Viewpoint

Crowdsourcing the Opioid Epidemic

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                    [post_content] => Boston’s streets are full of the evidence of the ongoing opioid epidemic, which is killing Americans at an alarming rate. Drug-use-associated litter is a problem that poses minor public health risks but stokes significant community anxieties. While many cities have established needle exchanges or safer needle disposal programs, these services are underutilized because of the stigma associated with substance use disorders, and some have recently closed, facing political and financial pressures.

In 2015, Boston established a Mobile Sharps Collection Team to respond to discarded needle pick-up requests throughout the city. These crowdsourced requests leverage the existing non-emergency 311 infrastructure by allowing Boston residents to request a needle pick-up through a website, Twitter or, most commonly, the Bos:311 mobile app. Notably, Boston has made the data from this program publicly available.
These crowdsourced and publicly available data shine a bright light on the role of citizen scientists in building healthy communities.  
As Boston-based clinicians and researchers caring for patients with substance use disorders and interested in publicly available data, we wondered: could the data from discarded needles provide an opportunity to address the underlying epidemic? More specifically, could examining temporal and spatial trends in discarded needles throughout the city help us develop community responses to the opioid-use and overdose epidemics? Our initial findings were published last month in the American Journal of Public Health. We highlight the rising number of reported needles in Boston, up from 600 needle pick-up requests in 2015 to well over 2,000 in 2017. We identify discarded needle hot spots clustered in the South End and Roxbury neighborhoods, with several outlying hotspots in the North End, Allston-Brighton and the South Boston-Dorchester border. Using additional geospatial methods like buffering analysis, where we calculate discarded needles within a set distance from points of interest, we also found an association between sites of high social stress (hospitals, homeless shelters, safe needle disposal sites, methadone clinics) and areas with a high density of publicly discarded needles. These crowdsourced and publicly available data shine a bright light on the role of citizen scientists in building healthy communities. By reporting discarded needles, Boston community members call attention to the immediate public health risks of needlestick injuries, while the resulting data can be used to target services for individuals with substance use disorders more effectively. People who inject drugs face significant stigma. They also lack safe places to use and reliable access to harm reduction services including needle exchange and naloxone to reverse overdose. There are at least two hundred municipal 311 programs in the United States and a number of international cities have followed. The crowd-sourced data generated by these programs provide a precise accounting of public concerns; however, few cities are reporting their data publicly. So far, only Boston, Seattle, and San Francisco are collecting discarded needle data. We hope that our work highlights the value in public reporting of drug-related litter. By uniting community members, researchers, and public health advocates we hope to catalyze an increase in targeted harm reduction services including syringe exchange, overdose prevention sites, and access to medications to treat opioid addiction. Map created in ArcGIS by John F. Pearson, MD. Sources: MassGIS, OpenStreetMap.org, BOS:311 [post_title] => Crowdsourcing the Opioid Epidemic [post_excerpt] => In 2015, Boston established a Mobile Sharps Collection Team to respond to discarded needle pick-up requests throughout the city. Data from discarded needle locations could provide an opportunity to address the underlying epidemic.  [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => crowdsourcing-the-opioid-epidemic [to_ping] => [pinged] => [post_modified] => 2018-09-06 06:36:59 [post_modified_gmt] => 2018-09-06 10:36:59 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5490 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

In 2015, Boston established a Mobile Sharps Collection Team to respond to discarded needle pick-up requests throughout the city. Data from discarded needle locations could provide an opportunity to address the underlying epidemic. 

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What’s Up with PEPFAR’s Anti-Prostitution Pledge?

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                    [post_content] => In July, 15,000 people living with HIV, activists, researchers, policymakers, and donors gathered in Amsterdam for the 22nd International AIDS Conference.  This year’s theme—Breaking Barriers, Building Bridges—focused the world’s attention on sex workers and other marginalized populations disproportionately affected by HIV.

Amsterdam was deliberately chosen to host the 2018 conference because of its high-profile red-light district and the legal status of sex work in the Netherlands. Sex workers were front-and-center in press conferences, panel discussions, and awards ceremonies. They even raucously interrupted President Clinton’s key note address to protest US policies and demand that the 2020 AIDS meeting not be held, as planned, in San Francisco. The US government, they argued, has a long history of violating the human rights of people who sell sex, implementing oppressive laws, and making it difficult for sex workers to protect themselves from HIV and violence.

The Prohibition on the Promotion and Advocacy of the Legalization or Practice of Prostitution or Sex Trafficking embedded in the President’s Emergency Plan for AIDS Relief (PEPFAR) is a particularly egregious example. The Anti-Prostitution Pledge requires organizations receiving US funding to certify that they will not “promote or advocate the legalization or practice of prostitution or sex trafficking.” They must have an explicit policy against sex work and trafficking and agree to not use private funds to support sex workers. It has been derided by many, but its restrictions have gradually loosened over the years. Simultaneously, PEPFAR has committed to promoting the health and wellbeing of sex workers through its focus on key populations. Here’s a brief overview of the current situation and how we arrived here.
Since 2003, PEPFAR has invested $70 billion dollars and has changed the course of the HIV pandemic. It is an enduring positive legacy of George W. Bush’s presidency.  
Since 2003, PEPFAR has invested $70 billion dollars and has changed the course of the HIV pandemic. It is an enduring positive legacy of George W. Bush’s presidency. At the same time, Bush’s conservative values also limited PEPFAR programming for many years by pushing abstinence over condoms as a primary form of prevention, and prohibiting needle exchange. Eradicating prostitution is a core goal of the PEPFAR legislation. Forcing countries and public health organizations to comply with the anti-prostitution pledge was one means to that end. The grip of the Anti-Prostitution Pledge has been the most enduring, but it too has gradually loosened. In 2013 the Supreme Court ruled the Pledge violates freedom of speech. A later win in New York went further, ruling that US organizations and their foreign implementers are protected by the First Amendment. Despite these successful challenges, all organizations receiving PEPFAR funding are still required to certify compliance. And foreign organizations receiving funding directly from the US government are bound by its restrictions. If you are confused, it’s with good reason. In a direct contradiction of the Anti-Prostitution Pledge, PEPFAR is channeling millions of dollars to programs that support sex workers. Simply type “PEPFAR key populations” into your search engine to find information about the many programs for sex workers the US government supports.  PEPFAR’s declaration that it “stands firmly and unequivocally with and for key populations” is based on detailed ethical frameworkensuring human rights and leaving no one behind.” I’m not complaining. I have worked with PEPFAR-supported programs focused on the health and human rights of people who sell sex in Ghana and elsewhere. These collaborations have sometimes allowed me to forget that the Anti-Prostitution Pledge is also part of the PEPFAR ethos. I led a PEPFAR-funded study that had an express goal of helping USAID and Ghana’s government better understand the vulnerabilities and needs of adolescents and adults engaging in sex work. The Anti-Prostitution Pledge rarely came up. But we cannot dismiss the Pledge as an unimportant policy relic. For now, evidence seems to be winning the tug of war with ideology. But we can’t afford to be complacent. Feature image: Michael Coghlan, Where the 'Ladies' Sit (detail), used under CC BY-SA 2.0 [post_title] => What’s Up with PEPFAR’s Anti-Prostitution Pledge? [post_excerpt] => The US government has committed millions of dollars to HIV prevention for sex workers, a major departure from the Anti-Prostitution Pledge. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => whats-up-with-pepfars-anti-prostitution-pledge [to_ping] => [pinged] => [post_modified] => 2018-10-03 07:12:54 [post_modified_gmt] => 2018-10-03 11:12:54 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5469 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The US government has committed millions of dollars to HIV prevention for sex workers, a major departure from the Anti-Prostitution Pledge.

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At a Crossroads: Medical Cannabis and Mental Health

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                    [post_content] => Legislation authorizing medical cannabis in 31 states over the past 22 years has transformed the marijuana infrastructure in the United States, enabling widespread access. Many now regard cannabis as no different, or even safer than, alcohol or tobacco. The alternative wellness community embraces cannabis as a therapeutic aid, fostering public perception of positive health benefits. Medical cannabis can be home grown or purchased at dispensaries via a physician recommendation in a wide variety of forms, to be smoked, vaped, or ingested in tinctures and edibles.

With this shift toward cultural acceptance, it is important to keep in mind that cannabis has addictive potential and may exacerbate mental health problems, particularly among adolescents and emerging adults. Portable vape pens are a popular form of cannabis use among youth due to convenience and discretion. Vaping may lead to more frequent use and misuse compared to smoking. Our research indicates that 18 to 30-year-old medical cannabis users are motivated to use cannabis out of boredom and show more problematic cannabis use than middle-aged and older adults.
Our research indicates that 18 to 30-year-old medical cannabis users are motivated to use cannabis out of boredom and show more problematic cannabis use than middle-aged and older adults.  
The two main chemical compounds in the cannabis plant are tetrahydrocannabinol (THC) and cannabidiol (CBD), both of which affect the naturally occurring cannabinoid system in the brain and body. Unlike THC, CBD does not cause intoxication or cognitive deficits, and has low potential for misuse. Emerging scientific evidence indicates that THC and CBD can be used to treat certain physical problems. Likewise, individuals are increasingly using cannabis to manage psychological conditions, such as anxiety, depression, stress, insomnia, trauma, attention-deficit hyperactivity disorder, and psychosis. Research consistently shows however that cannabis is not a viable treatment for depression. While CBD may help with psychosis, social anxiety, and sleep, THC is known to exacerbate psychosis, increase anxiety and impair sleep quality, especially if the individual relies on cannabis to sleep. Trauma survivors and veterans with PTSD, who use cannabis to cope with anxiety, nightmares, and insomnia may develop cannabis addiction and avoid dealing with their underlying issues. While some researchers promote cannabis as a less harmful substitute for opioids in treating chronic pain, Canadian physicians recommend against medical cannabis for all conditions except severe refractory pain when all other options are exhausted.
Although I have patients who claim cannabis works better than psychiatric medications, it should not be regarded as a first-line treatment for any mental health condition because of the potential for misuse and dosing inaccuracy.  
Although I have patients who claim cannabis works better than psychiatric medications, it should not be regarded as a first-line treatment for any mental health condition because of the potential for misuse and dosing inaccuracy. If psychotherapy and medications fail, low doses of cannabis could be considered in consultation with one’s doctor, depending on symptoms and case history. Because CBD is thought to offset the negative effects of THC, medical cannabis patients should consider using cannabis that contains elevated levels of CBD. Clinical outcomes often depend on cannabis dose and strain-type, as well as a person’s neurochemistry. Due to federal prohibition, cannabis research is still in its infancy. The expanding cannabis industry and its messaging have outpaced the ability of scientists to conduct and disseminate research. Public health initiatives driven by cannabis regulatory science could address misinformation being given by dispensary staff and the online cannabis community. Evidence-based recommendations for safe and effective therapeutic uses of cannabis are critically needed in the mental health arena. Feature image design by Daniel Paduano [post_title] => At a Crossroads: Medical Cannabis and Mental Health [post_excerpt] => Cultural acceptance of marijuana is increasing, but cannabis has addictive potential and may exacerbate mental health problems, particularly among adolescents and emerging adults. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => medical-cannabis-and-mental-health [to_ping] => [pinged] => [post_modified] => 2018-08-30 17:05:26 [post_modified_gmt] => 2018-08-30 21:05:26 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5436 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Cultural acceptance of marijuana is increasing, but cannabis has addictive potential and may exacerbate mental health problems, particularly among adolescents and emerging adults.

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Public Charge Regulation and Institutionalizing Immigrant Poverty

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                    [post_content] => Suppose you are in the United States on a student visa and want to enroll in a Marketplace plan. Or maybe you are on an H1-B work visa and want to enroll your newborn in WIC. Sure, why not? Well, do you want to stay? Then, not so fast. The Trump administration is pushing for a revision of the “public charge” rules, which could force non-citizens living here legally to choose between popular benefits and their future immigration status.

What is the Public Charge Rule?

For over 100 years, public charge regulation has played a role in who is allowed to legally immigrate into and remain in the United States as a permanent resident. The roots of this type of regulation stretch back to colonial times when "colonists were especially reluctant to…welcome…impoverished foreigners." These rules provide a legal basis to discriminate against those in need, creating a disincentive for immigration by those who would rely upon public support. For nearly two decades, “non-cash benefits,” like tax credits (e.g., Earned Income Tax Credit) and in-kind benefits (e.g., health insurance, nutrition support) have been excluded from such determinations. For example, “lawfully present” immigrants must generally wait five years before being eligible for Medicaid, but many can apply for coverage and get financial help in the Marketplace. (Oh, except if you here under Deferred Action for Childhood Arrivals, then you cannot participate in the Marketplace at all.) The complex patchwork of qualifying statuses for various programs is already a barrier to participation since many do not know that they are eligible.

The Leak

A draft proposal modifying the public charge rules leaked in March, broadening them to include those receiving “almost any form of welfare or public benefit, even popular tax deductions.” This would expand the scope of public charge determinations from about 3% of non-citizens to 47% under the draft rule. Benefits used by dependents, even those who are citizens, could factor in. Also, the current standard of being "primarily dependent" on government support for considering one to be a public charge would change to receiving nearly “any government assistance,” excluding only those receiving very low value of benefits (i.e., less than $1 per day for a single person). These changes could easily be framed as conserving resources for citizens and permanent residents, which is objectively defensible at face value. But this rationale ignores the larger context and apparent motives behind these changes.

How Would These Changes Affect Families?

Nearly 15% of the 27.5 million uninsured are ineligible for ACA coverage due to their own immigration status (e.g., undocumented, DACA). However, there are another 10 million children who are citizens with non-citizen parents. These children are not only at risk for separation if their parents are forced to leave, but this could also have the (un)intended consequence of discouraging parents from signing their children up for programs like WIC and Medicaid. There was a “chilling effect” of being in a mixed status household on Medicaid coverage prior to the 2016 election, likely deepening to a freeze with the anti-immigrant stance of this administration. In a country where Latinxs are already disproportionately more likely to be uninsured, a further disincentive to participation in widely used programs would make climbing the economic ladder even more difficult. The republic sits at an ethical crossroads. From remarks by then-candidate Trump about Mexican “rapists” to tweets about “infestation” by MS-13 and a reprehensible family separation policy, this administration continues its anti-immigrant assault. This change to the public charge rules would represent an insidious new low in how we treat immigrants in America. We should push the administration and Congress to enact comprehensive immigration reform rather than using regulation to institutionalize and further widen economic and health disparities between immigrants, particularly those in the United States legally, and their neighbors. Feature image: jordi.martorell, Statue of Liberty? (detail), used under CC BY-NC-ND 2.0 [post_title] => Public Charge Regulation and Institutionalizing Immigrant Poverty [post_excerpt] => The Trump administration's revision of public charge rules could force non-citizens living here legally to choose between benefits and their future immigration status. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => public-charge-regulation [to_ping] => [pinged] => [post_modified] => 2019-01-31 22:05:47 [post_modified_gmt] => 2019-02-01 03:05:47 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5421 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The Trump administration’s revision of public charge rules could force non-citizens living here legally to choose between benefits and their future immigration status.

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Racial Disparities, Prescription Medications, and Promoting Equity

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                    [post_content] => The United States has the highest drug prices in the world and it's not even close. For millions in the country, the cost of prescription drugs is an ever-growing barrier to proper disease treatment. This is most often the case for minority groups, who have long experienced disproportionally adverse health access and outcomes. But high drug prices alone do not explain the inequity we see. Though cost is a major factor, Colon, et al. found that disparities are not simply a function of socioeconomic status—the story is more complicated.

Minorities Face Many Barriers to Prescription Medicines

Costs White Americans are, on average, much wealthier than Black and Hispanic Americans. The median net worth of White households in 2016 was 9.7 times higher than African-American households and 8.3 times higher than Hispanic households. Wealth disparities result in negative health consequences. Among insured adults with diabetes, Tseng, et al, found race and ethnicity to be a significant predictor of medication underuse—patients underusing their medication in order to prolong supply—due to cost. (Medication underuse is a somewhat common cost saving strategy, per the CDC.) The authors attribute this to lower incomes and higher out-of-pocket drug costs. Although study participants all had health insurance, disparities persisted. Lack of Insurance Affording medications is even harder for those without coverage. Though the Affordable Care Act (ACA) reduced the number of uninsured Americans, over 28 million remain without insurance. More than half (55%) of uninsured Americans under the age of 65 are people of color. For those with no insurance, paying retail prices for medications is often financially impossible. Implicit Racial Bias in Prescribing Practice Race can have an implicit effect on the prescribing practices of providers. For example, one study showed that White children treated at pediatric emergency departments inappropriately received antibiotics for respiratory infections more often than Black or Hispanic children, indicating that prescribing patterns can vary depending on the race of the patient. Terrell, et al., found that in their sample, ethnic and racial minorities were prescribed analgesics at a lower rate compared to White patients when discharged from the emergency department.

Practical Policy Pursuits

Here are four policy options for addressing racial disparities in access to prescription medication: Continue to Expand Medicaid One in five people of color have access to prescription drugs through Medicaid. Virginia recently expanded Medicaid (becoming the thirty-third state to do so). Medicaid expansion is on the November 2018 ballot in Utah and Idaho (Atkeson and Jones write more about the Idaho intiative here) while supporters in Nebraska are collecting signatures to get it on the ballot. A Maine state court has ruled that Governor LePage must submit the paperwork to expand. Promote the ACA and an Essential Benefits Package The ACA has played a key role in increasing health insurance among low-income people of color. Prescription drugs are one of ten essential health benefits the ACA requires insurers to cover. Interventions to increase coverage are needed, particularly in regard to medications. Research shows that promoting coverage gains through increased advertising is effective. Reduce Implicit Bias in Prescribing   Parity in prescribing practices is possible. New research shows that reducing stigmatizing language in electronic health records can reduce implicit bias in physicians-in-training, influencing their attitudes about both patients and prescribing behavior. Value-based  Formularies to Reduce Costs Pharmacy cost reduction is critical. One method for cutting costs is to use value-based formularies (VBFs), which guide prescription decisions based on cost-effectiveness. Simply, if there’s a drug with similar efficacy that costs less, that drug can be placed on an insurer’s formulary in favor of a competitor. For example, Express Scripts, the nation’s largest pharmacy benefit manager, cut Amgen’s Repatha (evolocumab) in favor of Sanofi and Regeneron’s Praluent (alirocumab), which is used for preventing cardiovascular disease, because of the latter’s willingness to lower the price to match valuation done by the Institute for Clinical and Economic Review (ICER). The multidimensional nature of health disparities and pharmaceutical law, policy, and practice requires multiple, synergistic approaches like those mentioned here, as a means to promote equitable access to necessary and effective medications for minorities. Feature image: Thomas Hawk, Prescriptions (detail), used under CC BY-NC 2.0 [post_title] => Racial Disparities, Prescription Medications, and Promoting Equity [post_excerpt] => For millions in the US, drug prices are an ever-growing barrier. Here are four policy options for addressing racial disparities in access to prescription medication. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => racial-disparities-prescription-medications-equity [to_ping] => [pinged] => [post_modified] => 2018-08-21 07:45:46 [post_modified_gmt] => 2018-08-21 11:45:46 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5386 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

For millions in the US, drug prices are an ever-growing barrier. Here are four policy options for addressing racial disparities in access to prescription medication.

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On Vacation

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                    [post_content] => We're on vacation! Public Health Post is taking our #summertime publishing break. Thank you from the whole crew for reading PHP and The Public's Health, and for joining us in conversation on social media.

We'll be back online on Monday, August 20. See you then!

Feature image: Kevin Jones, Gatsby swimming, used under CC BY 2.0
                    [post_title] => On Vacation
                    [post_excerpt] => Public Health Post is taking our summertime break. Thank you from the whole crew for reading PHP and The Public's Health. We're back online Monday, August 20. See you then!
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Public Health Post is taking our summertime break. Thank you from the whole crew for reading PHP and The Public’s Health. We’re back online Monday, August 20. See you then!

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Race, Discrimination, and Health: 50 Years after MLK

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                    [post_content] => Now in the North it’s [discrimination’s] different… But it has its subtle and hidden forms and it exists in three areas: in the area of employment discrimination, in the area of housing discrimination, and in the area of de facto segregation in the public schools.” —Martin Luther King, Jr., 1963

On April 4, 2018, the United States commemorated fifty years since the assassination of Dr. Martin Luther King, Jr. From speeches to memorial services, the nation relived the transformative legacy of the reverend from Montgomery, Alabama. Nevertheless, fifty years later, many of Dr. King’s concerns remain unchanged. Racism, discrimination, and prejudice continue to fill the national discourse, especially regarding health care. The social justice that Dr. King fought for remains critical to American health today. These ongoing challenges include employment, housing, and education.

Employment Discrimination

The New York Times recently highlighted findings showing that Black men are less likely to create wealth than White men, regardless of family background and the neighborhood where they were raised. Researchers found that Black Americans make up nearly 35% of children raised in the bottom 1% of income distribution and less than 1% of children at the very top. Previous evidence has described the role that income plays in the prevention and management of disease, from the ability to afford healthy food to novel medications. Yet, while the overall US unemployment rate has dropped below 5%, Blacks continue to experience the highest levels of unemployment. Along with increased opportunities for healthy behavior, employment is crucial to gaining insurance, which remains central to health care access. As the number of states requiring employment to receive public insurance grows, the impact of job discrimination on health is as important as ever.

Housing Discrimination

The discriminatory practices of redlining and predatory loans that resulted in the segregated neighborhoods that Dr. King marched through, continue to influence society today. Such segregation persists despite President Lyndon Johnson signing the Fair Housing Act into law one week after Dr. King’s death, which outlawed racial discrimination in the rental, sale, and financing of housing. This Act should have transformed the geographic distribution of Americans nationwide, yet Blacks, including the most affluent, continue to live in poorer neighborhoods than Whites. Similar to employment, zip code may influence health as much as genetic code. Access to green space, safe environmental conditions, and healthy supermarkets all play a significant role in the prevention of poor health. Additionally, many researchers have shown the impact of housing instability and homelessness on higher rates of infectious and cardiovascular diseases.

Education Discrimination

Education is key to obtaining employment and maintaining housing. Since the Brown vs. the Board of Education ruling, education discrimination continues to shape our society. Today, Black and Brown students still study in overcrowded and under-resourced public schools, often separate from their White counterparts. A growing body of research shows that educational attainment has a lasting effect on life expectancy and health behaviors. In addition, access to education results in increased health literacy which has been closely linked to engagement in care, patient satisfaction, and improved health outcomes. Yet, compared to other high-income nations, the United States continues to spend a disproportionate amount on health care delivery compared to social services, including education.

The Next Half-Century

Fifty years after Dr. King’s death, the health system has increased its attention to the social determinants of health. Hospitals like Boston Medical Center recently launched an affordable housing initiative. Health insurance plans are working with providers to enhance collection of social determinants data while health care startups like City Block are designing Neighborhood Hubs to address non-medical factors. Despite these efforts, discrimination in employment, housing, and education, and its effect on health disparities requires further innovation and advocacy from researchers, physicians, and community leaders alike. This is the only way that the next generation can look back with a sense of pride, realizing that Dr. King’s dream of justice has finally been fulfilled. Feature image: B.C. Lorio, "Martin Luther King, Jr. Statue," Newark, New Jersey, used under CC BY-NC-ND 2.0 [post_title] => Race, Discrimination, and Health: 50 Years after MLK [post_excerpt] => Fifty years after Dr. Martin Luther King's death, racism, discrimination, and prejudice continue to fill the national discourse, especially regarding healthcare. The social justice that Dr. King fought for remains critical to American health today. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => race-discrimination-and-health-50-years-after-mlk [to_ping] => [pinged] => [post_modified] => 2018-06-13 13:39:55 [post_modified_gmt] => 2018-06-13 17:39:55 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5049 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Fifty years after Dr. Martin Luther King’s death, racism, discrimination, and prejudice continue to fill the national discourse, especially regarding healthcare. The social justice that Dr. King fought for remains critical to American health today.

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Viewpoint

No MENA Category is a Mistake

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                    [post_content] => An estimated 3.7 million Arab Americans live in the United States. Most are US citizens. Our understanding of this group’s health needs is limited. The limited research is partly due to the absence of an ethnic identifier for Arab Americans in official statistics. The research that does exist points to high levels of chronic disease (including hypertension), obesity, and depression in this population.

The US Office of Management and Budget (OMB) released racial and ethnic standards for federal statistics and reporting in 1977 and updated them in 1997. The OMB has not made changes to these race and ethnicity classifications since 1997 despite significant demographic changes over the last 20 years. Some groups have not received their own ethnic and racial identifiers despite having large representation in the United States. This includes those who consider themselves to be Arab Americans or who have ethnic, linguistic, or hereditary origins in 22 Arabic-speaking countries in the Middle East and North Africa.
Despite this guidance, best available evidence suggests that some Arab Americans select "Other" because they do not feel White properly describes them.  
The OMB issued a notice on March 1, 2017 soliciting comments from the general public about improving the accuracy of race and ethnicity information by including a Middle East and North African (MENA) reporting category. The category was tested in the 2015 National Content Test for the Census after significant lobbying by the Arab-American community. In January of 2018, the Census Bureau announced that they would not include the MENA category in the 2020 Census. Individuals with origins from the Middle East are therefore encouraged to indicate White/Caucasian on the Census and other health surveys. Despite this guidance, best available evidence suggests that some Arab Americans select "Other" because they do not feel White properly describes them. In epidemiologic terms, either choice is a misclassification that may ultimately impede our understanding of disease risk in this population. The potential for misclassification is highlighted with a thought experiment: imagine we are studying a hypothetical diverse population similar in racial/ethnic composition to metropolitan Detroit composed of 10% Arab Americans, 45% White Americans, and 45% who identify as Other.  Then imagine that respondents have only two racial classifications to choose from: White and Other. Imagine we know that 25% of Whites and 50% of those identifying as Other are at risk for depression while Arab Americans have an increased risk at 75%. If all those who are Arab American identify as White, we overestimate the relative risk of depression for Whites in the population by 36%. This misclassification will limit our ability to target interventions to the population most in need of appropriate mental health services.
The incorporation of a MENA category on the Census, and medical and public health surveys would improve our understanding of Arab American health and the health of the communities in which they live.  
The incorporation of a MENA category on the Census, and medical and public health surveys would improve our understanding of Arab American health and the health of the communities in which they live. When minorities with unique health needs and social experiences in the United States are counted within the majority group, researchers may be unable to properly calculate disease risk for either group and, therefore, unable to develop effective community-level interventions. Arab Americans represent a vulnerable minority population which is difficult to help without proper racial and ethnic classifications in electronic medical records, surveys, and the US Census. The lack of a MENA identifier on the Census inhibits a true understanding of the health of all Americans, not just Arab Americans. Feature image: AH86/iStock [post_title] => No MENA Category is a Mistake [post_excerpt] => The Census Bureau will not include a Middle East and North African (MENA) category in the 2020 US Census. The incorporation of a MENA category on the Census and medical and public health surveys would improve our understanding of Arab American health. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => no-mena-category-is-a-u-s-census-bureau-mistake [to_ping] => [pinged] => [post_modified] => 2018-06-07 07:13:45 [post_modified_gmt] => 2018-06-07 11:13:45 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=5091 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The Census Bureau will not include a Middle East and North African (MENA) category in the 2020 US Census. The incorporation of a MENA category on the Census and medical and public health surveys would improve our understanding of Arab American health.

...more
Viewpoint

Women in Leadership and Public Health

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                    [post_content] => Record numbers of women are running for office, especially Democrats, many inspired by the Trump election. However, large numbers of losses are expected. Not only are more women running this campaign year, but so are more men, and thus the share of women candidates has only moderately increased. Many of the women on the left are running in districts more likely to elect a male Republican candidate. But losing isn’t the end. The experience, name-recognition, and respect gained from the process both within one’s party and in the public eye, are valuable. NPR reporter, Danielle Kurtzleben, says this wave of women is not seen as “the next election’s worth of candidates” but rather “the next generation’s worth.”

How Women Are Underrepresented

Although the number of women in government has been rising since the 1960s, we are still struggling for equal representation. Women make up half of the population and yet barely hold 20% of the seats in the U.S. Congress. Pennsylvania does not have a single woman in its Congressional delegation. It’s not just the House and Senate that lack fair representation. Throughout all levels of government, the percentage of women is far below that of men. For all statewide executive offices (governors) and local offices (mayors) women make up less than one quarter of the seats. The percentage of women in state legislature positions is larger, highest in Arizona and Vermont at 40%. Positions of power are still unquestionably dominated by men.

Why Women Are Underrepresented

According to Pew Research, 75% of Americans believe that men and women are equally capable of leading. That’s across the board for Republicans, Democrats, and Independents. Women also win elections at the same rate as men and, once in office, demonstrate equal quality in performance. So why are there fewer women in office? Until this recent surge, women weren’t running. Gendered social roles and lack of encouragement have prevented women from feeling the confidence to run. Women reported feeling significantly less qualified and doubting their abilities. It took Senator Kirsten Gillibrand two decades as a law firm associate, and ten years of volunteering before she felt confident enough to run for office. Yet she knew as young as age 8 that she would one day run for office.  

The Good that Women Do for Public Health

Women being elected isn’t just good for visual representation. Women govern differently than men do when in office. A study by Michele Swers from Georgetown University found that women cosponsor the most healthcare legislation, with Democratic women cosponsoring the most overall and Republican women cosponsoring twice as many bills as their male Republican colleagues. Women also tend to focus on education, civil rights, and social welfare. Women were significantly more likely to sponsor bills in these area than men between 1973 and 2014. Women tend to have more legislation enacted as well, with women in Congress averaging 2.31 bills enacted versus 1.57 for men. Women in Congress also fare better when it comes to federal money. On average, women in Congress brought 9% more money back to their districts for federal programs than men did. These programs focus on agriculture, education, research, and more. Today, social networks focused on women and leadership, such as EMILY’s List (acronym for “Early Money Is Like Yeast”) and Maggie’s List help train and support women to become educated, authoritative, and to run strong campaigns.

So What's Next?

What can we do to get more women into office? According to the Center for American Women and Politics, a suggestion to run is the strongest predictor of whether a candidate will enter a political race. Women need to be encouraged to run, and not just once. They need to be encouraged repeatedly.  Rep. Monica Youngblood thought it was “a joke” when she was first called to run for Congress, and needed to be asked several times and encouraged by family before she felt confident enough to do so. Women are also more motivated when encouraged with phrasing that suggests opportunities to fix problems and improve communities. Women who are already campaigning need donations. Women face a gender gap in campaign financing, and many cite fundraising as a barrier to running for office. While women donate based on who they support regardless of gender, men tend to donate to male candidates, thereby tipping the scale in their favor. Women leaders such as as Susan Collins, Tammy Duckworth, and Tammy Baldwin have focused their efforts on improving health, human rights, and equity. We can all play a role in getting more women into office, and we’ll all be better off if we do. Feature image: Cheng-ting Chang, Women Power!, used under CC BY-NC-ND 2.0.  Graphics from Pew Research Center Social & Demographic Trends, Women and Leadership, Women in Congress, 1965-2015 and Men and Women Equally Capable Political Leaders, January 13, 2015. [post_title] => Women in Leadership and Public Health [post_excerpt] => Women make up half of the population and yet barely hold 20% of the seats in the U.S. Congress. Here's why women candidates are important for public health. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => women-in-leadership-and-public-health [to_ping] => [pinged] => [post_modified] => 2018-05-22 22:38:28 [post_modified_gmt] => 2018-05-23 02:38:28 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4371 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Women make up half of the population and yet barely hold 20% of the seats in the U.S. Congress. Here’s why women candidates are important for public health.

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Viewpoint

Why Not Single Payer Now?

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                    [post_content] => Democrats and moderates spent the last decade building support for, developing, and then defending the incrementalist Affordable Care Act. It has (narrowly) survived eight years of vicious, distorted attack.

Now, a resurgent progressivism would abandon it. Sixteen Democratic U.S. Senators (a record number) have co-sponsored Bernie Sanders’ Medicare-for-All bill, and Washington, D.C.’s influential Center for American Progress, recently rolled out Medicare Extra for All.

The policy arguments for a single-payer system have long been clear—universality, simplicity, administrative and (potentially) other savings. Even Taiwan, that bulwark of capitalist resistance to “communist” China, settled on Canadian-style Medicare as the best model for universal coverage.

And there’s an emotional factor as well behind the Democrats’ swing left: incrementalism seems to have done nothing to mollify the right. After withstanding repeated efforts at “repeal and replace,” resurgent liberals might take pleasure in dropping their unrequited efforts at compromise in favor of more fundamental change. Sweet revenge, indeed, on all those Republicans who mouthed sympathy for the uninsured before 2010, only to viciously attack the very moderate, market-oriented ACA!

However, a Democratic push for single-payer is exactly the wrong move now. It would be wrong for three reasons.

First, the ACA is working: The uninsured rate for legal residents has been cut in half. Expanding Medicaid and private coverage is associated with greater access to prevention, primary care and prescription drugs, higher rates of diagnosing and treating chronic conditions, and improved control of hypertension. Its reach is also growing. If Virginia expands Medicaid, as seems likely, two-thirds of the states (and the District of Columbia) will have done so under the ACA. More will likely follow if Democratic wins insulate it from repeal.

Second, the ACA can be improved. This can be done simply by reversing Republican efforts of the past 15 months to undercut it, plus relatively modest increases in the tax subsidies to encourage direct enrollment. Massachusetts Senator Elizabeth Warren has introduced The Consumer Health Insurance Protection Act to do just that.

With its growing popularity, the ACA offers a sturdy platform on which to build. It is now more popular than at any time since its passage, and most voters think Democrats and Republicans should work together to improve it. (See figure.) Independents, who will decide the next elections, can be turned by Republican strategists against single-payer “socializing medicine.” But 59% support fixing the ACA, as do 70% of Democrats. Promoting single payer would allow Republicans to switch from defending their record on Obamacare to attacking “spend-and-tax” Democrats.

Chart showing favorable and unfavorable views of the ACA

Third, re-taking Congress in 2018 and the White House in 2020 is more important to Americans’ health than any healthcare financing reforms. To cite just one among many issues, the health benefits of arresting this administration’s attack on the environment far outweigh the benefits of insuring another 5-7 percent of Americans (the legally resident, uninsured). There are many such issues – food insecurity, education, public housing and income inequality – where halting this administration’s policy trajectory would confer health benefits beyond the most optimistic expectations for single-payer.

So, NOT giving Republicans a big fat ideological target in November is crucial to our public health. Single-payer is so easily labelled a government takeover of medicine demanding massive tax increases. It has failed ballot initiatives in liberal California and Colorado by margins of 3-to-1. Even Senator Sanders’ home state of Vermont, having enacted single-payer in 2011, reversed course after calculating the tax requirements.

Trump’s Republicans have made a colossal mess—gutting reasonable restraints on pollution, cutting health programs, raising annual deficits into the trillions, and sabotaging the norms of decency and informed debate that are essential to representative government. Liberals should not allow them to evade the electoral consequences by scaring voters about a government “takeover” of healthcare. If Democrats do, we may yet snatch defeat from the jaws of victory.

Graph from Kaiser Health Tracking Poll – February 2018: Health Care and the 2018 Midterms, Attitudes Towards Proposed Changes to Medicaid, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. Published: Mar 01, 2018.
Feature image: Victor Moussa/Shutterstock
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Democrats and moderates spent the last decade building support for, developing, and then defending the Affordable Care Act. A resurgent progressive interest in single payer health care would abandon it.

...more
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