Lecture 7-first after midterm 1
-PH in the news: states have problems with people who
are uninsured using emergency services, how person
visited emergency room many times, every time he had a
heart attack he went to the ER, the state was paying for it
~address it with: health costs in check, quite expensive for
people to go to ER, Oregon is probably leading charge by
stretching health care. State of Oregon has an interesting
-HPV can cause cervical cancer in women.
Should HPV vaccine be required for school entry?
⁃ legislative session that takes place after FDA
licensed the use of the vaccine, ACIP has also
recommended routine use in school age
⁃ **even second world countries like Latvia,
Italy, France, Germany had vaccine campaigns
⁃ they had to think about public health
concerns as well, emotional testimony very strong ⁃ Step 2: 10th amendment allows state to
mandate vaccinations. States are welcome to pass
laws for vaccinations for children to enter school. In all
DC states, you can get a medical exemption for
getting the vaccine. Exemptions available in 48 states
except Virginia and another state. There are a lot of
personal belief exemptions.
⁃ Gardasil: over 100 strains of HIV and most of
them don't cause a problem. Gardasil protects against
4 different strains: 6, 11, 16, 18 (prevents 90% of
⁃ Cervarix protects against strains linked to
⁃ Today, we know that CDC recommends ALL
11-12 year olds to receive the vaccine. Step 5:
recommended routine use. The committee very
broadly recommends vaccines, they consider efficacy
and cost of vaccine, so sometimes they change or
⁃ They did it because they had the health of
young women in mind. Maybe this was a good
recommendation. It's worth considering if the body
⁃ allow opt-out because of the medical
reasons, extend the personal belief exemption (some believe it causes autism). Some people might form
their own opinions. We allow a personal belief
exemption in California: for medical reasons, religious
reasons. Vaccines for a lot of illnesses are the best
cure or reduce illness.
⁃ HPV is running rampant. It would be a good
idea to have a personal belief exemption because:
⁃ We should not have one because: defeats
the purpose of the vaccine.
⁃ What would we recommend?-
⁃ Why not?-
⁃ People in general have a high literacy rate
but low health literacy rate.
⁃ DQ: definitely a major PH issue.
⁃ California does recommend the vaccine for
11-12 year old boys, in 2011 our governor signed a
law letting 12-year-olds take responsibility for
themselves for the vaccine. At the time of the case,
we knew needle exchange programs don't cause
people to use more drugs, we knew the availability of
condoms didn't change their activity. We all have our
own beliefs and we have to be careful about that. Plan B
• available for young girls, similar ethical and
• takes place in August 2005, argument is
whether or not it should be available over-the-counter.
It is already available as a prescription.
• The FDA switched up approval process.
• Step 1: Plan B is an emergency
contraception that can be taken by women, a high
dose of progestin (in birth control pills), goal is to
prevent ovulation aka pregnancy within 72
HOURS of unprotected sex
• 18-24 most unintended pregnancies, low-
income and minority women, most unintended
pregnancies. Highest percentage of abortion is 81%
women aged 25 and younger make over half of those
• Of unintended pregnancies, only 5% resulted
from consistent use of birth control (used improperly).
• Teen moms (15-19) increased the birth rate
by 5% in 2 years, having a lot of babies. about 80% of
teen pregnancies are unintended. Perhaps we can
cut down on some of these abortions and unintended
pregnancies. • Opponents: promote lack of sexual
responsibility, causes an abortion because life begins
at conception, useful tool for sexual predators, is
contraception, concerned it may be traded on a black
market (younger males)
• Proponents: want it to go forward:
pharmacies and clinics are closed sometimes, so it
would help if it was available more readily (OTC),
could reduce unintended pregnancy and abortion
• Step 6: FDA advisory committee voted
unanimously that it was safe for Plan B to be available
OTC. But the FDA did not approve the switch.
• Current process 5 things: acceptable safety
profile, low potential to be abused (not addictive), an
appropriate safety and therapeutic index, not many
risks a lot of benefits, self-recognizable (they might
not know). They would have approved if they followed
• 4 years later, it was approved for women
17+. But in April 2013, it was approved for women as
young as 15. The FDA approved Plan B for all
women of child-bearing potential everywhere in June
2013. It took 8 years! • DQ: There are a lot of benefits having it OTC
but some people think it's giving resurgence for the
idea of unprotected sex. Maybe it depends on the
situation, how complicated the drug is. Different issue
because it deals with the female side of reproduction.
Proponents worried about those who were raped as
well. Look at pros and cons, do some research,
surveys, look at risks.
PH Case: Implementing policy changes
⁃ racial and ethnic disparities for pediatric
asthma, which is a common problem for young people
⁃ US in Chicago, Illinois. African Americans
have highest rate of asthma deaths in the US. Illinois
has the highest asthma death rate. The rate of
hospitals' is twice the city's average= Disparities.
Asthma is a chronic lung disease often being when
you're young during childhood. If you have asthma as
a child, you'd have to limit your behavior. It could lead
to death if not controlled properly.
⁃ 1/7 children have asthma. disproportionately
affects those with low income and minorities
⁃ high rates of hospitalizations, elevated risks
of mortality, for kids ⁃ adds 50 cents to every dollar for health
⁃ 9% of the kids are uninsured, probably don't
have access to regular checkups. About 50% of
children receive quality care, 50% don't.
⁃ The US government takes this seriously. The
President's Task Force was made to: do some
research into environmental factors that worsen
childhood asthma, use research data to reduce
environmental exposures, to identify the reasons and
remove the racial ethnic disparity, all equal priority
stuff, in 1999. 11 years after this was published, GWU
noticed that none of these steps were accomplished.
⁃ Childhood asthma treatment needs to be
very collaborative, including heath insurers, clinical
care providers, public health agencies. In addition,
parents need to work together. Children should not be
in the house during cleaning of the house. A lot of
places have established coalitions like S Texas and
Hawaii Asthma Institute.
⁃ Examples of environmental triggers:
cigarette smoke or other strong odors, nitrogen
peroxide, indoor allergens like pets, dust mites,
cockroach droppings. We can improve care if we
prevent asthma attack. provide health care for kids
specifically. We can get them treatment by using non- profits, so we can form initiatives. We can run some
interference by: educating the kids about emergency
things to do for asthma, telling the children about what
⁃ asthma: amount of air pollution, problems in
urban areas, dust mites is a common allergy
⁃ DQ: Why do you think low income and
minority-urban populations, often live in older houses
or houses not in the best repair/polluted, they don't
medicate their asthma as well (uninsured perhaps).
To increase awareness of childhood asthma, we can
educate parents and children, AIDSCAP Nepal
(dealing with HIV/AIDS) but in this case it's educating
people about what they can do in an asthma attack->
social marketing campaign like Heart Truth. just to
raise awareness for asthma like National Asthma
Capper book: Possible Bioterrorism in New Hampshire
⁃ CDC had been notified by FBI of a possible
bioterrorism attack. Dr. F briefed him on the situation
on March 25. The Costa Rican woman started having
diminished respiratory capacity and needed respirator
to breathe. They're thinking it's not the norm. 3 weeks after, she was transferred to hospital, diagnosed with
a disease. At this point they were getting concerned
and started telling her family and friends. They started
to take things very seriously. The relatives were
concerned, boyfriend is a marine biologist and had
recently been associated with a local uni. The
resident of the hospital asked if you could bring the
suspicious material so we could inspect it. The
boyfriend tried to remove jewelry from the girlfriend.
He was suspicious though.
⁃ Step 2: The lab materials seemed
suspicious. The samples got put in a storage room, so
this caused safety concerns because it could've been
infectious. Also suspicious/bioterrorism: the patient's
conditions worsened quickly, and boyfriend had weird
⁃ There were more cases, then. They were
concerned for their safety because if the bf was
reproducing biological components, it'd be
⁃ Brucellosis: disease of animals that can be
transmitted to humans. caused by organism of genus
Brucella, don't form spores, do metabolize oxygen,
they are bacteria, commonly affect mammals like
sheep, goats, cattle, deer, pigs. Humans infected by
animals or animal products. eating and drinking contaminated product, breathing in the organism
(inhale or open wound, bacteria might enter), but
most common is infection through milk or cheese from
infected animals. If milk is not pasteurized, opens up
to infection. People who work in slaughterhouses
often have open wounds as well as hunters.
⁃ Person-to-person very rare, but mother to
child is possible.
⁃ Brucellosis not common. 3 cases in several
days made them worried. can be common especially
in developing countries, esp. those with ineffective
public health and domestic animal programs.
⁃ incubation from 5-60 days. In the acute form,
you may have flu-like symptoms, loss of appetite,
nausea, back pain
⁃ low mortality rate (<5%)
⁃ take Doxycycline for 6 weeks, no vaccine,
only antibiotics, some people accidentally exposed to
⁃ They didn't have the staff to handle it, not
enough epidemiologists. The NHDH agreed it was a
public threat. HAZMAT does not have much
experience with bioterrorism. Problems: The
apartment door ended up with a big sticker on it (biohazard sticker) which compromised the whole
case. The apartment key didn't work. what if there's
nothing there? what if there is a biohazard? is the
threat large enough to render it? Recommendation:
hire an epidemiologist for the FBI. PH officials need to
communicate the threat to the public if it is
Brucellosis. protecting people and taking safety
seriously, give someone antibiotics if they're exposed
to it. What should be done to the bio-hazardous
⁃ educate people on risk of being infected-try
to appeal to emotion, focus on way people are
infected, that they are practicing pasteurization and
good food handling
⁃ DQ: how to create an awareness campaign:
public health agencies should be handling it, not the
media since they tend to create a frenzy. People are
sick, so how do we raise awareness of it for the
hunters or raw milk group?-targeting groups they're
associated with. appeal to them to make it to their top
⁃ Result: They went into the apartment (Dr and
other scientist) to look into suspicious materials. They
didn't find any bioterrorism stuff. He wasn't running a
biological lab there. It wasn't bioterrorism but it
could've been, which is a worry in the US. Video-infectious microbe staging a combat. 1/3 of world's
population has bacillus in their bodies. 10% before they
die will be infected with TB. Following regimen is critical. If
patients restart medicines, they'll become tougher to kill.
⁃ DOTS-directly observed therapy, they will
always be cured if they use the drug everyday for 6
months. However, some patients are compliant yet
they still have it.
⁃ In 1995, they sent the samples to
Massachusetts. Results: most samples resistant to all
5 antibodies used to treat TB. Not the patients that
were the problem, but it was MDR TB (multiple
⁃ the few drugs that cure MDR TB can cause
side effects and are so expensive that the Peruvian
government cannot afford it
⁃ not only economic problem, the treatment
was difficult to manage
⁃ Dr. Kim borrowed drugs from their hospitals.
http://www.youtube.com/watch?v=FTX5kwr1mk0 Lecture 8
Ph in the news: England shelves plans for cigarette
smoking=English is putting on plans for rolling out the
packaging because the Australian government is very
adamant to stand up to the tobacco industry. "Smoking
causes blindness". The UK government put it out to start a
change-kids talking about it. They're talking about how
cool it looks just by looking at it-marketing put into product
works for every age, every person. Great color.
Brazil Healthcare system
-population is pretty large, only slightly smaller than the
U.S., 5th most populous country in the world
-largest ethnic group Portuguese is their most common
-They had an active slave trade so they have many
-__ low income compared to the suburbs.
-They do have a lot of money. In 2011, $8600/person. We
were spending 8 times more. -60 years for men. overall they ranked 125th for their
healthcare system. Only 8% of their population is over the
age of 60. 16% of US population over 60.
-Infant mortality rate is also shocking-ranked 93rd. US is
174th. They have 19-20 deaths per 1000 live births.
-The ranking is tied to key indicators like birth rate, infant
mortality rate, life expectancy.
-has a unified national HC system. We don't, they do.
They have had it since 1988. In 1985 they shed the
dictatorship and became a democracy. They declared that
every citizen had the right to health and that the
government would protect that RIGHT. That is pretty strict
and bold. They have private health plans and about 78%
of population relies on the health system and no
insurance. 22% has private insurance. Some of them are
like private hospitals.
-*illegal for insurance companies to deny coverage to
patients with preexisting conditions-they're governing how
private insurance has a stake in that.
-they use tax revenue and private funding.
-funding has not been enough to ensure adequacy. PH
system not helping enough. Big gap between what health
can deliver. -long waiting list for appointments, staff shortages-makes
good primary care hard to get
-many now opting into private health insurance, which
could stigmatize the National Health Insurance. They're
worried about creating a segregation.
-geography, many regional differences between
prosperous southern and poor northern regions
-in 2006, the IMR was 2-24 x higher in north than the
-access to hospital care has been low, esp. those with
small hospitals or no hospital at all
-people in high SES report better health overall because
they can afford private health insurance. wealthy people
have a different health care than the poor.
-Heart disease and stroke same as us. Perinatal
conditions is anything that goes on with the fetus-late
pregnancy problems. Violence, diabetes, LRI, COPD, they
have a lot of problems with hypertensive heart disease,
road traffic accidents, IHD (when myocardium becomes
inflamed, heart value). They have a lot of trouble with
heart disease! Not as bad for us. DQ 1
-They have some wealth but their health care system is
problematic. They have $1100/yr. How to even out the
disparities of rich and poor?
-charge higher taxes. Everyone should pay the tax even if
they opt out.
-corrupt government but it's not the people's fault. Money
is obviously there. They have the resources for it but
change is slow.
-It's illegal in both Brazilian HC and Affordable Care Act to
deny care to those with preexisting conditions.
PH Case: Coal Ash: Disasters and opportunities (both
cases caused by disasters-one physical, other
-if EPA changes it regulations, …
-Many power plants in the U.S. are coal-powered, huge
push for clean coal in this country.
-2009, 48% of U.S. electricity came from coal. When we
burn coal, we get emitted gases and emissions, but we
also have coal ash. Not much we can do w/o electricity.
-emissions of coal that goes into air: -coal ash contains: silicon dioxide, and calcium oxide
(chemicals), but the ash itself contains arsenic, boron,
lead, cobalt, dioxins, and polycyclic aromatic HC
compounds- (which actually have the power to modify and
-we have made no changes overtime in how we handle
coal ash byproduct. ways have been the same.
-most states regulate coal combustion waste as non-
hazardous material. some states don't even require a
disposal permit so some of it goes to landfills. Some states
treat it like a liquid waste, others as solid waste. Every
different gruel of coal ash doesn't protect human health.
-proposal now of coal ash
-June 2013-U.S. reps approved legislation that would
enforce deadlines for states to have a permit process, also
allow the EPA to regulate how the states handle it.
-Real problem with putting coal ash in ponds is that it
sometimes fails, can also cause additional problems.
some concerned of leeches.
-Ex. Kingston Tennessee right before Christmas in Dec of
2008, worse case scenarios.-heightened awareness of
need to regulate -post-spill: waterway flooded, people's houses were lost.
Jan 2013 tried to reinforce the walls and lobbies around
-potential for cancer-causing agents and toxic substances
-goal: entire area cleaned within 6 weeks
-The EPA is not regulating coal ash because it's politically
-They're spending 3 years.
-The EPA should regulate it because it is dangerous, don't
want kids to be there. Because it's not regulated, they
didn't know what the toxicity is.
-Coal ash should be regulated as hazardous waste. If it
was, we wouldn't let people store it in open pumps-human
health risk. People exposed to all these things and their
river ways are destructed. The coal power plant's disposal
system is the cause.
-The EPA will probably have to regulate this in the future. DQ
It's a public health and environmental problem. The EPA
would already regulate the coal ash if it was a PH issue, if
not for political reasons.
Ask yourself: why is it not regulated?
PH Case: DES Story-changed how the FDA regulates
-how a product designed to be beneficial became a
-synthetic estrogen that's orally active, prescribed to
women, many were pregnant, prescribed from 1940-60's
-was considered to be safe despite that other studies
showed that estrogen was causing cancer in animals
-wasn't a lot of regulation of new drugs in this time, where
the problem happens
-became "magic bullet" so they prescribed it for many
things, like preventing miscarriage. It didn't treat many of
the issues it was prescribed for, it was actually likely to
induce miscarriage-more premature babies, low
birthweight babies, more miscarriage. -children of offspring who consumed DES while pregnant
had serious consequences-dependent on when they took
the drug. These young women were being diagnosed with
health problems, diagnosed usually in older women. (risk
of premature birth, uterus problem, increase in risk of
breast cancer). These women did not know.
Changing role of FDA regulations
-before 1938, no laws to prevent marketing of drugs. any
drug could be marketed if it was properly labelled.
Physicians could even sell things that they created
-1938-drug companies had to submit evidence of a drug's
safety.*They did it with DES, but ignored the animal
-The FDA had 2 months to get back to you. If they never
got back to you, you could just start selling it->automatic
approval. but things have obviously changed
-1962-shortly after thalidomide tragedy (birth defected
children) The US amended the drug law to require:
adequate clinical trials, permission, FDA got greater
control of supervising control studies, tested for safety for
pregnancy VIDEO-women who used the DES drugs
-DES was handed out for 30 years, first for problem
pregnancies, then for healthy babies
-higher rate of breast cancer in DES daughters. DES
daughters 2 x more likely to develop breast cancer than
Off-label use: once a drug is approved, it can be
prescribed off-label-for a condition other than that it is
labelled for. (ex. neuronal common medication for seizures
but can also be used for migraine).
off-label use would be beneficial if they're allergic to
something, it's nice to have an alternative. good that there
is flexibility, but the insurance company will not pay for it.
____ is responsible for protecting these women that took
DES. doctors who prescribed the drug, didn't pay attention
to animal models, the FDA who allowed it to get through.
They're in charge of foods that are not meat-based, drug
analysis, and they're chronically underfunded, things slow there. Ultimately, the manufacturers are responsible
because they have the best data. But many of these
things are rushed for approval.
PH Case: Red Tide
-Northwestern Florida-great weather and beaches
-The water was testing positive for higher than normal red
tides and algae. Red tide bloom moving inward towards
Pensacola, which can kill fish and make people very sick.
Red tide-red algae bloom
-caused by intense concentration of microscopic alga. It's
-harmful because it produces a suite of neurotoxins,
problem when it's intense concentration, normal levels not
-the phytoplankton overwhelms and can cause sickness
-you can be exposed to neurotoxin if: some organisms and
cells ingest it, sometimes they consume toxic prey that
already have it, aerosol. Fish receive some of the highest
exposure to some of these neurotoxins. Fish kill is the main effect of Red Tide!* not just marine animals, human
can also be exposed: infected
shellfish=sick=gastrointestinal elements. if you inhale it
sometimes, it can cause shortness of breath. If you step
on the dead fish and you have an open wound, it can
-Florida has so much trouble with red tide that DOH
-If you experience symptoms, stay away from beach
outdoors, wear paper mask if there's bloom, esp. if there's
an offshore wind. Make sure A/C has maintained filter.
After swimming, rinse off with clean fresh water. Dispose
of dead fish accordingly.major PH problems.
Healthcare in Ghana
-like Brazil, developing country
-In 2011, population 24.9 million. About 90% are Native
-Large population are women and children, and they don't
have equal access.
-have a very weak economy -have a lot of resources, but government isn't taking
advantage of this.
-Majority of people don't have healthcare. Things cost less
there. Health care isn't equally accessible to everybody.
-In 2010, women lived 61 years, men 58 years-pretty low
compared to U.S. standard.
-2013: 39 infants for every 1000 live births/For U.S., it's 6
per 1000 live births. Highest in Afghanistan. Not highest,
but very high.
-Their infant mortality rate is decreasing, which is
surprising given their health care system.
-They have a government-funded system directed by the
Ministry of Health, formed in 1957 when they gained their
-The Ministry of Health funds maternal and child health,
-The other system is traditional (folk) system, which is
equally respected. Most people in Ghana use both
systems, sometimes simultaneously.
-Polyclinics: When people got ill, they wanted people to go
to these polyclinics and see if they get help there. People
started using these clinics, but they were poorly staffed. Many people stopped going to them. They went to major
hospitals instead and would travel long distances.
-They only have one hospital in the entire country! It does
have a good reputation.
-*About 30% of doctors are medically trained. 70% use
sacrificial offerings, etc. Most doctors in urban areas. This
is a disparity.
-Unstable water and electricity=hard to do operations
-In 2002, doctors were paid about $170/month. Senior
doctors were paid $230/month. If you have a car, you get
a $1700 allowance, you get more money, slight raise in
payment. Many physicians dissatisfied-> big problem for
Ghana. They had a high attrition rate for skilled doctors
and nurses. They also have a system for paying for
-In Ghana, you only pay cash. Some people are able to
get this paid for, but it's rare.
-Patients without the ability to pay basically can't get the
treatment. You have to be able to pay.
-Many children are getting sick. -Doctors are paid very little-> favors people who have
Major Health Issues
-Perinatal conditions=Brazil, 24 weeks
-heart disease, COPD, stroke=some just like Western diet
-A National Health Service wouldn't work because
compared to physicians in different countries, the
physicians in Ghana are not as well-trained, and nurses
aren't as sophisticated in technology. In Ghana, the nurses
are like secretaries. If we helped them clean up their
water, diarrheal disease could be prevented. The funding
would have to come from donations/outside sources,
because the ministry and government wouldn't be able to
afford it with revenue. There's some political corruption
-A lot of budget cuts jeopardized a lot of the state health
funding. -Since 2007, there have been a lot of cuts. Some states
did across-the-board cuts, it depended on the state. This
case focuses on Louisiana. People's positions weren't
being filled again, they weren't being hired, caused a
complete elimination of