In a vote that followed party lines, the House Appropriations Committee passed the FY2018 Health and Human Services, Education, and Related Agencies Appropriations bill on July 20, 2017. The bill rejects most of the proposed cuts to health services recommended by the current Administration, but does little to boost funding for health services that desperately need additional financial support.
The bill “flat funds” – meaning there is no increase or decrease in funding – HIV programming, including the Ryan White Program, at the FY2017 level, with the Ryan White Program having already endured a $4 million cut in FY2016. While this flat funding does not allow the Program to keep pace with increasing need or rising health care costs, it is the preferred option to the $58.8 million cut to Ryan White funding that was requested by the President. The Committee also rejected an amendment brought by Rep. Barbara Lee (D – CA) to restore funding for the Minority AIDS Initiative Fund (MAI).
The bill also flat funds the CDC’s Viral Hepatitis programs at $34 million for the third consecutive year. Viral Hepatitis saw a modest $2.7 million budget boost in FY2016 to bring it to the $34 million mark, but funding has remained flat ever since. What is even more troubling is the comments made in the bill by the Committee concerning viral hepatitis prevalence. The Committee only makes a brief mention of its concern in the rise of cases of Hepatitis B in the U.S. despite the availability of a vaccine with an efficacy rate over 90%. There is no mention of concern about the skyrocketing rates of Hepatitis C in the U.S. among young adults tied to the opioid epidemic. While Hepatitis B and C rates are increasing in the U.S., rates of Hepatitis C are increasing at a far more rapid rate, and hundreds of thousands more Americans are affected by Hepatitis C than B. The Committee’s silence on this issue speaks loudly.
The Substance Abuse and Mental Health Services Administration (SAMHSA) was recommended to receive $2.2 billion for substance abuse treatment funding, including the continuation of a $500 million line item to fund state-level responses to the opioid epidemic. This SAMHSA funding recommendation is over $15 million more than what the President recommended for the Agency, despite the current President touting to constituents that he is committed to resolving the Nation’s opioid abuse crisis.
Legislators must start listening to the advice of health authorities and advocates who are imploring them to provide support to address the Hepatitis C epidemic in tandem with the opioid epidemic, as the two are fundamentally correlated. Actions such as this by the House Appropriations Committee indicate the government’s continued commitment to ignore data and insight from those working directly on health issues to provide the adequate resources needed to actually remediate the Nation’s most critical public health issues.
NASTAD has created a chart showing the breakdown of funding for HIV, Viral Hepatitis, and STD programs, which can be found here.
Improving your health can be as simple as choosing to walk to work or to take the stairs instead of the escalator. However, stairs are not even a viable option in some buildings and for some people it is not feasible to walk or bike to work. This blog post examines how public health is impacted by the way a community is designed.
The built environment (the structures and surfaces that make up a community) can negatively impact physical and mental health. Americans are suffering from increasing rates of noncommunicable diseases (NCDs), such as heart disease, cancer and diabetes. Much of this is due to lifestyle choices and the built environment, which, in many communities discourages walking. Studies show that the built environment can negatively impact mental health as well, causing stress, anxiety and depression, among other things.
According to the CDC, more than 1 in every 10 premature deaths in the United States can be explained by a lack of physical exercise. The CDC recommends that adults ages 18-64 get at least 150 minutes a week of moderate-intensity physical activity (such as brisk walking) or 75 minutes a week of vigorous-intensity physical activity (such as jogging or running), but less than half of Americans actually meet these recommendations. Sitting for 8 or more hours a day has been shown to nearly double the risk of Type 2 diabetes and drastically increases the risk for heart disease, cancer and premature death. The average American sits more than 9 hours a day.
Incidences of many NCDs can easily be decreased by encouraging people to exercise more. This can be done by changing the built environment to make cities more pedestrian and cyclist friendly. Oftentimes simple changes in zoning laws can make a city more walkable. For example, locating stores, worksites, public transportation, essential services and schools within short walking distance to residences and building and maintaining sidewalks or paths between destinations that are well-connected, safe and attractive will increase the likelihood that people will walk to their destinations. Studies show that wider streets encourage drivers to speed. Creating narrower streets and adding parking spaces as a buffer between streets and sidewalks creates a safer environment for pedestrians and encourages physical activity. These changes can save cities money by decreasing incidences of NCDs and thereby cutting health care costs.
Similar changes can be made to buildings. For example, making stairs (as opposed to escalators) more visible and accessible encourages people to take the stairs thereby helping to increase exercise and decrease incidences of heart disease, diabetes and other NCDs. Employers will be incentivized to do so because healthier employees bring down costs of health insurance in the long-term. Alternatively, single floor homes are more suitable for people with disabilities and the aging population. Some disabilities can actually be improved over time by staying active, and buildings and homes that are conducive to the needs of these populations can help.
Similarly, changes in landscape and design can impact mental health. For example, designing buildings so that people have more access to sunlight, both in their homes and offices, can decrease stress and depression. Further, creating more green spaces with trees and grass can positively impact mood and lead to increased mental health.
People make choices each and every day regarding their health. Some people choose to walk or bike to work instead of driving. Others do not have that option due to disability or location. When given the option between stairs and escalators some people choose the stairs. Either way, the built environment impacts physical activity, mood and thereby physical and mental health, and the way we think about this relationship will have an impact on the future design and zoning of cities.
Posted in Global Health, Health reform, National Healthcare, Non-communicable diseases; Tagged: activity, biking, built environment, Cancer, community, Diabetes, exercise, health, heart disease, infrastructure, NCDs, stairs, walking.
Rhesus monkey (Image source)
A new study published this week in Nature Microbiology brings good news for research toward the persistence of Ebola virus in asymptomatic individuals.
Ebola virus (EBOV) is the virus that causes Ebola (now referred to as Ebola virus disease, or EVD), a viral hemorrhagic fever that has a very high associated death rate (up to 90%). EVD symptoms include fever, severe headache, muscle ache, weakness, diarrhea, fatigue, vomiting, abdominal pain, and unexplained bleeding. The virus is endemic to central Africa, but outbreaks are rare. Earlier this month, an outbreak of Ebola in the Democratic Republic of Congo was declared over by the World Health Organization (WHO); eight people were known to be infected, and four died. This outbreak is the first since the conclusion of the 2014-2016 multi-country epidemic in West Africa, with total cases numbering more than 28,000, and total deaths in excess of 11,000.
EBOV has been known to persist in the seminal fluid of survivors for up to 18 months after the onset of symptoms, as well in tissues of the eye and brain. Viral transmission has been shown as a result of male-to-female sexual activity by EVD survivors, and has even been shown to cause new cases of EBD. As such, the WHO discourages male EVD survivors from sexual activity for up to 12 months after the onset of symptoms, or until their semen has tested negative twice in consecutive monthly tests.
This new study, by Zeng et al., is performed with rhesus monkeys. Though non-human primates (NHPs) have previously been used as experimental animal models for EVD, the rhesus monkeys used in this study are the first NHPs to display detectable, persisting EBOV genomic RNA in individuals that survived experimental EBOV infection.
The researchers found that a small percentage of these rhesus monkey EBOV survivors had detectable EBOV genomic RNA in their testes (1.32%), brains (1.25%), and most prevalently, their eyes (11.54%). Notably, EBOV genomic RNA was absent in these individuals from tissues known to be affected in acute EVD infections (liver, lymph, spleen). Researchers were also able to prove that in these tissues of these rhesus monkeys, viral replication was still taking place up until the point where the individuals were euthanized.
The 2013-2016 EVD outbreak in Liberia, Guinea, and Sierra Leone brought new information on EVD sequelae, or long-term symptoms from previous infections or illness. It is important to fully comprehend the persistence of EBOV in human survivors, and its impact on sequelae, as well as the morbidity and mortality risks for EVD survivors. It is especially important to fully recognize any risks of post-recovery EVD flare-ups or transmission. For these reasons, the discovery of the rhesus monkey as an animal model will greatly facilitate research into these questions with a living organism.
This blog post was authored by Javier Saladich, a Summer Research Intern at the O’Neill Institute. Javier is a third year law student at ESADE Business and Law School in Barcelona, Spain. Any comments or questions can be emailed to email@example.com.
In light of recent measles outbreaks in Europe and the United States and a European Court of Justice decision in a vaccine-liability case, this blog post considers the importance of public health laws and messaging to strengthen societal consensus and compliance with vaccination programs. It argues that governments and public health advocates should continue to counter the growing presence of the reactionary anti-vaccine discourse, which threatens to erode community immunity and public health gains.
Vaccination and the importance of societal consensus
There are very few public health issues in relation to which societal consensus is taken as granted, but none as misleading as vaccination. Every so often, new data reminds us of the fragility of such consensus and the peremptory challenge non-vaccination and incomplete vaccination pose to public health, including recent outbreaks of measles in Europe and the United States. Even though anti-vaccine responses can be traced back to a purported atavistic fear of chemicals, as brilliantly portrayed by Eula Biss in her essay On Immunity, the devastating consequences of infectious epidemics throughout history and the steady effectiveness of vaccines finally brought parents and societies together around a sort of collective trust in each other’s child vaccinated status. This allowed for what the medical community calls the “immunization of the herd”, a social contract whereby the group stays protected only insofar as no significant share of members opts out.
Concerning measles outbreaks in Europe and the United States
The core of this status quo, though, has come under question in recent decades. Take measles, for instance. Immunization coverage to prevent measles outbreaks – 95% is needed, according to global standards – has fallen to risky levels in some communities within the United States. Even more worryingly, up to 15 European Union/European Economic Area (EU/EEA) member states are not complying with the minimum threshold. These countries’ failure to have their population immunized despite availability of safe and affordable vaccines has been closely followed by the WHO, which launched a 2017 campaign with the goal of showcasing “immunization’s role in sustainable development and global health security”.
In the United States, measles outbreaks are due to an insufficient rate of infant vaccination. While 2016 data shows vaccination coverage of roughly 91% population, coverage is distributed unevenly throughout the country. Under US law, states are free to adopt non-medical exemptions based on personal and religious beliefs, which contributes to lower coverage in many communities. Recent studies show that despite the improving levels of vaccination, unvaccinated persons appealing to state-level exemptions tend to cluster geographically in schools and communities, “so vaccine-preventable disease outbreaks can still occur”. For example, in 2014/5, a measles outbreak traced to Disney theme parks in California sickened 147 people. A 2016 outbreak originating in rural Minnesota has sickened more than 70 people to date.
In Europe, measles are still endemic. Italy and Romania the two major hotspots, with thousands of new reported cases. Why are higher-income countries, often considered as leaders in public health, still experiencing outbreaks of preventable diseases?
The anti-vaccine movement: weakening societal consensus and public health
An important contributing factor is the anti-vaccine movement, which promulgates messages that vaccines are unnecessary and harmful. In some ways, vaccines have been victims of their own success. Low incidence of measles outbreaks thanks to vaccine inoculation has been used by these groups to spread the belief that there is no longer a public health threat that justifies this intervention. The intersection of the traditional anti-vaccine movement and winning populist parties, whose discourse openly questions the safety of vaccines and in turn the whole pharmaceutical industry, could be another reason. Yet, these theories have been repeatedly dismissed by public health advocates and the international community, who recently endorsed a joint resolution to support vaccination.
The Disney outbreak in late 2014, highlighted the problem of misinformation and complacency, in the air since 2000, when measles ceased to be a native infection in the U.S. After the 2014 outbreak many hesitant parents soon understood that these seemingly eliminated threats were not over, but just waiting for vaccination rates to drop again.
However, this may not always be the case. Minnesota’s measles outbreak originated in a large Somali immigrant community that had been successfully targeted by anti-vaccine theories, including personal visits from Andrew Wakefield, who founded the modern anti-vaccination movement. This situation in Minnesota reveals how misinformation that conjures fear and emotion can take hold, with serious ramifications for the public’s health.
Strengthening public health laws and public confidence
Following major measles outbreaks in Western countries, political leaders have strengthened legal requirements for vaccinations. In California, where the Disney outbreak started, tough new legislation was passed, which removes non-medical exemptions (religious and personal beliefs) from the requirement to vaccinate children prior to their enrollment in kindergarten. In France, the Macron administration has promised to reverse low-vaccination rates and it will follow the path of California and Italy, by enforcing vaccination and making it a prerequisite to access public schools. To date, France has shown the worst performance in vaccination (around 75%). In France, there is a strong negative perception of vaccines, aggravated by bureaucratic and a confusing legislation, which labels only three vaccines as mandatory and the rest recommended.
Although legislative efforts are a step in the right direction, laws should be accompanied by public health education aiming to counter misinformation around the safety and necessity of vaccines. The need for pedagogy is evidenced by the recent controversy surrounding the European Court of Justice’s judgment on a liability claim for Hepatitis B vaccine harm. At the request of French Supreme Court, the EU’s highest court made a preliminary ruling, which has been wrongly interpreted as endorsing liability of vaccine manufacturers for vaccine-related injuries in the absence of scientific proof of causation. Instead, the ruling confirms that, in the absence of medical or scientific consensus on a specific cause of harm, causation may be established based on serious circumstantial evidence. The court noted that a mere temporal relationship between the vaccine and the harm would not be enough. Controversy emerged among public health experts, who fear this decision may be manipulated by the anti-vaccination movement. This reinforces the importance of public education and messaging to create a counter-narrative strong enough to impede manipulation of this ruling and other scientific questions.
It’s time for policy-makers to deploy not only an enforceable agenda for immunization, but also a persuasive battery of arguments to convince families that vaccines are safe, effective, and necessary for personal and public health. To this end, the credibility of institutions such as the Centers for Disease Control and Prevention and the WHO should be reinforced against bizarre conspiracy theories. Primary health care providers and pediatricians, who work at the front line of children’s health care, should be empowered to educate misinformed parents on the risks that non-vaccination entails.
Neil Sircar, J.D., is an LL.M Candidate in Global Health Law at Georgetown University Law Center & the O’Neill Institute for National and Global Health Law. Any questions or comments related to this post can be directed to firstname.lastname@example.org.
Universal Basic Income (UBI), also known as Basic Income Guarantee (BIG), has been increasingly discussed in casual conversation, periodicals, and policy-making circles at city, state, and national levels. Over the past few years pilot programs have been proposed or undertaken in multiple countries and contexts, with GiveDirectly’s Kenya project perhaps kick-starting the newfound interest in the idea. Basic income projects (and similar programs) have supporters and critics across the spectrum, fueling a vivacious debate on whether and how basic income could be implemented. The traditional liberal and conservative divide is rarely bridged as interestingly as it is when discussing welfare reform that includes cash transfers.
The Basics on Basic Income
The gist of basic income is that everyone under a certain jurisdiction receives – conditionally or unconditionally – a cash transfer. Conditional cash transfers, as seen in Brazil’s very successful Bolsa Família Program, are one way in which basic income projects are considered that essentially create a quid-pro-quo interaction between guarantors and recipients. Unconditional cash transfers (such as with GiveDirectly in Kenya) come without strings attached and the recipients can use the money as they so choose. Similar programs – the US’ Earned Income Tax Credit, negative-income tax (and its 1970s’ pilots in the US) or Alaska’s Permanent Fund dividend program – might work towards the same end and achieve positive health outcomes, though they are conceptually and structurally different. Basic income is just that, an income floor under-which no beneficiary may fall. Whether your income is $20,000 or $200,000, you are guaranteed a stipend by virtue of your residency, citizenry, and/or humanity.
Think of the Children (and Former Children)
The question asked here is: what are the health impacts, and under what conditions if any are positive health outcomes realized? The social determinants of health include (and may be dominated by) economic factors and financial security by way of ensuring or supplementing income helps enable individual and family health. The effect of financial security might be especially meaningful for children, as one longitudinal study suggests after it followed a group of study participants over 35 years from childhood through adolescence and adulthood. Of course a litany of factors might influence such a study – individual behaviors, genetic profiles, etc. – though the increased likelihood for children to be physically and mentally healthier if up-brought in financially secure households is unlikely a new phenomena. There are benefits for adults as well, leastways lower stress. Every child of the lower or middle classes (if not all income strata) can likely remember short-tempered parents worrying about bills or expenses! The long-term health effects of stress are well known and contribute to adverse health outcomes on adults as well as children.
Cash Me Ousside (?)
Conditional and unconditional cash transfers carry with them a spate of challenges, risks, and rewards. While promising, there remain valid critiques of poorly designed cash transfer programs that go beyond whether basic income would disincentivize working (it does not; like, really) or people would spend money poorly (a cynical view of humanity to be sure, and also one that is unsupported). Absolute poverty though could be curtailed and with it the negative health consequences associated with destitution; middle-class individuals and families likewise could benefit in their health from supplemental income. Financial security for all persons, and especially those in the lower income brackets, is public health good with real and potential boons to individual and family health.
Posted in Global Health;
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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.