59 Pages

Public Health
Course Code
Eric Runnerstrom

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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 case. -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 girls=scandal. ⁃ **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 genital warts) ⁃ Cervarix protects against strains linked to cervical cancers. ⁃ 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 rescind recommendation. ⁃ 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 recommends it. ⁃ 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 moral issues • 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 unintended pregnancies. • 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 rates • 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 these steps. • 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 is important ⁃ 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 Month Capper book: Possible Bioterrorism in New Hampshire (1999) ⁃ 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 lab equipment. ⁃ There were more cases, then. They were concerned for their safety because if the bf was reproducing biological components, it'd be troublesome. ⁃ 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 cow ⁃ 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 material? ⁃ 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 10 ⁃ 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 resistant strains). ⁃ 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. 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 language. -They had an active slave trade so they have many Africans. -__ 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. Disparities -geography, many regional differences between prosperous southern and poor northern regions -in 2006, the IMR was 2-24 x higher in north than the south. -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 environmental) -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 cause cancer) -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 this. Video -potential for cancer-causing agents and toxic substances -5.4 sludge -goal: entire area cleaned within 6 weeks Step 5 -The EPA is not regulating coal ash because it's politically charged, expensive. -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 disaster Step 1 -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 themselves. -1938-drug companies had to submit evidence of a drug's safety.*They did it with DES, but ignored the animal evidence -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 -1971-DES~vaginal cancer -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 most women. DQ: 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 a phytoplankton* -harmful because it produces a suite of neurotoxins, problem when it's intense concentration, normal levels not hazardous. -the phytoplankton overwhelms and can cause sickness and death -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 cause infection. -Florida has so much trouble with red tide that DOH instructed them. -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 Africans. -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 independence. -The Ministry of Health funds maternal and child health, mostly. -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 sometimes. -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 medicine. -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. Disparities -Many children are getting sick. -Doctors are paid very little-> favors people who have more money. Major Health Issues -Perinatal conditions=Brazil, 24 weeks -heart disease, COPD, stroke=some just like Western diet DQ -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 going on. PH Case -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
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