Danger in the water: the epidemic of lead across America

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Lead exposure is a serious and widespread public health concern in the United States that has been highlighted recently through the tragedy in Flint, Michigan. Even small amounts of lead can have serious developmental effects, particularly children and pregnant women, and lead exposure can negatively affect nearly every bodily system. The CDC reports that despite the fact that there are no safe blood levels of lead there are approximately 4 million households across the country where children are being exposed to high levels of lead through their drinking water.

The Flint story should never have happened. The health dangers of lead exposure are well known and the Federal Government has a series of legislative instruments specifically designed to try and ensure accountability for the testing and treatment of drinking water. The Safe Water Drinking Act and the associated Primary Regulations are the enforceable legislative tools that require the Environmental Protection Agency (EPA) to set and enforce standards for public drinking water, outline maximum contaminant levels, treatment techniques, monitoring and reporting requirements. Under the regulations, states have delegated authority to meet a range of criteria that includes; establishing regulations at least as stringent as those recommended by the EPA, inventory the state’s public water system, conduct sanitary surveys and analyze water samples and have enforcement authority to compel water systems to comply. While the Act gives the states delegated regulatory authority, it also provides the EPA with authorization to act when agencies fail to comply and in emergency situations where there is an ‘imminent and substantial endangerment to the health of persons’.

While the story of Flint is a cautionary tale it is one that has already plagued many cities across the U.S. The city of Baltimore found elevated levels of lead in schools in 1992 and in 2007 the district changed to only using bottled water which the city considered a more cost-effective solution than replacing all lead-bearing pipes. In 2004, Washington DC faced a public health crisis when it was reported that lead-based utility lines servicing approximately 11.5 million people had levels of lead in the water exceeded EPA lead standards. In 2008, schools in Los Angeles were found to have levels of lead hundreds of times above EPA standards. Schools implemented a range of tactics to try and reduce lead exposure and in September of 2015, the district allocated $19.8 million to remove drinking fountains that were a lead threat. These are just a few examples of how widely issues of lead exposure have reached.

The failings in accountability at each level of the governmental system in Flint were highlighted in the final report of an independent task force appointed in October 2015 to investigate the cause of the crisis, assign accountability and prescribe recommendations on how to rectify the situation and prevent similar situations from occurring. The recommendations of the Flint Task Force point to the need to strengthen and empower existing authorities, especially the EPA, to ensure that required measures are clear, unambiguous and rigorously followed with clear consequences and accountability mechanisms at every level of government. Accountability measures alone will not be enough to counter the problem of a national infrastructure with approximately 7.3 million lead service lines. The EPA National Drinking Water Advisory Committee Working Group has recommended removal of all lead service lines as a public health priority, a mammoth undertaking logistically and financially. It will require investment in infrastructure, political will to enforce safety standards and a multi-sectoral commitment to address the widespread issue that runs beneath the surface of our cities and towns.

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Mexico’s first real attempt to legalize cannabis

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Last week, Mexican Senator Roberto Gil Zuarth, introduced a bill that would legalize cannabis, both for medical and personal use. This is only the last of a few drastic changes that Mexico has undertaken in recent months surrounding its marihuana policy. In the last six months, the Supreme Court has ruled on two cases on the issue. The first case was brought to the court by the parents of Grace, an 8 year old girl who suffers from a condition that causes severe seizures. After testing 19 different drugs, her parents sought out a drug whose main component is a derivative of cannabis, but because of the illegality of the substance they could not gain access to it. A long judicial process and media campaign led to Grace becoming the first person allowed to import and receive cannabis treatment in Mexico.

A few months after the “Grace case” a group of individuals—the Mexican Society for Responsible and Tolerant Consumption (SMART)—asked COFEPRIS (the sanitary regulatory agency) to authorize the possession, cultivation, harvesting and supply needed for the personal consumption of cannabis. It is important to note that the government legalized the personal use of cannabis in 2012 but gave no legal way to gain access to these amounts. When they were refused, they took the case all the way up to the Supreme Court. In a landmark ruling, the Court stated that the contested rules resulted in an undue restriction of the rights to personal identity, self-image, the free development of personality, self-determination and individual freedom. According to the Court, the absolute prohibition of marijuana also adversely affects the right to health. Read More

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The Importance of Knowing the History of HIV and AIDS

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HIV History







Hillary Clinton generated controversy last month when she praised Ronald and Nancy Reagan for starting a national conversation about HIV and AIDS. Clinton quickly issued a statement apologizing for her mistake about the Reagans’ record and later published an expanded response. She acknowledged not only how mistaken she was, but also made clear the real advocacy that took place during the 1980s. “To be clear, the Reagans did not start a national conversation about HIV and AIDS,” Clinton wrote. “That distinction belongs to generations of brave lesbian, gay, bisexual, and transgender people, along with straight allies, who started not just a conversation but a movement that continues to this day.”

Clinton deserves recognition for her correction and for her commitment to fighting HIV and AIDS in the United States and abroad. In fact, Clinton has recently outlined several specific plans for continuing that fight.

But Clinton’s mistake highlights a significant challenge the HIV community faces in engaging lawmakers on HIV and AIDS issues. Many members of Congress and state legislatures, for example, know very little about the historical struggles on these issues. This is especially true for Congress where both the Senate and the House of Representatives have had significant turnover since 2008.

To move the policy dialogue forward, it is important for us to know the history of HIV and AIDS and educate lawmakers about lessons learned. While the idea that Ronald and Nancy Reagan were HIV advocates is a fiction, we can draw important lessons from the Reagan Era. On June 24, 1987, Ronald Reagan issued an executive order to create the President’s Commission on the HIV Epidemic, whose members mostly comprised public health professionals as opposed to politicians responding to AIDS hysteria. This commission came too late for tens of thousands of people with AIDS who had died by that time, and its report was largely ignored by the Reagan administration.

Even so, the commission recommended a more sensible approach to certain issues than the approach adopted in later congressional enactments. HIV criminalization is a good case in point. HIV criminalization refers to the use of criminal laws to penalize alleged, perceived, or potential HIV exposure, alleged non-disclosure of a known HIV infection prior to sexual conduct, or actual HIV transmission. In its final report, the commission cautioned against using criminal laws in this way. The commission concluded that criminal laws should be used only when all other public health and civil actions fail and that criminal laws should not be a substitute for the use of public health measures. Based on these findings, the commission recommended that prior to initiating any criminal charges prosecutors engage public health officials to determine whether public health interventions would be more appropriate.

This recommendation is still relevant today. I see a great deal of value in requiring law enforcement to engage with public health officials and evaluate the appropriateness of public health interventions rather than bringing criminal charges. Such medical-legal partnerships are critical to crafting effective approaches to fighting HIV and AIDS. One promising approach is the creation of programs designed to avoid criminal charges. These programs would keep people out of prison and instead provide education about how HIV is transmitted, risk reduction counseling, triage to mental health and substance abuse services, and an emphasis on social healing.

Unfortunately, Congress encouraged states to criminalize HIV exposure without the nuance of the commission’s recommendations. The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, which created the Ryan White HIV/AIDS Program in 1990, initially required every state to certify that its criminal laws were adequate to prosecute any person living with HIV who knowingly exposes another person to HIV. The requirement was removed in 2000 after all states had certified that they had such laws. These ineffective and needless HIV criminal laws are legacies of the past that have real consequences today. From 2008 to 2013 alone, at least 180 prosecutions have occurred on the basis of these laws.

Knowing this history leading to the enactment of HIV criminal laws can help us to identify potential points of advocacy. Citing the recommendations of President Reagan’s Commission on the HIV Epidemic may also be a useful starting point for conversations with Republican lawmakers. The history of HIV and AIDS is as important today as ever before.

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HHS guidance on syringe service programs provides substantive support for HCV and HIV infection reduction efforts among injection drug users.

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On March 29, 2016, the Department of Health and Human Services released guidance to assist state and local health departments to request permission to use federal funds for Syringe Support Programs (SSPs). This guidance is in response to bipartisan legislation passed in December 2015 that relaxed previous restrictions on federal funds being used for any programs that promote syringe exchange interventions for people who inject drugs (PWID), and is part of the overall federal campaign to address the exploding opioid abuse epidemic in the U.S.

The guidance informs health departments that federal funds may not be used for the purchase of syringes or needles for the purpose of hypodermic drug use. Funds can, however, be used to support other aspects of comprehensive interventions for PWID, such as to pay personnel, for educational programs, Hepatitis C (HCV) and HIV testing, and for the provision of naloxone to reverse opioid overdoses.

In my last blog post, I stated that the government should do a better job in including initiatives that address the increased risk and incidence of HIV and Hepatitis C infections amongst PWID as part of the overall opioid abuse reduction initiative. The relaxed federal stance on syringe support programs and the availability of these funds is a significant benefit to the efforts to reduce the high rates of HCV and HIV infections amongst PWID. This effort falls in line with the call I made in that previous post for the government to implement holistic and practical programs to address the full range of medical, social and behavioral challenges faced by those who abuse opioids. The high risk of acquiring and spreading blood-borne illnesses such as HCV and HIV among injection drug users has borne itself out in outbreaks such as the one that recently occurred in Indiana, where new HIV infections were reported at a rate as high as 22 per week at the peak of the epidemic.

It is encouraging to see the government revisiting its hardline position against syringe support programs. While syringes cannot be purchased with the federal funds, this legislation allows federal dollars to cover expenses that can free up funds from other sources that programs can use to purchase syringes.

It is important not to frame the provision of syringes to PWID as an endorsement of their abuse behavior, but rather as an intermediary step on the way to the overall objectives of reducing opioid abuse and the adverse social and health effects that accompany it. There is no one simple plan that will produce the results of reducing opioid abuse in this country. Opioid addiction is difficult to addicts to overcome, and it takes time and persistence. Providing clean needles to them as a first step will at least lessen their risk of further burdening their health with an HIV or HCV infection, while also allowing SSP staff an opportunity to engage with addicts to build a rapport of trust and understanding that can ultimately lead the user to seek treatment and successfully overcome their addiction. Efforts such as this, that provide practical and holistic strategies, and that multi-task to address multiple public health issues are effective and fiscally prudent strategies that need to continue to be supported and expanded through legislation and budget allocations.

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American Women’s Reproductive Health at Stake in Whole Women’s Health and Zubik

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Image courtesy of Time

Since the 1960s, the U.S. Supreme Court has played a major role in establishing, expanding and defending American women’s reproductive rights. From Griswold v. Connecticut to Gonzales v. Carhart, the Court developed a line of jurisprudence that protects women’s rights to contraception, to abortion, and to bear a child.

This term, the Court is considering 2 cases that have the potential to dramatically curtail women’s ability to exercise their reproductive rights, particularly their rights to access abortion and to access contraception. In honor of International Women’s Day, which took place earlier this week, let’s consider what exactly is at stake in Whole Women’s Health v. Hellerstedt and Zubik v. Burwell.

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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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