“Thanks to decades of neuroscience research on brain development, adversity and toxic stress, we now understand how a child who is exposed to violence, or neglect, or homelessness at an early age may develop behavioral and physical health problems later in life,” said Jane Lowe, Senior Adviser for Program Development at the Robert Wood Johnson Foundation (RWJF). “We can now use this rapidly evolving knowledge to create real-world solutions.”

RWJF.org recently pulled together a collection of resources on “adverse childhood experiences”—how common they are and what they can mean for the adults those traumatized children become. The website includes an infographic that illustrates the subject:

NewPublicHealth has previously written about the importance of addressing and changing youth violence, so that these behaviors don’t become even more severe—and more damaging—while spreading from act to act and person to person. In a Q&A, Kristin Schubert, MPH and then-interim director of RWJF’s Public Health, spoke about the Foundation’s approach to the issue of violence prevention and strategies in the field that are working to create change.

“We know that the child who was abused is that much more likely to be a victim or perpetrator of bullying a few years down the line, and then is that much more likely to be a victim or perpetrator of dating violence a few years later in high school, and then is much more likely to be a part of more family violence later on. There’s no form of violence that stands alone,” she said. “It’s a multigenerational phenomenon that is passed down.

“This context is so essential—in considering why someone engages in violent behavior, it’s important to recognize that it’s not just the ‘bad apple,’ it’s not the person. It’s the behavior. As Gary Slutkin of CeaseFire says, ‘Violence is a learned behavior.’”

Schubert pointed to the Adverse Childhood Experiences Study, which found that the more “adverse” events a child faces in their youth—from maltreatment to neglect to abuse to witnessing violence—the more likely they are to have health problems later in life. That includes hypertension, diabetes and heart disease.

>>Read the full NewPublicHealth interview.

>>Read more about Adverse Childhood Experiences.

After years of deliberation, the U.S. Food and Drug Administration (FDA) has issued final guidance on the regulation of smartphone medical devices. In a nutshell, generally speaking any device used in diagnosis or treatment can’t be marketed until it’s approved by the FDA; other apps—such as calorie counters, or pedometers built into a phone—don’t need the FDA’s nod. The FDA’s criteria is how much risk an app poses for a consumer. The agency says it “intends to focus its regulatory oversight on a subset of mobile medical apps that present a greater risk to patients if they do not work as intended.”

Specifically, the FDA will focus its oversight on mobile medical apps that: 

• Are intended to be used as an accessory to a regulated medical device—for example, an application that allows a health care professional to make a specific diagnosis by viewing a medical image from a picture archiving and communication system (PACS) on a smartphone or a mobile tablet.
• Transform a mobile platform into a regulated medical device—for example, an application that turns a smartphone into an electrocardiography (ECG) machine to detect abnormal heart rhythms or determine whether a patient is experiencing a heart attack.

“We have worked hard to strike the right balance, reviewing only the mobile apps that has the potential to harm consumers if they do not function properly,” said Jeffrey Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health. “Our mobile medical app policy provides app developers with the clarity needed to support the continued development of these important products.”

While the final guidelines were only just released, FDA has cleared 100 mobile medical apps for marketing in the last few years, and 40 of those were just in the last two years.

Synim Rivers, an FDA spokesman, answered questions for NewPublicHealth about the final guidance on mobile medical apps.

Florence Fulk, MS, BS, a research biologist with the Environmental Protection Agency (EPA) and Tami Thomas-Burton, BS, MPH, of the Office of the Regional Administrator-Environmental Justice at EPA, will be speaking at the National Health Impact Assessment meeting this week on HIAs and environmental policy. NewPublicHealth caught up with Fulk and Thomas-Burton ahead of the conference to ask about EPA’s use of health impact assessments.

NewPublicHealth: What steps has the Environmental Protection Agency (EPA) taken with respect to health impact assessments?

Florence Fulk: Within EPA is the Office of Research and Development, and within that office we have a Sustainable and Healthy Communities Research Program which is providing tools, models and approaches to support HIAs across the country. We’re also demonstrating HIA as an approach to integrate and weigh tradeoff in community decision making.

NPH: Why is the EPA investing in health impact assessments?

Fulk: The primary vision for the Sustainable and Healthy Communities Research Program is to inform and empower communities to look at human health, economic and environmental factors in their decision making, and to do it in a way that fosters community sustainability. And that vision is very closely linked to the values and the function of HIAs. The number of HIAs that are being conducted in the United States and the number of people that are conducting HIAs in the United States has formed this growing community of practice, which can inform our Sustainable and Healthy Communities Research Program by understanding the decisions that communities are facing and how they’re bringing health, economic and environmental information to the process.

We also see that by growing a community of practice as a network to disseminate EPA tools, models, data and guidance, the research that we do to support HIAs also gives us a way to raise awareness about sustainable alternatives in community decisions.

One of the most sought-after experts at the second national Health Impact Assessment (HIA) meeting, currently underway in Washington, D.C., is Arthur Wendel, MD, MPH, team lead for the Healthy Community Design Initiative at the U.S. Centers for Disease Control and Prevention (CDC), which is a sponsor of the HIA meeting. Health impact assessments are decision-making tools that help identify the health consequences of policies in other sectors.

NewPublicHealth caught up with Dr. Wendel just after the first plenary session.

NewPublicHealth: How’s the meeting so far?

Arthur Wendel: The first plenary speaker, councilman Joseph Cimperman form Cuyahoga County in Cleveland, was just an outstanding speaker and made such a good impression for the whole conference. When you have a policymaker come in and provide a fresh perspective about how health impact assessments can make a difference, that sets the stage for attendees.

>>Editor’s Note: NewPublicHealth will be speaking with Councilman Cimperman later this week about his championing of HIA work in Cleveland, including a health impact assessment on the city’s budget, the first time the tool has been used that way.

NPH: How long has CDC been involved in health impact assessments?

Arthur Wendel: CDC has been involved with health impact assessments, through the Healthy Community Design Initiative, since 2003. The initiative is part of CDC’s National Center for Environmental Health, and initially we were just kind of trying to figure out the field of health impact assessments, learn a little bit about it from some domestic and international groups that conducted health impact assessments. Some of the initial steps were just trying to provide technical assistance for a few HIAs. That gave us a little bit of flavor for how health impact assessments were done, and from that initial effort we started to compile some research. One of the initial papers that came out of our group was identifying the first 27 HIAs that were conducted in the United States and some of the common characteristics among them.

>>Looking for examples of successful HIAs? Read stories from the field from CDC grantees.

Public health department accreditation is a key topic on the Association of State and Territorial Health Officials (ASTHO) annual meeting agenda this year. John Wiesman, DrPH, MPH, Secretary of Health for the state of Washington, will participate in a discussion on the issue during the meeting. He speaks with authority, as Washington, along with Oklahoma, is one of only two states recently accredited by the Public Health Accreditation Board.

>>Follow our ASTHO Annual Meeting coverage throughout the week.

In advance of the meeting, NewPublicHealth spoke with Wiesman about the benefits of accreditation to public health departments and the communities they serve.

NewPublicHealth: What are benefits of public health accreditation to share with directors of state health departments who have not yet applied for the credential?

John Wiesman: Honestly, I think accreditation gives you bragging rights in the sense that you’re saying “our organization values quality and outcomes.” For example, you can add that to a grant for a question that asks about quality processes. That states your commitment and that a national organization found that to be true. And it gives you bragging rights with fellow cabinet officers and the governor. To be able to say you are an accredited health department means something and you can value that.

Another critical thing is that for the local public health agencies in your state, the process of going through accreditation and developing a state health improvement plan gives you an opportunity to talk about how you want to improve health in your state and get everyone on the same page. So it’s a way to build relationships with health departments in the state and showcase priorities you want to work on together. In that sense, the process of applying for accreditation goes a very long way.

NPH: What benefit has the state health department accreditation brought to local health departments in your state who are considering applying for the credential?

Wiesman: We have learning collaborative in the state as well as some grants that allow us to work with local health departments on quality improvement to become accreditation-ready. And by having gone through the accreditation process ourselves as a state health department, we bring added credibility to the table and can answer many of their questions, and our firsthand experience gives things more meaning. I think it’s absolutely important for state health departments to become accredited if you want others to do that as well.

For the last several years, each incoming president of the Association of State and Territorial Health Officials (ASTHO) has introduced a President’s Challenge for the year of their presidency to focus attention on a critical national health issue. Previous challenges have included injury prevention, health equity and reducing the number of preterm births. This year, incoming ASTHO president Terry Cline, PhD, will focus his President’s Challenge on prescription drug abuse, a national public health crisis that results in tens of thousands of deaths each year.

>>Follow our ASTHO Annual Meeting coverage throughout the week.

Just before the ASTHO annual meeting began, NewPublicHealth spoke with Cline about the scope of the issue and steps Cline will introduce to help health officers collectively focus their attention on reducing this public health crisis.

NPH: Why have you chosen prescription drug abuse as your President’s Challenge?

Terry Cline: If you look at the trend lines in the United States, we’ve seen a very rapid increase in the number of deaths from the misuse of prescription drugs. We’ve also seen a huge increase in the number of children born with neonatal abstinence syndrome, which has actually tripled in the last decade. Prescription drug abuse has created an incredible burden on the health of people in the United States. Deaths are just one indicator; others include lost productivity, absenteeism and health care costs. Just using neonatal abstinence syndrome as an example, in 2000 the total hospital charges were about $190 million and in 2009, which is the last year we have that data, it was $720 million. Because in many states Medicaid pays for a large percentage of the births, in 2000 that amount was about $130 million out of the $190 million, and in 2009 it was $560 million of the $720 million. So that is becoming a larger and larger financial burden on states as well, and that does not include the long-term effects on babies.

The President’s Challenge will be looking at the absolute number—bringing down the number of deaths, which stand at more than 16,000 deaths per year. We’ve seen opioid deaths increase and continue every year over the last decade. And in most states now, the number of deaths from prescription drugs is actually greater than the number of deaths from automobile accidents, which has steadily gone down over the last decade. So, one is an example of a public health success; the decrease in motor vehicle deaths stems from a comprehensive approach and work with multiple sectors to bring that death rate down. The other, prescription drug deaths, is an alarming increase. My hope is that with the President’s Challenge, we can really increase awareness and leverage public health agencies across the country to mobilize around this issue.

For the last several years there’s been a bit of a tradition at the annual meeting of the Association of State and Territorial Health Officials (ASTHO), with the incoming president introducing a year-long “President's Challenge” to focus the attention of state health officers on a critical national public health issue.

José Montero, MD, outgoing president of ASTHO and director of the New Hampshire Department of Health and Human Services, chose the reintegration of public health and health care. The starting point for the challenge was a report by the Institute of Medicine, Primary Care and Public Health: Exploring Integration to Improve Population Health. In his announcement, Montero emphasized the need to take a systems approach to health care transformation in order to achieve lasting improvements in population health.

Throughout the past year, both state health departments and other public health organizations have added their integration projects to a project list maintained by ASTHO. This includes the State of New Hampshire Department of Public Health, which has collaborated with a community health center network and others to use electronic health records to link providers and tobacco quitline services, with the goal of cutting smoking rates.

>>Follow our ASTHO Annual Meeting coverage throughout the week.

Just ahead of the 2013 ASTHO annual meeting, NewPublicHealth spoke with Montero about the importance of the challenge he put forward for his fellow state health officers and next steps.

NewPublicHealth: What participation have you seen by the state health departments in your President's Challenge on reintegration of public health and health care?

José Montero: The specific metric that I used was to have states and the District of Columbia send stories that illustrate levels of partnership and integration. During the past year, the visibility of the topic has grown dramatically. In addition, ASTHO has an ongoing partnership that has brought together more than 50 different organizations for the same purpose. We meet regularly, working together on how to advance the agenda of better coordination and integration, and every day we identify new people who want to participate, and I think that has been an amazing result. I don’t want to claim that all of this is because of the ASTHO initiative. There were a lot of things that were out there already. But this was a timely call, and all of those who were working on it are joining efforts to make it happen.

The annual meeting of the Association of State and Territorial Health Officials (ASTHO) begins tomorrow in Orlando, Florida. Attendees at the ASTHO annual meeting head to the same sessions and listen to the same speakers over three days, which helps create a common fluency with critical public health issues. It also creates cohesion among state health officers, who often work with each other during public health crises and learn from each others’ successful approaches to dilemmas such as budget cuts and entrenched chronic disease.

>>Follow our ASTHO Annual Meeting coverage throughout the week.

Ahead of the meeting, NewPublicHealth spoke with ASTHO’s long-time executive director, Paul Jarris, MD, about the key issues participants will engage in during the 2013 ASTHO meeting.

NewPublicHealth: What are key themes at this year’s annual meeting?

Dr. Paul Jarris: There are a number of major health issues on the agenda for the conference, including an update on Healthy Babies are Worth the Wait, last year’s ASTHO presidential challenge. Together with the Health Resource Services Administration (HRSA) there’s an intention to roll out Healthy Babies learning collaboratives across the country, and we’ll be sharing successes of the initiative from the past year.

Another major area we’ll be talking about will be the reintegration of public health and health care. A lot of this work has been outgoing ASTHO president Dr. Jose Montero’s presidential challenge for the last year, and there’s been a lot of work going on, including the development of a national collaborative between public health and primary care that ASTHO is supporting. The collaborative involves more than 50 different health care and public health organizations, brought together for the purposes of improving the population’s health.

Incoming president Terry Cline will launch his Presidential Challenge, a major initiative on prescription drug abuse and misuse and overdose. There are more people who die from prescription drug overdose than from motor vehicle accidents in this country—and there’s much that can be done about it. We’ll also have the leadership from the Office of National Drug Control Policy speaking on this critical issue.

The Health Systems Learning Group (HSLG) is made up of 43 organizations, including 36 non-profit health systems that have met for the last eighteen months to share innovative practices aimed at improving health and economic viability of communities.

The idea for the learning collaborative came from a series of meetings at the White House Office and U.S. Department of Health & Human Services Center for Faith-Based & Neighborhood Partnerships. The HSLG’s administrative team is based at Methodist Le Bonheur Healthcare Center for Excellence in Faith and Health in Memphis, Tenn., and at Wake Forest Baptist Health System in Winston-Salem, N.C. The Robert Wood Johnson Foundation provided a grant to share the group’s findings and lessons learned.

In addition to its other work, earlier this year the HSLG released a monograph that aims to help identify and activate proven community health practices and partnerships. Once identified, they can be combined with other evidence-based initiatives to reveal new pathways to transform unmanaged charity care into strategic, sustainable community health improvement.

Recently, NewPublicHealth spoke with the Reverend Doctor Gary Gunderson, vice president of the Division of Faith and Health Ministries at Wake Forest Baptist Health and co-principal investigator of the Health Services Learning Group, about their vision for the future of healthy communities and the role that hospitals and health systems will play.

NewPublicHealth: What are the goals of the Health Systems Learning Group?

Gary Gunderson: The essence of the task was to help each other learn how we can fulfill our most basic mission. All of the Health Systems Learning Group members are not-profit. The vast majority are faith-based, and so in every case our essential mission boils down to improving the health of the community that created us.

All of the HSLG members are financially stable and we all provide a lot of charity care, but that does not add up to necessarily fulfilling our real aspirational mission and that’s what we came together: to see whether it’s possible to do that in the current environment. And our fundamental answer is that it is possible to do that, but we have to have some new competencies and expanded commitments in order to do it.

Ten new videos released today by Public Health Law Research (PHLR), a national program of the Robert Wood Johnson Foundation, with direction and technical assistance from Temple University, offer suggestions of proposed changes to laws and policies that can impact public health, such as fortifying corn masa flour to prevent neural tube defects and increasing taxes on alcohol to reduce consumption.  The five-minute videos offer examples of PHLR’s “Critical Opportunities” initiative—brief presentations which showcase legal approaches to improving public health.

“Laws can be cost-efficient and popular tools for achieving public health goals. This initiative captures specific actionable, evidence-based ideas for creative ways of using law or legal interventions to improve a public health problem,” said Scott Burris, JD, director of the PHLR program.

The release of the videos is accompanied by an article published this week in the American Journal of Public Health, “Critical Opportunities for Public Health Law: A Call to Action.” It outlines five high-priority areas where evidence suggests legal interventions can have big impacts on health, and calls for a national conversation to continue to identify and prioritize opportunities for legal and policy action.

“The Centers for Disease Control and Prevention, the Institute of Medicine, and others have called for better, smarter use of legal interventions to advance public health,” said Michelle Mello, JD, PhD, the lead author of the article and professor of law and public health at Harvard University. “That’s no small task, but there’s a treasure trove of great ideas to draw on and evidence to back them up.”

PHLR has also developed a toolkit for use by organizations or instructors to host Critical Opportunities sessions at their meetings or in classrooms. The toolkit offers a how-to guide for using the format to identify ways laws can be used to address public health issues.

All ten of the new Critical Opportunities videos are available here. To highlight just one of the presentations, NewPublicHealth recently spoke with Adam Finkel, ScD, of the University of Pennsylvania Law School, about his Critical Opportunity presentation on the benefit and limitations of “smart disclosures,” an alternative to regulations and laws for improving public health.