Since January, President Trump’s travel ban has triggered ongoing legal and political chaos. It’s been hard to keep up – one minute the order was to be instated, only for a court to stay it in full or in part. But, the order is now in force, for the next 90 days at least. The constant back-and-forth has paused for now, allowing space for reflection. This blog asks, what has happened so far, what’s to come, and should we fear for our health as a result?
Who is banned?
The original order barred entry of nationals of seven majority-Muslim countries (Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen) for at least 90 days; suspended the refugee resettlement program for 120 days; cut the total number of refugees admitted for resettlement to 50,000 in 2017, and imposed an indefinite ban on Syrian refugees. Refugees from a minority religion in their home country, e.g. Christians, would be prioritized. The order also mooted that a list of countries from which entry would be frozen be decided.
Almost immediately, organizations, states and individuals filed requests for a stay. And within a week of its issuance, a federal court stayed the order nationwide. In response, the government amended the order with targeted changes: Iraq was removed from the ban and preference for minority religions was removed. Yet again the order was suspended by courts, finally finding its way to the Supreme Court.
The Supreme Court reinstated the order with respect to foreign nationals who “lack bona fide relationship” with a person or entity in US. A “close familial relationship” is required or a relationship with an entity that is “formal, documented, and formed in the ordinary course” rather than to evade the order, such as a university student or employee.
In light of the Supreme Court decision, the government published guidance to its agencies to enforce the order. It did not include grandparents, grandchildren, aunts, uncles, nieces, nephews, cousins, siblings in law as close familial relationship. Further, having a resettlement agency in US provide formal assurance for a refugee is not enough. But, in State v. Trump, the government’s interpretation was found an “unduly restrictive” reading of “close familial relationship”, and the listed classes were included. This interpretation was left in place (for now) by the Supreme Court. The Supreme Court will decide on the cases in October session unless the ban has already been lifted.
The original executive order was called “Protecting the Nation from Foreign Terrorist Entry into the United States.” The express basis for the order was the need to prevent “terrorist or criminal infiltration by foreign nationals.” Yet, the administration did not present empirical evidence between the selected nationalities and the commission of terrorist attacks in the US. The Administration asserts that the temporary travel ban is in the interests of national security, and designed to strengthen vetting procedures from countries at risk of producing terrorists.
Opponents of the order argue that it amounts to discrimination, and preferential treatment of religion contrary to the constitution (the establishment clause). In Hawaii v. Trump, the Court had found that the order exceeded President’s authority under 8USC §§1182(f) and 1185(a) and motivated by anti-Muslim goal.
Direct and Indirect Health Impacts
The travel ban has had documented impacts on the mental and physical health of affected children, families and individuals. In a recent Amnesty International report on the ban, an informant tells of the health impact of feeling compelled to leave his baby in Malaysia for two months while he arranged an emergency visa:
“[The baby] was breastfeeding when she was separated from her mother. I am telling you the mother is like a crazy person now; she does strange things. She blames me: she says this is my fault. You can imagine how she is missing her child. Even I am truly suffering: I feel torn inside that I left my baby.”
All informants in the report speak of the underlying anxiety and concern they have for their future and that of their families. This uncertainty will likely have physiological impacts on those affected and those close to them. In particular, the manner in which the order was issued promoted discord: with no warning it was ushered in, meaning persons with valid visas were denied boarding or entry on arrival. The result was chaos and distress at major airports as citizens protested the sudden events. It has been estimated that immigration officials denied entry to at least 141 people in the first week the order was issued.
Attracting medical professionals
The US faces dire shortages of health workers. Yet, the uncertainty caused by the travel ban discourages workers from engaging in the laborious process of getting a visa to the US. This has implications not just for workers from the listed countries, but also workers from countries who may feel at risk of targeting at a later point. The most qualified applicants may prefer to immigrate to alternative destinations that are more welcoming.
This sad saga in US politics is far from over. Will the ban be lifted in 90 days or reinforced? Will the Supreme Court have the opportunity to decide on the case? The suggested health impacts are hard to quantify at this juncture and more data is required. However, what is sure, is that in many parts of the world, the image of the US as a beacon for the “tired, huddled masses” has slipped.
This post was written by Rebecca Reingold and Priscila Valencia.
Despite the tremendous strides made towards the realization of reproductive rights in Latin America and the Caribbean in recent decades, the region remains home to the majority of the world’s most restrictive abortion laws. However, reproductive rights advocates are leading efforts to change that in various countries, including Chile, the Dominican Republic and El Salvador.
This blog post was authored by Sean Bland and Javier Saladich, a Summer Research Intern at the O’Neill Institute and a third-year law student at ESADE Business and Law School in Barcelona, Spain.
Earlier this month, a group of organizations and advocates released a “Consensus Statement on HIV ‘Treatment as Prevention’ in Criminal Law Reform”. The consensus statement is intended to serve as a resource in efforts to modernize HIV criminal laws across the United States. Part of the motivation for the consensus statement is to clarify how best to utilize the new science about HIV in advocacy to combat the unjust application of criminal laws to people living with HIV (PLHIV).
New scientific evidence includes numerous studies demonstrating that antiretroviral therapy (ART) not only effectively suppresses HIV in people living with HIV, but can also be a powerful tool for preventing HIV transmission to others. This preventative benefit of treatment is often referred to as Treatment as Prevention. Results from the HIV Prevention Trials Network (HPTN) 052 study found that early versus delayed initiation of ART reduced the risk of HIV transmission from an HIV positive to negative partner by 96%, and a follow-up to HTPN 052 found no transmission from persons with fully suppressed viral loads to their partners. A second study, the Partner Study, followed 1166 serodiscordant couples (one partner was HIV positive and one was HIV negative) for nearly four years and found zero transmissions from the HIV positive partner when that partner was taking ART and virally suppressed. This study was seminal because it included both same-sex and opposite-sex couples. Most recently, results from the Opposites Attract Study, presented at the 2017 International AIDS Society Conference on HIV Science in Paris, found no HIV transmission among more than 350 serodiscordant same-sex couples, even when couples participating in the study reported nearly 17,000 instances of anal sex without a condom over four years.
Concerned that many people living with HIV, medical providers, and those at potential risk of acquiring HIV are not aware that ART treatment is a highly effective HIV prevention strategy and that this information could remain locked in the research community, the U=U campaign (“Undetectable = Untransmittable”) was launched. The campaign works to change the way organizations and people talk about HIV and infectiousness by underscoring that when a person living with HIV is on effective treatment and has an undetectable viral load, they will not transmit HIV to sexual partners. With that in mind, “U=U is a message of freedom and home. It is an unprecedented opportunity to improve lives of people living with HIV, dismantle HIV stigma, and improve treatment uptake and adherence.”
The advances reflected in the U=U campaign also have implications for criminal justice. There is a concern that if HIV criminal reform focuses solely on changing laws so that those who are virally suppressed are protected, that approach would continue to leave people of color, LGBT people, sex workers, and others subject to unjust criminal prosecution. The consensus statement notes a legal defense could include showing that low viral load and related non-infectiousness, but it also warns “we must be careful to avoid giving policy makers the impression that, absent treatment or an undetectable viral load, prosecution of PLHIV is warranted.” At bottom, the consensus statement points out “the two biggest problems with almost all HIV criminal laws and prosecutions are that 1) they focus on HIV disclosure rather than on whether the PLHIV had an intent to do harm; and 2) HIV laws’ felony punishment and severe sentences treat any risk of HIV infection as the equivalent of murder or manslaughter.” To respond to these two problems, the most pressing responsibility in HIV criminal law reform is to advocate for the following legal principles: 1) conviction must require proof that the person intended to do harm; and 2) the degree of punishment must be closely related to the level of injury.
The consensus statement is an important resource to aid advocates in pursuing criminal law reform without creating unintended negative consequences for people living with HIV. It also includes frequently asked questions with answers that further explore issues facing advocates as well as links to additional resources.
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.
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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.