Viewpoint

Saving Lives Begins with Death Certificates

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                    [post_date] => 2018-04-16 07:00:47
                    [post_date_gmt] => 2018-04-16 11:00:47
                    [post_content] => Death certificates are more than a bureaucratic record that collects dust. They are a trove of data that inform public health research, policymaking, and resource allocation. For instance, the current tracking of and planning to address the opioid crisis in Massachusetts relies heavily on information from death records. Based on how widely they are used, it seems logical to assume death certificates are accurate.

I learned otherwise in an epidemiology class. One of my classmates, a physician, challenged the legitimacy of death certificate data and offered a compelling explanation of the inaccuracies. I decided to dig further. For public health, demographic data is a core resource for understanding patterns of morbidity and mortality. If an information source is not trustworthy, in what ways do the inaccuracies affect health policy and programming? Can death certificates be trusted to inform research and the implementation of programs that aim to save lives? I set out to investigate this public health mystery by making a documentary film.

I chose documentary because I wanted to explore the veracity of death certificates in a narrative context. With open source equipment, I made a 10-minute film. Three respected experts graciously offered their knowledge to shape the narrative: Dr. Tom Land, a public health data scientist; Dr. Al DeMaria, an infectious disease epidemiologist; and Dr. Michael Grodin, a health law ethicist. Each helped me build the storyline by speaking from their decades of experience.
Today public health professionals are unveiling innovations in the way death certificates inform prevention efforts.  
The story begins in the Massachusetts State House. In 1849, the American Statistical Association successfully petitioned the Massachusetts State Legislature to legally grant the use of death records for tracking preventable and premature deaths. Following this legislative turning point, other states adopted similar laws that would also lead to a movement to establish public health departments. Tracking mortality is now a ubiquitous practice across the country. Today public health professionals are unveiling innovations in the way death certificates inform prevention efforts. Public health professionals often link death certificates with other government records to solve public health mysteries. Dr. Land described how the Massachusetts Department of Public Health employs this approach to track the current opioid epidemic: “We link together information from the Medical Examiner, the State Police, and death certificates to create a model that predicts the likelihood a death is opioid related.” Information collected across various government agencies can intertwine to tell the complete mortality story of an individual. Physicians are a vital character in the death certificate narrative and their training or lack of training influences accuracy. Other than coroners, they are the primary authors of death certificates. A lack of physician training on recording mortality data emerged during my interviews and research as a key factor that can lead to inaccuracy. Dr. DeMaria and Dr. Grodin, who are also clinicians, explained that junior medical staff with inadequate training are traditionally tasked with death certificate data entry in hospitals. Training medical students to correct data entry and emphasizing the public health value of death certificates will be an important step toward improving accuracy. Parallel themes build the death certificate story. The design of a strong data collection system and robust training for those recording data are critical to ensuring that mortality data is accurate. Moving forward, accuracy of data is not the only important consideration. Institutions, public and private alike, influence the structuring of data systems. I now work as a legislative aide at the Massachusetts State House. From observing the intersection of advocacy, policymaking, and community engagement firsthand, it has become clear to me that institutions are a key influencer in the use of data to improve health outcomes. History shows us that saving lives begins with keeping track of and scrutinizing how we die. Feature image: Alexander Lyubavin, IMG_2991 гроб, used under CC BY 2.0 [post_title] => Saving Lives Begins with Death Certificates [post_excerpt] => Death certificates are a trove of data that inform public health research, policymaking, and resource allocation. History shows us that saving lives begins with keeping track of and scrutinizing how we die. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => saving-lives-begins-with-death-certificates [to_ping] => [pinged] => [post_modified] => 2018-04-18 06:51:43 [post_modified_gmt] => 2018-04-18 10:51:43 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4163 [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 )

Death certificates are a trove of data that inform public health research, policymaking, and resource allocation. History shows us that saving lives begins with keeping track of and scrutinizing how we die.

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Viewpoint

Will you still need me?

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                    [post_date] => 2018-04-09 07:00:01
                    [post_date_gmt] => 2018-04-09 11:00:01
                    [post_content] => What comes to mind when you think of a children’s hospital? Imagine your child being rushed to such a place because of a serious illness. What kind of reception will staff give them? What will their room look like? How will they be treated? Now think about a nursing home. What comes to mind? If your parent had to move into one tomorrow, how would they react? And you?

If you have trouble conjuring pictures for this thought experiment, open two Google image search tabs, type in the phrases "children’s hospital” and “nursing home,” and scroll down. The contrast may surprise you. Personalization versus institutionalization. Colorful versus drab. Imaginative abundance versus boring repetition.

A recent survey asked 1,300 adults age-50-and-over whether they agreed with this statement: I would rather die than live in a nursing home. Sixty-two percent said they would rather die. Yet adults over 75 are more likely to die in nursing homes than at home.

I conduct research on improving nursing home quality and struggle with this disconnect between people’s desires and their likely reality. Most of us don’t want to think about nursing homes. And no wonder. We’re inundated with scary information about them. Nursing homes vary widely in quality. And the media predominantly portrays them negatively, which likely influences consumer choices. But interventions and advocacy can positively influence this negative tide.

After all, kids in children’s hospitals and adults in nursing homes are the same individuals, separated only by time. Remember that child you had in mind earlier? If they live to sixty, they have a greater than 50% likelihood of spending at least one night in a nursing home. And that percentage rises dramatically as they age. As we age. Because nursing homes aren’t for other people. They’re for our parents, our friends, our children. They’re for us. When we think about them and work on improving them, we’re reforming our own future.

What can you do to become part of the growing movement to improve the image and reality of nursing home care?
  1. Educate yourself about and become involved with organizations working on these issues, such as the Pioneer Network, the Green House Project, and the National Nursing Home Quality Improvement Campaign.
  2. Be proactive in thinking about the future possibilities for yourself and those you care about. Check out options and know what to look for and what to ask when deciding on care.
  3. Start a conversation. Age is irrelevant. Someday, you hope, you and your loved ones will get old. So someday, I wager, all of you will stay in a nursing home. So get over your fear and start embracing nursing homes as your future playground. They will be then what you make them now.
Together, as families, as age cohorts, as a society, we can help care become equally appealing and equally humane across the age spectrum. As the young Beatles asked decades ago, “Will you still need me, will you still feed me, when I’m sixty-four?” Let’s work together on making the answer, “Yes, just as much, my love.” Feature image: Heiko Küverling, iStock [post_title] => Will you still need me? [post_excerpt] => Nursing homes aren't for other people, they're for all of us. Here are three steps everyone can take to improve the image and reality of nursing home care. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => will-you-still-need-me [to_ping] => [pinged] => [post_modified] => 2018-04-08 22:37:44 [post_modified_gmt] => 2018-04-09 02:37:44 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4092 [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 )

Nursing homes aren’t for other people, they’re for all of us. Here are three steps everyone can take to improve the image and reality of nursing home care.

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Viewpoint

Clinical Pharmacy Innovations and Team-Based Healthcare

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                    [post_date] => 2018-03-26 06:45:26
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                    [post_content] => Clinical pharmacists are specially trained to provide comprehensive medication management to patients and to collaborate with physicians and other providers. Clinical pharmacy specialists (CPS) make significant contributions to patient care and are recognized as performing as well as physicians in managing chronic disease. In this era of team-based medical care, the CPS role has expanded beyond conventional medication dispensing in the United States. Health professionals differ in their expectations of clinical pharmacy services, which can range from prescribing medications to administering vaccines as well as working in mental health, cancer and surgical care, etc. Clinical pharmacy is rapidly expanding and the knowledge of what clinical pharmacists can contribute to team-based care is under-recognized. This article highlights what CPSs can contribute to patient care and their potential to ameliorate some persistent problems in patient care.

What are clinical pharmacy specialists?

Clinical pharmacy has undergone innovations in the past 40 years. In addition to involving a rigorous doctorate-level PharmD degree, pharmacy residencies (post-doctoral training) train pharmacists in particular skills and specialty knowledge in a wide range of areas like, pain management, specific disease management (diabetes, anticoagulation, blood pressure), mental health care, and more. In many medical schools, CPSs and doctors train side-by-side. CPSs in the Department of Veterans Affairs (VA) and in many states (through collaborative practice agreements) have the legal authority to prescribe, order laboratory tests, and perform all functions for comprehensive medication therapy management.

Exploring the CPS Scope of Practice

Clinical pharmacy specialists operate most effectively in close collaboration with physicians/prescribers. A CPS can operate in both independent and collaborative roles with a physician/prescriber. For example, CPSs can work collaboratively under physician recommendations to manage a disease state with a patient. A CPS can also independently run a disease clinic where they monitor dosing adjustments and work one-on-one with patients as needed in perpetuity (e.g., anticoagulation clinic) or until a patient’s goal has been reached (e.g., diabetes clinic). Clinical pharmacy specialists have the schedule capacity to meet with patients more frequently and to work intensively on one particular health problem. Given a physician’s packed schedule, access to a CPS may get struggling patients into care sooner. It is important to note that CPSs do not diagnose. A CPS may run a disease clinic independently but patients are referred by doctors to that clinic and are copied on clinical notes. Physicians often consult with CPSs to explore medication options for patients with multiple chronic conditions or to solicit drug interaction information. Additionally, CPSs can answer patients’ questions about their medications.

Challenges

The types of care CPSs are authorized to provide vary greatly by state and healthcare system. In the Veterans Administration, the largest integrated healthcare system in the United States, national policy dictates CPS scope of practice and reimbursement.  At the state level, however, patchwork regulations unevenly dictate what a CPS can and cannot do. Reimbursement for clinical pharmacy services is also complicated in terms of both policy and practice. U.S. healthcare is limited by a shortage of primary care providers, an aging population, and the troubling and thorny problem of physician burnout. Team-based medical care is here to stay and CPSs are in an excellent position to make substantial contributions to improving access, quality, patient outcomes and controlling costs. Improving clinical pharmacy practice and policy at a national level will allow CPSs to contribute to team-based health care more consistently across systems and, ultimately, improve patient care. Feature image: Clever Cupcakes, Doctor Themed Cupcakes, used under CC BY 2.0 [post_title] => Clinical Pharmacy Innovations and Team-Based Healthcare [post_excerpt] => Clinical pharmacy specialists make significant contributions to patient care and are recognized as performing as well as physicians in managing chronic disease. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => clinical-pharmacy-specialists [to_ping] => [pinged] => [post_modified] => 2018-03-26 13:32:03 [post_modified_gmt] => 2018-03-26 17:32:03 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=4063 [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 )

Clinical pharmacy specialists make significant contributions to patient care and are recognized as performing as well as physicians in managing chronic disease.

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Viewpoint

The Undeserving

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                    [post_date] => 2018-03-15 06:45:53
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                    [post_content] => The Center for Medicare & Medicaid Services (CMS) recently released guidelines for states interested in implementing Medicaid work requirements. The guidelines advocate for improving “work and community engagement” by making it a requirement for Medicaid eligibility. In other words, people would need to be deemed “engaged” in order to be eligible for Medicaid in interested states. The new Medicaid work requirement proposals further an ongoing dialogue about who is deemed deserving of help in the U.S.

Work requirements are not a new idea. Ronald Reagan famously coined the term “welfare queen” back in the 1970s referring to a single case of extreme welfare fraud in Chicago to urge welfare reform. Subsequent reform in 1996, during Bill Clinton’s presidency, replaced relatively broad eligibility for food stamp benefits with three months of benefits through the Supplemental Nutrition Eligibility Program (SNAP). SNAP tied eligibility for food aid to participation in work or work training in 36 month chunks of time. In other words, SNAP recipients who did not work or participate in a training program were cut off after three months.

The idea underlying SNAP and similar policies comes down to the belief that beneficiaries are taking advantage of these public programs—living off of government benefits without lifting a finger. Research from the University of California Berkeley Labor Center suggests otherwise. The center estimates 73% of enrollees in American public benefit programs are from working families. Working families are defined as having at least one family member who works 27 or more weeks per year and 10 or more hours a week. Most of these workers are in low-wage occupations such as fast food workers, child care providers, and home care workers.

Medicaid Work Requirements

Medicaid eligibility as outlined by the CMS would require “work and community engagement among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.” The working theory is that work and community engagement will improve overall health. They list other social determinants of health, such as education, as examples of factors that improve health. Higher levels of education clearly correlate with better health outcomes. But health problems can disrupt children from attending school, thus affecting academic performance. The same can be said of employment. Sure, “higher earnings are positively correlated with longer life span.” But causality can move in the other direction as health problems can hinder ability to work and lead to unemployment. At the heart of this policy is the speculation that many Medicaid beneficiaries can work but choose to stay unemployed. Data from the Kaiser Family Foundation indicates the opposite. Most Medicaid enrollees have good reasons why they are not working. As depicted in the figure, most are ill or disabled or taking care of home or family. Only 6% could not find work. What this means is that these extra hurdles imposed to gain eligibility could be a barrier to many who should be eligible and need the insurance. The CMS guidance does not adequately address how states would check for eligibility and support citizens attempting to meet eligibility. Pie chart showing primary reasons for not working among Medicaid enrollees Currently ten states have submitted work requirements. Kentucky’s Section 1115 waiver to implement Medicaid work requirements, approved on January 12, was the first of its kind. States like Wisconsin and Kentucky have proposed changes such as drug-testing and requirements for beneficiaries to pay more out-of-pocket. Kentucky also proposed a controversial health or financial literacy course to re-enroll in Medicaid should you fail to meet work requirements. Details are still hazy for the courses and their mandatory quizzes. But, as Austin Frakt points out, many Americans, not just Medicaid enrollees, would struggle with a health or financial literacy test.
These families will make too much money to be eligible for Medicaid and not enough to qualify for ACA marketplace assistance which starts at 100% FPL ($16,400 annually).  
Medicaid enrollees in states that have yet to expand Medicaid will face a unique challenge. Medicaid expansion raised the federal poverty level (FPL) for eligibility in participating states to 138%. Eligibility in non-expansion states is much more difficult with typically lower qualifying federal poverty level. For example, Mississippi is a non-expansion state that has submitted a work requirement waiver for its Medicaid population. A parent in a family of two (or a single parent with a child) must have an annual income under 27% FPL to qualify for Medicaid, which is about $4,385. The $7,540 salary for working at least 20 hours per week at minimum wage ($7.25 per hour) would disqualify families from assistance. These families will make too much money to be eligible for Medicaid and not enough to qualify for ACA marketplace assistance which starts at 100% FPL ($16,400 annually).

By the Bootstraps

The CMS guidance on Medicaid work requirements is another example that help is not given to those who need it the most. Medicaid work requirements are sold as welfare reform under the belief that the undeserving poor are doing nothing to improve their circumstances. Thus, help should only be offered with many strings attached. Elizabeth Bruenig, a journalist with the Washington Post, observes that help in the form of tax breaks and subsidies is readily given to the wealthy without a discussion of whether they are lazy or deserving. Yes, the American government spent $200 billion on Medicaid in 2012. But, the government also lost out on $120 billion by subsidizing employer-sponsored health insurance. The phrase “by the bootstraps” reflects this feeling that the poor must be lazy if they cannot pull themselves out of poverty. I am not downplaying the accomplishments of people who have started with nothing and made a comfortable living for themselves. However, not everyone is able to pull themselves up by the bootstraps due to a variety of circumstances. Often, systematic and structural obstacles stymie their efforts to achieve a comfortable life. Under work requirements, a beneficiary could have Medicaid revoked due to either failure to comply with community engagement or absence of paperwork. We are asking the impossible of the poor in the U.S.: become successful while being locked out of essential services. So, who is deserving of help? According to the Medicaid work requirements guidelines, only the poor who are able to consistently hop over tall hurdles. Feature image: Ben LelisThe Mop, used under CC BY-NC-ND 2.0 [post_title] => The Undeserving [post_excerpt] => Qing Wai Wong questions the assumptions behind Medicaid work requirements policy, that everyone could pull themselves up by the bootstraps. Medicaid enrollees in states that have yet to expand Medicaid will face a unique challenge. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-undeserving [to_ping] => [pinged] => [post_modified] => 2018-03-15 07:10:20 [post_modified_gmt] => 2018-03-15 11:10:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3877 [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 )

Qing Wai Wong questions the assumptions behind Medicaid work requirements policy, that everyone could pull themselves up by the bootstraps. Medicaid enrollees in states that have yet to expand Medicaid will face a unique challenge.

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A Writing Teacher’s Take on the Seven Words Controversy

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                    [post_content] => The public health community was catapulted into a state of righteous indignation last December after the Washington Post reported that seven words (diversity, entitlement, evidence-based, fetus, science-based, transgender, and vulnerable) had been prohibited by the U.S. Department of Health and Human Services from appearing in budgets submitted by the Centers for Disease Control. The reporters used the words prohibit, forbidden, and banned frequently (12 times in all) and interchangeably throughout the story.

The next day, a New York Times article reported that no words had been banned, but some style guidelines had been given to improve clarity and reduce the potential for negative reactions on the part of some Republicans. Policy analyst, Yuval Levin, parsed the likely intentions behind the unpopular words. Diversity, entitlement, evidence-based, science-based, and vulnerable are over-used and sometimes inappropriately used. They are vague buzz words easily replaced to improve clarity. Fetus and transgender, Levin argued, have a high likelihood of triggering “retrograde Republicans” into cutting budgets for projects associated with reproductive and transgender health.
I warn students away from empty aspirational words like empowerment and impactful. I tell anyone who will listen that they should purge the noun issue whenever possible.  
All of this got me thinking about the difference between choosing language strategically based on knowledge of your audience and self-censorship. As a writing teacher and editor, I understand the compulsion to give language guidelines. I spend an inordinate amount of time to trying to squeeze unnecessary and vague jargon out of other people’s writing. I try to do the same in my own writing. I warn students away from empty aspirational words like empowerment and impactful. I tell anyone who will listen that they should purge the noun issue whenever possible. I do this because it is overused to the point of being meaningless. Everything in public health is an issue. We have water issues, political issues, legal issues, structural issues, emotional issues, and we take issue with them all. This is known as semantic bleaching. Consider this compact sentence rich in jargon but devoid of meaning:

Evidence-based and science-based entitlements can make people less vulnerable and improve diversity.

You may be wondering: What kind of evidence? Science conducted in what way? Which entitlements? What kind of vulnerability and diversity? Arguably, each of these words carries more symbolic than semantic value. I read sentences like this in journal articles, grant-proposals, and student papers every day. Sentences that read as if they come from a random jargon generator. Sometimes we need our jargon. Often we do not, but we still use it. By contrast, transgender and fetus have clear definitions and expansive interpretations. Fetus is a standard clinical term associated with abortion debates and the in utero health risks posed by the Zika virus. Transgender is more than just an adjective embraced by individuals who live outside of binary gender roles. It is an identity. If I want a conservative congress to fund programs that promote reproductive or trans health, I may need to use alternative language to avoid tripping political alarms. This would entail self-censorship and a lot of soul-searching, but it may also be pragmatic and strategic. Ultimately, a recommendation not to use the word transgender is very different from being told to avoid a buzz word like vulnerable. This is a key reason that the HHS budget guidelines were so confusing. Describing exactly what it means to be vulnerable in a specific context is the opposite of self-censorship. It’s an invitation to say what we mean. “Words matter” has been a common refrain in the passionate responses to the seven words controversy. They do, but some matter more than others. PHP wants to hear your thoughts about public health language, jargon, and the difference between knowing your audience and self-censorship. Write to us at phpost [at] bu.edu. Word Cloud Made Using: https://wordart.com/create [post_title] => A Writing Teacher’s Take on the Seven Words Controversy [post_excerpt] => Public health, scientific, and academic writing are plagued by jargon and words that are so overused they become meaningless. PHP’s Associate Editor, Jennifer Beard offers a new spin on the recent “seven words” controversy. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => writing-teacher-take-on-seven-words-controversy [to_ping] => [pinged] => [post_modified] => 2018-03-14 06:47:27 [post_modified_gmt] => 2018-03-14 10:47:27 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3962 [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 )

Public health, scientific, and academic writing are plagued by jargon and words that are so overused they become meaningless. PHP’s Associate Editor, Jennifer Beard offers a new spin on the recent “seven words” controversy.

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Chemical Endangerment Laws Hurt Pregnant Women

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                    [post_content] => Multiple pregnant women  in Etowah County, Alabama have been arrested after testing positive for amphetamines. These women were charged with “chemical endangerment” of their fetuses—a relatively new interpretation of existing child abuse statutes. Those laws were originally meant to prevent exposure of children to drug-related environments such as methamphetamine laboratories, but the Alabama Supreme Court expanded the definition of child to include “fetuses,” meaning that pregnant women could be charged for using drugs (Kimbrough v. Alabama; Ankrom v. Alabama).

Alabama is not alone, as other jurisdictions have enacted measures to criminalize substance use during pregnancy. Recently, there has been a growing trend in pregnancy control measures in the United States and an increase in punitive policies toward women who use alcohol during pregnancy. These measures signal a growth in restrictions on sexual and reproductive health in general. According to the Guttmacher Institute, 30% of all such restrictions enacted since 1973 have only been established in the past six years. More than one-third of states punish pregnant women for substance use through pre-existing laws, erecting barriers to treatment. For example, in New Jersey, a pregnant woman using methadone prescribed to treat her opioid addiction—the accepted standard of care—faced a child abuse/neglect charge and her newborn subsequently was taken into custody (N.J. Division of Youth and Family Services v. Y.N.). In other states, by contrast, pregnant women who use substances have been civilly committed for declining similar addiction treatment. Currently, seventeen states hold that substance abuse during pregnancy qualifies as child abuse under civil child welfare statutes.
Punitive measures mistakenly pit the interdependent interests of the mother and fetus against each other.  
Punitive measures mistakenly pit the interdependent interests of the mother and fetus against each other. To our knowledge, there is no credible medical evidence that punitive measures lower rates of substance abuse in pregnancy. Instead, punishment may drive women away from prenatal care and treatment for fear of arrest or loss of child custody. Even when rehabilitation is available as an alternative to prison, few treatment facilities provide adequate services to mothers. Only 17% of centers have programs specifically for pregnant and postpartum women. These strict policies also turn physicians into agents of the state and undermine the crucial patient-physician relationship, a major foundation of therapeutic change. Eighteen states mandate reporting of suspected prenatal substance use and four mandate testing, despite concerns from numerous medical organizations. Alarmingly, physician reports are carried out in a discriminatory manner with low-income and minority women disproportionately affected. Although rates of substance use during pregnancy are similar across racial and socioeconomic groups, women of color are more likely to be reported to child protective services, even when drug screening policies are in place to universally test all women.
There is no evidence that punitive measures improve maternal or fetal outcomes.  
[ictt-tweet-inline]There is no evidence that punitive measures improve maternal or fetal outcomes. [/ictt-tweet-inline] More effective interventions would address the complex factors that contribute to substance use during pregnancy. Carrots, rather than sticks, should be used. One option is the expansion of contingency treatment programs, which offer rewards for abstinence and promote long-term abstinence and retention in treatment. Other approaches also hold promise, including investment in family and community supports and promoting contact with healthcare and social support services. We do not lack for better alternatives to punishment, which only perpetuates the medical and social problems facing these vulnerable women and their newborns. Chemical endangerment laws create barriers for countless women in need who might otherwise engage with treatment and fundamentally counterproductive in the battle against addiction. Feature image: Elena Saulich/Shutterstock [post_title] => Chemical Endangerment Laws Hurt Pregnant Women [post_excerpt] => Laws originally meant to prevent exposure of children to drug-related environments such as meth labs are being expanded to criminalize substance use during pregnancy. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => chemical-endangerment-laws-hurt-pregnant-women [to_ping] => [pinged] => [post_modified] => 2018-03-13 12:43:38 [post_modified_gmt] => 2018-03-13 16:43:38 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3929 [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 )

Laws originally meant to prevent exposure of children to drug-related environments such as meth labs are being expanded to criminalize substance use during pregnancy.

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Viewpoint

Beyond Marginalization: Supporting Life in the Community

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                    [post_date] => 2018-02-28 06:00:45
                    [post_date_gmt] => 2018-02-28 11:00:45
                    [post_content] => Marginalization from community life, stemming from stigma and other structural factors, is a common experience among people living with serious mental illnesses. It also emanates from a shield and protect framework implemented by well-meaning service providers, who endeavor to protect clients from those very factors or risks. This type of clinical intervention can create a gatekeeping dynamic that dampens social agency and prevents independent exploration of one’s rightful place in the community. One reason for perpetuating this dynamic is that individuals with serious mental illness are often seen as vulnerable and unable to participate in the complex social dynamics of their communities. Though well-intentioned, this can be tallied as one failure of the community mental health system. Project Connect in New Haven, Connecticut seeks to address this failure by operating on the edges of the mental health system and providing individuals with serious mental illness opportunities to develop community connections that build confidence through self-determination and pursuing their personal interest.
...individuals with serious mental illness are often seen as vulnerable and unable to participate in the complex social dynamics of their communities. Though well-intentioned, this can be tallied as one failure of the community mental health system.  
[ictt-tweet-inline]Project Connect recognizes participants as experts and staff as contributors.[/ictt-tweet-inline] This is quite different from more traditional community interventions that address client needs through a hierarchical framework in which clinician is expert and client is contributor. This is founded in a fundamental principle of the program: individuals with serious mental illness should not be defined only through their illness. When community integration is addressed through a mental health clinic, the integration is sensibly rooted in the person’s reason for coming to that clinic. Project Connect aims to work on the fringes of the traditional mental health system by recognizing these same individuals through their own expressed identities—their passions, talents, interests, and areas of curiosity. To this end, Project Connect does not use tools typical of treatment settings like referrals or applications. Instead, it relies on the typical connective tools of community settings, like networking and basic person-to-person introductions. Inspired by the work of Project Friendship in British Columbia, Project Connect staff leverage relationships with neighbors, friends, community activists, and even extended family to find connection opportunities. This maximizes the ability to find something that a participant wants to pursue, rather than falling into the pattern of creating a menu of activities, the contents of which are determined by the service provider rather than the person seeking community connection on his or her own terms.
Project Connect staff members deliberately have one foot in the mental health system and one foot in the community at large, as a way of bridging what is often experienced as a divide.  
Project Connect staff members deliberately have one foot in the mental health system and one foot in the community at large, as a way of bridging what is often experienced as a divide. They are employed within the mental health system and are active, long-time residents of the community in which most Project Connect participants reside. Some also have their own experiences with serious mental illness. This unique position allows staff members to navigate and broker communication between the worlds of the service system, the loose community of people living with mental illness, and the community at large, with a firm foothold in each. Project Connect has supported people in defining community engagement based on their own interests, including riding bikes with other cycling enthusiasts, joining in common cause with fellow activists, and teaching craft classes at a community center. In this configuration, service providers’ apprehension about the settings in which the social interactions occur cannot take precedence. Rather, the terms are determined by participants, community partners, and the resources of a given organization or neighborhood. This necessitates a realignment of the roles professionals play to support community participation. Policy makers and program developers bring people living with serious mental illness to the table as experts in their own aspirations, and include community partners as essential collaborators. Feature image: lee robertsCommunity, used under CC BY-SA 2.0 [post_title] => Beyond Marginalization: Supporting Life in the Community [post_excerpt] => Project Connect operates on the edges of the mental health system by providing individuals with serious mental illness opportunities to develop community connections. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => beyond-marginalization-supporting-life-community [to_ping] => [pinged] => [post_modified] => 2018-03-01 07:08:51 [post_modified_gmt] => 2018-03-01 12:08:51 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3853 [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 )

Project Connect operates on the edges of the mental health system by providing individuals with serious mental illness opportunities to develop community connections.

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Viewpoint

Tomorrow in Mind: Corporate Social Responsibility

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                    [post_date] => 2018-02-21 06:45:11
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                    [post_content] => Corporations, with all the power they wield in the U.S. and abroad, have a moral, ethical, and quasi-legal obligation to respect, protect, and fulfill human rights. This obligation mirrors the stringent and codified legal obligations of governments to ensure human rights for their people. Opportunity to do more is abundant.

The simple reason public health must increase advocacy for corporate social responsibility to uphold human rights is clear: when you elevate human rights, you elevate population health and prosperity. Dr. Jonathon Mann, former World Health Organization official who pioneered global AIDS research and response in the 1980s, once said, “[W]e have the responsibility to move forward by recognizing that true interdependence and real interconnectedness requires that we—from health and from human rights—advance together: equal partners in the belief that the world can change.”

The Coca-Cola Company

The Zambian government ratified the United Nations Convention on Economic, Social, and Cultural Rights in 1984, ensuring the right to the highest attainable standard of health for its citizens. But, thirty-four years later, the country still struggles to provide even basic primary care. As Dr. Joseph Kasonde, the Minister of Health in Zambia, has said: “You will find Coca-Cola in any village at any time in the course of the year, but you’ll not find medicines.” Without practical access to essential medicines, the right to health for the people of Zambia means nothing. Armed with this understanding the NGO Colalife worked to bring oral rehydration kits to Zambian villages, where UNICEF reports that “…It is expected that 60 per cent of babies born will not survive to the age of 40…[and]…Malaria is responsible for one third of under five deaths, with many others caused by respiratory infections, diarrhoea and neo-natal conditions.” The NGO turned to Coca-Cola to help them understand the distribution channels they rely on, and “the drinks giant responded, with advice, insight, detail, discussion and questions.” Within the UN system is a legal principle called ‘progressive realization.’ What it means is that although countries may not have the capacity to ensure human rights immediately, steps must be taken toward them. World Bank GDP rankings put Zambia at 131st in the world. While the country is improving infrastructure and is on an upward trajectory, achieving lower-middle income status in 2011, the country’s economy is still dependent on foreign assistance. Zambia would have significantly less ability to tackle health and human rights challenges without these external contributions. The lent capacity of the NGO partnership with Coca-Cola facilitated the movement of oral rehydration, saving lives and further realizing the right to health in Zambia.

Continuing the Push for Social Responsibility

Numerous multinational corporations support corporate social responsibility initiatives focused on improving health around the world. These include the Coca-Cola Foundation’s global HIV programming, Pfizer’s trachoma initiative, and John Deere’s agricultural and educational support to partner villages in India. But programs like these remain an exception, not the rule. Public health must be a leading force and continue to build partnerships with corporations to :

1.)   Influence corporate social policy to promote the wellbeing of populations. This must include advocacy and activism, as well as a strong push from inside companies to behave more outwardly responsible.

2.)   Push leaders to follow in the steps of CEOs like Blackrock’s Larry Fink and “contribute to society.”

3.)   Better educate public and private entities about the social determinants that affect health, and how improving indicators (like average family income) can improve health drastically.

Feature image: Hernán Piñera, Coca Cola, used under CC BY-SA 2.0 [post_title] => Tomorrow in Mind: Corporate Social Responsibility [post_excerpt] => PHP Fellow Gilbert Benavidez writes on corporate social responsibility to respect and protect human rights, and how public health must be a leader in building partnerships with corporations to influence social policy. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => tomorrow-mind-social-responsibility-corporations [to_ping] => [pinged] => [post_modified] => 2018-02-23 05:45:18 [post_modified_gmt] => 2018-02-23 10:45:18 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3768 [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 )

PHP Fellow Gilbert Benavidez writes on corporate social responsibility to respect and protect human rights, and how public health must be a leader in building partnerships with corporations to influence social policy.

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Viewpoint

A History of Work Requirements

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                    [post_content] => The state of Kentucky recently grabbed headlines for their plans to implement work requirements for Medicaid recipients. The Kaiser Family Foundation reports that, in addition to Kentucky, nine states have pending waiver requests that would require work as a condition for receiving Medicaid benefits. Indiana’s waiver was officially approved this month.

Requiring work as a condition for Medicaid is born from a history of politicians attempting to implement work requirements for all public benefit programs. Most often favored by Republicans and other conservatives, work requirements were first proposed for food assistance programs in the mid-1980s, and they have been proposed for subsidized housing programs since the 1990s. Neither of these proposals has passed so far; however, politicians were successful in making work a required condition for welfare programs. This is commonly known as “Welfare to Work.”
Democrats and Republicans alike have participated in the “welfare to work” phenomenon.  
Democrats and Republicans alike have participated in the “welfare to work” phenomenon. Beginning in the early 1990s, conservatives led a push to “end welfare as we know it” by reforming the federal welfare program known as Aid to Families with Dependent Children (AFDC). Sixty years earlier, AFDC was established in the Social Security Act of 1935 to provide “guaranteed cash assistance to needy families with children.” The Bush administration granted waivers to states which allowed them to independently change their AFDC programs, including waivers that implemented work requirements for welfare recipients. When Bill Clinton was elected in 1992, his administration continued to grant state waivers, but turned its focus to health care reform. Congressional Republicans, led by new Speaker of the House, Newt Gingrich, promoting their Contract with America, made passing a welfare reform bill one of their highest priorities. By 1995, 40 states had used waivers to implement work requirements, and one year later the AFDC was replaced with Temporary Assistance to Needy Families (TANF) through the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). Work requirements are a hallmark of the TANF programs created by each state after the passage of PRWORA.
Using these human capabilities as a metric, the success of work requirements is not clear even after 20 years of research and reflection.  
The success of “Welfare to Work” is a popular talking point among politicians who invoke the success of TANF programs as evidence that work requirements should be exported to other public benefit programs, such as Medicaid. Success in this case is usually defined as decreased program administration costs and/or fewer cases. Indeed, the U.S. saw steep declines in welfare caseloads almost immediately after the enactment of the PRWORA. States were also free to set benefit levels, and most lowered them substantially. In 2017, most states’ benefits were below 30% of the poverty line. Low caseloads and inadequate benefits persist even during hard economic times when public benefit programs should buoy families. A more meaningful way of measuring success may be the extent to which policies help families meet their basic needs and give their children a better future. Using these human capabilities as a metric, the success of work requirements is not clear even after 20 years of research and reflection. The evidence strongly suggests that work requirements at best do not improve the quality of life for low-income families and, at worst, result in harmful effects on income, material well-being, and health. Work requirements for welfare benefits have contributed to an increase in extreme poverty in the U.S. since 1996. Work requirements are not a new policy idea. Politicians, especially conservatives, have been proposing the addition of work requirements to every existing type of public benefit program for decades. Given the consequences of work requirements for welfare, states like Kentucky and Indiana might see fewer individuals receiving Medicaid after implementing work requirements. Given those same consequences, it is also very likely that individuals and families who lose Medicaid coverage will not replace it with other health insurance. Instead, even fewer public resources will be available to help families make ends meet, survive, and serve as a safety net to catch them if they experience misfortune and tragedy. Feature image: aaron gilson, working hands, used under CC BY-NC-ND 2.0  [post_title] => A History of Work Requirements [post_excerpt] => Nine states have pending waiver requests that would require work as a condition for receiving Medicaid benefits. Work requirements are not a new policy idea. Politicians, especially conservatives, have been proposing the addition of work requirements to every existing type of public benefit program for decades. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => history-of-work-requirements [to_ping] => [pinged] => [post_modified] => 2018-02-14 07:09:11 [post_modified_gmt] => 2018-02-14 12:09:11 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3794 [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 )

Nine states have pending waiver requests that would require work as a condition for receiving Medicaid benefits. Work requirements are not a new policy idea. Politicians, especially conservatives, have been proposing the addition of work requirements to every existing type of public benefit program for decades.

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Viewpoint

The Health of DREAMers

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                    [post_content] => In a recent defense of the now rescinded Deferred Action for Childhood Arrivals (DACA) program, Barack Obama remarked, “These Dreamers are Americans in their hearts, in their minds, in every single way but one: on paper.” In 2009 President Obama used executive power to establish the DACA program, in an effort to protect an especially vulnerable sub-group of the undocumented population. Hundreds of thousands of undocumented children were able to come out of the shadows and work, go to school, and live their lives with a semblance of normalcy and peace.

DACA recipients, often called DREAMers (Development, Relief, and Education for Alien Minors), present as high school valedictorians and service workers alike; they are unique human beings who are looking to succeed in a country they consider their home. And currently, their status is in jeopardy with the President’s rescindment of DACA.

They are also becoming sicker as a result. Physical and mental health outcomes have been clearly linked with immigration status. The health and wellbeing of DREAMers is influenced by politics, culture, racism, xenophobia, and discrimination. The health needs of these young people often go beyond lack of access to medical care.

Informing Immigration Policy with Research

“There is no [medical] help out there and if there is, it’s really hard to find,” remarked one DREAMer in an article by Raymond-Flesch, et al. published in the Journal of Adolescent Health. In the authors' study, 61 DACA-eligible Latinos aged 18-31 were recruited from the Los Angeles and Bay areas during the summer of 2013 to participate in qualitative interviews. The goal of the study was to assess the general health of DREAMers and their access to health care. Study participants were self-identified Latinos age 18-31 eligible for DACA.  Not much is known about this understudied population because they often live in the shadows.

Unmet Health Needs

Participants indicated that they had many unmet health needs, including stress and anxiety related to their immigration status and poor access to primary and specialty care. One participant speculated, “I think a lot of things get normalized, so stress, anxiety, working hours a week…I think a lot folks are in deep depression, but…don’t realize it.” Several other important barriers to care were identified by the authors. DREAMers identified challenges in transition to adulthood and poor physical health due to their inability to access preventive care like vaccination, reproductive care, and annual physicals. Twenty-three percent reported being depressed in the last month, 62% reported binge drinking, and 25% reported a history of smoking. DREAMers often sought alternative sources of care for all ailments except serious illness.  The most important barrier was cost. One DREAMer remarked, “Do I want to spend $40 or $35 on the checkup, or do I want to spend it on food?” Forty-three percent reported extreme poverty though most (80%) were employed. Health care literacy was the second major challenge. Fear and mistrust of medical professionals was also identified as a serious problem. A participant remarked, “[Doctors] don’t really know much about the status and what it means…so sometimes the alternatives that they offer…don’t work for you because you’re not eligible for them.” Despite all of this, DREAMers reported their circumstances were “inadvertently protective” by forcing them to be resilient despite the many impediments created by their immigration status.  One participant remarked, “I needed to find a way to progress pretty much on my own…I feel more empowered, like I did it by myself.” This study was published in 2014. Things have gotten much worse with the rescindment of DACA, but congressional intervention can play a major protective role in these hundreds of thousands of lives. As of this writing, Senate Majority Leader McConnell has promised debate on DACA and the President has said that DREAMers should be able to stay. Feature image: Ignatian Solidarity Network, DSC00333, used under CC BY-NC 2.0 [post_title] => The Health of DREAMers [post_excerpt] => DREAMers suffer from stress and anxiety related to their immigration status and poor access to health care including vaccination, reproductive care, and annual physicals. PHP Fellow Gilbert Benavidez writes on how congressional intervention can play a major protective role in these hundreds of thousands of lives. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-health-of-dreamers [to_ping] => [pinged] => [post_modified] => 2018-02-08 15:23:41 [post_modified_gmt] => 2018-02-08 20:23:41 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_viewpoint&p=3753 [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 )

DREAMers suffer from stress and anxiety related to their immigration status and poor access to health care including vaccination, reproductive care, and annual physicals. PHP Fellow Gilbert Benavidez writes on how congressional intervention can play a major protective role in these hundreds of thousands of lives.

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