Category Archives: Public health professionals
Ebola and U.S. Quarantines: Q&A with James Hodge and Kim Weidenaar of the Network for Public Health Law
On Monday, the U.S. Centers for Disease Control and Prevention (CDC) released new guidelines for people who have been exposed to the Ebola virus, either returning home from affected West African countries or looking after patients in the United States.
The guidelines establish four levels of risk -- "high" risk, "some" risk, "low" risk and "no" risk -- and recommend restrictions and health monitoring for each category.
Under the guidelines, people at high risk of Ebola exposure would be confined to their homes in voluntary isolation, while people carrying some risk would have their health and movements monitored by local officials. Those at high risk or with some risk would have daily in-person check-ups from state and local health departments for 21 days.
Immediately after yesterday’s CDC press conference, NewPublicHealth spoke with James Hodge and Kim Weidenaar, attorneys with the Network for Public Health Law, responded to questions from NewPublicHealth about laws and regulations that impact quarantines.
NewPublicHealth: Is there any legal support under United States law for possible quarantines for returning health workers and travelers from West Africa?
James Hodge and Kim Weidenaar: Yes, provided quarantine is limited in duration, consistent with due process, and based on known or suspected exposures.
Public health authorities must be prepared to demonstrate that 1) the subject of quarantine is actually or reasonably suspected of being exposed to an infectious condition, 2) that the infectious condition (like Ebola) poses a specific threat to the public’s health, 3) that the terms of quarantine are warranted, safe, and habitable, and 4) that procedural due process including fair notice, right to hearing, and right to counsel are provided.
News today that a fourth case of Ebola has been diagnosed in the United States underscores the urgent need to have health workers not just ready, but also willing to treat patients with the illness. Next Wednesday, the National Coordinating Center on Public Health Systems and Services Research (PHSSR) will be hosting a webinar on legal protections to help facilitate health worker willingness. Daniel Barnett, MD, an Associate Professor in the Department of Environmental Health Sciences at the Johns Hopkins Bloomberg School of Public Health, will be the main presenter. Barnett and three Bloomberg colleagues, Leonie Ratko, JD, PhD, MPH, Jon S. Enrick, JD, MPH Carol B. Thompson, MS, MBA received funding from the Robert Wood Johnson Foundation and PHSSR to study the issue. PHSSR's Center is funded by RWJF and based at the University of Kentucky.
NewPublicHealth recently spoke with Barnett.
NewPublicHealth: What are the concerns with respect to health workers being prepared to take some risks in order to protect the public?
Daniel Barnett: There’s been a longstanding tacit dysfunction about preparedness trainings: That if you train someone in knowledge and skills in terms of how to respond, that will necessarily translate into a willingness to do so. But our work has shown that “training to knowledge equals training to willingness” is a false assumption. In other words, I can teach someone how to recognize anthrax or some other infectious disease agent under a microscope, but that in no way ensures that that individual will be willing to come to work to look at anthrax or another infectious disease agent under a microscope, and by analogy, any other type of frontline public health or health care response.
That’s been, frankly, a missing piece in public health preparedness training nationally and internationally, and I think that we need to really rethink paradigms of preparedness training and education to take a more holistic approach. In other words, an approach that recognizes that frontline healthcare workers and public health workers have fears and concerns attached to a whole variety of aspects of the events at hand.
People tuning into news coverage of the Dallas Ebola cases have come to recognize David Lakey, the Texas state health officer. Every state has a similar position and those officials are charged with improving population health—from holding immunization clinics to responding to potentially fatal illnesses. The Association of State and Territorial Health Officers (ASTHO) is the professional association of the 50 state health officers. Jim Blumenstock is the chief program officer of ASTHO’s public health practice division. NewPublicHealth spoke to Blumenstock this week about state and federal coordination on Ebola detection and case treatment.
NewPublicHealth: What is ASTHO’s role in dealing with preparedness for Ebola in the United States and with the current cases?
Jim Blumenstock: In a crisis or a public health emergency like we’re experiencing with Ebola, ASTHO’s role principally is to do two things. Number one is to sort of be the glue or the hub that helps pull together the 50 states, the nine territories and the District of Columbia as an integrated, harmonious component of our public health infrastructure. The second feature is to provide a solid interface between federal efforts and state efforts. So, that’s our role with any significant public health issue.
During the H1N1 outbreak several years ago, both ASTHO and the National Association of County and City Health Officials (NACCHO) had key staff embedded in the U.S. Centers for Disease Control and Prevention’s (CDC) Emergency Operation Center because it was recognized that the value of the insight of a national organization that represents all the states and locals was so critical to the federal planning and response process. That was the first time it was done.
We’re on standby to do it and we’re sort of functioning in that capacity right now, but sort of in a virtual or remote area. For example, I’m not today embedded in CDC’s Emergency Operation Center. However, I would say I’m on the phone with them at least six to eight times a day—including last evening—and have had email exchanges already this morning, not only to get information, but also to be part of some planning and problem solving efforts they’ve requested our help on, or a request for our help on state consensus around a strategy or a tactic or an approach on a particular matter.
And our other critical roles are to help our members; to talk to federal public health officials; and to educate and inform the public.
Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. Today, Jeffrey Levi, PhD, Executive Director of Trust for America’s Health (TFAH), writes about the importance of identifying and implementing policies and practices that can benefit health across all populations.
I go to countless meetings where people debate the meaning of “population health”—often for hours and with no resolution.
What’s become clear to me is that no matter what perspective we’re coming from, our actual goal for population health is the same. We want to improve the health of Americans.
But, at the end of day, the problem may be that the hang up on a clear definition is getting in the way of solving one of the health system’s most pressing problems: How do we get the different silos of the system to work better together and improve health inside and outside the doctor’s office?
Because this is so vital, the Robert Wood Johnson Foundation has supported an upcoming National Forum on Hospitals, Health Systems and Population Health, which will go beyond semantics to specifically identify policies and practices that can benefit health, no matter what population you’re talking about. Some of the below examples will be highlighted at the National Forum.
Hennepin Health, a Social Accountable Care Organization (ACO)
When Minnesota expanded Medicaid to a poor, childless adult population in Hennepin County, the relevant parties formed a social ACO, called Hennepin Health. The ACO is comprised of Hennepin County Medical Center; NorthPoint Health and Wellness (a Federally Qualified Health Center); Metropolitan Health Plan; and the county’s Human Services and Public Health Department (including Health Care for the Homeless, the county’s Mental Health Center and other social services). The County has a global budget to spend annually, and the partners take on all the risk as they bill the plan per service and then, at the end of the year, split the gains or losses.
Hennepin Health serves more than 6,000 enrollees. Of this group, 45 percent have chemical dependencies, 42 percent have mental health needs, 32 percent have unstable housing and 30 percent suffer from at least two chronic diseases.
Paul Biddinger, MD, FACEP, director of the Emergency Preparedness and Response Exercise Program at the Harvard School of Public Health, was a member of this morning’s opening panel on disaster preparedness at the 2014 Preparedness Summit. NewPublicHealth spoke with Biddinger ahead of the conference on what students and communities need to know and do to be best prepared for a disaster.
NewPublicHealth: Is it a requirement for students in graduate school for public health degrees to take at least one class in disaster preparedness?
Paul Biddinger: It is not. They have the option, but it is not a required element of what they have to take.
NPH: How do you think recent disasters have informed what students and public health staff members need to know about response?
Paul Biddinger: I think some of what students need to know has always been the case—but maybe has been underscored by recent events—which is that no matter what you do in public health you may be needed as part of the response, and whether you're working in maternal and child health or smoking cessation or HIV/AIDS, when a disaster happens it’s all hands on deck. And I think the hurricanes, the pandemic and other events have showed that often we need to reach well outside the traditional emergency response or preparedness work staff in public health, and so everyone has to be flexible, has to be able to participate in the response. I think in order to participate in the response you have to know that there is an emergency operations plan, what your role in it would be, how you would get information, to whom you would be responsible or to whom you would report. And those are things that you should know ahead of time.
I think the other thing we see when we see these wide-area disasters like we saw in Sandy, like we saw in Katrina, is the central role that public health can play in coordinating the health response—that multiple hospitals, long-term care facilities, out-patient facilities such as dialysis centers all need to be coordinated in their response to achieve the best possible health outcomes for the community. And public health is in a particularly strong place in the community to be able to help make sure that each of those individual participants is pointed in the same direction and is leveraging the community resources as best they can.
Future of Public Health is an ongoing series focused on the emerging faces in the world of public health. We spoke with Azmina Lakhani, MD, MPH, about what helped lead her to the field and where she hopes to go from here.
NPH: What’s your educational background in public health?
Azmina Lakhani: I went to the Illinois Mathematics and Science Academy for high school, and then I did medical school, undergraduate and public health all at Northwestern University in Chicago. I received a BA in psychology and global health as an undergrad and then for the next five years I attended medical school and earned a Master’s in Public Health, as well.
NPH: This seems like something that you went into knowing full well that this is what you’re interested in. What was it that encouraged you to pursue a degree and a career in public health?
Lakhani: I had sort of been interested in health care in general in high school, and I wasn’t really sure whether I was going to do research or clinical work or public health work, but in college I really started becoming interested in public health. First through global health, I started learning about different health care systems abroad and doing some volunteer work in Ecuador and Mexico City. That’s really when I got interested in health care delivery systems and also how one can have a greater influence on health.
I appreciate the clinical side. I’m a family medicine resident in training currently, so I love working one-on-one with patients. I also see a lot of value in making an impact on a larger scale—whether that’s how someone gets their health care, what insurance systems we have in place, or the traditional public health things that you think of such as vaccines—that have a really large impact on people. But I think for a shorter answer to your question, I really got interested in college and then built on that in medical school while I was getting my MPH.
NPH: Within the field of public health, what’s your primary interest? What really speaks to you? The global approach?
Lakhani: I think public health is just so awesome because it has so many different facets, and to be honest, I don’t have one particular interest in terms of public health. During my year at the Chicago Department of Public Health (CDPH) I worked on a project called PlayStreets. It’s a very simple idea where we close down streets in the city—neighborhood streets—to allow children with little access to public spaces to have a place to play. The whole intent is to get people out there, meeting their community members, and, in the long term, trying to reduce childhood obesity. It’s kind of a lofty goal, but I am interested in making resources available to people so they can take control of their own health on a broader scale and PlayStreets was one example of that.
Several weeks ago, the Harvard School of Public Health celebrated its Centennial with fanfare, fundraising and a panel discussion featuring world health leaders who are graduates of the school. Following the centennial, NewPublicHealth spoke with the School’s Dean, Julio Frenk, MD, MPH, PHD, who has a joint appointment at the Harvard Kennedy School of Government. He is also a former health minister of Mexico and a former senior fellow in the global health program of the Bill and Melinda Gates Foundation.
NewPublicHealth: What do you think have been the key changes in public health efforts since the Harvard School of Public Health was founded 100 years ago?
Julio Frenk: The 100 years that have passed since the School of Public Health was founded are not just any 100 years—they’re the 100 years with the most intense transformations in health in human history. We have seen a more than doubling of life expectancy since the school was founded. Around 1900, the global average for life expectancy was 30 years. At the end of the century, the global average was about 65 years. It more than doubled in the 20th century, and that increase has continued with some setbacks, most notably the AIDS epidemic in Saharan Africa. And we have had a qualitative shift not just in the level of mortality, but in the causes of death. So we went from a preponderance of acute infections to now a predominance of mostly chronic non-communicable diseases, and that’s an incredible transition.
A critical change is that the experience of illness became very different starting from the beginning of the 20th century. Before then, illness was mostly a succession of acute episodes, from which one either recovered or died. If you recovered, you went on to get your next acute illness. Now, illness is more a condition of living. People live with cancer. People live with AIDS. So that’s a big transformation of the patterns of health, disease and death.
Another big change is the emergence of complex health systems, and that’s—again—a process that started at the beginning of the 20th century. Before the 20th century, the social function of the sick was mostly trusted to undifferentiated institutions, such as the family or religious institutions, and it’s not until the 20th century when you see this incredible explosion of specialized institutions and specialized human resources, doctors, nurses and other health professionals. In the 20th century, healthcare is 10 percent of the global economy and employs millions of people, including eight million doctors. These are all profound transformations.
NPH: How has the training of students of public health changed in the last 100 years?
Frenk: There has been profound change. What happened at the beginning of the 20th century was the emergence of public health as a field of action. The practices of engineering emerged in Europe, especially with the rapid urbanization there starting around the 17th century, but then greatly expanded in the 18th century. Engineering allowed for access to clean water and taking care of waste, which resulted in some diseases coming under control. In the 19th century the discovery of microbiology gave rise to the abolishment of the germs as causes of illness. That is the junction that gives birth to public health, along with the idea of social policy, of social activism that actually changed social conditions. It’s in that mix that public health gets shaped.
Today is Public Health Thank You Day 2013, when Research!America and other leading public health organizations recognize the public health professionals working to improve health where we all live, learn, work and play.
Among the biggest names in public health at the moment is Shiriki Kumanyika, PhD, MPH, a University of Pennsylvania professor who earlier this month became the president-elect of the American Public Health Association (APHA). In a recent Q&A on APHA’s Public Health Newswire blog, Kumanyika spoke about the overall landscape of public health and gave her thoughts on particular issues.
One of the big takeaways from the APHA annual meeting earlier this month—where she was named president-elect—was how APHA is shifting its focus to concentrate more on being an action- and goal-oriented organization, according to Kumanyika.
“We are going to be more convincing about the importance of a focus on prevention and wellness, while making better use of scientific evidence and creating a greater sense of urgency around health equity issues,” she said. “I think that, over time, this new positioning in the public arena will really enhance the sense of community among our thousands of diverse members, attract more members and align our combined efforts for greater overall impact.”
Kumanyika also has particular ideas on the greatest opportunities for improving health in African-American communities, especially when it comes to nutrition and obesity prevention. Not only are unhealthy foods too easily available in the average black community but, when compared to other communities, the situation is even more troubling, with black communities seeing more advertising for unhealthy food. The answer is targeted efforts to promote healthier alternatives.
However, she also noted how food and nutrition present their own particular public health obstacles.
“Food is a particularly complex area; we can’t treat it like tobacco and tell people to avoid it altogether. The changes we need are more complicated and will have huge implications across the spectrum from agriculture to environmental sustainability,” she said. “We have to make both a public health case and a business case for a healthier food supply and for marketing healthier foods and beverages. We have a tremendous opportunity to make progress that will change the food and health landscape for the population at large if we do our health diplomacy well.”
Read the full interview on Public Health Newswire here.
The Association of Schools and Programs of Public Health (ASPPH), like the American Public Health Association, held its annual meeting in Boston last week. NewPublicHealth spoke with Harrison Spencer, MD, MPH, executive director of the ASPPH, from Boston about the meeting and what’s ahead for students of public health.
NewPublicHealth: How was the meeting and what were some of the key sessions?
Harrison Spencer: Our meeting this year was the first one held since we formed our new organization, the Association of Schools and Programs of Public Health, on August 1. The new organization is now comprised of all accredited public health academic institutions, both schools and programs. We’ve got 93 members now, an increase from 57 members before, so this was a wonderful and exciting and dynamic annual meeting with lots of energy and lots of promise.
Among the highlights were Harvey Fineberg, MD, PhD, president of the Institute of Medicine, who gave us an inspirational talk about public health leadership, and Laura Liswood, Secretary General of the Council of Women World Leaders, who led a discussion on diversity as a way to make organizations and institutes stronger.
The celebrations earlier this month for the Harvard School of Public Health’s centennial included galas, world leaders and a $450 million fundraising campaign, about a third of which is already completed.
But the most poignant moments may have been watching former graduates, many who are now in key health leadership positions across the globe, in quiet conversations with current students, answering questions about how to get the most out of their time in Boston to help improve population health when they hit the field. Kelechi Ohiri, MD, senior adviser to the Nigerian Ministry of Health, who got his Harvard Master of Public Health eleven years ago, sat out some of the formal Centennial lunch to speak to a current student from his country whose excitement at meeting Nigeria’s top health official bubbled over.
“Meeting him makes me believe I’ll be able to use what I’m learning to help make a difference at home,” she said.
Ohiri said that a critical focus should be “networking to improve skills and create contacts,” which he said is often underutilized by students of public health, and contrasted that with networking as an “explicit goal” of the Harvard MBA program.
Several graduates who are now world health leaders convened for a panel discussion moderated by Institute of Medicine President Harvey Fineberg (who received all his degrees, including his MD, from Harvard) about their experiences in the field of public health. In addition to Ohiri, participants included:
- Gro Harlem Brundtland, MPH ’65, the former Prime Minister of Norway and former Director-General of the World Health Organization
- Suraya Dalil, MD, MPH ’05, the Minister of Public Health of Afghanistan
- Howard Koh, MD, a former professor at the Harvard School of Public Health and currently the U.S. Assistant Secretary for Health
- Pradit Sintavanarong, MD, MPH ’89, the Minister of Public Health of Thailan