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.

 

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Environmental justice and population health

A number of lectures have focused on the role of socioeconomic status on population health. Although our course has not focused on the “chemical environment” (e.g., air and water pollution), the concentration of health challenges in neighborhoods has been a recurring theme. PHS 795 Student Laurel Myers calls our attention to an interesting resource to help explore the relationship of health determinants to geographic location. She writes:

As we reflect on the effects of neighborhoods on health and happiness, I would like to highlight an important component of those outcomes: environmental justice. I am sure that many of us are already familiar with this concept, even if we don’t have a name for it. 

 The term “environmental justice” arose in the 1980’s and can be defined as “the unequal distribution of social and environmental costs between different human groups, classes, ethnicities but also in relation to gender and age.” Examples include increased pollution or decreased access to safe exercise spaces. Impoverished communities do not often have time or resources to fight the battles necessary to combat new factories that spew chemicals or to advocate for more sidewalks or green space. 

The EJ Atlas not only details the issue, but provides and interactive map where you can see violations of environmental justice worldwide: https://ejatlas.org/about

For those interested in exploring this issue more, Majora Carter explains environmental justice well in her talk “Greening the Ghetto” (https://www.ted.com/talks/majora_carter_s_tale_of_urban_renewal). I challenge you to consider what environmental injustices might exist here in Madison, or in your home communities.

Student offers thoughts on retirement income and health…

PHS 795 Student Zeeshan Yacoob writes in response to lectures examining the SES gradient of health:

One of the articles we are required to read for class talks about SES and the increasing retirement age. After reading this article I began to realize how this policy negatively impacts the poor while benefiting the rich. Therefore, I did a bit of searching to educate myself on the topic of raising the retirement age and the options that exist which is how I found the following article: http://host.madison.com/business/investment/markets-and-stocks/core-ways-to-fix-social-security—-which/article_3f879e25-5269-5c84-acdc-535a3c001754.html.

I personally believe that it is neither ethical nor does it make sense that our current maximum taxable income is set at $127,200. I feel as though it would make a lot more sense to eliminate the tax on income for individuals making less than $20,000 (or less than whatever the bottom 10% of the population makes) and also to eliminate the maximum taxable earnings cap. This in turn would not only allow us to finance social security for many more years to come but we would also be able to do it without raising the retirement age. Furthermore, it would also make our society are more just one and go towards eliminating the health disparities that exist. Also, who knows, it might even allow us to pay for universal healthcare, thus improving our abysmal Infant Mortality Rate.

A closer look at neighborhood data

By PHS 795 Student Grace Shea:

This project, called “The Equality of Opportunity Project,” was started by a Harvard grad and economist, Raj Chetty, who was interested in studying the effects of socio-ecological factors on a person’s long-term trajectory. This website shows much of the research that has been done by him and his staff using “Big Data” to analyze some of the financial and health outcomes associated with one’s neighborhood. This project was also featured on one of the Freakonomics Radio podcasts sessions, which you can find on the website. Primarily, I think this website can serve as a huge resource for many in the Public Health field because they provide all of their data to the public including lecture videos from a similar class that Dr. Chetty taught. The lectures are available via Youtube with links on the website.

http://www.equality-of-opportunity.org/neighborhoods/

In this link, you can scroll to the Local Area Rankings for Commuting Zones (Counties is also an option). The list provided shows the commuting (primarily urban) centers where your adult income is estimated based on where you live as a child if you are in the bottom 25th percentile for family income. Essentially, this data attempts to predict the causal effects of where you live if you are in a low-income family. Capture

If you look at the list provided, Seattle is at the top of the list. To understand this list, let’s use Seattle as an example. If a child were to grow up in the Seattle metro area instead of an average place, he/she would make about 12% more at age 26. The average level of household income at age 26 is $26,000, so this 12% gain translates to $3,120 of additional income.

If you look a bit further down, Madison is on that list. All kids in Madison have a 7.4% chance of making more as adults with boys at 10.4% and girls at 3.9%. My question to the class is why do we think we see such a significant gender gap for adult income for children in Madison. Additionally, do we think that a 7.4% increase in income is meaningful for predicting their long-term outcomes? How does this compare to the bottom of the list where in Fayetteville, NC, children have a -17.8% chance of making more money as an adult than their family’s current income? Can we use this data to predict where future public health efforts will be needed?

The effect of conflict on the mental health of children and adolescents

As we have been studying the cumulative effects of environmental stressors on population health, PHS Student Zeeshan Yacoob brings our attention to an article about the effects of the Israeli-Palestinian conflict on mental health through the experience of an 11-year-old boy. Zeeshan writes:

Zeeshan writes:

This article is about an 11-year-old Palestinian boy who suffers from PTSD after witnessing his brother die. After reading this article I began to wonder how these children will grow up and what type of society they will establish in the future. Furthermore, I also began to wonder about all of the health conditions they would have to face even if their situation would change overnight (for example if they were taken in as refugees to the U.S.). I’m sure that many of these children due to their stress will suffer from conditions like hypertension, cardiovascular disease and depression. As a result, their productivity as a society will decrease and also the societies educational attainment will also undoubtedly decrease. All in all, not only do I feel frustration and anger for the situation that these children have been exposed too but I also worry what their health future will look like not only for themselves but also for the next generation after them.

Zeeshan also points us to a systematic review on the effects of conflict on mental health of children in the Middle East:

https://www.ncbi.nlm.nih.gov/pubmed/?term=%22A+systematic+review+on+the+mental+health+of+children+and+adolescents+in+areas+of+armed+conflict+in+the+Middle+East%22

Image result for salwa massadPopulation Health graduate, Salwa Massad, PhD has done significant work in this area. She is currently a research manager in the World Health Organization’s Palestinian National Institute of Public Health and adjunct faculty at Columbia. Here is a link to a presentation of her brave and powerful work on the health of children living in chronic war zones:

http://health.oregonstate.edu/seminars/salwa-massad

Questions of non-binary gender and population health

PHS 795 Student Rissa Lane writes:

This article was published in CNN on Wednesday, September 20th, and refers to The Global Early Adolescent Study: An Exploration of the Factors that Shape Adolescence, an article published in the Journal of Adolescent Health volume for October 2017 and came from researchers from Johns Hopkins Bloomberg School of Public Health and the World Health Organization. The study draws connections between binary gender roles imposed on people from a very young age and the health implications that result. The article suggests that gender role expectations are the result of bias from group to group and the norms that exist in a community, because gender roles exist in nearly every culture across the globe, but the expectations for each gender are not necessarily synonymous across different populations. This study is particularly relevant to the content covered in this course as we have started to look at health of populations and social-ecological determinants of health. Typically, controls are imposed on study participants to regulate the effects of varying income, education level, age, and gender on the representation of results of evaluation. With this study, it becomes evident that the binary gender system may actually have health implications in and of itself.

http://www.cnn.com/2017/09/20/health/geas-gender-stereotypes-study/index.html

We’re Waiting for the Paperwork

By PHS 795 student, Gabrielle Waclawik

https://www.theatlantic.com/politics/archive/2017/08/president-trump-declares-the-opioid-crisis-a-national-emergency/536514/

A few weeks ago, President Trump proclaimed he considered the opioid epidemic a national emergency. Our nation’s opioid crisis has been brewing over many years, really since the 1990’s when pain gained recognition as the fifth vital sign and opioids, the ‘wonder drug’ were utilized in response. But it really was not until the problem began to infiltrate and make noise in the more white and affluent communities in the last 5-10 years, that the opioid epidemic began to gain traction in the mainstream and popular media. Now, this is no longer an issue that we, as a society, can ignore, as non-prescription opioid use, addiction, overdoses, and preventable deaths have increased at such a dramatic and exponential rate over the last decade. Most importantly, we must not forget that much of this illicit drug use started as a routine prescription for opioids from a licensed health provider. In fact, according to the CDC, people who are addicted to prescription opioid painkillers are 40 times more likely to be addicted to heroin.

However, some still argue against the use of their tax dollars towards funding free needle exchange programs, or easier public access to a readily available antidote (Naloxone), claiming that this only propagates a message that illicit drug use is tolerated by our society. Others, perhaps, believe this is an isolated problem among the drug user community, that does not affect them, thus how can it be a public health issue of national concern requiring collective action? But in reality, beyond the addiction, the overdoses, and the preventable deaths, downstream effects have now become extremely evident, with increasing numbers of new Hepatitis C and HIV cases on the rise. According to the CDC, new Hepatitis C cases in the U.S. grew nearly 300 percent between 2010 and 2015. In 2015, the state of Indiana’s new Hepatitis C cases were increasing as such a rapid rate that the state declared it a public health emergency, immediately making syringe exchange programs legal for the first time ever in its state. Furthermore, the access to medication alone for Hepatitis C treatment has been a greatly debated topic due to its high costs, and whether state and federal medical programming should be bearing this burden. This does not even begin to include the preventable drain of numerous other resources such as hospital costs or decreased work force productivity.

The degree of complexity the opioid epidemic presents requires multi-disciplinary action on many levels, and has, more recently, finally forced a government response.  On a state level, Wisconsin has led the charge with republican Representative Nygren, whose own daughter experienced heroin overdose and continues to battle drug addiction. Rep. Nygren brought forth the HOPE Act, which was initially signed in 2014 but continues to have addendums up for vote. On a national level, while President Trump may have made a public verbal statement acknowledging the issue, weeks later he still has yet to officially sign the paperwork to formally declare the opioid crisis a national emergency. In fact, the Atlantic article points out that despite Trump’s efforts to repeal the Affordable Care Act, the failure to repeal avoided a dramatic cut to Medicaid and thus maintained states’ ability to respond to the opioid crisis through the broader coverage of treatment and substance abuse programs. By signing the declaration, it will allow us easier access to federal disaster funds and waiving of certain federal program regulations. So that we can more quickly and robustly respond to this growing opioid epidemic, please sign the paperwork, President Trump.

Another look at soda taxes…

Using taxes to control the consumption of harmful products, including sugar-sweetened soda, is a matter of intense debate (see, e.g., http://www.nytimes.com/2016/11/26/well/eat/as-soda-taxes-gain-wider-acceptance-your-bottle-may-be-next.html)  A PHS 795 student points to a post on Kaiser Health News and questions the evidence on the effectiveness of soda taxes:

Last week, the soda-tax was brought up in our Epidemiology class. This Kaiser article discusses the passing of soda-taxes in many cities in the US in the November election. Based on our discussions on utility and marginal cost in class, I find it interesting that many cities are expecting to use a small increase in cost per soda to change the behavior of people in hopes of starting to solve the obesity epidemic and dental decay. Although there might be a causal relationship between sugary beverages and these poor health outcomes, there are many other contributing factors to these health problems. Further, the article doesn’t discuss whether implementing the soda-tax will actually decrease consumption. Instead the article focuses on the amount of tax revenue the soda-tax will bring in for the cities with the soda-tax. How high of an additional cost are people willing to pay before the cost forces a change in behavior? What other systemic issues are at play here that go beyond the cost of soda? The article only begins to touch on the other causes such as education, lack of access to alternative beverages, preference etc.

 1 Leading the Way? Northern California Cities To Embark On Soda Tax Spending

khn.org

Health advocates are expecting millions in new tax money for health education programs aimed at preventing obesity, diabetes and tooth decay. Other cities around the country are mulling similar mea…

Medicaid coverage for the incarcerated population

The incarcerated population faces numerous health challenges (see, e.g., http://www.annualreviews.org/doi/abs/10.1146/annurev-soc-073014-112326). A PHS 795 student draws our attention to a helpful overview of the role of Medicaid in caring for this population. They write:

Because incarcerated populations are so isolated from the general population, they are often overlooked in conversation. Given that incarceration rates are at an all time high and that incarcerated populations are particularly vulnerable to health disparities, I think it is important to understand how states are addressing their health management. Medicaid plays an important role in financing health care for criminal justice system involved individuals, a population with significantly lower socioeconomic status and disproportionately burdened by multiple health problems. Although very dense, this article discusses the guidelines for Medicaid spending on incarcerated individuals following introduction of the Affordable Care Act.

The expansion of coverage for criminal justice involved individuals has many benefits, as discussed in this article. This article brought to my attention the unique opportunity incarceration presents to effectively treat inmates for various health conditions. Treating them during incarceration decreases the chance of transmission of infectious diseases after release, decreases the risk of re-incarceration if mental health improves, decreases hospitalizations and emergency room visits, and lowers health care spending. It will be interesting to see how Medicaid funds are allocated to incarcerated populations and how total spending for this population changes over time if the ACA remains in effect for much longer.

http://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2016/08/how-and-when-medicaid-covers-people-under-correctional-supervision?utm_campaign=LM+-+GP+-+SFH+-+CHCS+-+Medicaid+Brief+08+01+16&utm_medium=email&utm_source=Pew

 

Sweet, sweet conflict of interest…

A PHS 795 student calls our attention to a recent NPR story on potential conflicts of interest associated with the soft drink industry’s funding of public health initiatives. They write:

The article and associated NPR story below discuss soda company sponsorship of U.S. health and medical organizations, along with corporate lobbying expenditures on public health legislation.

Listening and reading this made me think about the focus in our class on the economic aspects of population health, particularly operating in a world with limited resources. With budgets being cut or limited for health organizations, I think it is hard for organizations not to apply for or take money where they can get it, but it is important to keep the organization’s mission in mind.

It is not clear from the article, but I wonder if the organizations have to apply (e.g., for a grant) for the funding, and if they also do so from other companies (not just soda companies)? Does it matter whether money is just given freely, or if the organization has to apply for it? Was it a matter of getting a program or event funded in order to help individuals? If so, if that program or event supported the health and well-being of individuals, do the benefits of the program or event outweigh the potential conflict of interest issues?

On a related note, I’ve noticed increasingly that organizations are partnering with pharmaceuticals to offer grants funding. It might be interesting to see a similar analysis of the pharmaceutical industry.

I’d be interested to hear what others might have to say on this.

http://www.npr.org/2016/10/19/498582189/soda-industry-tries-to-woo-public-health-groups-with-sponsorship-deals

Here is a link to the study in the Am J Prev Med that motivated the story: http://www.ajpmonline.org/article/S0749-3797(16)30331-2/pdf