Category Archives: Q&A
New research presented at the American Public Health Association (APHA) annual meeting in Boston today finds that when public health funding increases in a community, its rates of infant mortality and deaths due to preventable diseases decrease over time, with low-income communities experiencing the largest health and economic gains.
According to the research, conducted by Glen Mays, PhD, MPH, director of the University of Kentucky’s National Coordinating Center for Public Health Services and Systems Research, each ten percent increase in public health spending over 17 years led to a 4.3 percent reduction in infant mortality, as well as reductions of 0.5 to 3.9 percent in non-infant deaths from cardiovascular disease, diabetes, cancer and influenza.
However, these health gains were 20-44 percent larger when funding was targeted to lower-income communities. Increases in public health spending also correlated with lower medical care costs per person, especially in low-income areas. The study, which analyzed data compiled by the National Association of County and City Health Officials from 3,000 local public health agencies over a 17-year period, also found that lower death rates and health care costs were seen especially in communities that allocated their public health funding across a broader mix of preventive services.
“The results clearly show that better health and lower health care costs are possible if we simply change how and where we allocate public health funding, even if new money isn’t available, said Mays. “And it also shows that new resources, such as funding from the Affordable Care Act’s Prevention Fund, can have a larger impact if targeted to lower-resource, higher-need communities and if spread across a range of prevention strategies.”
>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.
NewPublicHealth spoke with Mays about the new study just before the APHA annual meeting began.
NewPublicHealth: What are the key findings of the study?
Glen Mays: We’ve done prior studies that show communities that invest more on public health realize gains in health status and, over time, those communities see slower growth in medical care costs. So the goal of the study is to look at who benefits most from investments in public health.
What we found was that, not all that surprisingly, communities that are more economically constrained, that have lower income communities with higher poverty rates and lower socioeconomic status, tend to benefit the most from investments in public health activities over time. These low-resource communities see larger reductions in their preventable mortality, and they also see larger reductions in their medical care costs over time from investments in public health spending compared to more affluent communities. We expected to find that, but this is the first time we’ve been able to document the size of that effect. Those communities see about twenty percent higher rates of health and economic gain from their spending compared to more affluent communities.
Since 2008, local health departments have cut nearly 44,000 jobs, according to a recent survey conducted by the National Association of County and City Health Officials. Although workforce losses and gains were roughly equal in 2012, 41 percent of local health departments nationwide experienced some type of reduction in workforce capacity and 48 percent of all local health departments reduced or eliminated services in at least one program area. Currently, local health departments reporting cuts still exceed the percentage of local health departments reporting budget increases.
California’s Napa County has dealt with its budget cuts by revamping its health department in order to continue to stay on mission.
“I think we've come out the other end of all this as a much stronger health department,” said Karen Smith, MD, MPH, Health Officer and Deputy Director for Public Health at Napa County Health and Human Services. “We moved from what I think of as an ‘old style’ [public health agency] to a department that focuses on our role as a convener/partner, providing expertise and leadership, and helping to craft policy.”
NewPublicHealth recently spoke with Smith about the methods Napa Public Health used—and that other departments might follow—to adapt and improve in the face of budget cuts.
NewPublicHealth: How have budget changes impacted your department over the last five to ten years?
Karen Smith: Napa Public Health started out with a lean health division for the size of the county compared to some of our colleagues, and we remain lean. We have not really decreased services, however. We were able to get out ahead when we saw looming budget constraints.
Napa Public Health is part of the County’s Health and Human Service Agency, which includes social services, as well as mental health, drug and alcohol, child welfare services, comprehensive services for older adults and public health, and our administrative divisions. The previous director had a distinctive approach to budgeting: that the agency has a bottom-line budget and within that we have very detailed division budgets. So I have excruciatingly detailed budgets for every single program within public health, and that was crucial to our being able to respond to the budget shortfalls in creative ways that had limited impact on services.
More than 10,000 public health officials, academics and students will gather in Boston next week for the 2013 American Public Health Association Meeting in Boston. This year’s theme is “Think Global, Act Local,” drawing critical attention to the increasingly global world of health where events across the globe—from food safety, to infectious disease outbreaks, to innovative public health solutions—can impact every local neighborhood.
>>NewPublicHealth will be on the ground at the APHA Annual Meeting, with speaker and thought-leader interviews, video perspective pieces and updates from sessions, with a focus on what it takes to build a culture of health. Follow our coverage here.
Ahead of the annual meeting, NewPublicHealth spoke with Georges Benjamin MD, APHA executive director.
NewPublicHealth: Why is the theme “Think Global, Act Local” so important?
Georges Benjamin: We’re in a world in which everything is global. There are no boundaries anymore. Rapid transit through planes, the fact that our borders are so porous...public health has always been a global enterprise, but even more so today. Our food comes no longer from a single farm but from multiple farms and sometimes multiple countries, so foodborne risks for disease and illness are global. We’ve seen that terrorism disasters are global. We’ve seen that obesity, particularly with corporations that sell certain products globally, is a big issue, and tobacco has always been a global issue. So, public health is global, and the idea is that if we can learn from people around the world and then utilize those learnings within our local communities, we’ll be stronger
NPH: What are some of the meeting sessions you’d highlight?
Benjamin: Our opening session will feature Professor Sir Michael Marmot, Director of the International Institute for Society and Health and Research Professor of Epidemiology and Public Health at University College, London, who spoke at our meeting five years ago on the social determinants of health and is going to give us an update. In the closing session, we’ll hear from actor/physician/public health doctor, Evan Adams, MD, the deputy provincial health officer for British Columbia, who will speak about improving the health of native people. So in both our opening and closing sessions we’re looking globally, as well as emphasizing what happens locally. We’ll also hear from the minister of health of Taiwan, who will talk about universal health care as well as violence prevention. And we’ll also be holding sessions that track the many public crises that we’ve already had this year.
At the recent 2nd Annual National Heath Impact Assessment Meeting held in Washington, D.C.,Paul Anderson, MD, MPH, manager of the HIA Program at the Alaska Department of Health, spoke about his state’s HIA efforts and successes. NewPublicHealth caught up with Anderson following the meeting to ask about lessons learned that can benefit other public health officials considering and conducting health impact assessments.
NewPublicHealth: Tell us about the HIA program in Alaska and how the health department has made HIA a routine part of decision making.
Paul Anderson: HIA in Alaska started with a couple of health impact assessments done in conjunction with natural resource development permitting and environmental impact statements (EISs) in the north of the state. These studies generated increased interest in the human health concerns that arise during project permitting. The Department of Natural Resources (DNR) contacted the Alaska Division of Public Health, asking us if we could get involved with this new idea—called health impact assessment—as it related to natural resource development permitting.
After some deliberation, we realized the importance of being involved with this work, and so we developed an HIA working group. That working group met for about three years and developed an HIA Toolkit, which is our guidance document for performing HIA in Alaska. Out of that working group came a realization that Alaska needed an institutionalized HIA program in order to lead this process forward effectively. So the group eventually decided to create an HIA Program in the Division of Public Health under the Section of Epidemiology.
NPH: Have you worked collaboratively in Alaska on HIAs?
Anderson: When our program was new, we wanted to conduct field work because we needed additional health information regarding a specific region of rural Alaska. This field work involved utilizing surveys, which can be very tiring for rural communities because they are surveyed frequently. There are several agencies in Alaska that already do surveys as a routine part of their work, and one of those is the Alaska Department of Fish and Game. They go house-to-house and community-to-community and use a very well-designed survey tool to learn about subsistence foods. They worked with us to integrate some important questions about food consumption onto their survey form. This turned out to be an effective cooperative relationship that benefitted both agencies and reduced the strain on rural communities.
A key session at the Second National Health Impact Assessment Annual Meeting held recently in Washington, D.C., was a panel discussion on several evaluations of the value and benefits of health impact assessments (HIAs). Andrew Dannenberg, MD, MPH, an affiliate professor at the University Of Washington School of Public Health, was a consultant on a recent evaluation of HIAs funded by the Robert Wood Johnson Foundation and a member of the evaluation panel at the HIA meeting. NewPublicHealth spoke with Professor Dannenberg about some recent findings.
NewPublicHealth: What have the recent evaluations of HIA as a tool told us about the value conducting health impact assessments?
Andrew Dannenberg: Essentially, HIA works. The tool does seem to promote health, and does have influence in some cases but not others. HIAs can influence the health component of [policy] decisions.
There are also indirect HIA benefits: by getting public health professionals talking with decision makers in other sectors—such as transportation and housing—HIAs create partnerships and collaborations for longer-term value. So a transportation department building a highway may then always realize that there are health implications of what gets constructed.
We also came away with a list of factors that influence HIAs to make them successful. The list includes:
- Timeliness is often a factor when doing an HIA (in that the HIA must be completed and recommendations made in time to support or influence the policy decision).
- Involving stakeholders and decision makers gives a better chance that the recommendations will be considered.
- It is important to have community engagement and feedback, or, particularly when it is an HIA being done rapidly, it is critical to have a well-informed health leader at the helm.
- It is critical to screen the topic to be sure it is appropriate for an HIA.
- Dissemination to stakeholders, decision makers and media is very important, using methods, length and language appropriately customized for those audiences.
- HIA recommendations need to be clear and actionable.
- The Australian evaluation found that a key to successful HIAs was getting the right people at the right time to work together.
NPH: Do you have an example of an HIA that showed that using the tool leads to better decision making?
Dannenberg: An HIA conducted in San Francisco several years ago is one of our clearest examples. A developer wanted to tear down some low-income housing to build more expensive apartments that would have displaced the low-income people living at the site. The Department of Health conducted an HIA, which made it clear that it is bad for health to take low income people in an expensive city and throw them out in the street with no housing.
“[Health Impact Assessments have] taught people how to think and speak differently, clearly, objectively,” according to Cleveland Councilman Joe Cimperman. “Suddenly we are saying those words we don’t say often enough in government: Are you comfortable with the environmental and health impacts of this decision?”
NewPublicHealth caught up with Cimperman soon after his plenary address at the second annual National Health Impact Assessment meeting held in Washington, D.C., this week. He is an HIA supporter and enthusiast who is already engaged in health impact assessments for the city of Cleveland.
NewPublicHealth: What was your impression of the HIA meeting?
Joe Cimperman: I was blown away by so many different things—the geographic diversity of the people attending, and the many ideas they presented in questions and in private conversations after I spoke.
NPH: In your opinion, what is the intrinsic value of health impact assessments?
Cimperman: HIA has been a model for how to get things done right. But the tool also allows us to get closer to people and their specific needs by going through the process—which is such an important component—to find out how we help individuals when we make policy-level decisions. If we want to restore our cities, we need to ask what problems we’re solving.
NPH: What’s a strong example of an HIA in your community that was innovative and beneficial?
Cimperman: We have completed an HIA on the health implications of proposed legislation to expand agriculture into urban areas. Cities like ours have enough land that we can think about the different and best ways to use some of it—and urban agriculture is a means of helping people use the land themselves, and use it for something other than home and industrial construction. I think we’ve been able to do so much good by applying an HIA because we’re answering questions right up front. The Urban Agriculture overlay district is a proposed piece of legislation that would introduce intense farm uses in an urbanized environment, including livestock, community gardens and commercial gardens. While the uses are thought to have positive impacts on human health—such as access to fresh fruits and vegetables, community cohesion through the establishment of gardens, potential economic opportunities and a productive reuse of vacant land—unintended adverse impacts to human health include increased animal waste, potential exposure to carcinogens created by insecticides, and increases in noise and odor levels.
“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.
NewPublicHealth Q&A: Florence Fulk and Tami Thomas-Burton on the Impact of the Environment on Health
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.