a Taiwanese older adult population” published in Stress, Sarinnapha Vasunilashorn, Dana Glei (Georgetown University), Maxine Weinstein (Georgetown University) and Noreen Goldman use proportional hazard models to determine whether perceived stress predicted 11-year mortality in a population of older Taiwanese adults. After adjusting for sociodemographic factors only, they found that a one standard deviation increase in perceived stress was associated with a 19% increase in mortality risk during the 11-year follow-up period; this was no longer significant in the fully adjusted model that included medical conditions, mobility limitations, and depressive symptoms. The strength of the relationship was substantially attenuated when they excluded the item indicating perceived stress about the respondent’s own health. In the fully adjusted model, perceived stress was not a significant predictor of mortality. Perceived stress predicted all-cause mortality in an older adult population in Taiwan, but the relationship was greatly attenuated when perceptions of stress regarding health were excluded, and was not significant after adjusting for medical conditions, mobility limitations, and depressive symptoms.

Sarinnapha Vasunilashorn also authored “Retrospective reports of weight change and inflammation in the U.S. National Health and Nutrition Examination Survey,” published by Journal of Obesity which investigates the association between weight change and inflammation in a nationally representative population of adults aged 40 and older. Using the U.S. National Health and Nutrition Examination Survey (2005-2008), logistic regression models were used to determine the relationship between high levels of inflammation (C-reactive protein [CRP]) and infection (white blood cell count [WBC]) with 1- and 10-year change in self-reported weight status. The results show that change in 1- and 10-year weight was associated with high CRP but not high WBC. Individuals who gained or lost ≥10 kg had an odds of having high CRP that was 1.96 (95% CI 1.11-3.50) and 1.61 (95% CI 1.02-2.46) as high, respectively, as those who maintained a stable weight (<4 kg change) in the past year. The increased risk of elevated CRP among individuals who experienced at least 10 kg of weight loss or weight gain was also observed for weight change that occurred over the past 10 years; however, weight loss over the 10-year period was no longer associated with high inflammation. Vasunilashorn’s conclusion suggests that adult respondents who retrospectively self-reported weight loss or gain had higher levels of inflammation relative to their weight stable counterparts.

“Apolipoprotein E and measured physical and pulmonary function in older Taiwanese adults,” published in Biodemography and Social Biology which Sarinnapha Vasunilashorn authored with D. Glei (Georgetown), Y.H. Lin (Population and Health Center, Department of Health, Taiwan), and Noreen Goldman examines apolipoprotein E (ApoE) gene, which has three common alleles (ϵ2, ϵ3, and ϵ4), and its linkage to a number of health outcomes and longevity. The ϵ2 allele has been reported to have neuroprotective effects, whereas the ϵ4 allele has been shown to be a risk factor for cardiovascular disease and Alzheimer's disease in various populations. The relationships between ApoE and mortality and ApoE and physical function, however, are not clear-cut. They used the Social Environment and Biomarkers of Aging Study (SEBAS) to examine the relationship between ApoE polymorphisms and physical and pulmonary function in approximately 1,000 Taiwanese adults aged 53 years and older in 2006. In the 2006 SEBAS wave, measures of physical function included self-reported difficulties with respect to activities of daily living (ADLs) and other physical function indicators, as well as performance-based measures of grip strength (kg), walking speed (m/s) over a distance of 3 m, and chair stand speed (stand/s). Peak expiratory flow (PEF; L/min) rate was also examined as an indicator of pulmonary function. The researchers used logistic regression models to determine the association between ApoE and inability to complete each of the tests of physical and pulmonary function. These models revealed no significant association between ApoE carrier status and any of the indicators of function. Among participants able to complete a given task, next they used linear regression models to examine self-reported limitations with ADLs and performance on the given test by ApoE carrier status. Similarly, there were no significant relationships between ApoE carrier status and the measures of function. Their estimates provide further confirmation that the ApoE gene may not be a risk factor for functional decline among older Taiwanese adults.

Tom Vogl is an applied economist with interests in the economics of health and population, particularly among the socially and economically disadvantaged. While there is a growing literature documenting the links between long-term outcomes and health in the fetal period, infancy, and early childhood, a large proportion focuses on rich countries. Vogl’s recent research has examined this relationship in developing countries and has been published in 2013 as “Early-Life Health and Adult Circumstance in Developing Countries” (with Janet Currie) in the Annual Review of Economics. They survey recent evidence on the adult correlates of early-life health and the long-term effects of shocks due to disease, famine, malnutrition, pollution, and war. Sibling rivalry is examined in “Marriage Institutions and Sibling Competition: Evidence from South Asia,” and appeared in the Quarterly Journal of Economics.

In a study on genes and society published in the American Journal of Public Health special issue entitled, “Gene-environment Correlation: Difficulties and a Strategy Based on a Natural Experiment,” Brandon Wagner, with co-authors Jiang Li, Hexuan Liu, and Guang Guo (University of North Carolina) explored correlations between genes and environments. These correlations have been implicated as potential threats to estimation of genetic and environmental main effects, as well as gene-environment interactions. Combining multiple datasets, they find evidence of such a correlation, but that natural experiments, like random roommate assignment, could protect against this threat.

Based on national Demographic and Health Surveys (DHS) conducted in Cambodia in 2000, 2005 and 2010, Charles Westoff examined the reproductive preferences of Cambodian women and men. In a DHS Further Analysis Report, Reproductive Preferences in Cambodia: Further Analysis of the Cambodia Demographic and Health Surveys, Westoff, along with Kristin Bietsch (Ph.D. candidate, Princeton University) and Rathavuth Hong (ICF Macro), determined that the marital fertility rate declined from 4.5 to 3.5 during those years. These sharp declines were caused mainly by increases in the use of modern contraception among married women from 19 percent in 2000 to 35 percent in 2010, as well as from an increase in the abortion rate which reduced unintended births.

A recently published monograph in the DHS Analytical Studies, “Indicators of Trends in Fertility in sub-Saharan Africa,” Charles Westoff, along with Kristin Bietsch and Dawn Koffman (Princeton University), studied declines in the total fertility rate which are strongly correlated with declines in the number of children desired and with increases in the use of modern contraception, but only weakly connected with increases in age at marriage. In turn, changes in the number of children desired are determined mainly by urbanization, by increases in years of schooling, and by exposure to mass media, while changes in contraceptive prevalence are associated with increases in media exposure, mainly television, improvements in economic status, and reduction in child mortality.

Charles Westoff was lead author on DHS Further Analysis Report No. 90, “Rwanda 2010: A Dramatic Change in Reproductive Behavior,” where they discuss the radical declines in the desired number of children, actual fertility, and child mortality along with a large increase in contraceptive prevalence between 2005 and 2010. The explanations for the rapid change in reproductive attitudes and behavior are clearly related to the concerns of the country, the rapid rate of population growth, and its implications for economic development and reproductive health.