Letter from the Chair
In November 1948 APHA approved the creation of the Medical Care Section. When we meet this year for the APHA Annual Meeting in San Diego we will be just shy of 60 years old. Until this year I didn’t know anything about our section’s history: How it is that Medical Care became a section in APHA? Funny you should ask. Let me refer you to an extraordinary article by Arthur Viseltear (AJPH, November, 1973, 63(11): 986) that looks at the time before we were created, 1926-1948. If you can’t lay your hands on it, then make it a point to come to our Section booth in San Diego -- we’ll have reprints thanks to Ollie Fein. Also, make it a point to come to this year’s “Evening with…” because we will not only be honoring this year’s Viseltear Award winner, but we’ll be celebrating our history and the extraordinary work of doctors Steffie Woolhandler and David Himmelstein.
A big anniversary is coming up for us, and that creates a big opportunity to reach out to others to come and join us. To that end we are re-examining our Web site and our exhibit area. As part of that re-examination, one of my esteemed colleagues in Medical Care, Dr. Sidney Socolar, has long argued that the Medical Care Section stands for much more than a national health plan; that we are much more than a “Johnny (or Jill) One-Note,” which is apparent if you look at our history and our causes. He noted that as a Section we are concerned about all the inputs to health, i.e., the social determinants, and should include those determinants on our Web site. So, we began looking at models of inputs to health. While I struggled with copyright permissions, Sid focused on the content. I had found a model that we could, and did, get permission to use, but Sid, after reviewing it, pointed out the missing element –- there was no explicit mention of social hierarchy/class/ power. Socio-economic status explains a lot of variation in health, but not all of it, as anyone who saw the recent PBS series “Unnatural Causes” can attest to.
Sid, as usual, is right. A model that does not explicitly include class, or social hierarchy, or power as a social determinant of health is an incomplete model even in our so-called classless society. And so, within the next 1-2 months you will see something new on our section Web site when you come to check e-communities, AND you will see something new when you stop by the Section booth at the Annual Meeting and at the “Evening with...” We don’t know that it will become any easier to explain to your colleagues what “Medical Care” is, but hopefully it will demonstrate that we are a big tent Section, one that they’d like to join. Make it easier on yourself; bring them with you.
Medical Care is far from being a “Johnny one note.” The fight for a national health program is essential to what we are, but what we are does not stop at that. As you’ll read in this edition of our newsletter, Section members are also concerned about other threats to health, including the threats posed by highly enriched uranium (Vic Sidel) and climate change (Mona Sarfaty); Section members are concerned that Churchill was right that we will see a single payer solution but only after health care as we now know it totally decomposes (Wayne Myers).
I guess that’s all for now. Drop me a line, let me know what you think of what we’re doing and what we’re planning. Get involved!
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Desired transition: Carol Miller is running as an Independent for one of New Mexico’s Congressional seats. Find our more on her Web page: www.carolmillercongress.com
Kathy Virgo is leaving the VA and St. Louis after 20+ years to become of the director for health services research for the American Cancer Society. Wearing her new hat, Kathy will also take over as chair for the Medical Care Section Health Services Research Committee.
Leatrice Berman Sandler joined the Centers for Medicare and Medicaid Services as a Medicaid program integrity specialist in their newly formed Medicaid Integrity Group, AND Leatrice will be running for an APHA Executive Board seat, with the blessing of her new employer. Thank you, CMS.
Carolyn Brown has been appointed by the APHA Executive Board to The Nation’s Health Advisory Committee.
Camara Jones demonstrated her star quality in “Unnatural Causes: Is Inequality Making Us Sick?” Episode 2: When the Bough Breaks. The series was aired on PBS across the country in April 2008. If you didn’t see the series, do it now!
In Fall 2008, Oxford University Press will publish a paperbound edition of Social Injustice and Public Health with a new epilogue (2008) written by the authors, Barry Levy and Vic Sidel. The book launch will take place at the 2008 APHA Annual Meeting.
Julie Zito was honored in April 2008 with University System of Maryland Regents' Award. Congratulations! The press release says it all:
Pharmacoepidemiology Expert is the First School of Pharmacy Faculty Member to Receive the Honor
By: Becky Ceraul
Julie Magno Zito, PhD, a professor in the Department of Pharmaceutical Health Services Research at the University of Maryland School of Pharmacy and affiliate in the Department of Psychiatry at the University of Maryland School of Medicine, is one of four winners of the 2007-2008 University System of Maryland (USM) Regents’ Faculty Award for Research, Scholarship or Creative Acts. Dr. Zito is widely known for her pharmacoepidemiologic studies on medications for behavioral and psychiatric problems in children.
On April 11, the USM Board of Regents presented the awards during its spring meeting at the USM Hagerstown Regional Higher Education Center. The USM educators and researchers were honored for their professional accomplishments in the areas of research, scholarship and creative activity, teaching, public service, mentoring and collaboration.
Dr. Zito’s 2000 Journal of the American Medical Association study of preschoolers’ use of psychotropic drugs resulted in major national and international media attention. Additionally, a $10 million clinical trial on the efficacy and safety of methylphenidate in youth was designed in light of her pharmacoepidemiologic study findings. She currently works with the National Institute of Child Health and Human Development in response to federal legislation mandating annual reporting of the frequency of use of pediatric medications to prioritize drugs for further scientific evaluation. The significance of this work lies in the need to identify gaps in the evidence of efficacy and safety of marketed medications in pediatric populations and to promote research models to fill the gaps.
“I started as a practicing pharmacist and noticed that some patients with chronic conditions took their medications and got better, and others took medicines and didn’t get better,” says Dr. Zito. “This experience motivated me to go to graduate school, get advanced training in epidemiology and join others in the emerging scientific discipline of pharmacoepidemiology. This award is recognition of the field as an accepted scientific area.”
According to C. Daniel Mullins, PhD, chair of the Department of Pharmaceutical Health Services Research, Dr. Zito is one of the most productive members of the department with nearly 100 publications, numerous invited lectures and presentations, and more than $4 million in public and foundation research funding.
“Julie’s scholarship is pioneering in the field of pharmacoepidemiology and her students have benefited greatly from her mentorship,” Mullins says.
Established in 1995, the Faculty Awards are the highest honors presented to USM faculty by the Board of Regents. Awardees are selected by the Council of University System Faculty and approved by the board. Each award recipient receives $1,000 and a plaque of recognition for the honor.
OTHERS: Let us know what is going on in your life so we can share.
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Highly Enriched Uranium
Vic Sidel, MD
Radiopharmaceuticals are extremely important in medical care, but adverse public health consequences must be carefully avoided. The medical isotope technetium 99, useful in the examination of organs such as hearts, lungs and kidneys, is used in approximately 80-85 percent of the world's diagnostic imaging procedures (cardiac perfusion scans and bone scans among them) and 12 million procedures in the United States alone. But use of highly enriched uranium (HEU) to produce technetium 99 is a significant and unnecessary public health hazard that may lead to nuclear weapons proliferation and nuclear terrorism.
Technetium 99 is derived from molybdenum 99, which is made in nuclear reactors from HEU, which contains more than 90 percent uranium 235. Placing HEU "targets" in or near nuclear reactor cores produces about 95 percent of the global supply of the radioisotope. The radioactive cores produce high neutron fluxes that flood the targets and produce molybdenum 99, a short-lived fission product with a half-life of 2.7 days that decays into technetium 99. However, less than 5 percent of these "targets" are consumed; the rest is stockpiled as waste in Canada, Europe and South Africa, where companies use about 85 kilograms of HEU per year to make molybdenum 99. While the isotope producers provide security for HEU transport and storage, it's unclear whether the security is stringent enough to eliminate the risk of theft. If a sophisticated terrorist group acquired about 50 kilograms of this waste, they could build a simple Hiroshima-type nuclear bomb
Conversely, low-enriched uranium (LEU) contains less than 20 percent uranium 235 and cannot be used to make a nuclear bomb. But it still can be used to make molybdenum 99. Conversion of use of HEU in production to use of low-enriched uranium, which is not directly usable for weapons, is technically feasible and readily achievable. Converting facilities to use LEU is relatively inexpensive. The security cost savings alone would help defray the cost. This should prompt a global effort to replace HEU with LEU in medical isotope production.
Health professionals have an opportunity and an ethical obligation to close one of the most vulnerable pathways to a terrorist nuclear bomb by ending the use of HEU in the production of radiopharmaceuticals.
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Climate Change and the Public's Health
Mona Sarfaty, MD
Most of the popular attention given to date to the problem of climate change has focused on animal habitats, survival of animal species and changes in the world distribution of ice and water. This year, key public health organizations joined forces to deliver a different message that climate change affects people’s health and is, in fact, already affecting people’s health. This shift in framework to present climate change as a public health issue was the central message delivered by APHA along with several hundred national, state and local collaborating organizations during National Public Health Week (April 7-13, 2008).
There were thee goals for the week:
- To provide APHA partners and their communities across the country with the facts and tools to empower them to work on this problem to help ensure a healthy future;
- To educate policy-makers about the connection between climate change and health, and to ensure that in the future, the public health community is included in all discussions about policies that impact climate change; and
- To hold a summit with public health experts and policy-makers and develop a list of key recommendations for addressing at the local, state, and national level the health impacts of climate change.
A Web site (www.NPHW.org) was established to present the materials for the week. A Blueprint with recommendations for the public health community was posted that articulates recommendations in the areas of education, research and advocacy. The Blueprint recommends that all APHA members should educate themselves and others about the health effects of climate change and should establish collaborative relationships with associations in their locales who are addressing the causes or effects of climate change.
Research is needed to develop vulnerability assessments in all geographic locales that project the impact of climate change, especially on vulnerable populations. Research also is needed regarding the impact of emerging changes in climate on health. Advocacy recommendations include educating decision makers, supporting the development of public leadership and environmental work force capacity. Public health functions like surveillance and monitoring need strengthening. Best practices that benefit health and the environment must be identified. The public health system itself should go green.
A Toolkit was also made available through the Web site to assist groups around the country in their planning for National Public Health Week. This included fact sheets on the regional impacts of climate change, what the public health community can do to diminish the impacts, key messages for outreach to the public, legislators and the press, and a “Healthy Climate Pledge” that could be integrated into local activities. The pledge items were: 1) Be prepared; 2) Travel differently; 3) Eat differently; 4) Green your work; 5) Green your home. Each item in the pledge summarized key actions an individual can take to decrease the output and accumulating burden of green house gases -- people signed the pledge.
Hundreds of activities and events were held around the country during National Public Health Week. A white paper was also produced that will be published by APHA. Many organizations provided input and feedback on the development of the white paper. This paper is viewed as a strategic document to guide APHA in its future activities on climate and health.
A press conference with the Association for Health Care Journalists was held on March 29 ,which generated substantial national news coverage. More than 40 reporters attended. Hearings were held on both the House and Senate sides of Congress, and several APHA members testified. Legislative activities included drafting authorizing and appropriations proposals to strengthen public health involvement and funding with regard to climate change.
Contact Mona Sarfaty, MD, firstname.lastname@example.org, if you have further questions about this topic.
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Action Board Report
Simon Piller, MD
Action Board Representative for Medical Care Section
I had the opportunity to attend a mid-year meeting of the Action Board at APHA headquarters in Washington, D.C. It was a good learning experience for me. I am still the learning the ins and outs of the Action Board -- in the sense of what role it plays at this time and what possible role it could play. In my opinion there is the potential for the Action Board to take a leading role in policy implementation within APHA. To quote from a letter I received from APHA (signed by President-elect Cheryl Easley and Executive Director Georges Benjamin):
“The Action Board is charged with the facilitation and implementation of Association policies and positions. The Action Board takes action on APHA priorities, action alerts and other advocacy activities as needed. The Action Board selects three representatives for the Joint Policy Committee by participating in new policy review. In carrying out its responsibilities, the Action Board appoints subcommittees; collaborates with other units of the Association and its Affiliates; and encourages relationships with other organizations interested in collaborative action and building coalitions.”
I think there is more that the Action Board can do. As a member of the Action Board's Archiving Committee (more aptly named Existing Policy Review Committee), I was mandated to encourage APHA membership participation in review of policies from the recent or not so recent past. The idea is to streamline the policies we have, guaranteeing their relevance, and utility. I think the worry about permanently archiving policies that still have validity is overblown, because there are plenty of checks and balances that prevent this. I think two of the best aspects of this process are the learning process for rank-and-file APHA members when they participate, and the identification of policy gaps in which important APHA concerns could be addressed. Participation by the MC Section with this process was scant at best this year. I think it would be useful to discuss this process and the MC Section's relationship to it in San Diego.
During the Washington meeting, many of us went to the offices of our respective Congressional representatives to raise issues of importance that were identified by APHA executive leadership. It was a useful experience; certainly it helped me get an idea of where the politicians stand on some APHA issues.
There was an interesting “Grass Tops” project presented at the Action Board meeting. The project is intended to: “Identify, motivate, train and activate a core of capable, experienced advocates in the states who can communicate APHA's federal policy priorities to targeted public officials.” The goal is greater collaboration between APHA and state and local public health associations. Unfortunately some of this seems to be top-down prioritization of policies that the Action Board is encouraged to promote (either to our section membership, the public at large or our elected representatives). It also seems that the policies or actions are more reactive than proactive, e.g., promoting important policies not yet on the politician’s radar screen (such as single party payer or opposition to the Iraq war).
Finally, the choice by APHA of what policies to support sometimes manifests itself as a trade-off (sell-out?). This was clearly the case in a recent alert from the Government Relations team: “Contact your representative and urge him/her to support a provision in the Iraq war supplementation spending bill that would place a temporary one-year moratorium on seven questionable Medicaid regulations that would make significant cuts to the Medicaid program over the next five years. On May 22 the Senate passed a supplemental appropriations bill that included a moratorium on seven Medicaid regulations by a veto-proof margin. Including the Medicaid provisions in the Iraq war supplemental is our best chance of getting the president to sign the moratorium into law.” Am I missing something? Didn’t this pit one APHA policy (Medicaid funding) against another (opposition to the Iraq war)? If it wins, it is a pyrrhic victory at best!
Comments about the Action Board and its potential as a leading force for APHA policy are now being accepted. Ellen S. and Leatrice among others have expressed concern for quite some time and again, most recently. A significant discussion would be warranted in San Diego to help the Action Board chart its course and lead.
Please e-mail me with any concerns you might have.
Simon Piller, MD
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2011: Meltdown and Recasting
The following column was first published by “The Rural monitor” in its issue of spring, 2005. Myers’ columns appear quarterly under the series title, “Look What’s Coming.” This column is a fantasy written in response to the question, “how can we get from the current mess to a single payer system?”
Wayne Myers, MD
Health care bills are a factor in about half of household bankruptcies, which are at an all-time high. At this writing Congress is focused on controlling bankruptcy instead of its causes. Eventually the problem of health costs will have to be dealt with. Health costs have been taking increasingly large bites of our economy for 75 years and won't stop without major structural change. To gather material for this column I cashed in a bunch of frequent flyer miles and made a trip to the year 2011. This is what I learned.
Early on, the spiral toward meltdown was subtle and without a clear beginning. Since the early 1990s families' health costs had been continually shifting from employers to employees as unaffordable premiums, deductibles and co-pays. More recently, federal cuts to the Medicaid budget were interacting with states' budget difficulties to produce Medicaid enrollment cuts. The proportion of the population with real insurance was dwindling.
The health care meltdown began heating up in 2006. Hospitals and clinics were seeing their bad debt and accounts receivable climb. They shifted ever more costs to insured and paying customers, making insurance even less affordable, increasing the percentage of uninsured and accelerating the spiral. More and more providers became unable to pay suppliers, to make payroll or to keep their doors open. The first to go under were those with the largest share of indigent patients. Their demise shifted the indigent care load to more affluent hospitals. People getting into hospitals were sicker, and the number of preventable deaths climbed.
At first political economists spun the phenomenon as a necessary shake-out of redundant capacity. This interpretation had some early adherents since the bulk of early failures were in poorer communities. But within months even flagship institutions were in trouble.
Health care dominated the run-up to the 2008 election. In early 2007 about 17 percent of working Americans had jobs in health care. By Election Day a quarter of the hospitals and clinics had closed, and a quarter of these workers were out of work with no prospect of finding another health job. Any surplus capacity in health care was long gone. People couldn't find care. Investors holding hospitals bonds were screaming.
The administration was paralyzed. There were two key arguments. First, is health care a right or a purchasable service – i.e., should hospitals and clinics have to care for people who can't pay? Second, should essential services be preserved by government action or should the market handle the issue? The administration stayed the market course.
The fact that it was an election year hurt and helped. It thwarted prompt action, but it also exposed the issues to brutal public debate and extracted very public commitments from candidates. Special interests often collided and were neutralized. The new administration took office with a mandate to stabilize the situation. In its "first hundred days" it laid out a plan to buy selected hospitals for their indebtedness. Except in a few remote rural areas, failing private clinics were permitted to go under. There were just too many to deal with. Instead, hospital-based clinics and community health centers were expanded, hiring docs from the private sector. There was no question about the need to manage this federal hodgepodge. Legislation was passed permitting the feds to negotiate with venders of essential drugs, goods and services. The Veterans Administration hospital personnel management and patient care protocols were applied in the foundling institutions, as were various longstanding recommendations for safer, more equal care. Consolidation of management and billing structures, plus direct federal payment, saved some money as did bulk negotiated purchasing and other economies of scale. Overall savings approached 20 percent, but hundreds of thousands of fiscal and billing personnel lost their jobs.
The switch-over was paid for by a broad employer-employee payroll tax, which replaced insurance payments. The indigent care piece was covered by a wealth tax on individuals with net worth of over $5 million.
There were unanticipated consequences. There was a surge in development when people with ideas for small businesses could count on affordable health care. The competitive advantage of "big box" retailers decreased when they had to help pay for employee health care through the health payroll tax. The small service companies thought they couldn't afford the health payroll tax, but since all their competitors were in the same boat most survived.
By 2011 America had two tiers of health care. The wealthy continued to use boutique providers who continued to do very well. Over half of all hospitals continued in private ownership receiving federal payment through a Medicare sort of scheme. But for many Americans the federal health program was their health care home. It was "big government," clumsy and imperfect, but fair and affordable.
In future columns, I hope to fill in more details on the program and how it evolved.
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