Environmental data assessment for use in public health surveillance

Public health surveillance is the ongoing systematic collection, analysis, interpretation, and dissemination of data on health-related events for use in public health action to reduce morbidity and mortality and to improve health. Total trihalomethanes are an example of a chemical in drinking water that is regulated by the U.S. Environmental Protection Agency (U.S. EPA) but is not under public health surveillance. The U.S. EPA database that stores this environmental information is called the Safe Drinking Water Information System (SDWIS). Its purpose is to collect data on noncompliance events in drinking-water utilities in each state. For this discussion, the SDWIS data on TTHMs, which are an example of environmental data, were assessed for public health surveillance system attributes as defined by the Centers for Disease Control and Prevention: simplicity, flexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability.     

Beyond "medical tourism": Canadian companies marketing medical travel

ABSTRACT: BACKGROUND: Despite having access to medically necessary care available through publicly funded provincial health care systems, some Canadians travel for treatment provided at international medical facilities as well as for-profit clinics found in several Canadian provinces. Canadians travel abroad for orthopaedic surgery, bariatric surgery, ophthalmologic surgery, stem cell injections, "Liberation therapy" for multiple sclerosis, and additional interventions. Both responding to public interest in medical travel and playing an important part in promoting the notion of a global marketplace for health services, many Canadian companies market medical travel. METHODS: Research began with the goal of locating all medical tourism companies based in Canada. Various strategies were used to find such businesses. During the search process it became apparent that many Canadian business promoting medical travel are not medical tourism companies. To the contrary, numerous types of businesses promote medical travel. Once businesses promoting medical travel were identified, content analysis was used to extract information from company websites. Company websites were analyzed to establish: 1) where in Canada these businesses are located; 2) the destination countries and health care facilities that they market; 3) the medical procedures they promote; 4) core marketing messages; and 5) whether businesses market air travel, hotel accommodations, and holiday tours in addition to medical procedures. RESULTS: Searches conducted from 2006 to 2011 resulted in identification of thirty-five Canadian businesses currently marketing various kinds of medical travel. The research project began with what seemed to be the straightforward goal of establishing how many medical tourism companies are based in Canada. Refinement of categories resulted in the identification of eighteen businesses fitting the category of what most researchers would identify as medical tourism companies. Seven other businesses market regional, cross-border health services available in the United States and intranational travel to clinics in Canada. In contrast to medical tourism companies, they do not market holiday tours in addition to medical care. Two companies occupy a narrow market niche and promote testing for CCSVI and "Liberation therapy" for multiple sclerosis. Three additional companies offer bariatric surgery and cosmetic surgery at facilities in Mexico. Four businesses offer health insurance products intended to cover the cost of obtaining privately financed health care in the U.S. These businesses also help their clients arrange treatment beyond Canada's borders. Finally, one medical travel company based in Canada markets health services primarily to U.S. citizens. CONCLUSIONS: This article uses content analysis of websites of Canadian companies marketing medical travel to provide insight into Canada's medical travel industry. The article reveals a complex marketplace with different types of companies taking distinct approaches to marketing medical travel.     

The Fukushima radiological emergency and challenges identified for future public health responses

On 11 March 2011, northern Japan was rocked by first a magnitude 9.0 earthquake off the eastern coast and then an ensuing tsunami. The Fukushima Daiichi Nuclear Power Plant complex was hit by these twin disasters, and a cascade of events was initiated that led to radionuclide releases causing widespread radioactive contamination of residential areas, agricultural land, and coastal waters. Radioactive material from Japan was subsequently transmitted to locations around the globe, including the U.S. The levels of radioactive material that arrived in the U.S. were never large enough to be a concern for health effects, but the presence of this material in the environment was enough to create a public health emergency in the U.S. The radiation safety and public health communities in the U.S. are identifying challenges they faced in responding to this incident. This paper discusses three of those challenges: (1) The growing shortage of trained radiation subject matter experts in the field of environmental transport and dosimetry of radionuclides; (2) the need to begin expressing all radiation-related quantities in terms of the International System of Units; and (3) the need to define when a radiation dose is or is not one of "public health concern." This list represents only a small subset of the list of challenges being identified by public health agencies that responded to the Fukushima incident. However, these three challenges are fundamental to any radiological emergency response. Addressing them will have a significant positive impact on how the U.S. responds to the next radiological emergency.     

Firearms, youth homicide, and public health

Homicide is seven times as common among U.S. non-Hispanic Black as among non-Hispanic White youth ages 15 to 24 years. In 83% of these youth homicides, the murder weapon is a firearm. Yet, for more than a decade, the national public health position on youth violence has been largely silent about the role of firearms, and tools used by public health professionals to reduce harm from other potential hazards have been unusable where guns are concerned. This deprives already underserved populations from the full benefits public health agencies might be able to deliver. In part, political prohibitions against research about direct measures of firearm control and the absence of valid public health surveillance are responsible. More refined epidemiologic theories as well as traditional public health methods are needed if the U.S. aims to reduce disparate Black-White youth homicide rates.     

Shaping public policy and population health in the United States: why is the public health community missing in action?

Renewed international interest in the structural determinants of health manifests itself in a focus on the social determinants of health and the public policy antecedents that shape their quality. This increased international interest in public policy in support of the structural determinants of health has had little traction in the United States. This should be surprising since the United States presents one of the worst population health profiles and public policy environments in support of health among wealthy developed nations. The U.S. position as a health status and policy outlier results from long-term institutional changes that are shaped by political, economic, and social forces. U.S. public health researchers' and workers' neglect of these structural and public policy issues conforms to the dominant ideological discourses that serve to justify these changes. The author presents some means by which public health researchers and workers can challenge these dominant discourses.     

"Dualities of interest": the inter-organizational relationships between disease-specific nonprofits and the pharmaceutical industry

Health care and biomedical research environments in the United States are largely characterized by strategic relational practices conducted beyond the public gaze. The very nature of health care has been widely reconceptualized from a response to physical/biological imperatives regulated by health promotion and the epidemiological distribution of diseases to profit/market imperatives regulated by "product/brand" promotion and market dynamics. At critical decision points throughout the system, we find the multinational pharmaceutical industry wielding the influence that its wealth and power have bought. This study contributes to the growing body of work that seeks to illuminate the relationships between the pharmaceutical industry and the various entities that constitute the U.S. health and research systems. Through the use of case studies, it examines the relationships between the multinational pharmaceutical industry and the large disease-specific public and professional nonprofit organizations. It explores several questions, including: Is the concept of what constitutes a conflict of interest being purposefully manipulated? Is the public benevolence afforded to nonprofits extended to their corporate partners in ways that preclude critical oversight of relational dynamics? And are public donations, solicited by and given in good faith to these organizations, inevitably serving the economic interests and profits of donor pharmaceutical companies?     

A preliminary comparison between local public health units in the Canadian Province of Ontario and in the United States.

This comparison between public health departments in the United States and in the Canadian Province of Ontario addresses the funding and staffing and the size and program content of local health departments after Canada''s national health reform provided universal access to personal health services. Ontario''s local health departments are required to provide a uniform set of public health services. In the United States, there is substantial variation among jurisdictions in kinds and amounts of services delivered. Ontario health units have staff sizes and budget levels that increase in proportion to population served, like those in the United States. But in Ontario, per capita expenditures increase with decreasing population, while the reverse is true in the United States. This anomaly may be attributed to lack of critical staff or elimination of key programs in small U.S. departments. Medical care of indigents probably accounts for the increased per capita costs seen in very large U.S. health departments. An estimated price for uniform public health services meeting the Ontario requirements in all U.S. jurisdictions as they were organized in 1989 is $5.8 billion per annum (not adjusted for inflation). If smaller health departments were consolidated, a savings of more than $1 billion could be realized. Even with this reorganization, average expenditures in smaller U.S. health departments would need to be doubled, and staff sizes increased by about 50 percent to meet Ontario''s uniform public health program standards.     

Public health, global surveillance, and the "emerging disease" worldview: a postcolonial appraisal of PEPFAR

Drawing upon a postcolonial lens, this project looks at how meanings of HIV/AIDS are discursively constructed within the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which was launched in 2003 under the presidency of George W. Bush and has been heralded as the largest global public health intervention program in history. Building on existing literature that theorizes the interrelationships of public health and national security, global surveillance, and transnational hegemony, the postcolonial theoretical standpoint interrogates how such meanings are constructed within PEPFAR. A postcolonial deconstruction of the 2009 PEPFAR report to the Congress revealed three meanings of HIV/AIDS that were discursively constructed in such policy documents: (a) the "Third World" as a site of intervention, (b) U.S. altruism as "lifting" the burden of the soul, and (c) AIDS, economics, and security. The themes put forth the linkages among the symbolic representations in neocolonial configurations and the politics of material disparities across the globe, thus issuing a call for the creation of participatory and dialogic spaces for engaging subaltern voices that are typically treated as targets of policy and intervention discourses.     

HIV prevention in young homosexual men. A medical ethical challenge

Although considerable progress in the treatment of patients with AIDS has been achieved over the recent years, AIDS remains a non-curative disease. Therefore the prevention of new infections with HIV is an important goal for medicine and public health. However, during recent years the number of new HIV-infections in young gay men increased. New empirical data from the U.S. and the U.K. suggest that the traditional prevention methods fail to reach young gay men in Western countries who become HIV-infected by unsafe sex within intimate relationships. The paper discusses these problems from the perspective of medical ethics. New approaches to sex education and prevention of HIV and other sexually transmitted diseases are developed and the importance of personal values, responsibility, intimacy and emotions are emphasized.     

Public health approaches to tobacco use prevention and cessation in the U.S.

Tobacco has a long history of use in the U.S., and its serious health effects have been well-documented during the past half century, U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 25 years, during which time there has been a 34 percent reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one-fourth of the population continuing to smoke. Many organizations are involved in tobacco use control activities, the most broadly focused of which is the National Cancer Institute (NCI). As an example of the type of program needed to address the problem of tobacco use on a national scale, the NCI's public health research plan and activities are described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco use control in the U.S. are suggested.     

Global health for undergraduates: "we are not alone"

This paper presents a review of an undergraduate global health curriculum implemented at the George Washington University School of Public Health and Health Services. It is in concert with the framework and principles of the Association of American Colleges and Universities and their vision of Shared Futures of Global Learning and Social Responsibility. The rationale for a deep and broad undergraduate public health curriculum, which includes a global health component, is clear. Global health is a necessary and timely pathway for undergraduate liberal arts education. The world has dramatically changed in the past 50 years, and undergraduate education must continue to keep pace with these changes. Pathogens will adapt to changing ecologies, demographics, disease burdens, and population distributions. They are able to cross the world in hours or days. No country is invulnerable to disease importation and consequent indigenous transmission. Broad epidemic preparedness is required across all academic disciplines from epidemiology to sociology, from medicine to economics. Global health is anchored in the complementary application of various disciplines effectively joined to address a particular problem and mitigate potential adverse consequences. Our students recognize the reality of this interconnected world and are eager to take their place as global citizens. Knowledge, understanding, technical acumen, and humility represent the foundation of the global citizenry required to address the changing global pattern of disease worldwide. Undergraduate public health, and particularly undergraduate global health, will enable our undergraduates to embark on a myriad of professional trajectories that include public health, medicine, biomedical research, law, policy, environmental studies, anthropology, economics, sociology and other disciplines. The "Y" Generation in the U.S. (individuals born between 1980 and 2000) is poised for action; we must give them the tools to succeed.     

Lead exposures in U.S. Children, 2008: implications for prevention

Objective

We reviewed the sources of lead in the environments of U.S. children, contributions to children’s blood lead levels, source elimination and control efforts, and existing federal authorities. Our context is the U.S. public health goal to eliminate pediatric elevated blood lead levels (EBLs) by 2010.

Data sources

National, state, and local exposure assessments over the past half century have identified risk factors for EBLs among U.S. children, including age, race, income, age and location of housing, parental occupation, and season.

Data extraction and synthesis

Recent national policies have greatly reduced lead exposure among U.S. children, but even very low exposure levels compromise children’s later intellectual development and lifetime achievement. No threshold for these effects has been demonstrated. Although lead paint and dust may still account for up to 70% of EBLs in U.S. children, the U.S. Centers for Disease Control and Prevention estimates that ≥30% of current EBLs do not have an immediate lead paint source, and numerous studies indicate that lead exposures result from multiple sources. EBLs and even deaths have been associated with inadequately controlled sources including ethnic remedies and goods, consumer products, and food-related items such as ceramics. Lead in public drinking water and in older urban centers remain exposure sources in many areas.

Conclusions

Achieving the 2010 goal requires maintaining current efforts, especially programs addressing lead paint, while developing interventions that prevent exposure before children are poisoned. It also requires active collaboration across all levels of government to identify and control all potential sources of lead exposure, as well as primary prevention.     

National profile: overview of capabilities and core functions of local public health jurisdictions in 47 states, the District of Columbia, and 3 U.S. territories, 2000-2002.

This is the first nationally conducted survey targeting the full population of all local public health jurisdictions to assess the three core functions of public health: assessment, policy development, and assurance, as well as overall capabilities. Data were analyzed from 2,007 local public health jurisdictions in 47 states, the District of Columbia, and 3 U.S. territories (American Samoa, Northern Mariana Islands, and Puerto Rico) between July 2000 and April 2002, in a collaborative effort between the Centers for Disease Control and Prevention and the Department of Justice. An unweighted overall mean summary score of 65.4% (on a scale of 0% to 100%) was calculated from the responses to the 20-question survey. The mean summary scores across all 2,007 local public health jurisdictions for assessment, policy development, and assurance were 66.8%, 67.4%, and 63.0%, respectively. Also, data was analyzed by the population size of jurisdiction and the type of jurisdiction. The results provide national population baseline data for estimates of local public health jurisdiction capabilities and core functions that may be useful in identifying areas for improvement, in building a stronger U.S. public health system to better serve each community, and in educating the public about the core functions of public health to help ensure that public health agencies are accountable to those they serve.     

State-specific trends in U.S. live births to women born outside the 50 states and the District of Columbia--United States, 1990 and 2000

Persons born outside the 50 states and the District of Columbia (DC) comprised an estimated 11.1% (31.1 million) of the U.S. population in 2000, and approximately one fifth of all U.S. births in 2000 were to women in this population. Racial/ethnic disparities in U.S. health outcomes are of public health concern, and the increasing cultural and linguistic diversity of the U.S. population poses challenges to the delivery of maternal and child health services. This report presents state-specific comparisons of live births in 1990 and 2000 to women born outside the 50 states and DC and compares maternal characteristics and live-birth outcomes for these women with those of state-born mothers (i.e., women born inside the 50 states and DC). The findings indicate that women born outside the 50 states and DC had better birth outcomes than their state-born racial/ethnic counterparts. However, a larger percentage of these women began prenatal care later and had other problems accessing health care, which might reflect economic, cultural, and language barriers. The U.S. public health system and maternal healthcare providers should understand and address the health needs of an increasingly diverse population.     

From service provision to function based performance - perspectives on public health systems from the USA and Israel

If public health agencies are to fulfill their overall mission, they need to have defined measurable targets and should structure services to reach these targets, rather than offer a combination of ill-targeted programs. In order to do this, it is essential that there be a clear definition of what public health should do- a definition that does not ebb and flow based upon the prevailing political winds, but rather is based upon professional standards and measurements.The establishment of the Essential Public Health Services framework in the U.S.A. was a major move in that direction, and the model, or revisions of the model, have been adopted beyond the borders of the U.S.This article reviews the U.S. public health system, the needs and processes which brought about the development of the 10 Essential Public Health Services (EPHS), and historical and contemporary applications of the model. It highlights the value of establishing a common delineation of public health activities such as those contained in the EPHS, and explores the validity of using the same process in other countries through a discussion of the development in Israel of a similar model, the 10 Public Health Essential Functions (PHEF), that describes the activities of Israel’s public health system. The use of the same process and framework to develop similar yet distinct frameworks suggests that the process has wide applicability, and may be beneficial to any public health system.Once a model is developed, it can be used to measure public health performance and improve the quality of services delivered through the development of standards and measures based upon the model, which could, ultimately, improve the health of the communities that depend upon public health agencies to protect their well-being.     

"So We Adapt Step by Step": Acculturation experiences affecting diabetes management and perceived health for Chinese American immigrants

This study examines how acculturation affects type 2 diabetes management and perceived health for Chinese American immigrants in the U.S. Acculturation experiences or cultural adaptation experiences affecting diabetes management and health were solicited from an informant group of immigrant patients and their spouses (N = 40) during group, couple and individual interviews conducted from 2005 to 2008. A separate respondent group of immigrant patients and their spouses (N = 19) meeting inclusion criteria reviewed and confirmed themes generated by the informant group. Using interpretive phenomenology, three key themes in patients’ and spouses’ acculturation experiences were identified: a) utilizing health care, b) maintaining family relations and roles, and c) establishing community ties and groundedness in the U.S. Acculturation experiences reflecting these themes were broad in scope and not fully captured by current self-report and proxy acculturation measures. In the current study, shifting family roles and evaluations of diabetes care and physical environment in the U.S. significantly affected diabetes management and health, yet are overlooked in acculturation and health investigations. Furthermore, the salience and impact of specific acculturation experiences respective to diabetes management and perceived health varied across participants due to individual, family, developmental, and environmental factors. In regards to salience, maintaining filial and interdependent family relations in the U.S. was of particular concern for older participants and coping with inadequate health insurance in the U.S. was especially distressing for self-described lower-middle to middle-class participants. In terms of impact, family separation and relocating to ethnically similar neighborhoods in the U.S. differentially affected diabetes management and health due to participants’ varied family relations and pre-migration family support levels and diverse cultural and linguistic backgrounds, respectively. Implications for expanding current conceptualizations and measures of acculturation to better comprehend its dynamic and multidimensional properties and complex effects on health are discussed. Additionally, implications for developing culturally-appropriate diabetes management recommendations for Chinese immigrants and their families are outlined.     

A cost-benefit analysis of physical activity using bike/pedestrian trails

From a public health perspective, a cost-benefit analysis of using bike/pedestrian trails in Lincoln, Nebraska, to reduce health care costs associated with inactivity was conducted. Data was obtained from the city's 1998 Recreational Trails Census Report and the literature. Per capita annual cost of using the trails was 209.28 U.S. dollars (59.28 U.S. dollars construction and maintenance, 150 U.S. dollars of equipment and travel). Per capita annual direct medical benefit of using the trails was 564.41 U.S. dollars. The cost-benefit ratio was 2.94, which means that every 1 U.S. dollar investment in trails for physical activity led to 2.94 U.S. dollars in direct medical benefit. The sensitivity analyses indicated the ratios ranged from 1.65 to 13.40. Therefore, building trails is cost beneficial from a public health perspective. The most sensitive parameter affecting the cost-benefit ratios were equipment and travel costs; however, even for the highest cost, every 1 U.S. dollar investment in trails resulted in a greater return in direct medical benefit.     

U.S. Department of Energy policies, directives, and guidance for radiological control and release of property

U.S. Department of Energy (U.S. DOE) regulates its operations with a system of rules, directives, and guidance under the Atomic Energy Act. U.S. DOE's policy is to conduct its radiological operations in a manner that ensures the health and safety of its employees, contractors, and the public. U.S. DOE uses an annual dose limit of 100 mrem (1 mSv) with an "as low as reasonably achievable" (ALARA) process to achieve radiological protection. The primary directive for radiation protection of the public and the environment is DOE Order 5400.5. It contains requirements for the protection of the public and the environment from routine operations, including controlling and releasing property. Since the publication of Order 5400.5 in 1990, U.S. DOE has issued guidance for meeting requirements under it; Guide G 441.1-xx consolidates this guidance. DOE applies a dose constraint of 25 mrem y (0.25 mSy y(-1)), plus ALARA, for the release of real property, and 1 mrem y(-1), plus ALARA, for release of personal property. Models and guidance to develop the needed documentation for release of property are easily available and user-friendly. While achieving protection of human health and the environment, U.S. DOE's dose-based release process has resulted in significant cost savings. U.S. DOE has recently adopted a management systems approach for general environmental and public protection programs. The integration of the radiation protection program into this new approach is a high priority.     

Improving the quality of health care: who will lead?

National interest in the quality of American health care increased dramatically in 1999. The press, the Institute of Medicine, legislators, physicians, and hospitals joined in a vigorous policy discussion. But a similar debate occurred in 1988, following reports from four public agencies that detailed their concerns about health care quality. In the intervening decade, research has not documented much improvement. In this paper we outline the quality problems in U.S. health care, review some of their most prominent causes, consider the biggest obstacles to bringing about major improvement, and discuss the vital role of leadership in achieving this goal.     

Forces for reforming the U.S. health care system: a review of the cost and access issues.

In recent years, a spate of health care reform proposals have emerged on the American agenda. Although the elements of the reform proposals often vary substantially, most of the initiatives are fuelled by two common concerns: rising health care expenditures and a growing uninsured population. National health spending, for example, commands an increasing share of U.S. gross national product despite numerous cost-containment efforts initiated by public and private payers throughout the 1980s. And the uninsured population continues to grow--by an estimated 30 percent between 1978 and 1989. To facilitate understanding of the public policy options being considered to address these concerns, the article examines U.S. health care expenditure data and some of the causes of rising health care costs. The article also discusses the demographic characteristics of the uninsured population, the reasons why they lack health coverage, and the health consequences associated with being uninsured.