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                    [post_content] => We're on vacation! Public Health Post is taking a #springbreak publishing break. Thank you for reading PHP and for joining us in conversation on social media. We'll be back online on Monday, March 18. See you then!

Feature image: Daniel Rothamel, Rubber Duckie, You're the One, used under CC BY 2.0
                    [post_title] => Spring Break Vacation
                    [post_excerpt] => We're on vacation! Public Health Post is taking a #springbreak publishing break. Thank you for reading PHP and for joining us in conversation on social media. We'll be back online on Monday, March 18. See you then!
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                    [post_date] => 2019-03-07 23:30:53
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                    [post_content] => More than 80% of Americans who qualify for life-saving medication treatment for opioid addiction do not actually receive it. Methadone maintenance therapy—which involves the daily use of a liquid or pill—is the oldest, most researched form of medication treatment for opioid addiction, and has been used in the US for fifty years, yet it remains prohibitively difficult to access, especially for those living in rural areas. Many other developed countries have allowed community clinics and pharmacies to dispense methadone, but this is not usually an option in the US. In a recent article, we wrote with a group of addiction medicine providers from Canada and the US, we argue that it is time for the US to follow suit.
Access
Current US regulations allow methadone for addiction to be distributed only through designated facilities called Opioid Treatment Programs (OTPs), often referred to as methadone clinics. These are independent facilities mandated by federal law to provide a host of services for patients with opioid addiction, including access to physicians, counselors, nurses, and on-site dispensing of methadone. Around 1,500 OTPs currently operate within the US, with 96% based in urban areas. With the opioid epidemic decimating rural communities, and few OTPs nearby, patients often drive hours every day to access life-saving methadone. This leaves little time to focus on other important components of addiction recovery, such as keeping a job with regular working hours.

Despite rising numbers of opioid overdose deaths in the US, the number of active OTPs in the country has remained roughly the same over the past 15 years. Of course, methadone is not the only treatment option available; naltrexone, a monthly injection, and buprenorphine, a daily medication that can be taken at home, are also highly effective. But for many individuals with severe opioid addiction, methadone remains the safest and most effective long-term treatment.
The development of innovative treatment strategies is critical to curbing the opioid epidemic.

 
International perspectives
Our Canadian neighbors have shown that dispensing methadone from pharmacies (rather than restricting access to specialized clinics) is safe and highly effective. Unlike the United States, Canada, Australia and the U.K. have passed legislation that permits a prescription for methadone to be taken to participating pharmacies where methadone can be administered under direct observation by the pharmacy staff. Having the option of receiving methadone in community pharmacies is more convenient for patients. In the US there are approximately 67,000 pharmacies, nearly 50 times more than the number of OTPs, that might be used to widen to provision of methadone during this epidemic.

The costs of dispensing methadone in the community in countries like Canada, Australia and the U.K. are very similar to the costs of dispensing methadone in an OTP like in the US (approximately $10-15 USD per patient per day). This contrasts sharply with the individual and societal costs associated with untreated opioid addiction, and the immeasurable cost of overdose deaths, when individuals are not able to access appropriate and timely treatment.
A call for action
The development of innovative treatment strategies is critical to curbing the opioid epidemic. But we should maximize access to existing treatments like methadone. Pharmacists are widely available, highly trained healthcare professionals whose expertise could be further leveraged in the effort to combat the opioid crisis. This is a lesson that has been learned around the world and it’s time for the US to make this life-saving treatment more available.

Feature image: thierry ehrmann, Défense de prendre des narcotiques (detail), CC BY-NC-ND 2.0
                    [post_title] => Methadone Matters
                    [post_excerpt] => With opioid addiction on the rise, how prepared are we to care for those in need of treatment? Researchers study problems with access to methadone clinics.
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                    [post_content] => In his February 5, 2019 State of the Union Address, President Trump said, “My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years… Together, we will defeat AIDS in America. And beyond.”

A bipartisan commitment to end HIV transmissions in the US and around the world by 2030 would be a welcome development. The US global AIDS relief program, launched in 2003 with bipartisan support, has had great success in helping get 20 million people onto life-saving treatment, and dramatically reducing HIV incidence and deaths. Despite treatment scale-up and advances like pre-exposure prophylaxis (PrEP), every year 38,000 people are newly infected in the US, and 1.8 million around the world. Striking racial/ethnic, gender, and sexuality disparities exist.

Trump’s promise was greeted with some skepticism among HIV and LGBT advocates because, in the first two years of his administration, he promoted policies that exacerbate HIV and LGBT stigma and discrimination, key drivers of the epidemic. He has also made it harder for people living with HIV and LGBT people to get health care.

The Peace Corps and the US Air Force have dismissed individuals diagnosed with HIV. The Trump Administration has banned transgender people from military service, and is housing transgender federal prisoners based on their sex at birth instead of their gender identity, which increases their chances of being raped.

The administration has promoted regulations that authorize religious conservatives “not to act contrary to one’s beliefs” when providing health care. What does this mean for a lesbian couple seeking fertility assistance? A transgender patient seeking gender affirming care? Or a bisexual man seeking testing or treatment for a sexually transmitted disease?
Trump has not appointed an AIDS czar for two years. His FY18 budget proposal sought to cut domestic HIV prevention funding by 17%, eliminate entire Ryan White programs, and cut more than $1 billion from the global AIDS program.

 
Trump has not appointed an AIDS czar for two years. His FY18 budget proposal sought to cut domestic HIV prevention funding by 17%, eliminate entire Ryan White programs, and cut more than $1 billion from the global AIDS program.

In late 2017 Trump summarily dismissed the Presidential Advisory Council on HIV/AIDS (PACHA) though the council was reconstituted in late 2018 and is supposed to meet in March, 2019.

President Trump has taken a number of steps to weaken the Affordable Care Act, which has dramatically reduced uninsurance rates among people living with HIV, LGBT people and people of all racial and ethnic backgrounds. In 2018, his administration expanded access to cheap, short-term insurance plans that do not cover pre-existing conditions, like HIV or cancer.

A recent study found that Black and Latino men who have sex with men (MSM) were more likely than other MSM to regard having to talk with their doctor about their sex lives as a barrier to accessing PrEP for HIV prevention. Half of Black MSM live in the South, which has mostly refused to expand Medicaid eligibility. As a result, many Black gay men—25% of new HIV diagnoses in the US—do not access basic health care, let alone competent care.

The Trump Administration has dropped LGBT equality, and human rights more broadly as foreign policy priorities. This is in sharp contrast to the Obama Administration, which promoted LGBT equality as a key goal of US foreign policy.

It is no coincidence that, since 2017, governments have unleashed waves of anti-gay persecution in Tanzania, Chechnya, Russia, and Indonesia.

We welcome President Trump’s initiative to dramatically reduce new HIV infections in the US and look forward to learning more. However, if the President really wants to have success with this initiative, he should stop promoting discriminatory policies that exacerbate HIV stigma and make it harder for vulnerable gay and bisexual men and transgender women, especially Black LGBT people in the South, to access preventive health care.

Feature image: Ted Eytan, 2015 World AIDS Day (Obama Administration) - Red Ribbon on White House - Washington DC USA 00410, used under CC BY-SA 2.0
                    [post_title] => Trump Policies Hinder HIV Fight
                    [post_excerpt] => Trump’s 2019 State of the Union promise to eliminate the HIV epidemic in the US within 10 years is undermined by policies his administration has promoted. 
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                    [post_content] => I love a good debate. Growing up in a household where my parents often held opposing political views, I learned that discussion sharpens our understanding of other perspectives. When I began my graduate degree in public health policy, I expected debate to be valued by my fellow students. Unfortunately, I was wrong.

Promoting diversity is an essential component for public health students to grow into professionals capable of interacting with an increasingly diverse and divided America. While diverse racial and ethnic backgrounds are valued on campus, and rightly so, political diversity is stifled. The growing political division that afflicts American culture has crept into our classrooms. Our discussions are overwhelmed by groupthink: a round-robin of like-minded ideas where dissent is considered to be against the morals of the group. It is critical, in this period of severe political division, that the public health community evaluate how we discuss politics in the classroom.

At a midterm election viewing party thrown by public health students at my university, all victorious Democrats got applause, while every Republican was booed. A candidate’s qualifications came second to political party. There is a culture on campus of “us versus them” that suppresses healthy discussions in class. I have tried to spark conversations by playing devil's advocate—arguing pro-business, pro-capitalism, and pro-religious expression. An uncomfortable silence falls over the classroom. This silence is a pillar of groupthink. It is a subtle but powerful influence that discourages students from thinking independently. Missed opportunities for students to explore ideas is the cost of letting this conformity persist.
There is a culture on campus of “us versus them” that suppresses healthy discussions in class.

 
Public health students likely fall on the left of the political spectrum, and this is especially true at my university, where Republicans make up 9% of the student body and faculty have a 40:1 Democrat/Republican ratio. We cannot let this overwhelming majority alienate our discussions from nearly half the US population. They are the people we hope to serve and therefore understanding their concerns and values is paramount.

Liberals are not the only Americans who care about public health. People across the political spectrum have a stake in health outcomes. It is our responsibility to consider the values of the people we are trying to serve when implementing evidence-based approaches. Communities are our primary stakeholders, and we need strategies beyond science to argue for public health. Even critical issues, such as climate change, can be dismissed when scientific evidence alone is used to rally public support. When “I don’t believe your science” is a viable counter argument, how do we connect with the community to make meaningful change?
It is our responsibility to consider the values of the people we are trying to serve when implementing evidence-based approaches.

 
Learning how to engage with communities politically should be a core competency in public health classes. There are well-documented methods that professors, managers, and students can follow to encourage critical thinking and constructively and respectfully debate challenges to our ideas. Ultimately, students should be encouraged by their peers and professors when they bring outside political perspectives into the classroom.

As public health students, we shape our learning environment. We have chosen to be comfortable rather than challenged. Our first responsibility towards ourselves is to be proactive rather than passive. If you disagree, embrace that difference and create a conversation. Be curious. This is our education, and we should not deprive ourselves any opportunity to learn, even when we need to be courageous and step out of our safe bubble. If we don’t we are only sabotaging ourselves and the people we hope to serve.

Feature image: wildpixel/iStock
                    [post_title] => Are Public Health Schools Politically Diverse?
                    [post_excerpt] => People across the political spectrum have a stake in health outcomes. It is our responsibility to consider the values of the people we are trying to serve when implementing evidence-based approaches.
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                    [post_content] => Old age is customarily associated with retirement, vacationing, and enjoying time with grandchildren. But not for undocumented immigrants. If you are undocumented, retirement as a regular part of the life transition is a fantasy. Immigration policies upend the life course as we know it.

According to the Institute on Taxation & Economic Policy, undocumented immigrants contribute over $11 billion in taxes every year. Although undocumented individuals may contribute to the Social Security Administration, they are not eligible for the benefits associated with federally funded social pensions. Ordinarily, workers and individuals in the United States benefit from employer-based pensions and retirement investments, accumulated Social Security, as well as income support programs (e.g., Supplemental Security Income) for low-income elderly individuals. Despite this astounding exclusion, aging undocumented people are not a priority for a majority of pro-immigration advocates and policy efforts. They should be.

Not having retirement benefits is a time-sensitive issue for elderly undocumented immigrants. As we age, we all need frequent and distinct types of care. Health concerns are alarming for undocumented people due to their limited healthcare access. They are less likely to see a doctor compared with migrants with a legal immigration status. Protecting the health and well-being of the aging undocumented population is a clear health policy need.
Over half of the undocumented population is over age 35. Quasi-solutions such as Deferred Action for Childhood Arrivals (DACA) affect a small portion of the US undocumented population.

 
Though recent news articles acknowledge the problem, few offer ideas for moving forward. And, even fewer note that advocacy in immigration policy is myopically focused on helping young undocumented immigrants, often called Dreamers. Over half of the undocumented population is over age 35. Quasi-solutions such as Deferred Action for Childhood Arrivals (DACA) affect a small portion of the US undocumented population. Older undocumented adults’ existence and unique challenges are eclipsed by the more popular and palatable cause of undocumented youth (e.g., the Dreamers and the DACA recipients).

Some aging adults may migrate back to their country of origin. However, we can reasonably expect that many will stay in the US throughout old age because of their social, familial networks. In the absence of state-based retirement support, undocumented individuals must rely on their families and communities for financial survival. The lack of financial and healthcare support for the aging undocumented population stands to perpetuate intergenerational transmission of disadvantage, the effects of which might be seen for generations.

There is glimmer of optimism for elderly undocumented individuals. Although federally supported programs continue to exclude undocumented older individuals, states such as California are pushing the boundaries. In 2018, California Senator Ricardo Lara proposed a bill (SB 974) to relax the eligibility for Medicare for California residents, making immigration status irrelevant. Although the bill died in the appropriations committee, it allows us to imagine the possibility that local and state governments as well as advocacy groups and non-profit human service organizations may one day support their undocumented stakeholders.

The aging of undocumented individuals is a matter of health, retirement, and inequality/welfare policy. My research agenda as a doctoral student in sociology explores how immigrant status shapes inequality in older-age. This issue is relevant on the global scale because high-income countries rely on foreign-born labor. As a society, we must include the plight of older immigrant adults in policy conversations to ensure that their health, financial stability, and welfare are prioritized. Just like your grandparents and your parents, elderly immigrants deserve the opportunity to retire.

Feature image: C-Monster, Border wall Tijuana, used under CC BY-NC 2.0
                    [post_title] => Aging Knows No Borders
                    [post_excerpt] => Although they contribute $11 billion in taxes every year, undocumented immigrants are not eligible for federal or state retirement benefits. Older immigrants should be a priority for pro-immigration advocates and policy efforts. 
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                    [post_date] => 2018-12-21 05:30:49
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                    [post_content] => Dear PHP Readers, Happy Holidays!

It’s been an exciting time for us. We are starting our third full year of publication and we continue to grow by leaps.

We published hundreds of diverse stories in 2018, one each day, and sent a week-in-review to subscribers every Friday. We are now read in all 50 states and 150 countries. You can subscribe to the Friday Roundup here.

Our goal is to share with you a wide range of public health topics that speak to the conditions under which we live, the challenges of different populations across the country, and the range of social, cultural, and economic environments that make us healthy or unhealthy. No other single media site finds and publishes the stories that we do.

Our current writing team of superlative PHP Fellows is moving on. Chrissy Packtor, passionate about sexual and reproductive health, is headed home to West Virginia. She will be finding a job working in health communication any day now. In addition to writing dozens of articles for PHP, Chrissy was the driving force behind all our social media this year.

Sampada Nandyala’s roles on the BUSPH campus are many and varied. In addition to being a PHP Fellow, she worked as a Peer Writing Coach and served on the Student Senate as Vice President. She did all of this while studying epidemiology, biostatistics, and infectious disease.

Erin Polka, cyclist and environmental justice warrior, is a part-time student so she will be part of our BUSPH community for a while longer. For her next adventure, she will be working on a community-engaged research project with urban gardeners focused on local food production and lead contamination in New Orleans.

That leaves Jen Beard, our wondrous Associate Editor, and Melissa Davenport, our Managing Editor and arts magician, to hold on until the new crew of Fellows arrives in February: a warm welcome to Oluwatobi Alliyu, Jori Fortson, Julia Garcia, and Gregory Kantor.

Our staff writing is complemented by dozens of thoughtful guest contributors—academics, think tank staffers, community-based critics, technology sector innovators. Those authors took up all the important subjects of the year: marijuana, extreme weather, childhood poverty, bullying, opioids, the ACA, video gaming, the digital divide, sexbots, water quality, the minimum wage, trans rights, good sleep, physical injury and mental health needs, bereaved military spouses, paid sick leave, obesity, homelessness, aging, and so much more.

Our most widely read articles in 2018: women are shamed in jails and prisons for being women; social isolation is on the rise with ill effects; and gun violence seems unending.

Nine months ago, we launched our accompanying newsletter, THE PUBLIC’S HEALTH, to further explore the complexity of the world. You can subscribe here.

We will continue to bring you the issues of the day and engage you along the way.

Thanks for reading Public Health Post and for all each of you do to improve population health.

Please send me thoughts, questions, comments, ideas for topics you’d like to see us cover. I’m at mdstein@bu.edu.

It’s been a great year, and we hope to see you again in 2019.

—Michael Stein, M.D., Executive Editor

Public Health Post goes on our winter publishing break today. We'll return with our first post of the new year on Monday, January 7, 2019. 

Feature image: Paul Iwancio, Thank You, used under CC BY-NC 2.0
                    [post_title] => 2018 Year in Review
                    [post_excerpt] => Executive Editor Michael Stein looks back at the best of 2018 and forward to 2019 with the announcement of our new fellows. 
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                    [post_content] => In 1985, at the start of the AIDS epidemic, President Ronald Reagan's administration implemented a deeply polarizing policy that jeopardized the health of some of the world’s most vulnerable populations. With each administration elected since 1985, politicians of both major parties have either repealed or reinstated the Mexico City Policy, also known as the “Global Gag Rule” or Protecting Life in Global Health Assistance. In 2016, the Trump administration reinstated the Mexico City Policy with additional restrictions on funding for the President's Emergency Plan for AIDS Relief. PEPFAR provides essential HIV prevention, testing, and treatment resources for sexual minority men and other groups at high risk for HIV such as sex workers in low-resource settings like Uganda.

The Mexico City Policy prohibits foreign nongovernmental organizations that perform or promote abortion from receiving US government family planning funds. NGOs can either accept US federal funds and discontinue delivery of comprehensive sexual and reproductive health services or maintain these services without US federal funds.

The reinstatement of the Mexico City Policy under previous Republican administrations restricted $575 million from US family planning funds, but the current Mexico City Policy has pulled $8.8 billion. The drastic move has many in the global health community concerned. As Dr. Monica Onyango, Clinical Assistant Professor of Global Health at the Boston University School of Public Health, notes, “we can anticipate that other populations affected by HIV/AIDS and other diseases, both infectious and non-infectious, will also become vulnerable under Trump’s policy.”
Sexual minority men are among those affected by HIV/AIDS who will also become vulnerable.

 
Sexual minority men are among those affected by HIV/AIDS who will also become vulnerable. NGOs that refuse to comply with the Mexico City Policy lose federal funds and receive fewer resources to provide condoms, pre-exposure prophylaxis (PrEP), and HIV testing and treatment. Health providers delivering sexual and reproductive health services often respond to the needs of LGBT populations and, when health facilities lose resources because of a failure to comply with the Mexico City Policy, this population is left with even fewer options.

Public Health Post articles by Sera Bonds and Madeline Bishop have discussed the Mexico City Policy and its effects on women’s health.  But we must also consider its effects on sexual minority men in low-resource settings, whose access to health services often depends on facilities supported by US funding.

Benjamin, whose name has been changed to protect his safety, remembers the day he went to an LGBT-friendly doctor in Uganda to seek a prescription for PrEP. But the HIV test he took that day held a shock. He already had the virus and left the clinic with medication to treat HIV rather than prevent it.
“I felt bad, but I love my life, so let me start the drugs,” Benjamin said.

 
The reinstated Mexico City Policy impedes Benjamin’s and other sexual minority men’s access to essential sexual and reproductive health services like HIV treatment. Globally, about 36.7 million people are living with HIV. Sexual minority men are disproportionately affected by the virus. The risk of HIV acquisition for this group is 28 times higher than among heterosexual men. Sexual minority men account for 18% of new HIV infections globally and 6% of new HIV infections in Eastern and Southern Africa. In Uganda, HIV prevalence in the general population is 5.9% but 12.7% among sexual minority men.

Benjamin began working as a peer educator to mobilize sexual minority men for HIV prevention, testing, and treatment. In the communities where he works, Benjamin encourages using PrEP, which is a combination of antiretroviral drugs that reduces the risk of HIV acquisition from sex by more than 90%.

“Where I work, we give it to those at the most for HIV,” Benjamin said. “If you know that you don’t use condoms, it’s better that you use PrEP. If you know that you don’t trust someone in a relationship, you use PrEP.”

Like Benjamin, Joseph also works as a peer educator with the Ugandan LGBT community and links sexual minority men in need of PrEP to LGBT-friendly health providers. They both work in one of the six districts with urban centers where PEPFAR focuses its prevention interventions on sexual minority men.

“I just mobilize, so I connect my fellows to the health facilities, to the right people, to the trained personnel who can be able to provide services without discrimination,” Joseph said. “PrEP protects you from getting HIV, specifically, not STIs [sexually transmitted infections]. I just started it of recent because we have not been having access to it, but now it has been brought out to people. I got it just about two weeks back.”

December 1 is World AIDS Day. The global public health community must prioritize the needs of sexual minority men and mitigate the HIV epidemic despite the Mexico City Policy’s deafness to the stories of men like Benjamin and Joseph.

The names of informants have been changed and the name of the LGBT community-based organization has been excluded to protect their safety. You may also read parts one, two, three, and four of Nicholas’s series about LGBT health in Senegal and his reporting on LGBT health in Nigeria and Uganda for Public Health Post.

Feature image: New York, NY: May 5, 1988. Watched by a line of police, ACT UP stages a demonstration at International building, 5th Avenue: AIDS, a World Crisis. © Lee Snider/The Image Works. 
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                    [post_content] => In July of 2014, Governor Charlie Baker signed a bill into law protecting the civil rights of transgender individuals in Massachusetts. Supported by a broad coalition of business, community, and civic groups, this Transgender Anti-Discrimination law ensures equal rights of transgender individuals in public spaces, including parks, restaurants, and public transportation. It also guarantees access to public restrooms, enabling individuals to use restrooms in accordance with their gender-identify.
What’s this week’s Ballot Question 3?
Ballot Question 3 asks: “Do you approve of a law summarized below, which was approved by the House of Representatives and the Senate on July 7, 2016?”

After a summary of the law, voters are guided: “A YES VOTE would keep in place the current law, which prohibits discrimination on the basis of gender identity in places of public accommodation. A NO VOTE would repeal this provision of the public accommodation law.”

That is, a YES vote keeps the existing law in place, continuing to protect transgender rights across the state.
What the Current Law Protects
Taking intimate photographs of people without consent and sexual assault are crimes, and violators are prosecuted under existing criminal law. The Transgender Anti-discrimination Law protects transgender individuals from acts of discrimination and social exclusion. It does not change criminal law. The anti-discrimination law states that a person’s gender identity cannot be used for an “improper purpose” and a person must assert a “consistent and uniform” gender-related identity if questioned in court.
The Opposition
Opponents of the anti-discrimination law include Keep MA Safe, funded primarily by the Massachusetts Family Institute, gathered 50,000 resident signatures to place the Transgender Anti-Discrimination Law on the 2018 ballot with the goal of repealing it. The passage of the 2014 law had immediately sparked opposition among some, based on fear that the law would allow sexual predators, posing as transgender women, to enter women’s restrooms to engage in criminal behavior. Opponents of the law also suggested that civilians who report suspicious gender-based behavior (such as questioning a person’s intent for entering a bathroom) risked being arrested and fined up to $50,000.

Neither of these hypothetical concerns has come to pass.

In fact existing laws do not allow male sex offenders to enter a women’s restroom or locker room. It also does not penalize citizens from reporting criminal behavior. Chapter 151B Section 5 of Massachusetts General Laws: Individuals and organizations can only be arrested or fined if found to have participated in the “discrimination or restriction” of a person based on gender identify. Contrary to 'No on 3’’s campaign ads, fines of $50,000 many only incur when multiple acts of discrimination occur over a seven-year period.
The Nondiscrimination Law Promotes Health and Wellbeing
A study by the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy at the UCLA School of Law found that laws protecting transgender rights have had no effect on the number of bathroom-related crimes in the state of Massachusetts. In fact, they found that safety and privacy violations decreased in areas with stricter implementation of the nondiscrimination law. The researchers also found bathroom-related violations to be extremely rare, providing evidence that many of the opposition’s arguments are based on hypothetical outcomes rather than quantifiable data.

A 2015 report by the National Center for Transgender Equality found that 40% of transgender respondents expressed experiencing psychological distress (depression, stress, and anxiety) in the past month. Suicide attempts by transgender persons is 9 times higher than the national average. Before anti-discrimination legislation passed in North Carolina in 2016, 60% of transgender respondents reported avoiding public restrooms in fear of confrontations, 32% limited what they ate or drank so they didn’t have to use a bathroom, and 8% suffered from bladder-related infections as a result of bathroom avoidance.
What’s in Store for the Future
A June 2018 poll found that 49% of respondents were in favor of keeping the law, as oppose to 37% who reported in favor of repealing it. The margins are slim. This is especially concerning given the recent memo from the Department of Health and Human Services seeking to change Title IX’s legal definition of sex, which currently bans gender discrimination in schools that receive federal funding. This HHS change would create binary definitions of gender (male or female) based on an individual’s biological sex, as assigned at birth. It would eradicate the ability of 1.4 million transgender Americans to self-identify their gender.

Massachusetts is a leading state for policies concerning freedoms and equality. We were the first in the nation to recognize marriage equality. What message will we be sending to the rest for the nation if we repeal this law?

Your vote matters. So on November 6th, get out and vote YES on question 3!

Opportunities to volunteer with the Yes on 3 campaign can be found here.

Feature image from Freedom for All Massachusetts Coalition
                    [post_title] => Vote Yes on 3
                    [post_excerpt] => Erin Polka urges a YES vote on Massachusetts Ballot Question 3, to uphold a state non-discrimination law and protect the the civil rights of transgender individuals. 
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                    [post_content] => Think about where you work or another place you gather regularly with others. Do you have a sense of what the norms are, how you should behave, and how people react? You don’t shout commands to actors in a theater, for example. Yet it’s fine to yell at players at a sports event. Yes, for silence and anti-social behavior in a library. No, for never speaking with your colleagues at work. Okay to eat with your hands at a pizza shop. Not so much at a French restaurant.

What is this sense of “the way we do things around here”? It’s culture. It’s the usually unexpressed assumptions, values, and beliefs of people within an organization. It can manifest in myriad ways. Aviation provides some heart-stopping examples of why culture is important to understand, measure, and change. In the 1980s, the reporting culture around near misses (crashes that almost happened) was in its infancy. The attitude of “nobody knows, so let’s keep it secret” was common. Yet just last year a crash of five full-sized airplanes was averted. One factor in avoiding that disaster may have been that air traffic controllers now work in a culture where speaking up about errors is encouraged.
But as anyone interested in transforming organizations will tell you, changing a culture is difficult. Organizations comprise many levels and micro cultures.

 
But as anyone interested in transforming organizations will tell you, changing a culture is difficult. Organizations comprise many levels and micro cultures. Setting up structures and processes that support change requires consistency, institutional commitment, local champions, effective channeling of resources,  constant communication, and more. The list is long. And these potential difficulties are frequently compounded by everyone’s tendency to defer to the status quo.

An ever increasing part of my career nevertheless focuses on changing cultures. Why? First, my area of choice needs help. I work with nursing homes, particularly those in the Veterans Health Administration (VA) system. The VA Community Living Centers (as nursing homes are known there) yearly serve over 40,000 veterans, many of whom are among the system’s most vulnerable. I detailed in a previous post the reasons nursing homes deserve attention from all of us. The residents who live there—the future you and me—deserve the best care and living environment society can provide. Yet the staff working closely with older adults are often underpaid and overworked. And despite years of effort to change the culture of care, change has been slow. For those of us who love a challenge, it’s a good area to choose.
But there’s another reason I’m increasingly drawn in this direction: our work focuses on the positive.

 
But there’s another reason I’m increasingly drawn in this direction: our work focuses on the positive. If a nursing home is trying to improve prevention of pressure injuries (a.k.a. bed sores), for example, frontline staff can gather for a quick huddle and focus their attention on instances when (a) someone was at risk for developing a bed sore but (b) did not develop one. In these huddles, everyone can have a voice—and it’s easier to speak up when the focus is positive. From the positive examples, staff can learn from what’s already working, then devise an action plan to test small changes they can monitor, repeating this huddle-discuss-plan-observe process in an ongoing cycle. We call this “learning from the bright spots.” It helps change the culture by creating high-functioning, relationship-based teams ready to tackle all kinds of quality, safety, morale, and other challenges.

The consultants with whom we work have achieved miraculous changes in nursing home cultures across the nation for decades. But for the first time, with support from VA’s central leadership, we are tackling change in a large, integrated healthcare system.

Sometimes you don’t want to change the way things are done around here, like eating pizza with your hands. But sometimes you need to. Nursing homes need change. There are some terrific, shining examples of what’s possible. But we need to raise the level of all. I believe changes in systems, to the benefit of everyone, is possible.

Feature image: Jeffrey Smith, Senior Dance 1. Jeff Smith/Staff Photographer, used under CC BY-ND 2.0. Used for illustrative purposes only.
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                    [post_content] => Though the surgeon general recommends more people carry naloxone to enable opioid overdose reversals, economists in a recent study argue that greater access increases crime and incentivizes drug use. They allege naloxone allows people who survive an overdose after receiving naloxone to go on to commit more “opioid-related” crimes. They claim the cost of reversing overdoses is burdensome, arguing some people may need to be reversed again. They correlate changing naloxone laws with increasing rates of opioid use and suggest naloxone increases such use by “providing a safety net.” They argue that naloxone presents a moral hazard, an insurance policy guarding opioid users from the consequences of their actions. Yet no credible evidence exists that providing naloxone increases compensatory substance use, and economic arguments do not tell human stories.

While on call this past year in Central Appalachia, an area heavily affected by opioid use and overdose, we heard from a pregnant patient with opioid addiction. She had overdosed the night before. Thankfully, she was with people who had naloxone—they used two kits to get her breathing again. She went on to enter substance use treatment and deliver a healthy baby. Without naloxone, she would have died; she would not have gone on to parent a wanted child. For anyone with an un-medicated chronic illness, a relapse or worsening of symptoms is common. Unlike other diseases, in addiction, relapse can be deadly. What compelling economic argument is there that people deserve to die from relapse How many reversals do these economists consider too many?
Four North Carolinians die every day from overdose—because of poverty, pain, and lack of access to treatment and health care overall.

 
Working in a harm reduction program in Western North Carolina, we distribute naloxone to people who use drugs. In the last year we noticed a dramatic increase in the number of naloxone kits requested, and reversals reported—188 fatal overdoses were prevented through peer reversals, in the first half of 2018 in one county, alone. We know that people who use drugs and access harm reduction services are five times more likely to enter treatment than people who don’t. Part of the reason is that harm reduction—which includes the provision of naloxone—offers a judgment-free space for stigmatized opioid users to get what they need, and to be heard. Unfortunately, the high demand for substance use treatment is not currently met in North Carolina or throughout the South, where opioid use disorders rates are higher and access to treatment is lower than elsewhere in the country. Four North Carolinians die every day from overdose— because of poverty, pain, and lack of access to treatment and health care overall. Naloxone is a life-saving solution to a structural overdose problem.

We do not consider the likelihood of a future property crime before offering naloxone, safe injecting equipment, or treatment. We do think about people overdosing and dying. Substance users deserve to live. We have at our disposal an overdose reversal medication that enables survival. It is immoral not to provide and use it.

Feature image: VCU CNS, Narcan_Product_Image_2, used under CC BY-NC 2.0
                    [post_title] => Is There a Risk to Naloxone?
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