The O’Neill Institute for National and Global Health Law’s Hepatitis Policy Project recently released a report offering recommendations to strengthen data collection and monitoring of cases of Hepatitis C in the U.S. in order for public health authorities to gain a better understanding of the effects of the disease and most effective strategies to curb the continuing rise in new cases. The report was informed by an expert consultation of key stakeholders working on viral hepatitis issues, and legal and policy analysis by Hepatitis Policy Project staff. The report can be found here.
There are currently 3.5 million Americans currently living with Hepatitis C, and approximately 33,900 new cases of the disease occurred in 2015. Despite this high prevalence, there is little actual data collected on individual cases of the disease, with many cases going unreported to public health authorities. Many cases that are reported offer little other information on gender, age, race, or risk factors that may have contributed to the person getting the disease, such as injection drug abuse. This type of information is critical for public health authorities to be able to identify those at risk for infection, prevent new infections, and get treatment and other health services to those infected to lessen the impact of the disease on their health. Data collection and the availability of hard numbers of the scope of the health issue are essential tools to influence the legislature and policy makers to improve resource allocation and prioritization of Hepatitis C interventions, and to change laws and policies that encumber those with Hepatitis C from getting the health care services they need.
The recommendations given in the report for improving monitoring of Hepatitis C are as follows:
1) Expand and standardize reporting to the CDC: Policy makers should phase up active surveillance of HCV in more states and territories, and as well as work with local jurisdictions in identified hot spots. The CDC’s Division of Viral Hepatitis (DVH), working with congressional appropriators, should develop a five-year plan for building the capacity to conduct active surveillance in the great majority of US states.
2) Utilize electronic medical records to collect data on HCV cases and the cure cascade: State epidemiologists should be funded to establish and utilize an integrated electronic medical records database, which would also provide matching metrics with cases, such as race, age, gender, and progress of treatment.
3) Fund epidemiologic research using clinical data sets: Clinical care data are a largely untapped resource that holds great potential for better informing responses to HCV and relies on data that already exist. In addition to the CDC, agencies across HHS and in other Departments such as Veterans Affairs and Defense should be directed to fund epidemiological research on HCV.
4) Integrate improved monitoring of HCV with responses to the opioid crisis: The Nation is increasingly recognizing the scope of the public health crisis we are facing related to the opioid abuse. Preventing and treating HCV must be elevated as a signature component of the national response to opioid abuse.
5) Establish and monitor HCV elimination plans across major US health systems: Strategic plans are needed to eliminate HCV in the United States. One example is the Cherokee HCV elimination project currently being implemented, where the tribe plans to screen 85% of Cherokee Nation health patients between the ages of 20 to 69 by the end of 2018. The Department of Veterans Affairs also is leading the way toward eliminating HCV in the Veterans Health Programs. Other public programs and systems should be tasked with developing their own elimination plans, including the Ryan White HIV/AIDS Program, the Health Centers Program, and various correctional systems in the US.
**A limited number of hard copies of the report are available for distribution. Please contact the author of this article to request copies. **
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Do the courts, and does the law more generally, have the power to advance the right to health? It would be hard to conclude at the end the O’Neill Institute’s weeklong Health Rights Litigation Intensive anything other than an emphatic yes — even while acknowledging limitations of health rights litigation, and exploring questions that make it difficult sometimes to even answer the seemingly straightforward question of what effect health rights litigation is having on the right to health. While hardly invariably so, the law, including litigation, can be a powerful tool to advance health rights – particularly when it is able to shift power.
The health rights litigation intensive lived up to its alternative name of the Global School Health Rights Litigation Course, for it truly was a global school. The course featured a host of health rights experts, from as far away as Mexico – none other than Supreme Court Justice Alfredo Gutiérrez Ortiz Mena – to the O’Neill Institute’s own staff, along with top-notch professors, campaigners, and human rights funders. The course participants – many lawyers, but also students and other health rights advocates – came from countries spanning the global, from Uganda, Kenya, and South Africa, with a strong American contingency including from Mexico, Honduras, and the United States, as well as Asia, with South Korea well represented.
This diversity matters, not only because the different perspectives enriched the experience for all, but also because, as came out from the various sessions, the experience of and possibilities for health rights litigation vary by country. And as histories of the court system and health rights litigation in India, Brazil, Argentina, Colombia, South Africa, and Mexico, demonstrated, the health rights jurisprudence of each court system and the very nature of that system are products of both judicial and political history, and the functioning of government institutions. Many of the courts most active in advancing health rights are those in highly unequal societies – Colombia, India, and South Africa, for example – with both the inequality and the courts’ sense of obligation to intervene a product, at least in part, of political dysfunction.
Whether judicial or otherwise, action to advance the right to health is most effective when it changes power dynamics on behalf of people who are poor, marginalized, discriminated against, on the short end of health inequities. Courts may have a role in changing these dynamics, as courts are a countermajoritarian institution that can exercise their authority to protect people’s rights, as Justice Gutiérrez emphasized. The court can stand for a robust implementation of the principle of nondiscrimination, as the Supreme Court did in Mexico, declaring unconstitutional a law establishing an employment certificate program for people with autism, where they could receive a medical certificate affirming that they had certain skills, meant to protect them from discrimination at jobs requiring these skills. Not only did the law reinforce stereotypes, but as Justice Gutiérrez stated, people’s right to be free from discrimination does not depend on their receiving a medical certificate. Power had shifted to people with autism. In the 760/08 judgment in Colombia, not only did the Constitutional Court demand a wholesale reform of the health insurance system, creating a unified scheme where the level of covered health benefits no longer depended on whether a person could pay into the system, but it also established a deliberative process to plan for the unification, with all stakeholders participating, and transparent justification for decisions. This representing a significant, if limited, opening of the political process to people otherwise kept outside and in the dark.
Ever since WHO declared the end of Ebola virus transmission in West Africa in June 2016, the world has wondered when (not if) they would see Ebola again. In May 2017, the virus reemerged from its secret jungle lair, but not before a brief panic in Liberia just a few weeks prior that would briefly catch the world’s attention.
On Sunday, April 23, 2017, a funeral for a religious leader took place in Greenville, Liberia, a small coastal city approximately 150 miles southeast from the capital city of Monrovia. Later that day, an 11-year-old girl that attended the funeral was admitted to a hospital with symptoms of diarrhea, vomiting, and confusion; she died that evening. Another patient with similar symptoms arrived the next day on Monday; on Tuesday, April 25, 14 people arrived. In the days that followed, 31 cases would be reported, including 13 deaths, several of which had attended that funeral.
Traditional funeral ceremonies were one of the elements that amplified the West African Ebola outbreak of 2014-16. In some communities, these ceremonies may include activities that can potentially spread disease from the recently deceased to uninfected mourners — from grievers making contact with the deceased, to family members or traditional healers preparing and cleaning the corpse by hand. Illness and fatalities linked to a funeral attendance would almost certainly raise alarms of a potential Ebola resurgence, and prompt an aggressive investigation.
But Liberia’s health workers are now better trained, “post-Ebola”, to monitor and report suspicious events on the off-chance that an outbreak is linked to Ebola. That Tuesday, an investigative team was dispatched from Monrovia to Greenville, and simultaneously, patient samples were sent to Monrovia for testing. The samples arrived that same day, and that evening, laboratory testing ruled out Ebola.
And so it was that on Wednesday, April 26, the report was sent out around the world about the outbreak, along with the emphatic statement that Ebola had been “ruled out” (the disease in question was later determined to be meningitis). It’s not often that a disease outbreak is newsworthy due to not being Ebola, but it is understandable that all West Africa, and particularly Liberia, is on high alert in case the virus returns.
As time goes on, this event will likely be forgotten. But for the moment, let us appreciate this visible, positive outcome. The framework that has been put in place in Liberia “post-Ebola” is designed to integrate and improve the detection of and response to diseases. The amount of time needed for transporting and analyzing samples has been greatly reduced. Not only does it seem that Liberia “learned” from the 2014-16 outbreak, they have endeavored to improve the necessary elements for Ebola readiness. The Greenville meningitis outbreak may have been a “false alarm”, but it gave Liberia a moment to shine.
As we stay tuned to the waning days of the current Ebola outbreak in Likati, Democratic Republic of Congo, we will inevitably ask more questions of Ebola readiness, and whether we have “learned” from the West Africa pandemic. Liberia, it appears, has.
With severe threats to the health and well-being of the most vulnerable Americans populating the headlines – from repealing and replacing the Affordable Care Act with a system that would send the number of uninsured skyrocketing, with poorer and older Americans suffering most, to the administration’s proposed FY2018 budget, with its drastic cuts in a social safety net that already lets millions of people fall through it – it is easy to focus only on limiting the damage. Yet even now, there are initiatives to advance health equity and the right to health within the United States. Most far-reaching may be the initiatives in states including California and New York to create a single-payer health system to provide universal health coverage. Perhaps the most innovative initiative comes from Hawaii, with a proposal that could dramatically improve the health some of the state’s most marginalized residents, and serve as a model for the nation.
Many doctors who recognize the underlying vulnerabilities of their patients would like to be able to address them directly. A prescription for economic opportunity for people with depression or substance abuse disorders that appear to stem from economic uncertainties. A prescription for peace to reduce post-traumatic stress syndrome. A prescription for fruits, vegetables, legumes, and whole grains for patients experiencing symptoms of poor nutrition, from childhood stunting and anemia to diabetes and heart conditions. A prescription for housing to address the multitude of health risks that give the homeless population in the United States about 30 years lower life expectancy than that of the overall U.S. population.
This last possibility is suddenly within the realm of possibility thanks to an emergency room doctor and Hawaii state senator, Josh Green. At the beginning of 2017, he introduced two pieces of legislation aimed at enabling doctors to literally prescribe housing and supportive services for chronically homeless individuals. As the Senator said, “The single best thing we can do today is to allow physicians and health care providers in general to write prescriptions for housing.” Senator Green further observes, “We’re already spending the money on homeless people, we’re just paying for it in the most inefficient, expensive way possible.”
One piece of legislation would have required health insurers to cover treating homelessness, though the bill was later significantly amended in committee, and would instead require the state auditor to study using Medicaid funds “for the treatment for homelessness.” The other bill “would have required the state Department of Human Services to create a Medicaid housing benefit plan.” It, too, was amended in committee, and instead would require the department to “continue to pursue efforts to utilize Medicaid to provide supportive housing services for chronically homeless individuals.”
The linchpin for Senator Green’s proposals is the economics of Medicaid, which would be the source of funding. Hawaii’s $2 billion in annual Medicaid spending is not spread evenly across the state’s 362,000 Medicaid beneficiaries. Rather, reflecting health care costs writ large, where most of the spending is directed towards a small proportion of people with the poorest health and greatest medical needs, 60% of Medicaid spending in Hawaii ($1.2 billion) goes towards about 3.6% (13,000) of the state’s most vulnerable residents. Among these are chronically homeless people, whose condition leads to frequent, expensive emergency room visits and other care that would become unnecessary if they were no longer homeless.
Hanhsi Indy Liu is an SJD candidate at Georgetown University Law Center. Sarah Roache is a Senior Associate at the O’Neill Institute for National and Global Health Law. Any questions or comments on this post can be sent to: email@example.com.
Advocates for public health-based soda taxes had two important victories this month: a Pennsylvania appeals court dismissed an industry lawsuit challenging Philadelphia’s soda tax and the Seattle City Council became the ninth US jurisdiction to tax sodas.
On June 14, 2017, the Pennsylvania Commonwealth Court ruled in favor of the tax in a 5-2 decision., This is the second judicial affirmation of the legality of the tax in Philadelphia, which has the second highest prevalence of obesity (29.3%) and diabetes (10.7%) among large US cities.
Appellants, led by the American Beverage Association, argued that the 1.5 cent-per-ounce tax violates the prohibition on duplicative taxation and is pre-empted by the federal Food Stamp Act and the Tax Code, which prohibit taxes on items purchased under the Supplemental Nutrition Assistance Program (SNAP). The majority opinion written by Judge Wojcik, rejected the appeal, holding that the tax does not violate either Pennsylvania state laws or federal law because it applies to non-retail distribution transactions and not retail sales to the consumer.
Philadelphia mayor Jim Kenney released a statement on the same day, saying “Two courts have now considered the arguments of the beverage industry and both are certain that the Philadelphia Beverage Tax stands on solid legal grounds.” He urged the beverage industry to cease its legal and public relations battle that has already cost millions. “Our entire city desperately needs us to be able to move forward with the programs funded by the tax and we will be unable to do that in full until full legal action is resolved.”
The city has committed to spend revenue from the soda tax on for improving Pre-K and community education, rebuilding city facility like libraries, parks and community centers. Revenue is predicted fall short of the $46.7M projected for January-June 2017. At this stage, the reason for the shortfall is unclear. But if the reason is decreasing soda purchases, then the tax is achieving its public health objectives to discourage consumption.
Moving from the East coast to the West, Seattle City Council passed its $ 1.75 cent-per-ounce soda tax on June 5, 2017. The 7-1 vote makes the emerald city the ninth US jurisdiction to embrace a public health-based soda tax, joining Albany, Berkeley, Oakland, and San Francisco in California; Boulder, Colorado; Cook County, Illinois; Philadelphia, Pennsylvania, and the Navajo Nation. The legislation covers sweetened beverages such as soda, juice, sports drinks, flavored water, energy drinks, and pre-sweetened coffee or tea, with exceptions for mike products, 100% juice, formula or sweetened medication. Diet soda was slated for taxation in Mayor Ed Murray’s proposal, but it was eventually removed by the City Council on the basis that diet sodas are less harmful to health than regular sweetened beverage products. The tax will take effect on January 1, 2018, and is expected to collect $15 million annually. The revenue will be spent on education programs and food access strategies like fresh bucks, which will help ensure access to nutritious food and beverage products.
Seattle’s new soda tax confirms the growing momentum behind soda taxes as a popular and effective means of helping to reduce sugar consumption and obesity. The appellate court’s ruling on Philadelphia’s soda tax confirms that cities can take on – and overcome – industry efforts to undermine valuable public health interventions.
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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.