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Aging & Public Health
Section Newsletter
Spring 2011

From The Editor

From Editor


We are pleased to share this spring newsletter with you on behalf of our Section. It’s chock full of colorful news items about our members, Section committees, important alerts on the 2011 Annual Meeting, and various announcements that will be of interest to you.


We wish to extend special thanks to Section Chair Susan Miller for her contribution describing the outstanding work she and her colleagues are doing on hospice care, and to Chair of the APHA Ethics SPIG Chair Bruce Jennings for his important contribution on elderly persons and climate change.  


We are particularly pleased to highlight in this issue the appointment of APHA’s Executive Director, Dr. Georges Benjamin, to Maryland’s Health Benefit Exchange board. Don’t miss Dr. Benjamin‘s comments on the implementation of the Affordable Care Act in our legislative update!


We also report on Dr. Linda Rae Murray's illuminating presentation to the Public Health Association of the City of New York on June 1.


Please continue to send us your updates, contributions and announcements about the range of activities in which you are engaged -- from all corners! We wish to continue to encourage regional diversity in our newsletter.



Best wishes,

Mary Beth Morrissey

From The Chair

From The Chair

Once again, the A&PH leadership has been busy on a number of fronts. Junling Wang, our program chair, has been busily coordinating the review of abstract submissions and in finalizing the education program for APHA’s Annual Meeting. Junling has been assisted in these efforts by PJ Desai and Nancy Miller. We thank the many members who volunteered to review abstracts as your help was essential to this effort. Abstract submitters will be notified in early June regarding acceptance.

Now, the process of selecting abstract/paper award recipients has begun and is being led by Award Committee Chair Irena Pesis-Katz. This selection effort includes numerous member volunteer hours since abstracts/papers for eight awards are reviewed. Each award review is coordinated by an award chair who is assisted by at least three reviewers. As always, awards will be presented on the Monday afternoon of the Annual Meeting, followed by an Awards Reception and Silent and Live Auction (led as always by Gerry Eggert).

The Membership Committee, led by Carolyn Mendez-Luck and Daniel Meng, is again planning a networking dinner following the Section’s business meeting on Sunday. Last year’s dinner was a resounding success, and we hope you plan to attend this year. As we did last year, the Section (through membership donations) will subsidize the dinners of student members.

The Policy Committee led by Mary Beth Morrissey, together with Karen Peters, the Section’s Action Board Representative, contributed numerous hours reviewing 28 policies that were submitted to APHA for adoption. On behalf of the Section, they submitted to APHA their recommendations regarding policy adoption (and needed changes as applicable). This group also completed a review of existing APHA policies and recommended to APHA whether these policies should be archived or updated.

Given the number of Section awards and the endowment dollars the Section has been accumulating, a Finance Committee has been established. This Committee is led by Gerry Eggert. After approval from the Finance Committee, I submitted to APHA leadership a request that the Section be allowed to establish a process for making recommendations to APHA on how to invest (permanently restricted) endowment dollars. We have a “go ahead” from both APHA and Section leadership to do this. I am now in the process of finalizing a Memorandum of Understanding between the Section and APHA which will outline all the specifics regarding our investments. Once this Memorandum of Understanding is approved by APHA we can begin to operationalize our process.

In closing, Lene Levy-Storms has assembled an excellent ballot this year, and I want to encourage all you to vote! Also, check out the new information and links that have been added to the Section’s website by Ruqaiijah Yearby (go to

Last, congratulations to the following Section members who have been appointed to APHA-level positions: Keith Elder, Equal Health Opportunity Committee; Helena Tempkin-Greener, Editorial Board, American Journal of Public Health; Mary Beth Morrissey, Annual Meeting Program Planning Committee; Karen Peters, Action Board; and Junling Wang, Awards Committee.

I wish you a wonderful, safe and healthy summer!

Susan Miller

APHA President Speaks to PHANYC

Dr. Linda Rae Murray, President of APHA, Addresses PHANYC


On Wednesday, June 1, 2011, Dr. Linda Rae Murray addressed the Public Health Association of New York City (PHANYC) at Hunter College, NYC, where she was greeted with enthusiasm by the Association’s members. Dr. Murray, who hails from Chicago and has a long history in community medicine, was invited to speak to PHANYC about federal health care reform legislation. She gave a powerful presentation, challenging the adequacy of market-based systems to meet the health needs of all Americans and reflecting her strong public health perspective.


In her opening remarks, Dr. Murray described herself as a “single payer” person. She was among others in hailing the Affordable Care Act for what it accomplished in expanding coverage to many Americans, but was less optimistic about what the legislation might mean for the future of public health. Dr. Murray suggested that in certain cases health care reform might possibly result in disenfranchising individuals who currently had coverage, such as undocumented immigrants. She also struck a chord in turning upside down more conventional notions about the legislation’s progressive approach to a person-centered framework to care delivery in highlighting that it was important not to lose sight of the community and the role of community organizing in implementing this framework.


Calling for more focused attention on community-based care

and a commitment to social justice, Dr. Murray recognized health care as a human right. In light of her perspectives on improving public health and changing social structures that impede access to health care, Dr. Murray was asked about how she saw the complex and thorny issues of implicit and explicit forms of rationing, so frequently a source of disagreement in the context of costs spent on care for the seriously ill and persons approaching the end of life. Dr. Murray was very clear in expressing her view that rationing was not appropriate to U.S. policy formulation at this point in time given the wealth of the nation’s resources. In further engagement with the meeting participants about the political process, Dr. Murray described differences in ideological perspectives about the role of government as one of the central issues in the public discourse about health care reform. 


Reported by Mary Beth Morrissey, PHANYC member

Member News

Member News

Section Member Elected into Leadership of State Affiliate

Long-time Aging & Public Health Section member James H. Swan has been elected the 2nd vice president of his state affiliate, the Texas Public Health Association. This starts a five-year trajectory through 1st vice president, president elect, president, and past president. As 2nd vice president in the coming year, Jim will be tasked with overseeing TPHA membership. Jim was also inducted as a TPHA fellow at the recent TPHA annual conference.

Section Member Earns Research Award and Is Guest Editor of Special Journal Issue

Mary Beth Morrissey earned the Fordham University Nicholas J. Langenfeld PhD Research Award this May for her dissertation research on suffering and decision making among seriously ill women. In a January-March 2011 special issue of the national Journal of Social Work in End-of-Life and Palliative Care, for which Morrissey and APHA Ethics SPIG Chair Bruce Jennings, served as co-guest editors, Morrissey framed a humanistic perspective in gerontological health and social work on suffering among older adults (Morrissey, 2011).

A Primer on the APHA Policy Development Process

One major advantage to membership in APHA exists with being a part of the largest professional public health organization with lobbying clout. While any individual in the democratic United States can be “heard” by calling or writing their local congressional representatives, APHA affords its members an amplifier of sorts: it can rally members to advocate together, thus increasing the advocacy volume on an issue. A policy statement on a public health issue by a Section serves as the foundation for APHA’s efforts and provides a historical record. The question remains: how does one go about getting APHA to support a policy statement? This article will overview the major steps to developing a policy or to modifying an existing policy in such a manner as to garner APHA and its ample affiliates and members’ formal support.

Step #1: Refer to APHA’s website. APHA has a formal system of procedures by which new policies or amendments to existing ones may be introduced by any section according to a set calendar ( Its website provides a policy submission checklist (, which also outlines the major steps in the policy development process.

Step #2: Check APHA’s policy statement database. This step will help one identify policy statements that were previously supported by APHA. If a previous policy statement exists, one may consider updating or amending it.

Step #3: Collaborate. Getting APHA’s formal endorsement of a policy statement requires a network of supporters from APHA’s 30,000 individual members, 20,000 state and local affiliate members, and 27 sections.

Step #4: Link new or modified policy efforts with an APHA priority or policy gap. Some public health issues may already be identified by APHA as a policy target.

Step #5: Provide an evidence-base. APHA requires that a policy statement be credible based on sound scientific evidence.

Step #6: Follow the policy development format. Do not let your policy get ignored because of a technical error in not following format protocols. The formatting refers to the content of the policy statement as well as its references.

In closing, on behalf of the A&PH Section, I ask you: what is your public health issue? Now, I challenge you: Take a stance. Network within and between sections. Write a formal policy statement and be a part of the APHA policy development process. The public health of our nation will be better for your advocacy efforts!

Lené Levy-Storms, PhD, MPH
A&PH Chair Elect


From the Action Board

From the Action Board

The annual Midyear meeting of the APHA Action Board was held in Washington, D.C., at APHA headquarters May 16-17. The focus of the meeting was public health advocacy with particular concern expressed about the proposed reduced funding to the Centers for Disease Control and Prevention and Health Resources and Services Administration budgets in the current budget discussions taking place in Congress.

As APHA Executive Director Dr. Benjamin explained to us during the meeting, some in Congress are looking to make use of the newly established Prevention and Public Health Fund recently created through the Affordable Care Act as the mechanism for 'plugging' the budget gaps for public health at CDC and HRSA. Action Board members also discussed APHA support for continuation of the Clean Air Act and promotion of public health concerns regarding health, safety, and equity as the United States considers the transportation system. 

An important aspect of the Action Board's Midyear meeting is to participate in Hill Visits, and I was pleased to visit with Illinois Sen. Richard Durbin's legislative assistant for health during the meeting. I also want to thank several members of the section's Policy Committee (Patricia Alt, Lene Levy-Storm, Kathy Sykes and Chairwoman Mary Beth Morrissey) for their generous time and efforts to review and provide commentary on both of the APHA's annual policy review processes. We reviewed a total of 26 newly submitted policies for APHA adoption consideration and 28 existing policies written between 1950-1955 for archival consideration. It was interesting to note that while the policy advocating for Yellow Fever eradication in the United States had been achieved, policy calling for increased funding of state and local public health departments continues to be a concern 60 years later! Finally, I look forward to seeing many of you at the APHA's first ever Midyear Meeting in Chicago, June 23-25, on Implementing Health Reform!

Karen Peters

Spring-Summer Donor Campaign

The A&PH Section Spring-Summer Donor Campaign

We are going to ask Section members to support our Endowed Awards through a Special Appeal in June. Since we are going to be able to invest our Endowment in bonds and equities, all new donations will be able to be added to our Award Endowments. Donations to support our Section Award Reception can be made at any time through the APHA Donor site. Expect more information this June.

Gerry Eggert and Steve Wallace, Development Co-Chairs

The CLASS Act -- Session ID 33275

The CLASS Act -- Session ID 33275

The A&PH Section is sponsoring an invited Symposium on the CLASS Act. The Affordable Care Act of 2010 established the Community Living Assistance Services and Supports, or CLASS, Plan, a voluntary, publicly administered long term care insurance program. By law, CLASS must be self sustaining through premiums without the infusion of federal tax dollars. As currently structured, however, the program does not appear to be financially viable. Many policy-makers have called for its repeal.

Speakers include Connie Garner, PhD, executive director of Advance CLASS. Connie was Sen. Ted Kennedy's staff member who drew up the CLASS provisions in health reform. She now heads up an advocacy group trying to insure a sustainable program. John Wren, deputy assistant secretary for community living assistance services and supports, heads up the CLASS Office for the U.S. Department of Health and Human Services, which is charged with program implementation. Regulations must be issued by Oct. 1, 2012. Joan Van Nostrand, DPA, formally director of research, ORHP, HRSA, DHHS will discuss the challenges of enrolling "hard to reach" population groups.

There have been several articles in the Wall Street Journal and the New York Times discussing the merits and pitfalls of the legislation. Most address the financing dilemmas. All acknowledge the need. Few have viable solutions to the solvency issue.

Gerry Eggert is the organizer and moderator.

Need-Based Scholarships

Need-based scholarships available for students to attend Annual Meeting

APHA is proud to announce the availability of need-based scholarships, sponsored by External Medical Affairs, Pfizer Inc., for student members to attend the 139th Annual Meeting and Exposition in Washington, D.C., from Oct. 29-Nov. 2, 2011. Twelve students will be granted registration and up to a $500 stipend to use toward food, lodging and transportation. An additional four students will be given Annual Meeting registration only. Recipients of the scholarships will be chosen based on financial need and essay. As part of the award, students will be strongly encouraged to attend at least one Section business meeting. Please inform the student members of your Section about this unique opportunity!

Visit: for complete details and application.
Please contact Pooja Bhandari at with any questions.


New Goals for APHA 2011

New Goals for APHA 2011 -- Less Trash! Less Plastic!

The 2011 APHA Annual Meeting theme "Healthy Communities Promote Healthy Minds and Bodies" gives APHA members an opportunity to build on the 2009 and 2010 themes of Water and Social Justice as public health priorities.

Green Goals. The APHA Food and Environment Working Group, the Environment Section's 100th Anniversary Committee, and APHA are setting goals to reduce waste and promote a sustainable, just, and healthy food and water system.

Got Trash? We encourage everyone at the 2011 APHA Annual Meeting to increase efforts to reduce trash, especially paper and plastic.

The Diversion Rate (the recycling/trash ratio) in D.C. at APHA 2007 was 34 percent.
The Diversion Rate in Denver at APHA 2010 was 52.75 percent.
Can we achieve a Diversion rate of 75 percent at APHA 2011?

-- The D.C. Convention Center’s water fountains and food service sinks provide filtered water! Bring your own refillable bottle to the conference to cut down on plastic waste.

-- Plan events using local resources and services that encourage wise use of water and other resources. If you need advice or suggestions, contact us:

-- Buy food sourced from sustainable producers and distributors. -- If using disposables, use compostable products and use the facility compost program. Label containers so compostables do not go into the waste stream.

-- Take advantage of the DC Convention Center's Green Initiatives:

 -- Learn more about APHA 2011 Environmental Initiatives:

Be an Ambassador of public health and social justice in your own community. Share information about the social justice, public health and environmental problems caused by bottled water and water privatization, especially disposable plastic water bottles. Use the "Resources and References" below and on the Food and Environment Working Group’s Facebook page:

Share ideas for waste reduction at 2011 APHA Annual Meeting programs, scientific sessions, events and exhibits. Send your questions and suggestions to Ellie Goldberg and join the conversation on the Food and Environment Working Group’s Facebook page


The APHA Food and Environment Working Group is a multi-disciplinary collaboration across APHA Sections, housed in the Food & Nutrition and Environment Sections. Colleagues work together to protect public health by promoting and cultivating a safe, healthy, just and sustainable food system.

If you would like to work with us toward these goals, contact Rebecca Klein,, Working Group membership is open to all APHA members.

~ ~ ~ ~ ~ ~ Resources and References ~ ~ ~ ~ ~ ~ ~

Bottled Water Myths

Bottled Water: Get the Facts

Blue Gold, Maude Barlow Book:


Rebecca A. Klein

Legislative Update

Legislative Update


Maryland Appoints Dr. Georges Benjamin to Health Benefit Exchange Board


Several states have already passed legislation establishing health insurance exchanges under the Affordable Care Act, including the state of Maryland. In late May, Maryland Gov. Martin O’Malley appointed Dr. Georges Benjamin, executive director of the APHA, to a nine-member board that will oversee Maryland’s Health Benefit Exchange. The exchange will allow Maryland residents to compare rates, benefits and quality among health insurance plans online to help them find one that best suits their needs.


“I am honored to serve in this capacity in helping reform our nation’s health system and implement a key provision of the Affordable Care Act,” said Benjamin. “Maryland has emerged as a leader in the health reform era. The lessons we learn will serve as a model for much of the nation and will strengthen coverage and improve health. As a former health secretary of Maryland, I am particularly proud to see Maryland make such progress in working to improve the health of its residents.”


Maryland has implemented reforms that have already expanded health coverage to more than 260,000 people living in the state. This year, Gov. O’Malley signed into law legislation to establish a framework for Maryland's health benefit exchange. According to research by the independent Hilltop Institute, implementing the Affordable Care Act will save Maryland an estimated $850 million and cut the number of Marylanders without health insurance in half by 2020.



Testimony on New York’s Health Insurance Exchange


New York is lagging behind other states such as Maryland in creating its health insurance exchange under the Affordable Care Act. On May 18, Section member Mary Beth Morrissey, PhD, JD, MPH, presented testimony before the New York State Insurance Department at Baruch College, New York City, on behalf of the Women’s Bar Association of the State of New York (WBASNY) on establishing New York’s Health Insurance Exchange. WBASNY is the largest New York statewide women’s bar association, and is committed to the well-being of all women in society and to the fair and equal administration of justice. WBASNY is also a member of the 57-member New York Alliance for Women’s Health.


In her capacity as a chair of the Health Law Committee of WBASNY, Morrissey called for swift action to establish New York’s Health Insurance Exchange before the end of the 2011 legislative session.  Morrissey’s testimony addressed overarching policy challenges including issues of access, health literacy and training critical to the design of a consumer-friendly structure in the exchange, and recommended steps to support the empowerment of women to make informed decisions.  Morrissey also commented on expected migrations back and forth between the Medicaid program and the State Health Insurance Exchange, and the need for appropriate structures and administrative support systems to deal with rapid transitions across programs.


Other organizations that presented at the New York City public hearing were Raising Women’s Voices, the Public Health Association of the City of New York, Greater New York Hospital Association, and Health Care for All New York.  There was a growing consensus among most of the organizations heard at the forum that there should be a statewide exchange in New York that would be responsive to the needs of all consumers from diverse backgrounds and communities including immigrants. By the time this newsletter is published, it is likely that New York may have passed its health insurance exchange legislation.


(Please contact Mary Beth Morrissey at if you wish a copy of her full testimony.)



Federal Court Decision Will Increase Access to Off-Label

Prescription Drugs Under Medicare Part D



The Federal District Court in the Southern District of New York handed down a decision on March 7, 2011, holding that regulations promulgated by the U.S. Department of Health and Human Services barring coverage for medically necessary off-label prescription drugs under Medicare Part D, were unreasonable and based upon an incorrect statutory interpretation.


The Medicare Rights Center, a national, non-profit consumer service organization, filed suit over three years ago against HHS on behalf of two seriously ill plaintiffs who had been denied coverage by HHS under Medicare Part D for their medically necessary prescription drugs. The drugs had been prescribed for off-label treatments not approved by the Food and Drug Administration. Judith Layzer had been prescribed the drug Cetrotide to control her rare form of ovarian cancer, a use documented and supported in the peer-reviewed medical literature.  The second Medicare beneficiary and plaintiff, Ray Fisher, had been diagnosed with myotonic muscular dystrophy type 2, and prescribed the drug Increlex to slow the deterioration of his muscle, strengthen range of motion, and improve quality of life. 


The statutes in issue in this case were Title XVIII of the Social Security Act (42 U.S.C. § 1395 et seq.), establishing the Medicare program and providing health insurance to individuals aged 65 and over, as well as certain eligible individuals with disabilities; and the 2003 Medicare Prescription Drug, Improvement, and Modernization Act (“MMA”), requiring a plan sponsor to provide coverage of qualified prescription drugs. (See 42 U.S.C. §§ 1395w-102-§ 1395w-104.) Under Section 1395w-102(e) of the MMA, the definition of a “covered Part D drug” makes reference to the term “medically accepted indication” as defined at 42 U.S.C.§ 1396r-8(k)(6): “any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act [21 U.S.C.A § 301 et seq. (the”FDCA”)] or the use of which is supported by one or more citations included or approved for inclusion in any of [three compendia].” The implementing regulation promulgated by the Secretary of HHS imposed the requirement that to be a “covered Part D drug”, a drug must be prescribed for a “medically accepted indication.” (See 42 C.F.R. § 423.100.) According to the Court in a decision written by District Judge Harold Baer, “in this case, coverage of the Plaintiffs’ drugs was denied because the uses for which the drugs were prescribed were not approved or listed in any of these compendia.”


The Court’s conclusion in this case was based on an analysis of the statutory language defining “covered part D drug” that made clear that, “Congress did not intend to impose the Compendia requirement.” The Court ordered that appropriate coverage be provided to the Plaintiffs. This decision, and the work of the Medicare Rights Center that helped to achieve this result, have been hailed as victories for Medicare beneficiaries such as the very sick Plaintiffs in this litigation. While the Medicare Improvements for Patients and Providers Act that became effective in 2009 did make incremental progress toward establishing patient rights to coverage for off-label treatments by authorizing use of peer reviewed literature to support off-label coverage determinations, it is clear that advocacy in Congress for enactment of legislation that would establish full off-label prescription parity under the Medicare Part D Program needs to continue.

Hospice Care in Nursing Homes and Policy Issues

Hospice Care in Nursing Homes and Policy Issues
Susan C. Miller, PhD

A half million older adults die in U.S. nursing homes each year. Hospice care, certified and reimbursed by Medicare, offers specialized end-of-life care in the nursing home when nursing homes contract and collaborate with hospice providers. There has been much growth in the use of nursing home hospice care (and in average lengths of stay), which has been accompanied by greater costs to the Medicare hospice program. These greater hospice costs (in and outside of nursing homes), and a 50 percent growth in the number of (mostly for-profit) Medicare-certified hospice providers, raised policy concerns which lead to review by the Medicare Payment Advisory Commission, or MedPAC.

MedPAC commissioned analyses which resulted in a recommendation that there be a strengthening of procedures for determining recertification of hospice eligibility. (It recommended procedures for greater provider accountability and more Office of Inspector General investigations). MedPAC also recommended a changed Medicare payment system that would vary per diem payments to better reflect the differing intensity of hospice service provided across hospice episodes of care. (MedPAC, 2009) Under the Patient Protection and Affordable Care Act of 2010, Congress gave CMS the authority to revise, in a budget-neutral manner, the payment system, but it did not mandate it be changed in the manner recommended by MedPAC. CMS has just released an RFP to study creation of revised payment system.

To inform efforts in Medicare hospice reform, we undertook a number of studies at the Center for Gerontology and Health Care Research at Brown University. Specifically, given our ability to expertly link nursing home resident assessment (MDS) data with Medicare enrollment and claims data (Intrator et al., 2011), we aimed to conduct analyses of nursing home-linked data to inform policy regarding hospice care in nursing homes. Below I highlight some of our research findings.

Previous research has found the use of hospice care to augment nursing home end-of-life care to be beneficial.(Gozalo & Miller, 2007; Miller et al., 2002) However, its use has been historically low. However, while in the 1990s a low proportion of U.S. nursing homes contracted with a hospice, recent analyses show this proportion to now be closer to 90 percent. We have also found a doubling of hospice use by nursing home residents between 1990 and 2006, and in 2006 one-third of Medicare beneficiaries who died in nursing homes accessed hospice. (Miller et al, 2010). For nursing home residents who die with dementia, use of Medicare hospice care nearly tripled, with approximately 40 percent of decedents accessing hospice in 2006. (Miller et al., 2011) Additionally, of the nursing home residents who died in 2006 and received hospice, only 17 percent had cancer diagnoses.

While the increased use of hospice care in nursing homes is viewed as a positive development, this increased use has been accompanied by longer average lengths of stays and thus greater costs to the Medicare hospice program; and, average lengths of stay are longer for nursing home versus non nursing home hospice patients. (Miller et al., 2010) In fact, for residents dying with advanced dementia in nursing homes, average lengths of stay have tripled -- from 46 days in 1999 to 118 days in 2006. Averages, though, are misleading, and what we are really seeing is a growth (in some states) in the proportion of long hospice stays (>180 days), and nationally an increase in the length of long hospice stays (i.e., stays at the 90th percentile of the distribution are longer). Notable, however, is that hospice length of stay distributions are bimodal, and approximately 25 percent of hospice patients continue to have stays of seven days or less.

In addition to the above, we have observed significant differences across U.S. states in the use of nursing home hospice. In conjunction with this, the volume of growth in hospice use within a state is associated its growth of Medicare certified hospice providers. Furthermore, hospice average lengths of stay are longer in states with the greatest provider growth (versus those with lower growth).

Based on the above and other analyses, we concluded that there is support for MedPAC’s recommendation to modify the current Medicare hospice reimbursement system. Also, It appears that varying payments as a function of length of stay may be a logical approach for reducing lengths of stay (some of which are believed to be provider driven) and Medicare costs. However, we cautioned (in our published work) that it is important for any new policy to explicitly acknowledge the challenges inherent in the timing of hospice referral for nursing home residents in the last stages of (noncancer) chronic terminal illnesses by recognizing “early” referrals leading to long hospice stays will occur. We believe these longer stays should be deemed “acceptable” in the presence of well-documented physician evaluations and eligibility determinations. Without such explicit acknowledgement, the fear is that undue scrutiny may occur, resulting in decreasing enrollments and a higher prevalence of very short hospice stays.

The above work was supported by grants from the Agency for Health Care Research and Quality (R03HS016918), the Shaping Long Term Care in America Project funded by the National Institute on Aging (P01AG027296), and by an Alzheimer’s Association grant (IIRG-08-91343). Our continuing research is examining the effect of nursing home hospice use (at the resident and nursing home level) on health care utilization and quality outcomes. Also, Dr. Gozalo and colleagues have a contract with the National Hospice Foundation of the National Palliative Care Organization to examine changes to the Medicare Hospice Benefit Payment System, using visit data from for- and non-profit hospices. Last, through our NIA-funded Shaping Long Term Care in America Project, we have created a website that has much hospice and nonhospice nursing home-, county- and state-level data (go to

Gozalo P, Miller S. Hospice enrollment and evaluation of its causal effect on hospitalization of dying nursing home patients. Health Serv Res. 2007;42: 587-610.

Intrator O, Hiris J, Berg K, Miller SC, Mor V. The Residential History File: Studying Nursing Home Resident’s Long Term Care Histories, Health Services Research, 2011;46: 120-137.

Medicare Payment Advisory Commission. Reforming Medicare's Hospice Benefit. Report to the Congress: Medicare Payment Policy. Washington, DC, 2009, pp. 347-376.

Miller SC, Lima J, Gozalo P, Mor V. The Growth of Hospice Care in U.S. Nursing Homes, Journal of American Geriatrics Society, 2010;58:1481-88.

Miller SC, Lima J, Mitchell SL. Hospice Care for Persons with Dementia: The Growth of Access in U.S. Nursing Homes. Journal of Alzheimer’s Disease and Other Dementias, 2010;25: 666-73.

Miller SC, Mor V, Wu N, Gozalo P, Lapane K. Does receipt of hospice care in nursing homes improve the management of pain at the end of life? J Am Geriatr Soc. 2002;50: 507-515.

Climate Change and the Elderly

Climate Change and the Elderly

There is a growing and important recognition of the health implications of global climate change within the field of public health. Abundant evidence of this is available at both the national and international levels, but here let me mention some of the recent resources and activities of APHA. For example, APHA has been conducting a webinar series on the health implications of climate change and the public health response. In addition, there are two important new documents — Conveying the Human Implications of Climate Change and Climate Change: Mastering the Public Health Role, A Practical Guidebook. (Information about the webinars and both of these documents are available at

Unfortunately, there is an influential discourse of climate change denial in the United States. The fact of the matter is that this is an ideological discourse, not a scientific one; and it is promoted by those with a vested interest in carbon intensive technologies. The scientific evidence for excessive and increasing levels of green house gases in the atmosphere, the rapid melting of ice sheets and glaciers around the world, and measurable warming of the atmosphere in interaction with the conditions of the world’s oceans combine to present us with plethora of changes that will affect the health, the food and fresh water supply, and the quality of life of people throughout the world.

This truth is certainly “inconvenient,” to use Al Gore’s memorable phrase, but it is more than that, it is frightening and alarmingly urgent. The human and ecosystem costs of climate change are upon us now, and those costs and challenges will be probably the single most significant background condition of political, economic and personal life for generations to come.

Today’s public health agenda is rich and crowded, to be sure. Global health justice and disease prevention is enormously important. Promoting health and human rights by getting at the underlying social determinants of health and the health inequities and disparities around the world is enormously important. The aging demographics of many countries (which is the fruit of public health’s twentieth century successes) and the crisis of long term care and disability in virtually all countries of the world are enormously important.

But none of these challenges is more daunting in its implications than climate change; and indeed, I would argue, none can be understood or dealt with properly unless placed in the context of climate change.

The fields of environmental science that study climate change and the fields of public health that study social epidemiology and policy contain the same lesson and message: No organism (including human beings) exists as a separate, self-contained biological unit. All biological functioning (and dysfunction) is embedded in a context of natural and social systems. When we talk of “environmental health,” we can no longer attend only to a pollution model in which we simply see the environment as a source of pathogens or toxins affecting human disease. To supplement that perspective, there is a growing awareness that we must understand ecosystems as webs of life that are the ground and the fundamental infrastructure of human health and flourishing.

Climate change and public health perspectives converge in another way, as well. Both fields are underscoring the vital importance of recognizing vulnerability, resiliency and social justice.

That is where climate change becomes especially relevant to the public health needs of the elderly and to public health policy in an aging society. As people age, they generally become less directly and personally involved in those activities that create the largest carbon footprints. Despite some silly stereotypes, most retirees do not jump into their gas-guzzling recreational vehicles and tour the country. Aging in place and new forms of congregate residential and support facilities are patterns much more conducive to personal well-being, community cohesion and environmental sustainability. (There is a huge infrastructure to be built in the coming decades to house the elderly boomers, and it no doubt will be constructed in much greener ways than current housing was.)

The problem arises because it is precisely the life circumstances and the health needs of the elderly that make them most susceptible to the various manifestations of climate change. In the United States significant risks are posed by extreme weather events such as long, severe heat waves, and violent storms that cause flooding or severe blizzards. As these situations become more intense and frequent, as climate change scientists expect they will, those with underlying health conditions, low-income groups, and those with various types of disability will be an increased risk. Extreme weather events often require evacuation, or else they confine people to their homes without adequate access to necessities for prolonged periods of time. They also routinely lead to breakdown of our social infrastructure and support services, such as loss of electricity, communications and emergency response services. One recalls the crisis and loss of life in flooded neighborhoods and at medical facilities and nursing homes in the New Orleans area in the aftermath of hurricane Katrina. This profile of climate change induced stress and disruption is bad news for the elderly.

At least two lessons grow out of these sobering considerations.

First, climate change adaptation planning and public health emergency preparedness planning must be coordinated and go hand-in-hand. Better synthesis is beginning to happen, but too often in the past these two types of community awareness and preparation were proceeding in isolation from one another. In these activities, it is essential that the special needs of vulnerable populations, including the elderly, be represented and provided for. Climate change is detrimental to everyone, but it will be more detrimental to some than to others. Seniors are not without resources and resiliency of their own, but they will need well informed plans and targeted resources, which may not be forthcoming if their voices are not heard and if they are not present at the planning table.

The second lesson concerns ethics and responsibility. Climate change is often portrayed as a distant problem for a future time and the next generation. Seniors may well ask, should I worry about that? The obvious answer is that the elderly should care about climate change because its effects are already upon us, and they are going to be at risk during the remaining years of their own lives. A more interesting response takes note of the fact that many of today’s elderly have grown up and lived through times of common struggle and hardship. It is not characteristic of their generation to be exclusively focused on narrow self-interest, a “what’s in it for me” attitude. The elderly are the custodians of the future, not in the sense that they will make the future, but in the sense that they tend to be the principal trustees of the values that protect the future. Time and time again, they show themselves to be identified with issues they perceive to be important, not primarily to themselves, but to their children and their grandchildren.

The challenges of climate change are not merely threats to elderly. These challenges are also a call to the elderly — a call to step up on behalf of the generations to come, a call to draw upon the wisdom and experience of their own lives so as to shape their own legacy.

Bruce Jennings is Director of Bioethics at the Center for Humans and Nature and is a lecturer at the Yale School of Public Health. He is currently the chair of the APHA Ethics SPIG.

Raising Awareness of Elder Abuse

Elder Mistreatment: Debunking Common Myths

Mickey Rooney’s experience with elder mistreatment shines a light on this often hidden but widespread problem. Elder mistreatment is defined as intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder. This includes failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm. A first step might be addressing common myths about elder abuse and neglect.

MYTH 1: Elder abuse happens mostly in nursing homes and is perpetrated by strangers.

Four percent of people 65 and older lived in nursing/skilled nursing facilities in 2008. Sixty-eight percent of people 65 and older lived in households with relatives in 2008. Twenty-seven percent lived alone. Reports of abuse in community settings vastly outnumber reports of abuse in institutions. The 2000 Survey of State Adult Protective Services found that APS programs across the United States received a total of about 473,000 elder/adult abuse reports, for the most recent year for which data were available. Of these, 60.7 percent, or 287,000 reports, involved domestic settings, 8.3 percent, or 39,200, involved institutional settings, and the others were not tracked by setting. An estimated 10 percent of the complaints or about 20,000 complaints received by the Long Term Care Ombudsmen during fiscal year 1998 claimed abuse, gross neglect or exploitation. The 2000 APS survey and a more recent study which interviewed community-dwelling elders found that the majority of abusers were family members, particularly adult children and spouses.

MYTH 2: Elder abuse is not a problem in my community.

Elder abuse affects people from all socio-economic groups, cultures and ethnicities. Studies show that between 2 and 11 percent of the nation’s older adult population experiences abuse, neglect, exploitation or self-neglect each year. The few studies comparing different cultural groups’ perceptions of elder abuse found significant variations between groups in the identification and perceived seriousness of psychological, physical and financial elder abuse and neglect. It’s important to consider how people define elder abuse, and how cultural norms may affect willingness to report or cooperate with interventions.

MYTH 3: If I report suspected abuse, Adult Protective Services will remove the older adult from their home.

If there is no serious threat of immediate harm, Adult Protective Services workers will not remove a non-consenting adult from their residence. Unlike when child abuse is suspected, in elder/adult abuse cases the social worker presumes the client has decision-making capacity. Unless a court adjudicates otherwise, they must accept the client’s choices. Adult Protective Services are those services provided to older people and people with disabilities who are, or are in danger of being mistreated or neglected, are unable to protect themselves, and have no one to assist them… Guiding Value: Every action taken by Adult Protective Services must balance the duty to protect the safety of the vulnerable adult with the adult’s right to self-determination.

—National Adult Protective Services Association. Code of Ethics

MYTH 4: It’s a family issue and I shouldn’t get involved.

Families are often ill-equipped to identify and address elder abuse, so it’s critical for community members to notice and help elders at risk for mistreatment. For every case of suspected elder abuse that is reported to authorities, five cases go unreported. Many older victims’ needs are not being addressed by health, legal and social services systems. While the effectiveness of interventions needs to be thoroughly studied, systems won’t even have a chance to help unless mistreatment is reported.

Join the fight against elder mistreatment! Shine a light on this issue to help people recognize and address it! For helpful information and materials, visit:·

Center of Excellence on Elder Abuse & Neglect at University of California, Irvine

Downloadable posters, handouts of “Red Flags of Elder Mistreatment" in multiple languages·

International Network for the Prevention of Elder Abuse

Downloadable posters in several languages, press releases·

National Adult Protective Services Association

Publications describing APS and clients served·

National Center on Elder Abuse

Community Outreach kit, publications, factsheets·

National Committee for the Prevention of Elder Abuse

Speaker’s Directory, publications·

National Consumer Voice for Quality Long-Term Care

Policy tools, fact sheets, publications on nursing home care and residents’ rights

Elaine Chen, MS

Building Healthy Communities for Active Aging

Building Healthy Communities for Active Aging

Will your Community Apply to be Recognized this Year?
The Building Healthy Communities for Active Aging awards recognize communities that have excelled in strategies, planning and programs that support active aging and smart growth. The Achievement Award, the top honor, is awarded to communities for overall excellence in building healthy communities for active aging. The Commitment Award recognizes communities that have developed and begun to initiate a specific plan to implement smart growth and active aging principles.

Communities self nominate for the award. A panel of judges selects the winners each year. Applications for 5th annual Building Healthy Communities for Active Aging the 2011 are due July 11, 2011. For more information, see:

2011 Rachel Carson Poetry, Essay, Photography and Dance Contest

Teams will share through one of these distinct mediums their own interactions and reflections on the wonders of nature. Mixed media entries are also welcome, such as a photo accompanied with a poem or essay. Dance video entries can be of performers or capture movements and visible changes in nature from dawn to dusk. This year, we invite entries in Spanish. The deadline for entries is Friday, June 10, 2011.

The contest is sponsored by the U.S. EPA; the National Center for Creative Aging; Creative the Dance Exchange; the Rachel Carson Council, Inc; and Generations United. For more about the contest and to see previous winners please see

International Conference on Age-Friendly Cities

The first international conference on age-friendly cities will be held this Sept. 28-30, 2011, in Dublin, Ireland.

International Federation on Aging 11th Global Conference on Aging

It's time to start thinking about the International Federation on Aging’s Global Conference on Aging. It will be held Prague, Czech Republic, May 28-June 1, 2012.

Deadline: December 2011.

New Aging and Public Health Section in Texas Public Health Association

New Aging and Public Health Section in Texas Public Health Association

The Texas APHA affiliate, Texas Public Health Association, has just created a new section: Aging and Public Health. A petition was successfully circulated to create the section at last year’s state conference, signatories agreeing to join the section when created. Upon receipt of membership registrations from sufficient new TxPHA members joining through Aging and Public Health, the TxPHA Governing Council voted on March 14 to create the new section, which will now be in existence for this year’s TPHA Annual Educational Conference, April 13-15. Several members of the APHA Aging and Public Health Section are members of the new TxPHA section of the same name.

- James H. Swan


These are exciting times when considering the many ways our transportation systems impact health and equity in our communities. Congress extended the current federal surface transportation bill until Sept. 30, 2011, and Congressional committees are aiming to draft a new transportation bill before this latest extension ends.

Want to learn more about the connections between transportation, equity and health? View our archived webinar series, subscribe to the monthly transportation and health eNewsletter that offers an array of new events and updates, and download the newly released online public health and transportation toolkit and accompanying resources today.

We also invite you to send a message to your members of Congress urging that they ensure that strong public health provisions are included in the federal surface transportation reauthorization. For more information, visit

New Program in Public Health at University of California

New Program in Public Health at University of California, Irvine

The Program in Public Health at the University of California, Irvine is pleased to offer the Master of Public Health in three concentrations: Environmental Health, Epidemiology, and Sociocultural Diversity and Health. The mission of the UC Irvine MPH program is to create public health practitioners who can effectively reduce the burden of disease and disability in culturally diverse communities in Southern California and around the world. A broad training in the global dimensions of public health principles prepares students to lead and work collaboratively on the assessment of health-risk factors and the management of prevention strategies. The MPH is a professional, interdisciplinary degree designed to give students the skills, knowledge and experience they need to make a difference in the field of public health. The Program in Public Health also plans to offer a PhD in Public Health and establish a dual-degree MD/MPH with the School of Medicine in coming years. More information about the MPH program can be found on the UCI Public Health website at:


Age Healthier, Breathe Easier

Age Healthier, Breathe Easier

Kathy Sykes

One of the indelible memories I have of my grandfather, Lars Svensson, was the trouble he had breathing. For as long as I can remember he struggled to breathe, even when we went for a short walk or just a few feet to the mailbox in the front yard. My grandfather was a smoker and suffered from a serious lung disease called emphysema, also known as chronic bronchitis, chronic obstructive pulmonary disease, or COPD.

COPD is now the fourth leading cause of death in the United States and also causes long-term disability. Both asthma and COPD are common chronic respiratory diseases that take a toll on the quality of life for persons of all ages. More than 12 million Americans suffer from COPD, and another 12 million may have it and not know it.

I was a teenager when my grandfather died, at a time when very little was known about treating the disease. We fortunately know a lot more now about living with COPD and asthma, including how to avoid the environmental triggers that can cause an attack. By reducing exposure to environmental triggers, one can control and reduce the frequency of symptoms and make it easier to breathe.

Triggers in the environment include outdoor particle pollution and ozone. Indoors, where we spend 90 percent of our time, common indoor hazards may trigger an asthma or COPD attack including tobacco smoke, direct and second-hand smoke, animal dander, dust mites and cockroaches, mold and pollen. It is also important to check furnace and heating units each year and fix water leaks quickly help to reduce the occurrence of these triggers in your home. Pesticides, household cleaning products and substances with irritating odors may also exacerbate COPD and asthma. And don’t forget to check the air quality index where you live to see if the air quality is a problem. If it is, reduce outdoor activity as much as possible on poor air quality days.

Asthma and COPD have a lot in common and affect the health and quality of life of older Americans. The U.S. EPA Aging Initiative has developed a poster in English and Spanish called Age Healthier, Breathe Easier. The fact sheet on the same topic has been translated into 17 languages. See:

About the author: Kathy Sykes began working for the U.S. EPA in 1998. Since 2002, she has served as the Senior Advisor for the Aging Initiative.

Call for Papers

Call for Papers
Journal of Health Behavior and Public Health in Academy Journals 

The Journal of Health Behavior and Public Health explores research on health education, health communication, health behavioral changes, and public health policies, evaluates them with multilevel aspects, and exchanges knowledge in public health in interdisciplinary and international arenas.

The journal is published using an open access publication model, which means that all interested readers are able to freely access the journal online at without the need for a subscription.

For more information about the Journal of Health Behavior and Public Health, please visit:
The HBPH site is:

Tetsuji Yamada, PhD
Professor of Health Economics Department of Economics and Center for Children and Childhood Studies
Rutgers University, the State University of New Jersey, USA
Office Telephone: (856) 225-6025 

Update on APHA Book Publications – June 2011

Update on APHA Book Publications – June 2011

I am very pleased to announce that there are a number books in production as well proposals for books that have been accepted, and work on them is under way.  Furthermore, several authors of current products will be available to sign their books at the fall APHA Annual Meeting in Washington, D.C.

APHA members of all Sections are encouraged to using existing, new and emerging products in their academic courses. These resources are also very relevant to policy, prevention, advocacy and client care initiatives. Please encourage your colleagues to use these timely and evidence-based resources.  Go to the APHA website to find out more: 

We are also looking for new proposals for books. If you have an idea for a book, please send a few paragraphs describing the idea, intended audience and your qualifications to Nina Tristani, Director of Publications, APHA,

Thank you for supporting APHA Books and promoting these products.

Norman Giesbrecht, PhD, Chair, APHA Publications Board



o    Environmental Health and Racial Equity in the United States, Authors: Robert D. Bullard, PhD; Glenn S. Johnson, PhD; and Angel O. Torres, MCP

Books at Printer in June

·         Megacities and Public Health, Omar Khan, MD, MHS

·         Public Health Management of Disasters, 3rd edition, Linda Landesman

Books Currently in Production

  • Injury Prevention for Children and Adolescents: Research Practice, and Advocacy, 2nd edition, Karen D. Liller, PhD
  • School–Based Health Care, Terri Wright, MPH and Jeanita Richardson, PhD

Books in Development

  • Control of Communicable Diseases Manual, 20th Edition
  • Control of Communicable Diseases Lab Book
  • Compendium of Methods for the Examination of Foods, 5th Edition
  • Caring for Our Children, 3rd edition
  • Standard Methods for the Examination of Water and Wastewater, 22nd edition


·         Communicating Public Health Information Effectively is now on Kindle.

Co-sponsored Books

Jossey-Bass: Emerging Infectious Diseases published in April 2011.


Jones and Bartlett Learning books to be published before the 2011 annual meeting: Essentials of Biostatistics in Public Health, Essential Case Studies in Public Health: Putting Public Health into Practice, Global Health 101, Field Epidemiology in Public Health Practice, Epidemiology in Women's Health, Essentials of Health, Culture and Diversity, Epidemiology of Chronic Disease, Introduction to Air Pollution Science, and Essentials of Program Planning and Evaluation.


APHA is also co-publishing with Wiley, Designing Healthy Communities by Richard Jackson.  The book is a companion to a PBS series to air this fall.