Scott County, Indiana, which only has a few thousand residents, has historically had an average of five HIV cases per year. Since December 2014, however, the county has seen an outbreak, with more than 140 newly diagnosed cases. Dr. Jonathan Mermin, the director of the National Center for HIV/AIDs, Viral Hepatitis, STD and TB Prevention at the Center for Disease Control (CDC) calls this “one of the worst documented outbreaks of HIV among IV users in the past two decades.” Dr. Joan Duwve, the chief medical consultant with the Indiana State Department of Health, explained that the abuse of the prescription drug Opana was one of the catalysts for the increase in HIV cases, with some residents injecting it as frequently as 10 times a day, and sharing syringes with other members of their community.
HIV is mainly spread either by sexual contact with another person with HIV, or by sharing needles or syringes with someone who has HIV. One way to reduce the spread of the disease is to implement syringe exchange programs (SEPs) that reduce the transmission of blood-borne pathogens like HIV by providing free sterile syringes and collecting used syringes from injection-drug users (IDUs).
Policy surveillance is the ongoing, systematic collection, analysis, and dissemination of data about laws and policies. There is a long tradition of conducting “50 state surveys” to identify laws of public health significance, but the methods for creating these surveys are largely unscientific. Unlike this traditional legal research, policy surveillance uses systematic quantitative and qualitative coding to create scientific datasets and track policies over time. Throughout the past year the Robert Wood Johnson Foundation’s Public Health Law Research program, the Network for Public Health Law, ChangeLab Solutions and the CDC Public Health Law Program have been exploring policy surveillance through a Delphi process and within their programs. This webinar will present the findings from that Delphi study and will explore the role of policy surveillance in understanding the impact of law on public health.
Jennifer Ibrahim, PhD, MPH, Associate Director, Public Health Law Research program, Associate Professor, College of Public Health at Temple University
David Presley, JD, Policy Surveillance Manager, Public Health Law Research program
Matthew Penn, JD, MLIS, Director, Centers for Disease Control and Prevention, Public Health Law Program
Donna Levin, JD, Director, Network for Public Health Law (Moderator)
On this, the last day of National Public Health Week 2015, we’re looking forward by looking backward. There is nothing new about using law and policy to promote healthier environments, products and behavior. There is no good future for public health that does not include even more, and more effective, legal interventions.
Evan Anderson and I wrote in 2012 about the legal regulation of health-related behavior over the past half-century. The story we told offered several reasons for unabashed optimism about what law can do for health. The record is clear that law works, and works across a wide range of different health threats. We pointed to CDC lists of Great Public Health Achievements from the last century and the first decade of the 21st. Every one of them — from high levels of vaccination, through motor vehicle safety and cancer prevention to maternal and child health – could not have been successful without law and policy. Continue reading →
As part of the Public Health Law Research program’s participation in National Public Health Week 2015, we have been sharing materials and resources under the daily themes. Today’s theme, Building Broader Connections, is about expanding partnerships and making connections to benefit public health.
We spoke with Laura Hitchcock, JD, Policy Research & Development Specialist for Public Health – Seattle & King County and the King County Executive/Department of Executive Services Partnerships Initiative Lead. We asked her to offer some insight from her work as a lawyer and researcher in a public health department.
PHLR: What role can researchers play in building partnerships with health departments and contributing to the policy-making discussion?
Laura Hitchcock, JD
LH: Public health researchers can help to support development and refinement of evidence-based policies. Because policies are created in a political process, it is important for public health departments to continue to offer their scientific knowledge to support creation of effective policies, including repeal of ineffective policies or refinement of existing policies to better result in a healthy population by 2030. Health departments may need help to define local or state-focused areas for policy evaluation by working together with researchers, and should contribute to development of research agendas by identifying areas where policy makers, communities, medical professionals and others have concerns about the public’s health, and are likely to need support from researchers to know how to ‘plug in’ to research agenda development. Continue reading →
On November 20, 2014, the Public Health Law Research program released a new 50-state dataset analyzing state law governing the short-term emergency commitment process. These laws give law enforcement officers and others the right to involuntarily admit someone into a mental health care facility if they are in danger of harming themselves or others because of a mental illness.
At first glance, last Thursday’s decisions by the Supreme Court in McCullen v. Coakley and the New York Court of Appeals in New York Statewide Coalition of Hispanic Chambers of Commerce v. New York City Department of Health and Mental Hygiene, have little in common. McCullen, which struck down a Massachusetts law establishing a 35 foot buffer zone around reproductive health clinics, was a First Amendment case that dealt with the always contentious issue of abortion. In contrast, N.Y. Statewide Coalition, which upheld a lower court decision striking down a regulation of the New York City Board of Health barring the sale of large portions of sugary soda, was decided on state administrative law grounds, with the court finding that the Board exceeded its authority.
On closer inspection, however, the two cases share several features in addition to their date of decision. One is the failure to give substantial weight to the state’s interest in protection health. In his opinion for the Court in McCullen, Chief Justice Roberts accepted that the buffer zone law was content neutral and therefore not subject to strict scrutiny. Nevertheless, a unanimous Court held that the Massachusetts law was not narrowly tailored to serve the government interests of protecting public safety and access to health care. In reaching this decision, the Court focused on the “toll” that the buffer zone placed on the abortion opponents who tried to dissuade woman from having abortion, rather than the impact of the lack of such a zone on woman seeking reproductive health care. Equally important, the Court showed no willingness to defer to the state’s contentions that alternative regulatory approaches had proved unsatisfactory. Rather the Court insisted that given “the vital First Amendment interests at stake, it is not enough for Massachusetts simply to say that other approaches have not worked.”
About a year ago, my colleague Scott Burris blogged on this forum about the two polities of public health that compete for our visions – one view sees public health as “incredibly popular with citizens and lawmakers” and the other as the despised “nanny state.” Burris suggested that the former view is largely the truth, but the latter view is driving budgets and policymaking. His action plan centered on mobilizing public support for public health initiatives rooted in sound science, and engaging battles over public health law budgets and lawmaking. To do so, he recommended, among other things: a) that ideological or economic arguments against public health initiatives be challenged with data and science, including collaborations with state public health agencies, b) that legislators be supported more vigorously with real public opinion data and evidence, and c) improved normative work by law professors to develop a proactive intellectual, cultural, and political framework to evaluate, and perhaps influence, public health law interventions.
With respect to my own area of expertise, three recent developments seem designed to provide responses to Burris’s clarion call. First, the LawAtlas policy surveillance web portal has expanded significantly over the past year and has become a one-stop shop for public health law advocates and lawmakers to objectively evaluate existing public health law interventions and to learn about key elements of such laws. LawAtlas, as readers of this blog know, has expanded from an initial public health law surveillance of four broad public health law regimes to more than 20 datasets covering laws at a variety of levels – some statewide, as in my work on youth sports TBI laws, and some at a county or community-level such as the Seattle and King County public health law surveillance tool, which tracks policies adopted by local governments, public sector institutions, and private organizations in King County, Washington. My own policy surveillance portal, which has been substantially revised and re-launched this week, is one tool that contributes data to conversations that can too often be overrun by politics and emotion. Whether on LawAtlas, or in other forums, perhaps countering political noise with raw data will help reduce the level of misinformation in this policy space and promote a more reinvigorated evidence-based approach to public health lawmaking.
In honor of last week’s National Public Health Week, we have a lot of fresh, new PHLR. The latest crop of papers from public health law researchers touch on a number of important points and issues including transportation safety, implementation, tobacco control, and media presentation of public health law. Check out Scott Burris’s brief summaries after the jump!
In the last few decades, there has been a broad effort to strengthen the use of evidence-based law as a tool for the promotion of population health. There are two major fronts in the campaign, each essential, and both largely successful, though much work also remains. One aims to increase the quantity and quality of empirical research on the health effects of existing policy choices. The other focuses on how best to get such knowledge into action in the form of policy and practice. In a new PHLR Theory Practice and Evidence paper, Evan Anderson and I draw attention to a third front: the formulation of new legal interventions. Though policy experimentation is inevitable, it has been the subject of relatively little systematic study. For proponents of evidence-based public health law, policy experimentation presents a paradox: if a legal intervention is truly innovative, there will not yet be direct evidence of its impact. Yet direct evidence from policy evaluations is never the only source of research knowledge relevant to a policy decision, even under conditions of novelty and uncertainty. And few interventions are truly new in a broad sense; in most instances, similarly designed laws have been deployed before, just not for the same specific purpose.
We use the case of youth sports concussion and Washington’s Lystedt Law as a case study of how even new legal strategies dealing with new problems can be built on evidence. We show how evidence about the problem lawmakers are addressing, combined with widely-used analytic tools like the Haddon Matrix and an understanding of the generic mechanisms through which law influences behavior and outcomes, can bring existing research knowledge into the crafting of even very innovative legal interventions for newly perceived problems. While we don’t expect the policy sausage factory to suddenly start looking like a research lab, there’s no question that legislators typically care about getting policy right and want evidence. The point of our paper is to get the research world to think about ways we can help even when no one has yet studied the specific law at issue.
Effective salespeople often practice something called an “elevator speech,”—a clear, persuasive pitch for their product that’s so succinct they can deliver it on the ride between the lobby and the mezzanine. Recently I found myself giving exactly such an impromptu presentation, literally on an elevator in a conference hotel in Atlanta, trying to explain to a fellow conferencista the nature and significance of our study with Assertive Community Treatment (ACT) teams implementing Psychiatric Advance Directives (PADs) in North Carolina.
“So, there are these legal documents called psychiatric advance directives, or PADs,” I said. (We were attending the annual conference of the Robert Wood Johnson Foundation’s Public Health Law Research Program; she wasn’t a mental health specialist.) “They’re similar to ‘living wills’ but they’re for people with serious mental illnesses who want to plan ahead for their own treatment during a future mental health crisis. At a time when they’re feeling well, people can complete a PAD to document their treatment choices and preferences and also appoint someone they trust to make treatment decisions for them. Ideally, PADs are a ‘recovery tool’ that helps people to obtain treatment they prefer—something that works for them during a mental health crisis—including medication and hospitalization, when needed, but without involuntary commitment. In the meantime, PADs can help clear the lines of communication between the person with mental illness and clinicians and even family members; just the exercise of completing one of these documents can make people feel more in control of their own lives, and give them some peace of mind.”
“Wow! That’s the best new idea I’ve heard all day,” my elevator-companion responded. Just then the elevator doors opened on the hotel lobby and the ride was over. Unfortunately, my speech was just getting started; I guess I’d make a terrible salesperson. But now my new friend seemed interested and didn’t walk away, and so we stood there in the lobby and I kept talking.
Laura Brennan, Ross Brownson and Tracey Orleans have come out with an important paper reviewing the evidence on policy and environmental strategies for reducing childhood obesity. Twenty-four strategies and 2000 published and gray literature documents are covered. This is a menu of more-or-less evidence backed ideas for intervention.
Sam Harper and colleagues come out with an interesting new argument for primary seat belt laws, based on a disparities analysis. Looking through the lens of education level, they (well, we, since I am one of the authors) find that, while primary enforcement has a powerful affect at every educational level, the impact is greater on people with less education. Thus, existing SES differentials in seat belt use could be reduced if all states (finally) went to primary enforcement.
Even kids like paternalism? Well, that may not be the best interpretation of this next study. Williams and McCartt surveyed New Jersey teenagers about three GDL requirements that are unique to that state: minimum licensing age of 17; application of full GDL rules to beginners younger than 21; and requiring license status decals on vehicle plates of GDL drivers. 84% liked licensing at 17, and 77% approved applying Gthe rules even to older novices. The decal policy was approved by only 23% — but a PHLR study showed it works, so I say get used to it.
Two new tobacco law studies round out the week’s harvest. Heikki et al. map the diffusion of health warning regulations since 1966, showing a big impact of the FCTC. Finally, in a paper that may start some arguments, Kevin Callison and Robert Kaestner report that adult smokers may not be as responsive to cigarette taxes as many believe. They suggest it will take increases on the order of 100% to get a further 5% reduction in smoking rates. Well, I’m okay with that.
Over on the George side of things, Peter Jacobson and Wendy Parmet have posted a thoughtful response to Larry Gostin’s Bloomberg commentary in the Hastings Center Report. They are helping us move away from a habitual application of the paternalism critique and reminding us that public health can play in the democracy sandbox pretty well.
This week, PHLR launched its SciVal Experts PHLR Community website. The core of the site is publications and other information for 300 leading public health law researchers doing empirical evaluations of the impact of laws and legal practices on health. The SciVal system allows visitors to find experts by topic, to trace their institutional and individual networks, and to find the latest publications in the field.
We encourage you to visit the site and explore for yourself, but we’ll also begin periodically sharing batches of publications on this blog.
The National Program Office (NPO) for Public Health Law Research (PHLR), a nationally recognized program sponsored by Robert Wood Johnson Foundation for the evaluation of the health impact of laws and legal practices, seeks a postdoctoral fellow who will provide quantitative analytical support to the PHLR team. The successful candidate holds a Ph.D. with significant experience in quantitative methods and law/health policy or a J.D. with strong quantitative and health policy research skills. The individual will produce empirical papers using the quantitative legal data currently on LawAltas.org and provide literature and systematic review support for journal publications, white papers, and grant submissions. This person will become a full member of the NPO for PHLR at the Temple University Beasley School of Law for a period of two years. PHLR staff and affiliated scholars will mentor this person in public health law research methods and provide networking opportunities with leaders in the field of public health law research. The postdoctoral fellow will be required to attend the PHLR Annual Meeting each year.
Working with Corey Davis of the Network for Public Health Law, PHLR has completed and posted updated longitudinal datasets of state laws authorizing naloxone distribution and creating “Good Samaritan” immunity for callers reporting a drug overdose to 911. Take a look at www.lawatlas.org.
On the theory that an image beats a few hundred words, here’s a report on the state of the law:
This is the last in a series summarizing a panel from the George collaborative of law professors at last week’s APHA meeting. My talk had a smiley icon for a title and a rant for a structure. I wanted to engage the audience with two very general ideas: that public health legal interventions are popular, and that we are both factually and strategically wrong to buy into the framing of public health law controversies as turning on principled questions of paternalism or tensions between individual rights and collective welfare.
The first is a point I have made in past posts of one kind or another, and that Evan Anderson and I elaborate in our article just published in the Annual Review of Law and Social Science. In that article, we point to the fact that Rs and Ds have been happily passing laws that regulate our behaviors, our environment and our machines for public health reasons for decades and show no signs of slowing down. In the talk, I also reference the Morain and Mello Health Affairs piece on pro-public-health public opinion. At PHLR, we are working on another aspect of all this, the fact that a lot of the controversy and complaint about “intrusive” measures often dies down once the new behavior is adopted. We don’t have a paper on this yet, but just ask yourself who misses smoke-filled rooms, transfats, cars without airbags… And of course, as Mayor Bloomberg makes his exit as the symbol of the local nanny state, it’s worth recalling his poor paterniated charges re-elected him twice.
One of the themes of what we might call Georgian Legal Scholarship has been the neglect of public health as a core object of government. This is a theme Wendy Parmet set out at length in Populations, Public Health and the Law, and that Renee Landers took up at APHA.
Landers’ timely example was the ACA and its individual mandate, which has been characterized in litigation as a mandate to purchase an “unwanted” product in violation of individual liberty, exceeding Congress’s power under the Commerce Clause, not a valid exercise of Congress’s Taxing Power, and an intrusion on the prerogatives of the States. The Chief Justice’s opinion in the Supreme Court’s decision in NFIB v. Sebelius, upholding the individual mandate, but declaring the structure of the Medicaid expansion a violation of the Tenth Amendment, provides her many examples of the focus on these legal abstractions. She also points to language from the joint dissent that indicates the same limited perspective. Absent from the opinions was acknowledgment of the significant public health problems—human suffering—that the ACA was designed to address. As she sees it, a focus on abstractions over lived experience has resulted in millions of intended beneficiaries of the ACA being left out of the Medicaid expansion because 26 states have taken advantage of the ability to opt out of the Medicaid expansion.
Landers argued that this was not a problem confined to the ACA case. Courts have reasoned in similar ways in recent public health preemption, First Amendment and abortion cases, showing a disregard for real human situations or scientific and economic evidence. To her, these recent examples echo the approach of the courts in the early part of the twentieth century when the Lochner case defined judicial review of economic and public health regulation, as Wendy Parmet has discussed in Populations, Public Health, and the Law. Public health lawyers and scholars, she concluded, must work to demonstrate for courts that role of economic regulation in promoting the public health, elevate the concerns of real people above legal abstractions, and lift the mask on punitive measures masquerading as public health laws.
(Second in a series of posts on the George Project session at APHA last week.)
Lindsay Wiley, who has been writing some interesting stuff lately about the democratic foundations of public health, used her talk to discuss Building and Honoring Coalitions in Controversial Times. Part of the George discussion has been directed to changing the public health law conversation from a set of complaints about setbacks to an exploration of new possibilities. In thinking about the pivot from challenges to opportunities, Wiley has been focusing on opportunities to protect and strengthen coalitions across progressive advocacy communities and with other potential allies.
This issue arises in a range of contexts: from health and environmental issues surrounding food production, marketing, and labeling to employers’ and private health plans’ efforts to cut costs by providing incentives for healthy behavior. Wiley’s presentation focused on recent tensions between public health advocates and civil rights, anti-poverty, and anti-hunger groups. Within the public health community, she argued, we in public health law tend to automatically see public health goals as compatible with broader social justice goals. We claim social justice as the moral foundation of public health practice and advocacy. But over the last few years – intensifying in the last several months – that synergy has been threatened.
Wiley discussed three recent controversies: the soda industry’s framing of the legal challenge to the NYC soda portion rule as a civil rights issue; anti-hunger and anti-poverty groups’ vehement opposition to proposed restrictions on the use of SNAP benefits to purchase unhealthy foods and beverages; and opposition to primary enforcement seatbelt laws based on concerns about racial profiling. Wiley’s examination of these events suggests that in some instances, the public health community needs to work more closely with civil rights and anti-poverty groups to promote a more progressive, ecological approach to public health issues and to make the case for health disparities as a civil rights and anti-poverty issue (rather than simply claiming civil rights or anti-poverty as public health issues). In other instances, public health advocates may be picking the wrong battles altogether, siding with groups who want to penalize socially and economically disadvantaged communities without working to facilitate healthier options in those communities. But in some instances, public health advocates have been able to forge compromises that result in a true win-win: promoting public health goals while also achieving reforms in other areas.
Like Wendy Parmet’s talk, described yesterday, Lindsay Wiley’s challenges the comfortable notion that public health is automatically given credit for its high moral standards and good social intentions. She doesn’t say we can’t occupy the moral high ground, but we may have to work harder to get there, and she has some practical ideas about how to do it.