Global Health vs. International Health: A distinction without a differece?

By PHS 795 Student Ryan Rohde

John Hopkins Bloomberg School of Public Health Global Health NOW published this article discussing the growing popularity of the term “global health” and its presumed distinction from “international health”. The author, David Peters mentions that there is little distinction between the bodies that use either term. Peters further explains that health equity and multidisciplinary approaches have always been attributes to international health and have recently been claimed as new and unique to global health. He goes on to give detailed explanations of how health equity and multidisciplinary approaches are fundamental to international health by illustrating accomplishments achieved by WHO and UNICEF by working as nongovernmental entities.

I was recently having this discussion with colleagues of mine about the distinction between using the term “international health” and “global health” and if there truly is any difference. My understanding of each is that international health was multi-national, recognizing nation-states, borders, and governmental powers within that border and are not always universal; whereas, global health is universal by definition. Global health in my mind emphasizes the importance of global citizenship which transcends borders. Moreover, highlighting the vulnerability of those who do not have national citizenship (e.g. displaced people). Though we can debate over possible distinctions, I believe the use of either term has become interchangeable and the line distinguishing each is a thin one.

 

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The effect of marijuana legalization on opioid-induced fatalities

A PHS 795 student has some observations about a recent study associating medical marijuana legalization with lower opioid-induced fatalities at the state level between 1999 and 2010. While this misses the recent wave of mixed heroin/synthetic deaths, it is interesting food for thought! They write:

Due to the recent focus on opioid use in America, this study explores the legalization of marijuana and how it has led to a decrease in fatal opioid overdoses. The researchers found that opioid-related deaths decreased by approximately 33% in 13 states in the following 6 years after medical marijuana was legalized.

 This study presents a new possible solution for the United States’ epidemic on opioid use. The use of cannabis is extremely controversial in medical practice but some studies indicate that it is also strongly effective for chronic pain. The study concluded that there needed to be further investigations on how medical marijuana laws interact with laws preventing opioid overdoses.

 Overall, this article brought up an excellent option for opioid fatalities in American and how the legalization of marijuana might change the statistics. As of July 2014, 23 states had enacted laws creating cannabis programs that were directed towards chronic pain. These states will be excellent case studies relating to opioid use and overdoses over the next ten years.

 

A pet problem…

Pop Health 795 student Kelsey Baubie draws our attention to another possible factor in the nation’s ongoing opioid crisis: veterinary prescriptions. In response to a recent article in the Washington Post, she writes:

The Washington Post worked with Pew Charitable Trusts to publish this report recently

http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/08/23/war-on-opioids-moves-to-veterinarians-offices

about certain states’ attempts to require veterinarians to look into the pet’s medical record and the owner’s medical record to see if a pattern of opioid prescriptions appears. Colorado and Maine (one of the hardest hit states in terms of percentage change in overdose deaths) are two states which have enacted new legislation like this recently. The thing that stuck out so much to me that I wanted to write about this is the reaction of Dr. Kevin Lazarcheff, the California Veterinary Medical Association president, who pushed back on these new laws, saying he should not have access to human’s medical records.

What do you think about this reaction? My initial response to this was indignant: “How could you not want to do something fairly small to help stop the opioid epidemic?”. Yet I’m sure for vets, this issue is more complicated than my initial simplistic reaction allows. Do you think Dr. Lazarcheff is acting as a mouthpiece for the CVMA, whose members do not want extra responsibilities or ways they can be implicated for wrongdoing? We talked a little about malpractice and suing providers in class…are vets just trying to protect themselves from that? What more could be done to close loopholes like “vet shopping” for opioid access? What systematic changes can be made to decrease the chance of someone becoming addicted in the first place?

Population health in a boom economy…

A PHS 795 student draws our attention to a thought-provoking article in the New York Times describing a perhaps counterintuitive finding that mortality seems to increase during economic booms. They write:

This article encompasses the idea that has been brought up in every lecture – studying population health is messy. There are so many different factors that lead to the populations health outcomes that make it hard to study.

The article presents some surprising connections to economic growth and health of the population. The author referenced several studies that found an increase in mortality during economic booms. One factor that may lead to this is the increase in pollution and waste that enters the environment during these times. I think this links how everything effects everything in the system and you can’t study two factors without confounders being present. I also think it links to the post earlier on the blog about environmental health and environmental justice.

While a richer economy means people have the funds to afford health care, maybe it also means they have less time to eat healthy or exercise due to increase workloads or maybe people spend their money on more frivolous goods that contribute to a ‘stuff culture’ that harms the environment from excess production. The article states that alcohol and tobacco consumption increase during economic booms as well as occupational hazards and stress – all things that lead to greater mortality. Even though the initial thought of having a richer economy increasing mortality may be surprising, if you think about it, it makes a little more sense.

I liked how the author brought up the life time effects on an individual’s health depending on life events such as birth and college graduation. Being born in a healthy economy means you more likely have access to resources to develop skills and learn how to live a healthy life. Another example he talked about was graduating during a recession can reduce the amount of money you are able to earn over your life time.

This article brought up so much so many factors and how they are all connected to our health. Always a good thing to keep in mind when preforming or reading studies.

A closer look at soda taxes…

In response to a recent CNN story on recent declines in sugar-sweetened drink sales (featuring comments by UW LaFollette School Professor Jason Fletcher), a PHS 795 student offers comments about challenges in identifying the effect of soda taxes:

In certain areas of the country, sugary beverage tax policies have not always proved as effective of a strategy on reducing obesity rates as policymakers hoped. Well, what happens when independent citizens take it upon themselves to implement low-dose public health interventions within the community?

One could argue, speaking strictly about the 2017 Cornelsen article that studied Jamie Oliver’s restaurant intervention, that it’s even difficult to determine with certainty whether private businesses who’ve imposed additional taxes on unhealthy beverages have indeed seen the victories they’re heralding as significant wins in the fight against obesity. For example, how can one be certain (thanks, in part, to study design flaws and insufficient study controls) whether the reduction in sugary drink purchases, in one quasi-experiment involving a number of Oliver’s restaurants, is attributable to patrons having in fact made healthier choices? Is that the only alternative explanation/option that’s left, or couldn’t there be some other confounding factor(s) that might explain the sales declines and change in patron behaviors, like perhaps customers buying sodas at nearby stores instead? And, while Oliver’s business did accompany this price hike with a televised public health campaign, how do we know this increase alone is sufficient enough to inspire customers – from all backgrounds – to actually adopt measurable health reforms for themselves?

In short, what are some potentially unhelpful assumptions underlying incomprehensive studies such as this, and what might happen when we try to generalize these sort of limited results into real-world policy constructs?

Harassment and stress: addressing a threat to population health

PHS 795 Student Laura Bunke draws connections from current events to principles of population health. In response to an article commenting on France’s consideration of enacting fines for catcalling and other forms of sexual harassment, she writes:

After Trump’s campaign and election and the Harvey Weinstein, many women have been speaking up about sexual harassment. It feels that this has been a head line in some way for the past 6 months with more women coming forward and speaking out. The #MeToo and, #BalanceTonPorc (#Expose Your Pig). in France, this past two weeks has highlighted how many women are affected and show people that it happens to so many they personally know. The outcry has been criticized by some saying women don’t owe any one their story or that this is better handled in court. I think we are at a turning point and the fact that social media gave so many women a chance to identify and speak out is healthy and helpful to the cause.

There are several articles surrounding this topic in the US, but I picked this one from France because they are actually taken action to change the culture. This article states that there are proposals under ‘discussions to fine men for aggressive catcalling or lecherous behavior toward women in public, to extend the statute of limitations in cases of sexual assault involving minors and to create a new age ceiling under which minors cannot legally consent to a sexual relationship.’

If our countries took sexual harassment more seriously and changed the culture of how women are treated, I believe the mental and physical health of half of our population would be better. We talked in class about how internalized stress can affect a person’s health in so many ways. We thought of this mostly with racial and SES disparities, but I think we could apply it to gender disparities as well. Many women carry the burden of remembering an unwanted sexual advance and having their guard up to defend themselves from another. How did we let this be our culture for so long? And now that we are here, how do we change our policies, laws, and conversations to protect women and change the actions of men?

STDs are on the rise: why, and what to do…

A PHS 795 student draws our attention to recent findings that 2016 saw the highest number of STDs ever reported in the U.S.  See: http://www.cnn.com/2017/09/26/health/std-highest-ever-reported-cdc/index.html

They write:

This news article about the recent increase in cases of Gonorrhea, Syphilis, and Chlamydia in the United States relates to our lecture from Professor Higgins. Syphilis, a disease that was at such low levels in the mid 1900’s that it was basically eliminated, had 28,000 new cases in recent times. The author of the article cites funding cuts, ineffective sex education, and the lack of symptoms in most cases as factors that have led to the increase in new cases. As Professor Higgins stated, frequently, public health approaches to STDs and other risks associated with sexual contact don’t reflect one of the main reasons that people engage in sexual intercourse. Building on the idea that sex related public health initiatives must take into account context to increase effectiveness, public health initiatives focused on STD prevention must take into account that STDs carry a social stigma in many places that prevents people from seeking care. The author references the movement to reduce HIV infection as a STD related initiative that navigated the social stigma more effectively than the current movement to prevent Gonorrhea, Syphilis, and Chlamydia. My question is: what are ways in which the movement to reduce HIV infection gained traction? How did it overcome challenges? And, can we use some of those methods to reduce the rates of other STDs?

Lessons from a hospital infection cluster outbreak…

PHS 795 student Kelsey Baubie came across an article that touches home on a couple of fronts. First, this particular series of serratia infections happened right here at UW — the article highlights the role of Pop Health graduate Dr. Nasia Safdar in helping solve this case. Second, the sad cause of the outbreak touches on a number of issues we discuss in class, including our upcoming lecture by Dr. Randy Brown on the opioid addiction.

https://www.statnews.com/2017/09/14/blood-infection-medical-mystery/

Kelsey writes:

There are a handful of population health science concepts in this article: random sampling procedures, an epidemic, a cluster, and single-source origin. The addition of opioids being involved also makes it relevant for many of us who are interested in this national crisis or will be working with opioids in the future; we can also use this to talk about the social contexts with which this crisis has been painted. The UW serratia cases are a clear example of an epidemic in that cases are higher than expected. The layperson may think “epidemic” means something widespread which affects a lot of people, but the actual definition is that cases are simply higher than one would expect. Have you experienced any opioid control measures in your work? What do you think should be focused on in order to better control the flow of these highly addictive substances? Looking at it from a social justice lens, have you seen a difference in how the opioid crisis has been couched versus the crack epidemic in the 1990s?

UW News — Autism Prevalence and Socioeconomic Status: What’s the Connection?

http://news.wisc.edu/autism-prevalence-and-socioeconomic-status-whats-the-connection/

By Gabrielle Waclawik (PHS 795 student):

As Durkin points out in her study, we have seen an increase in prevalence of Autism Spectrum Disorder (ASD) over the years. Many reasons likely exist for this including advances in screening techniques, changes in medical training and education, and even increase in coverage in the popular mainstream media. Moreover, the DSM-V criteria switched in 2013, although after Durkin’s study period, to recognize Autism Spectrum disorder (with varying severity) to include what was previously diagnosed separately as Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder (Not Otherwise Specified). Despite all of these changes, Durkin states that the “findings collectively support the idea that children living in poorer or less well-educated areas are being diagnosed with ASD at lower rates because they have less access to health care providers who could make the diagnosis and provide needed support.”

While the Durkin calls for better access to screening and health care providers in lower SES areas, the most interesting and timely point for me comes towards the end of the article. Durkin states “if we are under-identifying ASD in certain socioeconomic groups — as seems likely — we need to be prepared to provide services at a higher level to more people. We need to find cost-effective interventions and supports and make sure they are distributed equitably and in a way that reaches everybody who needs them.” While this is likely only referring to childhood and early intervention programs and services, we must not forget that as many of these children age, they too likely continue to require services as adults. I say this is timely, because Dane County is currently undergoing a drastic long-term care reform as it transitions from a regionally structured individualized approach to a more standardized statewide insurance model, which includes medical care, that will take effect in 2018.

I recently attended an informational meeting on the Dane County long-term care transformation, since the change will directly affect my older brother who has severe Autism and medical needs that require 24/7 supervision and care. Throughout the meeting, it was difficult to ignore many of the current caregiver’s and advocate’s echoes of frustrations and complaints about the current transition, as they are fearful the new structure could jeopardize supportive services by combining them with medical care in contracts run by insurance companies. And trust me, I can tell you firsthand how any change or interruption of routine can be devastating for a someone with severe autism. However, the Dane County waitlist currently holds about 600 people unable to receive any covered support services. Under the new “family care” model, all of those people will gain coverage.

As 2018 is quickly approaching, we will see how the changes unfold. I have no doubt it will be an extremely unsteady transition, as every change is for my brother. We will see how the state budget and coverage for such long-term care services upholds over the coming years, and if waitlists will continue to be a part of the past. As Durkin points out, as we increase access to screening and health care, we will continue to see a rise in prevalence of ASD. And we will need to be ready to meet the increasing demand for these support services.

 

Contraception and population health: changing the narrative

Following up on a lecture on the determinants of contraceptive use by Prof. Jenny Higgins, Pop Health 795 student Katherine Brow comments on a recent executive order from the Trump administration affecting requirements for employer health plans to pay for contraception.  She writes:

During Dr. Higgins’ lecture today, I could not stop thinking about how relevant her discussion on changing attitudes regarding contraception use is to current legislation and policies being pushed by our current administration. On October 6, the Trump administration rolled back the Obama-era requirement that employer-health plans cover birth control methods at no additional cost to their women employees, on the basis that this requirement infringes on the employer’s rights to religious freedom. Although its predicted that many companies will continue to provide coverage for birth control, this new rule creates a huge loophole for any employer who doesn’t wish to provide coverage and thus many women will be forced to pay out of pocket for their prescriptions.

What I find to be the most devastating ramification of this new rule is the affirmation by our government that access to contraception and the basic tools for sexual and reproductive health is not considered to be an inalienable human right. It makes access to contraception and basic control over reproduction even more of a privilege – this policy won’t affect affluent women who can still afford insurance that covers contraception, but rather those who depend on their employer to provide coverage. The same administration is also launching attacks on organizations like Planned Parenthood that provide care to disadvantaged individuals who don’t have the insurance to cover birth control. After this new rule rolled out, the response on social media condemning this action was overwhelmingly based on the fact that many women go on birth control for a slew of reasons: including management of irregular, painful, or heavy menstruation, control of premenstrual symptoms and acne, prevention of bone thinning and anemia, among many others. These are all extremely legitimate reasons for a person to go on birth control but what stood out to me is that the majority of people didn’t talk about one of the major (if not THE major) reason women choose to go on birth control: to prevent unwanted pregnancy. Since the beginning of the reproductive rights movement, advocates have had to market the pill and other methods as being a medically relevant good in order to overcome the enormous stigma against positive female sexuality.

So, this leads me to my biggest question following Dr. Higgins’ lecture: how can we shift the overall narrative of contraception as a medical good to a sexual good when we are still fighting for the social and legal legitimacy of birth control? How can we assure the sexual acceptability of contraction for all women when it’s still a privilege simply to have access to quality birth control? As Dr. Higgins discussed in lecture, we can start this cultural shift within our own personal relationships with family members, clients, or patients, which can give a lot of hope in times where significant change seems futile. And going along with the general theme of this class; we do have evidence-based research and measures of the sexual acceptability of contraception – we just have to continue our work and empower others so that change is possible.