Research

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                    [post_date] => 2018-11-26 06:20:17
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                    [post_content] => “Environmental federalism” may seem like an arcane topic, but it has been a major concern of the Trump Presidency. In a recently published article, we argued that the Trump Administration has pursued a strategy of reducing federal government responsibility for environmental protection and devolving some of this responsibility to the states. Because this approach is starkly different from that of the Obama Administration, the result has been whiplash in terms of  the role of the federal government in protecting human health and the environment.

The Trump Administration’s environmental federalism agenda has at least three components:

 	
a comprehensive attempt to roll back federal environmental regulation;
 	
a strong signal that few new federal pro-environment initiatives will be pursued;
 	
an attempt to turn more environmental policy authority over to the states.

The rollback of federal environmental regulations has involved several steps, the first of which occurred in concert with Republicans in Congress. Using the Congressional Review Act, the Trump Administration rescinded more than a dozen regulations, including transparency rules aimed at US energy companies, the Office of Surface Mining’s Stream Protection Rule, and a measure outlawing “extreme hunting” practices on federal lands. Subsequently, the Environmental Protection Agency, Department of Interior, and other agencies announced implementation delays of other rules (e.g., ozone nonattainment, limits to toxic discharges from power plants into public waterways, methane venting and flaring from oil and gas wells on federal land), as well has high profile efforts to weaken if not fully undo major rules such as the Obama-era Clean Power Plan, Waters of the United States rule, and fuel economy standards. Finally, the Administration has dramatically reduced enforcement of other existing environmental regulations.

A second component involves a broader diminishment of the federal government’s role in promulgating new environmental protection measures. That is, although the Trump Administration has been quite active in environmental policymaking, it has not put forward any serious measures—either legislation or regulations—intended to enhance environmental protection. Moreover, the Trump Administration has promoted a regulatory reform strategy, instituted mostly through executive orders, that aims to limit the adoption of new regulations. Examples of this strategy include a regulatory budget that requires the total costs of all new regulations to be no greater than zero and a two-for-one rule that requires agencies to identify at least two regulations to be repealed for every new rule proposed.
Lastly, the Trump Administration’s initial budget proposal and strategic planning documents have emphasized a version of “cooperative federalism” that would entail giving more authority and leeway to state governments.

 
Lastly, the Trump Administration’s initial budget proposal and strategic planning documents have emphasized a version of “cooperative federalism” that would entail giving more authority and leeway to state governments. Somewhat paradoxically, these increased responsibilities have not been backed by budgetary resources. At the same time the EPA committed to empowering states to do more, the Trump Administration has proposed cutting cooperative grants to states for this very purpose.

As the Trump Administration attempts to shift the balance of authority from the federal government to states, it is important to note that all these actions are being taken through administrative tools. This strategy can be effective in the short-term, since administrative actions like executive orders and regulations can be used to change policy relatively quickly. However, their durability for the medium- and long-term is tenuous since they often run afoul of legal scrutiny. (Many Trump Administration actions have already been rejected by the federal courts.) They also face the risk of being undone by a subsequent president with a different policy agenda and different views about the role of the federal government in providing environmental protection.

Featured image: Toadstool Hoodoo, Grand Staircase-Escalante National Monument. PGKempf/iStock. 
                    [post_title] => Trump, Federalism, and the Environment
                    [post_excerpt] => The Trump Administration has pursued a strategy of reducing federal government responsibility for environmental protection and devolving responsibility to the states.
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                    [post_date] => 2018-11-21 07:00:53
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                    [post_content] => We all use Google Maps to get from one place to another. And, we use Street View, one of Google Map’s online features when we want to view high resolution, 360-degree, panoramic scenes of where we’ve been or where we’re headed. But what about using Google Street View (GSV) for a scientific purpose? Some researchers are doing exactly that. Investigators from Michigan State University and the University of Otago conducted a systematic review of 54 studies to identify the ways in which Street View has been used for public health research.

Forty-six studies used Street View to assess how neighborhoods are built. These studies measured sidewalks to judge walkability or measured associations between neighborhood green space and happiness and wellbeing. One study used images from Street View to measure the influence of visible vegetation on how residents perceive their safety. In Boston neighborhoods, residents in areas where vegetation was higher than 2.5 meters felt safer than in areas where bushes and shrubs were lower; higher vegetation may suggest others are living nearby. These results can help direct city planners who aim to design neighborhoods that lower crime rates.
In Boston neighborhoods, residents in areas where vegetation was higher than 2.5 meters felt safer than in areas where bushes and shrubs were lower.

 
Five studies used GSV to measure compliance with health policies and regulations. Studies looked for no-smoking signs, crosswalks, and access ramps. One study surveyed the effectiveness of a mobile phone applications that uses geographic information systems (GIS), Google Street View, and crowdsourcing to help blind users find the location of marked (zebra-striped) pedestrian crosswalks.

The review also includes a Japanese study that tested a disaster evacuation simulation presented as a “choose your own adventure” virtual reality game. The game’s storyline, similar to a dating simulation game, asked participants to decide what to do in the event of an emergency in regards to helping friends, finding an elevator, and behaving in a crowded stairwell. Participants scored points for helping friends, while losing points for choosing to take the elevator or shoving people out of the way in the crowded stairwell.
A New Zealand study aiming to measure how GSV compared to in-person neighborhood auditing found that GSV could only find half of the alcohol stores that could be found in-person.

 
Using Street View to conduct these kinds of social experiments can be less expensive than in-person neighborhood audits. However, virtual explorations have limitations. Poor image resolution can hinder utility. Also Street View images capture only one point in time so how neighborhoods change cannot be easily assessed. A New Zealand study aiming to measure how GSV compared to in-person neighborhood auditing found that GSV could only find half of the alcohol stores that could be found in-person.

The researchers propose that as GSV imaging and geospatial data improves, the opportunities to dive into uncharted public health topics will expand. Increased “foothpath” view data could allow researchers to study how the physical design of playgrounds might reduce the risk of injury, or to locate previously undiscovered sources of pollution.

Feature image: BanksPhotos/iStock
                    [post_title] => A Street with a Public Health View
                    [post_excerpt] => A review of 54 studies identified ways in which Google Street View has been used for public health research, including gathering data on neighborhood green space and health policy compliance. 
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                    [post_date] => 2018-11-15 07:00:18
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                    [post_content] => Robots are the future of sex. Fitted with artificial intelligence, these hyperrealistic sexbots are programmed to engage in simplistic conversations, imitate basic emotions, and perform sexual acts with humans. This latest trend may seem like a dystopian reality, but sexbots are being created by companies like Realbotix in California, True Companion in New Jersey, and Synthea Amatus and AI-Tech internationally. Although the technology is relatively rudimentary, experts predict that within a century sexbots will have artificial consciousness, and perhaps robot personhood, legal status, and rights.

The market for sexbots is potentially huge. According to a 2017 YouGov poll of 1,146 US adults, 1 in 4 men and 1 in 10 women would consider having sex with a robot. Approximately 50% of adults surveyed believed it was important the robot resemble a human.

If people are having sex with robots that resemble humans, we must consider how this will impact human-to-human interactions and behaviors. This begins in the design phase where predominantly male consumers can customize sexbots to their preferences and fantasies. Sex robots tend to be white or Asian with hypersexual female bodies that reinforce unhealthy beauty ideals like extreme thinness, breasts and butts of extreme proportions, and flawless fair skin. This design of hypersexual female sexbots profoundly impacts users’ expectations of women’s bodies and sexual performance.
Customization does not stop at users selecting the physical appearance. Consumers can even customize sexbots to have specific personalities.

 
Customization does not stop at users selecting the physical appearance. Consumers can even customize sexbots to have specific personalities.

True Companion offers “Frigid Farah” who is “very reserved and does not always like to engage in intimate activities.” Sexbots like Frigid Farah are programmed to be passive and explicitly fail to consent to sex, which enables users to simulate rape.

Sexbot companies program sex robots to either give passive consent by always being willing to participate in sexual activity or to explicitly deny consent. Both cases perpetuate rape culture and the belief that ideal sex partners are always ready for sex, and those that do not provide consent can still be dominated through force. And while some argue that sexbots are simply extravagant sex toys, their purposefully humanlike functions and appearance affirms beliefs that female bodies are objects to be used for sexual gratification, consensual or otherwise.
Sexbot companies program sex robots to either give passive consent by always being willing to participate in sexual activity or to explicitly deny consent.

 
Supporters of sexbots argue they can be used therapeutically by sex offenders, providing them an outlet to redirect their sexual aggression and abuse towards robots rather than humans. However, sexual aggression is an expression of power rather than sexual desire. Critics of therapeutic sexbot use argue it ignores power dynamics involved in sexual violence and will likely be ineffective because robots will not satisfy a sexual offenders’ desire to control another person. They believe that it may actually increase sexual violence perpetration. It would be unethical to prescribe sex offenders a sexbot as therapy without empirical research illustrating its effectiveness and the parameters and contexts for its use.

Sex robots are here to stay, so public health professionals must become involved in the industry. We need to understand the nuances of consent and the potential impacts of technology on individual and population sexual health outcomes. We need to be intimately involved in the development, design, and research of sexbots and their impact on health. As tech companies develop sexbot artificial intelligence, they will play a greater role in determining what constitutes consent. Public health must inform these processes and hold companies accountable for their design choices.

Public health professionals, sexual health educators, and sexual and intimate partner violence advocates should neither ignore sex robots nor should they demand that they be banned. We must lead the conversation about how sexbots can be safely integrated into our sex lives.

Feature image: Ars Electronica, Samatha / Sergi Santos, Synthea Amatus SL (ES), photo by Tom Mesic, used under CC BY-NC-ND 2.0
                    [post_title] => Sexbots: The Future of Fornication?
                    [post_excerpt] => Sex robots are here to stay. Public health professionals need to be involved in the development, design, and research of sexbots and their impact on health. 
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                    [post_date] => 2018-11-14 07:00:11
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                    [post_content] => Each year in the United States, about 1,330 people die of cold exposure, essentially freezing to death. You may picture outdoor adventurers dying of hypothermia on snowy mountaintops. While rates are higher in rural areas, many cold-related deaths and illnesses occur in cities too.

To prevent these deaths, it is important to understand how often they occur and who is most at risk. We analyzed hospital discharge, death certificate, and medical examiner data for deaths and illnesses directly attributed to cold in New York City (NYC).

Cold-related illness and death are underreported because only a small number are appropriately recognized and coded as hypothermia and tissue damage. Yet, cold temperatures can worsen conditions like heart disease and respiratory illness, causing hospitalizations and deaths that may not be recognized as related to the cold on death certificates or hospital records. Still, focusing on those cases that are recognized and coded as cold-related can provide valuable information.

In NYC, we found that each cold season between 2005 and 2014 had, on average, 180 treat-and-release emergency department visits and 240 hospital admissions for cold-related illness, and 15 cold-related deaths. The rate of cold-related death in NYC was lower than the rate in the Northeast. Nearly all people who were admitted to the hospital (94%) also had one or more other health problems, including heart disease, alcohol and drug use, and mental illness. Rates for cold-related hospital admissions were highest among adults aged 85 and older. Very young children (age 0–4) had higher rates than older children and young adults.
Of those exposed outdoors, about half were homeless or suspected to be homeless. The remaining 25% were inside when they were exposed to the cold and none had heat in their home.

 
As with hospital admissions, most people who died had other health conditions, most commonly heart disease, substance use, and mental health disorders. According to detailed medical examiner records, 75% of those who died from cold exposure were outdoors. Of those exposed outdoors, about half were homeless or suspected to be homeless. The remaining 25% were inside when they were exposed to the cold and none had heat in their home. All were age 60 or older and two thirds had a mental illness, including one third who showed evidence of hoarding. Nearly all were living in single-family or row homes, rather than apartment buildings which are more common in NYC. A study by the Urban Green Council in NYC showed that single-family and row homes lose heat more quickly in cold weather than apartment buildings.

Many of these preventable deaths and illnesses occurred outside of the coldest weather periods. More research is needed, however, to add to our descriptive analysis. We need to better understand the relationship between weather conditions and cold-related illness and deaths, as well as chronic conditions worsened by cold weather.

In the meantime, we are sharing findings with the public and our partners to ensure that prevention efforts are data driven and targeted towards those at an increased risk during cold weather: people who are homeless and unsheltered, residents who use drugs or alcohol and become incapacitated outdoors, and older adults with medical and mental health conditions who don’t have heat at home. For instance, connecting adults who have trouble paying their winter heating bills with financial resources through the Home Energy Assistance Program, is an important strategy to prevent cold-related deaths. Other strategies include enhancing homeless outreach during periods of cold weather, and communication with the public about who is at risk and how to prevent illness and death.

Feature image: newelly54, ny sunny winter morn (detail), used under CC BY-NC-ND 2.0
                    [post_title] => The Dangers of Cold Weather
                    [post_excerpt] => Lane and colleagues analyzed hospital discharge, death certificate, and medical examiner data to identify deaths and illness caused by cold weather in New York City to understand who is most at risk. 
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                    [post_date] => 2018-11-12 02:00:52
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                    [post_content] => Among all forms of health insurance, Medicaid stands alone in its strength, its ability to evolve in response to emerging public health needs, and its resilience. Over more than five decades, Medicaid has become the nation’s largest public health program and one of its most indispensable. Today Medicaid finances half of all births and, along with its small companion the Children’s Health Insurance Program, 40% of all pediatric care. Medicaid is the means by which the nation has created community-based long-term services and supported children and adults with advanced health needs. Indeed, deinstitutionalization could not have happened without it.

Medicaid is how we pay for treatment for uninsured patients diagnosed with breast or cervical cancer. It is the single most important funder of treatment for people living with HIV/AIDS and the largest funder of health care safety net clinics and hospitals that anchor health care in the poorest communities. In times of public health disaster, whether naturally-occurring or man-made, the nation turns to Medicaid. It has, for example, been the go-to source for funding the range of health treatments needed to combat the opioid epidemic.

Over a half century, these and more responsibilities have been assigned to a program that, in its original state, was understood as a companion to Medicare, a pathway for covering a modest number of public assistance beneficiaries. In 1965, few could have foreseen Medicaid’s ultimate potential as a centerpiece of public health, owing to its ability to finance health care for populations and conditions excluded from both Medicare and the market norms of a voluntary insurance system.

Two factors account for Medicaid’s remarkable growth. First, unlike other forms of insurance, Medicaid financing rests on general federal, state, and local revenues coupled with broad-based provider taxes. Because Medicaid is not tied to premium contributions or payroll taxes, its reach is not limited by narrow funding structures that inevitably constrain program design and growth.
Its services—provided virtually free with only nominal cost-sharing—span the entire life-cycle, from pregnancy and birth through long-term care.

 
Second, unlike private insurance or Medicare, Medicaid is designed to embrace risk rather than avoid it. From enactment, its beneficiaries have been the poorest and most medically vulnerable people. Its services—provided virtually free with only nominal cost-sharing—span the entire life-cycle, from pregnancy and birth through long-term care. Enrollment happens in community settings and at the point of care—something unheard of in insurance markets. Medicaid does not use waiting periods, and eligibility can be established retroactively in order to cover incurred costs.

Because of Medicaid’s unique financing and structure, the program has become the solution of choice for policymakers on a host of public health priorities such as coverage for low-income children and pregnant women, creating an insurance pathway for low-income working parents without affordable workplace coverage, and community based services for children and adults with serious and lifelong disabilities. Most of this growth has come, not as top-down federal commands, but as state innovations under federal legislative options. When it finally came time to insure the nation’s poorest working age adults, it should surprise no one that, rather than relying on a restructured yet fragile individual insurance market, Congress chose to expand Medicaid (the hardy perennial rather than the hothouse flower).
Yet Medicaid’s flexibility and responsiveness have also triggered a deep challenge owing to its sheer size.

 
A veritable deluge of studies over decades have built an unusually strong evidence base for the program. Yet Medicaid’s flexibility and responsiveness have also triggered a deep challenge owing to its sheer size.

By 1967 policymakers, already aware of what they had unleashed, began to apply the brakes. The first legislative effort to cap overall Medicaid spending came in 1981, the first year of the Reagan presidency. Nearly 40 years ago, the effort to end Medicaid failed, as the program’s importance to the health care system was becoming clear for all to see. Since then, Medicaid has endured two more near-misses: first, during the 1995 Gingrich revolution that most famously produced welfare reform, and in 2017 when the program’s survival became a centerpiece of the battle over “repeal and replace.”

The summer of 2017 witnessed a war worthy of Game of Thrones, with the stakes being not simply the Affordable Care Act’s adult Medicaid expansion but the entire program. Ultimately the repeal effort toppled. In good part, this collapse could be traced to the implacable opposition to the Medicaid provisions by the nation’s Governors, who understood better than anyone the degree to which Medicaid—insurer of 75 million people—has become the foundation on which the health system rests.
Medicaid needs progressive reforms that emphasize innovation in care delivery and increased efficiencies.

 
Medicaid survived 2017. Still, it faces many challenges. Seventeen states remain outside the ACA adult expansion, leaving millions with no pathway to affordable health insurance. Perhaps the 2018 mid-term state election results will begin to change this, as was the case for Virginia in 2017. For all states, Medicaid’s sheer size and budgetary demands represent an ongoing challenge, even as Medicaid revenue helps fuel state economies.

Medicaid needs progressive reforms that emphasize innovation in care delivery and increased efficiencies. We need to couple these reforms with a broader public health strategy aimed at integrating Medicaid services with health and social interventions aimed at addressing the root causes of poor health. The consequence of failure likely will be more legislative attacks—apparently a post-midterm-election priority for Republican Senate leaders—or, as we are now witnessing, efforts to drive away the poor through work “experiments” or immigration “reforms” designed to punish the poor rather than advance the public health and welfare.

Feature image: Arwen Twinkle, Peony-2, used under CC BY-NC-ND 2.0
                    [post_title] => Medicaid’s Remarkable Endurance
                    [post_excerpt] => Over more than five decades, Medicaid has become the nation’s largest public health program and one of its most indispensable. Its sheer size and budgetary demands represent an ongoing challenge, even as its revenue helps fuel state economies.
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                    [post_date] => 2018-11-09 05:30:45
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                    [post_content] => Change is nothing new for young adults; they experience it as they move on from high school to college, from college to internships and jobs, and from one job to another. During these phases, health insurance is one of the many elements of a young adult’s life that keeps changing. Insurers call these changes “churning,” representing the rolling from one type of health plan to the next. Younger adults churn more than their elders.

Between 2008 and 2011, only 21% of adults of ages 19 to 35 had continuous health insurance coverage. Lack of complete or continuous coverage because of churning may result in few doctor visits and not enough preventive care. It may also lead to young adults delaying receiving care because of costly procedures and medications. Those not fluent in the language of healthcare coverage may struggle with navigating the insurance landscape during times of transition.

Researchers from University of California, San Francisco conducted a study to identify gaps in health insurance clarity among youth. They studied young adults in California, the state with the most people ages 18 to 34 in the country, and a state where income and wealth levels are particularly diverse. California was also one of the first to expand Medicaid in the wake of the Affordable Care Act, producing a historic drop in the number of uninsured people as a result. Still, California ranks high in the amount and frequency of churning.

The researchers interviewed health department administrators, state legislators, insurance company employees, and health advocates. These key informants explained why young adults are more vulnerable to churning, and how it affects their care.
When faced with the reality of having to independently manage their purchases of health insurance, many young adults have trouble grasping the meaning of basic health insurance lingo.

 
The results demonstrated that when faced with the reality of having to independently manage their purchases of health insurance, many young adults have trouble grasping the meaning of basic health insurance lingo. Terms like deductible, cost-sharing, premium, and in-network are difficult to understand, and how they affect what insurers actually pay for is not always clear. One key informant indicated how this may be particularly true for young women who discover their contraception method is not covered under a new insurance plan. Further, this lack of clarity regarding coverage may act as a barrier to accessing services like behavioral health, which go underutilized.

Some state policies exist to protect coverage in times of churning. In California, patients who have to change their insurance are still allowed to visit their primary health provider during the transition period. But this is not made clear to young adults before they experience churning.

The researchers and their key informants emphasized how current information on health plans assumes that everyone understands insurance and health-specific terms. They called for simpler language and greater promotion of health care services that may be available through high schools and colleges where young adults can better access and receive care. The informants also mentioned how insurers need to focus on helping youths who are not fluent in English, are from low-income backgrounds, or lack stable housing—like foster youth; these young adults may be particularly vulnerable to missing out on the benefits of health insurance. Finally, any young adult-oriented information about health insurance may be delivered best online, as opposed to through the mail or phone. The Kaiser Family Foundation has compiled a list of frequently asked questions that may be a good place to start.

Feature image: rawpixel on Unsplash
                    [post_title] => Feel the Churn
                    [post_excerpt] => Health insurance is one of the many elements of a young adult’s life that keeps changing. Insurers call these changes “churning," or rolling from one type of health plan to the next.
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                    [post_date] => 2018-11-08 06:30:58
                    [post_date_gmt] => 2018-11-08 11:30:58
                    [post_content] => Black men in the United States experience unique, sociocultural stressors that affect their physical and mental health. As a result, Black men not only have poor health outcomes, they also have the shortest life expectancy compared to other races and women. Despite these differences in health and life expectancy, developing a body of evidence on the health of Black men has been slow. More research on the physical and mental health of Black men is necessary.

We have been exploring the ways in which the Black Church provides spiritually and culturally relevant services for Black men in their communities. Our work complements previous research about religion, spirituality, and health focused on Black women.

Previous research has shown that Black individuals are less likely to use mental health services even though they experience levels of distress similar to individuals of other racial/ethnic backgrounds. A Black man’s decision about whether to seek help for his mental or physical health is influenced by gender norms and cultural beliefs. Black men may also experience racism in the healthcare system or financial barriers to care. These factors result in Black men not using professional mental health services and instead relying on others such as clergy or family members.
Almost 50% of the Black individuals surveyed in 2014 by the Pew Research Center attended religious services weekly. Among those attending church 32% were men.

 
The church has always been a significant institution within the Black community and it has connections to many other institutions such as Black colleges and universities and the NAACP (the National Association for the Advancement of Colored People). Membership in Black Churches has remained steady or increased at a time when many religious institutions have declining memberships. Almost 50% of the Black individuals surveyed in 2014 by the Pew Research Center attended religious services weekly. Among those attending church 32% were men. Those who attend church regularly are more likely to seek help for spiritual and personal problems from clergy.

While Black Churches continue to positively affect the lives of many within the Black community, they can enhance the support they provide to many of their congregants. Two theoretical frameworks can help Black Churches to increase the effectiveness of the support they provide to congregants and Black men in particular. The Body, Mind, Spirit, Environment, Social, Transcendent (BMSEST) model is based on Maslow’s hierarchy of needs. It acknowledges the relationship between spirituality and well-being and thus complements the healing work being done in the Black Church. The Health, Illness, Men, and Masculinities (HIMM) model, by contrast, emphasizes understanding gender as a determinant of Black men’s physical and mental health.
Combined, these theoretical frameworks can improve the Black Church’s ability to address the mental health needs of Black men.

 
These theoretical frameworks can assist professionals and academics working in the social sciences to organize the concepts that are most relevant to this problem and this population, such as spirituality and help-seeking behavior. The models can be used by Black Churches as a foundation upon which program developers can create spiritually-sensitive, culturally-competent, and empirically-based community interventions to support Black men’s mental and physical health needs. Combined, these theoretical frameworks can improve the Black Church’s ability to address the mental health needs of Black men.

The church is a preexisting source of strength and support in the Black community, but it has a responsibility to do more for Black men given their poor physical and mental health outcomes. Our recently published review summarizes existing research and introduces these models as a strategy Black Churches can use to better meet the needs of men. Black academics and professionals need to collaborate with the clergy of Black Churches to develop and implement programs that are spiritually-sensitive, culturally appropriate, and grounded in evidenced-based practice. It is time to devote our attention to the mental health challenges experienced by Black men.

Feature image: sevenstockstudio/Istock 
                    [post_title] => Black Church, Black Men(tal) Health
                    [post_excerpt] => Black Churches continue to positively affect the lives of many within the Black community. Black Churches have the potential to increase the effectiveness of the support they provide to congregants, and Black men in particular. 
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                    [post_content] => Heroin lasts in the human body for just a few minutes before being converted into morphine and other compounds. The drug’s short half-life may be one reason why it is so addictive. It also complicates the task of a medical examiner or coroner trying to identify the substance that caused an overdose death. A death from heroin may be labeled as “morphine intoxication,” “narcotic intoxication,” or “drug overdose” without any specific mention of the real culprit.

How often does heroin escape mention in death certificates for overdose? We (with colleagues) conducted a study using data from Maryland to find out.

From 2012 to 2015, death certificates in Maryland noted heroin in 1130 cases of overdose. Using a protocol of enhanced surveillance, the Department of Health and Mental Hygiene assessed for heroin in a different way. Reviewing the toxicology results and the death scene records, the Department (where we worked) counted a death as heroin-related if at least one of the following criteria were met:

 	
Heroin was listed in the cause of death section of the death certificate;
 	
Toxicology screen showed a positive result for 6-monacetylmorphine, a metabolite of heroin;
 	
Toxicology screen showed positive results for quinine in combination with either morphine or free morphine; or
 	
Scene investigation notes suggested that heroin was likely to have been involved in the death.

 

We found 2,182 cases of heroin-related overdose, nearly double the original number. Our finding, which is consistent with other research, suggests heroin may be undercounted as a cause of opioid overdose. It is known that the epidemic of opioid overdoses in the United States began to shift around 2010 from prescription drugs to illicit drugs. Our results suggest this shift might have been more abrupt and significant than recognized to date.
We found 2,182 cases of heroin-related overdose, nearly double the original number.

 
Appreciating the magnitude of this shift is important for the response to the opioid epidemic. When the goal is reducing overdoses from prescription drugs (regardless of whether the pills find their way to illegal markets), then work tends to focus on changing clinician prescribing behavior. The federal government and states spend substantial resources on prescription drug monitoring programs and educational efforts to facilitate judicious prescribing.

However, when the goal is reducing deaths from heroin and other illicit opioids (such as illicitly manufactured fentanyl), then policymakers should do much more. They should expand rapid access to effective treatment for opioid use disorder with the medications methadone, buprenorphine, and depot naltrexone in emergency departments, jails and prisons, and primary care. They should also expand harm reduction and engagement programs such as naloxone distribution, syringe exchange, and fentanyl checking. These efforts help people who use illicit drugs to reduce their risk of a fatal overdose and provide opportunities to connect them to effective treatment and to begin the process of recovery.

The opioid epidemic in the United States involves much more than prescription drugs. Higher quality data on what is driving the increase in overdoses can improve public understanding of our national crisis and shine a light on what is needed to be done.

Feature image Barry Robinson/iStock
                    [post_title] => Undercounting Heroin
                    [post_excerpt] => Heroin lasts in the human body for just a few minutes before being converted into morphine and other compounds. This complicates the task of a medical examiner trying to identify the substance that caused an overdose death. 
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                    [post_content] => Religion is an important force in the history of American prisons. Through the early efforts of the Quakers in colonial America and the formative years of the United States, religion was ingrained into the DNA of corrections. Penitentiaries derive their name from the act of penitence and inmates were sentenced to repent their sinful (i.e., criminal) ways. Prison chaplains were entrusted with overseeing this moral reform.

Starting in the 1850s, crime was increasingly seen through a scientific lens. Explanations based in biology, psychology and sociology gradually replaced demonic influences as the primary explanation for criminal behavior. The role of prison chaplains slowly changed as many of their original job duties fell to licensed counselors and social workers.
The role of prison chaplains slowly changed as many of their original job duties fell to licensed counselors and social workers.

 
Passage of the Religious Land Use and Institutionalized Persons Act (RLUIPA) in 2000 ushered in a new era for prison chaplains with a shift to primarily administrative duties. RLUIPA ensures the religious rights of the 2.2 million inmates currently incarcerated in 1,100 state and federal US prisons. Consequently, the estimated 1,600 chaplains are responsible for connecting inmates with religious groups inside and outside of prison. A key duty of modern prison chaplains is overseeing faith-based volunteers from a variety of religions to lead inmate worship. (Chaplains rarely lead worship services.) As such, the primary role of modern prison chaplains is to protect their institutions from costly lawsuits brought as RLUIPA violations.

Approximately 630,000 inmates are released from prison every year and 67.8% return to prison within three years. In the face of such high recidivism, I decided to explore the role chaplains currently play and explore the possibilities for better targeting their skills to meet prisoners’ psychological and emotional needs.

I conducted in-depth interviews with 19 prison chaplains employed by a department of corrections in a Midwestern US state to understand their perceptions about criminal behavior and recidivism. Chaplains answered a series of questions focused on 1) causes of crime, 2) successful practices for reducing recidivism, and 3) the role that personal religion or faith can play in recidivism.

Four prominent themes emerged. Chaplains overwhelmingly viewed illegal drug-use, poor social support, low self-control, and having a ‘criminal mind’ as primary reasons for criminal behavior. Nearly half perceived offenders as having a ‘criminal mind’ that psychologically sets them apart. Some chaplains reported that changing ‘criminal thinking’ is imperative, echoing some basic tenants of cognitive behavioral therapy (CBT). That is, changing criminals’ general thinking patterns to make non-criminal choices.
The chaplains who participated in this study noted that people leaving prison face many barriers to successful reentry, such as unemployment and poor social support.

 
Most chaplains saw religion and faith as essential to building a moral code and avoiding criminal choices. Religion and spirituality, they explained, offer offenders a sense of community support. Conversely, nearly 25% of the chaplains did not view religion or faith as necessary for desistance.

The chaplains who participated in this study noted that people leaving prison face many barriers to successful reentry, such as unemployment and poor social support. Many chaplains explained that these and other challenges such as substance use disorders and problematic reasoning must be addressed. Some chaplains reported that they had the ability to create new programs to meet these needs.

Findings suggest that many prison chaplains still have influence over institutional programming. As such, prison administrators should encourage prison chaplains to assume a more hands-on role with substance abuse treatment programming and CBT and simultaneously reduce their administrative responsibilities. Ultimately, a shift back to their original hands-on role may help to ease the transition from prison to society and reduce recidivism.
                    [post_title] => Prison Chaplain Views on Criminality and Reform
                    [post_excerpt] => Prison chaplains answered a series of questions focused on causes of crime, reducing recidivism, and the role that personal religtion can play in recidivism. Four prominent themes emerged.
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                    [post_date] => 2018-10-30 07:00:15
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                    [post_content] => Air pollution from vehicle exhaust has a substantial impact on health. Exhaust pollutants are linked to increased risk of lung and respiratory infections, cardiovascular disease, and high blood pressure, and stroke.

Public transportation is known to reduce transport-related air pollution.

Public transit moves many people efficiently, producing significantly less air pollution  and increasing health benefits in surrounding neighborhoods. For example, one study from Atlanta found increased public transportation corresponded with improved air quality and a decrease in child asthma during the 1996 Olympic Games. While interventions exist to improve people’s health by decreasing air pollution, few studies have measured how pollution interventions can impact cardiovascular outcomes. Researchers Eun Park and Ipek Sener took advantage of the 2004 light rail installation in Harris County, TX  to study if the transit system decreased vehicle emissions and in turn affected deaths from stroke between 2002-2005.

Traffic exhaust pollution was estimated as ambient acetylene concentration data from ten volatile organic compound (VOC) monitoring sites. Acetylene is a chemical specific to vehicle exhaust emissions, and thus a good measure of traffic census. Mortality data was collected from the Texas Department of State Health Services Center.
The researchers found that, after the installation of a light rail transit (LRT), average acetylene levels were reduced by 13% and stroke mortality was reduced by more than 30% within a 10-mile radius.

 
The researchers found that, after the installation of a light rail transit (LRT), average acetylene levels were reduced by 13% and stroke mortality was reduced by more than 30% within a 10-mile radius. In contrast, control areas experienced a less than 10% reduction of stroke mortality, and less than 1% reduction in acetylene levels.

Although there was a reduction in vehicle exhaust pollution, there were other factors associated with light rail transit stations that could have contributed to the decline in stroke deaths. A LRT station mitigates exposure to traffic noise pollution, which also could reduce the risk of stroke. Increased physical activity is another effect from installing a LRT system, and also decreases people’s risk of stroke.

Since passing the Clean Air Act in 1970, the EPA has been in charge of regulating air pollution, and supports the development of public transportation infrastructure. California is the only state that has successfully bargained for a Greenhouse Gas Federal Waiver to regulate its own vehicle pollution, adopting stricter emissions standards than those of the EPA’s. California’s regulations has since been embraced by thirteen states. As seen from Park and Sener’s study, reducing vehicle exhaust pollution can have positive health impacts on the surrounding community. These findings may be important to keep in mind as the current administration has announced plans to revoke California’s stricter emissions waiver.

Feature image: Michael Chu, Sunset TC Station, Portland MAX light rail train at Sunset Transit Center.
                    [post_title] => All Aboard for Light Rail Transit
                    [post_excerpt] => Public transit moves many people efficiently, producing significantly less air pollution than vehicles. Park and Sener measured how light rail transit decreased vehicle emissions and in turn affected deaths from stroke. 
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