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Hanhsi Indy Liu is an SJD candidate at Georgetown University Law Center. Sarah Roache is the director of  Global Health Law LL.M. Program and Capacity Building Initiative at the O’Neill Institute for National and Global Health Law. Any questions or comments on this post can be sent to: hl580@georgetown.edu.

Supporters of regulations to reduce consumption of sugary drinks may feel a chilling wind in San Francisco. Just last month, a three-judge panel of the US Ninth Circuit Court of Appeals ruled that the city government’s warning label about the health of sugar-sweetened beverages violates First Amendment protections for commercial speech.

In June 2015, San Francisco passed an ordinance, S.F. Health Code § 4203(a), to mandate a health warning statement on certain sugar-sweetened beverages (“SSB”) advertisements, including billboards and vehicles:

WARNING: Drinking Beverages with added sugars(s) contributes to obesity, diabetes, and tooth decay. This is a message from the City and County of San Francisco.

The ordinance provides details about the form, content, and placement of the warning, including the controversial requirement that it occupy 20 percent of the ad space.  The industry, represented by the American Beverage Association, California Retailers Association, and the California State Outdoor Advertising Associations (“associations”) , alleged the content of the warning is misleading and the 20% size requirement places an undue burden on their commercial speech. (See the sample advertisements provided by the industry to the court below)

On 19 September 19, 2017, the United States Court of Appeals, Ninth Circuit, reversed and remanded a previous district court decision which denied the associations’ motion for a preliminary injunction against the implementation of the warning label. The Court of Appeals concluded that the associations are “likely to succeed on the merits of their claims that the ordinance is an “unjustified or unduly burdensome disclosure requirement” in violation of “protected commercial speech.” Therefore, the court held, the district court “abused its discretion in denying the Associations’ motion for a preliminary injunction”.

Perhaps more concerning to public health advocates, the court also found that the required warning statement is not “purely factual and uncontroversial”. The court held that, because the FDA deems sugar “generally recognized as safe” and recognizes that it “can be a part of a healthy dietary pattern when not consumed in excess amounts,” San Francisco’s warning is therefore misleading. The judgment suggests that the warning might survive scrutiny if it used qualified language such as: “overconsumption” of sugar-sweetened beverages “may” contribute to obesity, diabetes, and tooth decay

Furthermore, the appeal court held, the warning is “misleading and, in that sense, untrue,” because it singles out SSB rather than including “all other products with equal or greater amounts of added sugars and calories.” This implies that SSBs are less healthy than other products with added sugars, which is “deceptive in light of the current state of research on this issue.”

Although the ruling could still be appealed, or San Francisco could revise its warning in line with the judgment, this ruling may have a chilling effect on efforts to nudge towards healthier choices through warning labels.


Posted in Non-communicable diseases ; Tagged: NCDs, Diabetes, obesity, public health law

Posted in Non-communicable diseases;


Ebola Taï Forest: A Unique Emergence, and the Dawn of the Modern Age of Ebola

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“These woods are where silence has come to lick its wounds.”  – Samantha Hunt


In 1994, Ebola, a lethal virus that had been silent for fifteen years, awoke. Two separate outbreaks would shatter this silence, but one of these was unique, the likes of which has not been seen since.

Though the last known Ebola outbreak that affected humans had occurred in 1979 in Sudan, in 1989, Reston virus, a species of Ebolavirus, emerged in laboratory macaques in Virginia that had been imported from the Philippines. The lethal virus caused hemorrhagic fever symptoms in macaques, but was determined to be nonpathogenic to humans. The virus was a new type of Ebola; similar outbreaks would take place in Alice, Texas and again in Reston, Virginia in 1990, and in Sienna, Italy in 1992. The Reston outbreaks would later be dramatized in Richard Preston’s 1995 best-selling book, The Hot Zone, which captures the tension of an Ebola outbreak in a dense urban area, followed by the relief experienced after it was found to be harmless to humans.

The world once again took notice of human cases of Ebola in December 1994, when it reemerged from its fifteen-year slumber in Gabon. As with most mysterious febrile illnesses, the cases of hemorrhagic fever were initially assumed to be yellow fever. The epidemic took place in early December 1994 and was declared over on February 17, 1995; 52 cases were confirmed, 31 died from the virus. The outbreak originated near gold mining encampments near Makoukou, just 75 miles west of the border with Republic of Congo, and 160 miles north of the capitol city of Franceville. The causative virus was identified as Ebola Zaire on December 14, 1994.

However, unbeknownst to investigators in Gabon, the virus had already reemerged elsewhere a month prior. On November 16, 1994, a chimpanzee in the Taï Forest National Park, Côte d’Ivoire was discovered dead by a primate behavior researcher, and was dissected on the spot. The researcher developed dengue-like symptoms on November 24th, and was hospitalized in Abidjan on the 26th after developing further symptoms and not responding to anti-malarials. On December 1, she was evacuated to Switzerland for further treatment and monitoring, and would eventually make a full recovery after 6 weeks of illness.

The cause of infection was determined to be from the handling of the infectious blood and/or tissues from the necropsy of the dead chimpanzee. It was determined to be new species of Ebola, though not until February 1995, months after the Gabon outbreak identification. It was named Ebola Côte d’Ivoire (though its name was changed in 2002 to Ebola Taï Forest to conform with new naming conventions), and it was unlike any Ebolavirus that had been seen prior, or that has been seen since.

First, the infected researcher is the only known case of Ebola Taï Forest, ever. This is especially interesting given the timing of the infection, after a fifteen-year period of Ebola quiescence. The four other known species of Ebola have each had multiple outbreaks, but 1994 Taï Forest was a unique event.

Second, similar to the first outbreak of Ebola in 1976–which had since been discovered to be two separate outbreaks of non-concurrent, differing species of Ebola (Zaire and Sudan)[i]–the Ebola Taï Forest case happened within a month of the Ebola Zaire outbreak in Gabon. This is also interesting in the context of the fifteen-year period of Ebola going undetected.

Third, the Taï Forest outbreak is the first time that a human Ebola case had emerged outside of the central African area known as the Congo River Basin.  In fact, prior to 2014 it was the only time Ebola emerged outside of this region; it would be twenty years before Ebola would be discovered in West Africa again, and it would be under much different, catastrophic circumstances. However, the emergence from the Taï Forest is not inconceivable, given the environmental similarities to the tropical rainforests within Ebola’s known zone of endemicity in the Congo River Basin. The possibility exists that Ebola Taï Forest is a viral relic of times long ago, when the rainforests of Côte d’Ivoire and Central Africa were one and the same, stretching from coastal West Africa with the Congo River Basin.

Fourth, the Taï Forest case was the first documented human Ebola infection associated with naturally infected nonhuman primates in Africa. This discovery would shift research toward transmission of Ebola between primates and humans for years to come.  Today, epizootic Ebola transmission research is focused mostly on bats, but Ebola is still a significant issue for primates: recent research indicates that up to a third of the world’s chimpanzee and gorilla populations have been wiped out by Ebola.

Finally, the Taï Forest case, though unrecognized as such, is the first Ebola outbreak in what can be viewed as the modern era of Ebola; since 1994, an average of one Ebola outbreak has taken place every year. The questions remain, decades after the Taï Forest outbreak: What has precipitated this frequency of outbreaks, particularly after the fifteen-year lull? Why have we not seen Ebola Taï Forest again? When Ebola emerges again, will we be ready, or will it emerge someplace new?


[i] Cox NJ, McCormick JB, Johnson KM, Kiley MP. Evidence for two subtypes of Ebola virus based on oligonucleotide mapping of RNA. J Infect Dis. 1983;147:272–275.

Posted in Uncategorized; Tagged: .


Statement on arrest of ISLA director, activists in Tanzania

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On October 20, 2017, a team of human rights lawyers and activists were jailed in Dar-es-Salaam, Tanzania – a clear violation of Tanzanian and international human rights obligations.

The initial arrests came on Oct. 17 after a consultation they were holding was raided by the Tanzanian police. Thirteen people were arrested. After authorities initially released all but one of them on bail, all are back in custody today after their bail was revoked.

The group was preparing strategic litigation against the government of Tanzania for violating the right to health of Tanzanians by eliminating and outlawing key programs to fight HIV. These human rights leaders are accused of “promoting homosexuality.” Those arrested include attorney Sibongile Ndashe, executive director of the Initiative for Strategic Litigation in Africa (ISLA), an O’Neill Institute partner organization. Activists from Community Health Education Services and Advocacy, a Tanzanian NGO, are also being held.

The detaining of thirteen attorneys and their clients, including nationals of Tanzania and South Africa, brings recent Tanzania’s targeting of civil society to unprecedented new heights. The detention of human rights attorneys and leading public health and community leaders is not only a severe violation of their rights, but also raises the level of threat to human rights defenders in the country – another step backwards for human rights. If a South African legal organization supporting local clients in litigation could be arrested on spurious charges, what human rights defender in Tanzania is not at risk? It is critical that this action not stand.

We strongly urge the government to release the detainees, discontinue the legal proceedings against them, return passports to the foreign nationals who have been arrested and restore their freedom of movement. The government should also ensure and affirm access to legal representation and support, as ISLA sought to provide, without intimidation. We’ve reached out to our partners to show our support and commitment to challenging this action.

Oscar A. Cabrera
Executive Director
O’Neill Institute for National & Global Health Law
Visiting Professor
Georgetown Law

Matthew M. Kavanagh
Director, Global Health Policy & Governance Initiative
O’Neill Institute for National & Global Health Law
Visiting Professor
Georgetown Law

Posted in Global Health, Human Rights; Tagged: , , .


Uber Accessible: How Health Care Providers are Partnering with Ride-Share Companies to Improve Transportation for Non-Emergency Care

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More and more, technology is becoming a part of our everyday lives.  Increases in technology can have both positive and negative impacts.  We now live in a world where we can order anything, including food and car services on our phones.  Recently, ride share programs such as Uber and Lyft are partnering with medical providers to help ensure patients have reliable transport to their health care appointments.

Technology has long been used in the medical profession.  Today, almost all patient files are computerized and many doctors have switched to tablets or computers to input patient data.  This can ensure faster diagnosis as well as increased efficiency and help to coordinate care among health care professionals.

One of the major barriers for many people accessing medical services, particularly the elderly or people with disabilities, is a lack of reliable and safe transportation.  A 2013 analysis of 25 studies, found that 10 to 51 percent of patients reported that lack of transportation is a barrier to health care access.  One study reported that people who rely on buses were twice as likely to skip appointments compared to people who use cars.

Health care providers offer other alternatives to assist with transportation for non-emergency services.  This includes volunteer drivers who work with health care providers to schedule pick-ups for patients.  However, this usually requires scheduling ahead of time, which is ineffective when a patient forgets to book in advance or an unexpected or unscheduled appointment arises. Alternatively, patients sometimes call 911 for non-emergency services when they need transportation for a non-emergency medical appointment.  This is not cost effective and can divert resources away from people that need it.

For patients living in cities, relying on public transportation for medical appointments can take hours.  Additionally, in many cities, public transportation is not easily accessible for the elderly or people with disabilities.  Sometimes, public transportation or even contracted transportation provider services are not reliable and can leave people waiting outside in extreme temperatures for long periods of time, causing potentially dangerous situations.  Alternatively, car services such as Uber and Lyft can arrive in as little as 2 minutes and are able to provide door-to-door service.

When getting to a medical appointment is a hassle, patients are likely to miss the visit.  This can lead to undiagnosed conditions or worsening health, which can lead to an overall increase in health care costs, for both individuals and providers.  Out-of-pocket transportation costs for patients can vary.  Medicaid patients are covered for transportation costs of non-emergency medical visits, however reimbursement rates vary by state. Traditional Medicare does not cover non-emergency medical transportation, however, there are some private Medicare Advantage plans that may offer such benefits.

To help alleviate some of the stress of finding transportation for health care visits, some hospitals and medical providers are utilizing services such as Uber and Lyft, and sometimes these costs are covered by Medicaid or insurance.  Such partnerships between car service companies and medical providers are emerging all over the US.

MedStar Health, a nonprofit health care system in Maryland and Washington, DC, began a partnership with Uber in January 2016.  The program allows patients to access Uber while on the hospital’s website and set up alerts and reminders for upcoming appointments.  This program is available for patients that already have an Uber account.  For Medicaid patients who do not have an account with Uber, the hospital’s patient advocate services can assist with arranging the ride.

Recently, National MedTrans Network, a national transportation system provider that provides non-emergency medical rides for patients and providers, has expanded its services through in New York, Nevada, and California in a partnership with Lyft.

There are other programs in place that will make transporting patients obsolete.  The idea of an Uber for Healthcare app is gaining momentum and has attracted large name investors such as Lionel Richie and Ashton Kutcher.  One such app is called Heal and allows users to input their location, medical symptoms, personal information, insurance and credit card information, choose an appointment time, and then request a doctor who is guaranteed to arrive with an hour.  Such a house call costs around $99.

While these partnerships are fairly new, many people predict that this is just the start of what could be a very big program.  In fact, dozens of startups use Uber as a template for bringing on-demand convenience to the market and there has been an influx of investment in such programs.  It will be interesting to see what the future holds.

Posted in Health reform, National Healthcare; Tagged: , , , .


Unconstitutional and Unacceptable: H.R. 36’s 20-Week Abortion Ban

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This post was written by Brenna Gautam and Rebecca Reingold.

Image courtesy of Vogue

Earlier this month, on October 3, the U.S. House of Representatives passed H.R. 36, the “Pain-Capable Unborn Child Protection Act.” Under H.R. 36, it is a crime for any person to perform an abortion if the probable post-fertilization age of the fetus is 20 weeks or more.

This federal ban on virtually all abortions 20 weeks after fertilization marks a departure from the U.S. Supreme Court’s abortion-related jurisprudence and flies in the face of both international and comparative law standards.

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Posted in Human Rights; Tagged: , , , , .


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