Community health centers provide the sole access to healthcare in many remote and underserved communities – they should be funded in full in the current federal budget
Community health centers are primary care health facilities that provide a wide range of medical, dental, and mental health services to underserved communities, especially in remote rural areas.[i] The federal funding for these facilities will end in March unless the U.S. Congress and President agree to provide the funding for the rest of fiscal 2018. The current opioid abuse epidemic and the severity of the seasonal flu epidemic are two urgent and ongoing health crises affecting communities lacking a robust health infrastructure and adequate numbers of healthcare providers. If funding is not restored to this program, many services for about 26 million people who may not have any other access to healthcare services will end. This would include substance abuse treatment for the impoverished areas most severely affected by the opioid crisis and preventive and acute care for the seasonal flu epidemic which has not yet reached its peak.
The U.S. Centers for Disease Control and prevention reports the current flu season is the worst in many years. Influenza related deaths have surpassed previous epidemic thresholds. While the virus remains susceptible to antiviral drug therapy, patients must first obtain a prescription from a healthcare provider. The number of opioid abuse related deaths continues to rise with the number for2016 exceeding the number for 2015. Effective addiction treatment requires both medical and mental health support services. Chronic disease is a complicating factor for many people suffering from both severe flu and substance abuse. Any interruptions in treatment may increase the risk of adverse outcomes. Federally funded community health centers are located in places where there are few opportunities for healthcare outside the facilities themselves, so residents who have health insurance and residents who can pay out-of-pocket are at a similar disadvantage as those who rely on community health centers to obtain low-cost or free health services.
Preventive care provides direct and indirect cost savings to the economy. The direct savings include effective management of chronic conditions and vaccination to prevent the spread of infectious disease. The indirect savings include reduced labor productivity losses from sick days and a reduction in disability due to chronic disease. Funding community health centers is a wise investment. If federal funds are not extended, many communities will lose access to the only health services available to them.
[i] Department of Health and Human Services, Health Resources and Services Administration, "Health Center Program,” August 2017, available at https://www.bphc.hrsa.gov/about/healthcenterfactsheet.pdf on February 1, 2018.
Delays in Puerto Rico hurricane recovery affect U.S. public health systems
The continuing crisis in Puerto Rico is affecting public health in the rest of the United States because of an unusually severe winter flu season and disruption of the supply chain of medical products manufactured on the island. Data from the U.S. Centers for Disease Control (CDC) and Prevention shows Influenza-like illness in every part of the United States except Hawaii is widespread.[i] According to a U.S. Food and Drug Administration (FDA) statement of January 4, intravenous saline solution shortages continue for the national healthcare system.[ii] These products are essential for the treatment of hospitalized patients suffering severe respiratory symptoms including influenza. Additionally, recent FDA testimony to Congress described 30 critical medical products either solely or primarily manufactured in Puerto Rico that were disrupted by hurricane Maria.[iii] Similarly, an FDA statement of October 20, 2017 reported Puerto Rico also manufactures a range of other medical goods including surgical instruments, cardiac pacemakers, insulin pumps, and pediatric/adult amino acid formula (for intravenous nutrition) among more than 1000 products.[iv] The 18,000 strong labor force in this sector is also affected by the destruction of housing and essential services like water purification.
Puerto Rico is an indispensable and essential component of the U.S. healthcare infrastructure and rapid hurricane recovery and reconstruction will benefit us all. As of December 27, the Department of Energy reported about 70 percent of Puerto Rico’s electricity has been restored.[v] As of mid-December, the U.S. Federal Emergency Management Agency (FEMA) reported about 14 percent of Puerto Rico still lacks potable water.[vi]
[i] U.S. Centers for Disease Control and Prevention, “FluView Weekly U.S. Influenza Surveillance Report - 2017-2018 Influenza Season Week 2 ending January 13, 2018,” available at https://www.cdc.gov/flu/weekly/index.htm on January 22, 2018.
[ii] U.S. Food and Drug Administration, “FDA Statement: Statement by FDA Commissioner Scott Gottlieb, M.D., update on recovery efforts in Puerto Rico, and continued efforts to mitigate IV saline and amino acid drug shortages,” January 4, 2018 available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm591391.htm on January 22, 2018.
[iii] U.S. Food and Drug Administration, “Testimony of Scott Gottlieb, M.D, Commissioner on Food and Drugs, before the Subcommittee on Oversight and Investigations, Committee on Commerce, U.S. House of Representatives,” October 24, 2017 available at https://www.fda.gov/NewsEvents/Testimony/ucm581757.htm on January 22,2018.
[iv] U.S. Food and Drug Administration, “FDA Statement Statement by FDA Commissioner Scott Gottlieb, M.D. on medical device manufacturing recovery in Puerto Rico,” October 20, 2018 available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm581436.htm on January 22, 2018.
[v] U.S. Department of Energy, Infrastructure Security and Energy Restoration, “Hurricanes Maria and Irma – December 27 Event Summary (Report 84), available at https://energy.gov/sites/prod/files/2017/12/f46/Hurricanes%20Maria%20and%20Irma%20Event%20Summary%20December%2027%2C%202017_2.pdf on January 22, 2017.
[vi] U.S. Federal Emergency Management Agency, “FEMA Hurricane Maria,” available at https://www.fema.gov/hurricane-maria on January 22, 2018.
Disease outbreak update
There is an outbreak of Lassa hemorrhagic fever in West Africa. It began with the detection of two separate cases in February 2017, one in Burkina Faso and one in Benin. Both cases were reported to the World Health Organization upon confirmation of the diagnosis. A case was detected in Togo and reported to WHO in early March 2017. The Nigeria Center for Disease Control reports an ongoing outbreak of Lassa since the beginning of 2017 affecting 10 states. None of this is remarkable since Lassa is endemic to the Nigeria and there is constant travel among border communities in Nigeria, Benin, Togo, and Burkina Faso. It is noteworthy, however, that the outbreak is being effectively managed locally with the epidemiological investigation conducted by health officials in the affected countries: Togo, Benin, Burkina Faso, and Nigeria, and the laboratory diagnoses were completed in local government facilities.
Overall, there have been 239 contacts monitored and ongoing contact tracing is underway to identify persons who may be at risk for infection. This coordinated international response is the result of the January 2017 establishment of a multilateral African institution for disease control. The Africa Center for Disease Control (CDC) is a component of the African Union and collaborates on public health continent-wide. The creation of the African CDC also represents an enhancement of health capacity called for by the World Health Organization international health regulations (IHR). The improved capacity for local response will facilitate timely outbreak investigations and is especially important in circumstances where an international response would be hampered by difficulty in gaining access to affected areas.
Black women and life expectancy
Recently reported findings on the health of several demographic groups in the United States have been concerning. Life expectancy for middle age white women and men, and black men declined during 2014- 2015.[i] An increased death rate from suicide and opioid abuse for middle age white women and men during 1999-2014 and a four month decline in life expectancy among all white Americans was noted in a 2016 report from the U.S. Surgeon General.[ii] Black women as a group, however, did not have a decline in life expectancy.
Black women and men continue to experience health disparities based on race. For example, there remain differences in life expectancy between white women and black women as well as higher death rates for black women compared to white women for breast cancer. Racial disparities in health measures for black children compared to white children persist.
Improvements in important social determinants of health, such as educational attainment, may play a role in the life expectancy findings. The precise reasons for the absence of a decline in life expectancy for black women compared to white men and women of similar age is unclear. One finding of interest is a comparison of the percentage of black women completing post-secondary education compared to other race and gender cohorts.[iii] During 2012-2013, black females completed a higher percentage share of associates and bachelor’s degrees within their racial group compared to white males and white females. Sixty-seven percent of associate degrees and 65 percent of bachelor’s degrees completed by black students were granted to black women while 61 percent of associate degrees and 56 percent of bachelor’s degrees completed by white students were granted to white women. In addition, black women represented a higher percentage of completed post-secondary degrees than white, Hispanic, Asian, Pacific Islander, or American Indian/Alaskan native women. Black women have lower suicide rates than black men and all white persons as well as relatively low rates of crime, cigarette smoking, alcohol use, and illegal drug use.[iv] Higher education and avoidance of health damaging behaviors are associated with better health.
Monitoring post-secondary degree completion for black women as well as life expectancy and death rates for all gender/racial cohorts over a longer period of time may clarify the explanation of the observed data.
[i] Source: National Center for Health Statistics Data Brief No. 267, December 2016, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics Mortality in the United States, 2015 Jiaquan Xu, M.D., Sherry L. Murphy, B.S., Kenneth D. Kochanek, M.A., and Elizabeth Arias, Ph.D. [ii] Source: U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016 [iii] Source: U.S. Department of Education, National Center for Education Statistics. (2016), Status and Trends in the Education of Racial and Ethnic Groups 2016 (NCES 2016-007), Degrees Awarded [iv] Source: Ann N Y Acad Sci. 2010 Feb; 1186: 69–101. doi: 10.1111/j.1749-6632.2009.05339.x
America's public health horizon
Health and economic status trends can indicate some of the challenges a population may face in the future. The overall health of the U.S. population will be shaped by the lifestyle factors and the economic inequalities that underlie health status. For example, if there is a high percentage of obesity, one expects to see increased rates of diabetes and high blood pressure along with the related health consequences. Likewise, if there is a high percentage of people who are poor and unable to afford proper nutrition and medical care, there is likely to be a higher percentage of infectious and chronic diseases that are associated with poverty among that group.
In the United States, income inequality has increased in recent years, with formerly middle class persons falling into the ranks of the poor due to changes in U.S. labor markets and other forces. The U.S. public health horizon, a medium-term timeframe of three to five years when the impact of public health problems can be recognized based on historical health and economic status trends, has several challenges looming that can affect both the United States and wider world.
Infectious and chronic diseases, and food insecurity will continue to afflict people in the United States and raise the demand for health resources to address an expected increase in morbidity and mortality. The emergence of infectious disease health crises such as the Ebola outbreak and the continuing challenges posed by diseases such as Zika are important health issues which must be monitored and mitigated. Novel infectious diseases seem to be appearing at an increasing pace, in part driven by the movement of human settlements into previously undisturbed environments, and the worldwide spread of such diseases is facilitated by ever more efficient transportation systems that allow the movement of people and goods anywhere in the world in a matter of hours. Additionally, infectious disease transmission is sometimes facilitated by conditions characterized by poverty, such as crowding and inadequate housing and sanitation.
Developed countries have effective health surveillance systems to detect and sequester infectious disease outbreaks but may have some difficulty in quickly diagnosing novel diseases with early symptoms that are similar to other well-known diseases. A few examples of this phenomenon include the Lyme disease, West Nile virus, and Hantavirus outbreaks in the United States. Developing countries face insufficient health care infrastructure, including everything from a dearth of health professionals to a dearth of laboratory capacity and developing countries also are affected more severely by the challenges of poverty. In many developing countries where agricultural animals live in close proximity to human dwellings, shortcomings in the management of animal diseases that are also hazardous to humans can be a factor in human health risk.
The ultimately successful effort to control the spread of Ebola virus disease provides a lesson in how one challenge on the public health horizon may be met in the short-term; international cooperation to deploy health resources and transparency from the crisis-affected country were essential for controlling the disease. In the longer term, adequate health capacity must be created in countries that currently do not have it. Recognizing it is impossible to prevent a novel infectious disease from emerging in the United States, it is essential to have robust disease surveillance and emergency response systems to prevent its spread. There is some amount of self-interest for the United States and developed world to provide assistance so hazardous infectious diseases are identified and contained close to the source when the source is outside our borders. The threat to everyone is reduced and there is less disruption in the movement of goods, services, and people that animate the domestic and international economy.
Developing countries must improve conditions in their health sector and effectively and efficiently use donor funding. The most successful approach is likely to be a collaboration where a country with identified shortcomings can direct goal setting and other countries can assist with supporting the most pressing needs with technical advice and financial resources.
A second set of health challenges appearing on the U.S. public health horizon is the management of chronic diseases. For the United States, this includes addressing the growing substance abuse crisis. During November 2016, the U.S. Surgeon General issued a report describing the rise of substance abuse since 2002. Substance abuse is considered a chronic disease because of the long-term health consequences that require medical treatment. While the underlying reasons are not understood, one result of the rise in substance abuse has been an observed “increase of mortality among middle aged White Americans between 1999 and 2014 that was largely driven by alcohol and drug misuse and suicides, although this trend was not seen within other racial and ethnic populations…”[i] Chronic diseases generally have significant treatment costs and may also have associated indirect costs related to disability and early death. If the early signs of chronic disease can be detected by health screening, the progression can be prevented by behavior changes and/or medical treatment. In the absence of health education, early detection, and behavior changes, the epidemic of obesity and metabolic syndrome (a range of health characteristics that increases the risk of developing heart disease and stroke) along with an increase of substance abuse is expected to drive an increase in healthcare costs. Rising healthcare costs related to increasing obesity are also expected to occur in other parts of the world including China.
In one respect, food insecurity may be the most important challenge on the U.S. public health horizon because nutrition has a profound impact on every other aspect of health. While rates for food insecurity and hunger have declined over time, 42.2 million people lived in U.S. households with some level of food insecurity during 2015 according U.S. government estimates.[ii] Food insecurity and the accompanying nutritional deficits can cause developmental problems for young children, increased susceptibility to some infectious diseases among all people, and contribute to the emergence of chronic diseases such as diabetes. Young children, especially those under the age of three years, require a variety of micronutrients for cognitive and physical growth. The absence of these micronutrients adversely alter cognitive development, which has direct consequences for learning and long-term labor force productivity.[iii] For people of all ages, micronutrients such as vitamins A and D, iron, and calcium are important for immune function and dietary deficiencies increase the risk of illness from numerous infectious diseases.[iv] Lastly, the relative prices of nutrient dense healthful food (compared to many processed food products) can have an impact of the development of chronic diseases that are caused by overconsumption of calories from cheaper food products with higher concentrations of sugar and fat. As the rates of diabetes and metabolic syndrome increase, kidney dysfunction, hypertension, and heart disease can be expected to result in increased healthcare costs in the United States and other countries around the world.
The medium-term U.S. public health horizon presents both challenges and opportunities for improving health of people in the United States and around the world. Many conditions contributing to ill-health are well understood and can be prevented or remediated with wise resource investments and robust health promotion. The cost savings of preventing infectious and chronic diseases, and malnutrition not only will have a positive direct economic impact but will also have a positive effect on reducing the costs associated with disability and early mortality.
[i]U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: 2016. [ii]Coleman-Jensen A, Rabbitt MP, Gregory CA, and Singh A. Household Food Security in the United States in 2015, ERR-215. Economic Research Service, 2016 September. Sponsored by the U.S. Department of Agriculture. [iii]Prado EL, Dewey KG. Nutrition and brain development in early life. Nutrition Reviews. 2014 April [cited 2016 November 30] Available from http://onlinelibrary.wiley.com/doi/10.1111/nure.2014.72.issue-4/issuetoc [iv]Chandra RK. Nutrition and the immune system: an introduction. American Journal of Clinical Nutrition 1997 August [cited on 2016 November 30] Available from http://ajcn.nutrition.org/content/66/2/460S.abstract
The United States Government has two publications that document U.S. policies and laws. The Federal Register provides information on policies originating in the executive branch of government. It is published every business day and includes Presidential Executive Orders and notices of rules, regulations, and other activities within the Cabinet departments and independent agencies. The Congressional Record, is the documented activities of the U.S. Congress, the federal legislative branch of government. The Jackson Health Extract is a digest of published activities related to health issues. The extract includes a short summary providing background and context as well as links to the relevant Federal Register or The Congressional Record discussions.
The General Accountability Office (GAO), an agency of the U.S. Congress that reviews the use of federal funds, recently released a report saying the U.S. Department of Agriculture (USDA) should formulate a plan to improve its response for an outbreak of avian influenza. Avian influenza is a disease that affects poultry, often causing massive mortality in commercial flocks. In addition, some strains of avian influenza can infect humans, causing illness and death. The ongoing outbreak of low pathogenic H7N9 avian influenza in China is responsible for over 1400 human infections since 2013 and it is more difficult to control the spread among humans than other strains of avian influenza. Among the GAO recommendations are for USDA to facilitate an increase in the number of trained personal that depopulate infected flocks and to work with poultry producers to improve preventive biosecurity measures to reduce the risk of an avian influenza outbreak. A related human health concern is the reliance on “pathogen-free eggs” to produce the seasonal human influenza vaccines. The Department of Health and Human Services is supporting work to develop alternative manufacturing processes. The GAO report is available at http://www.gao.gov/assets/690/684084.pdf
The Department of Health and Human Services announced consultations with state/local governments on funding to address the opioid crisis on April 21. Over 33,000 opioid related deaths occurred in 2015. The notice is available at https://www.federalregister.gov/documents/2017/04/21/2017-08068/opioid-state-targeted-response-grants
During January 2017, two Joint Resolutions (S.J. Resolution 10 and H.J. Resolution 38) were introduced in Congress to disapprove a Department of the Interior rule to protect streams from contamination from coal production operations. The rule was issued on December 20, 2016 to “better protect water supplies, surface water and groundwater quality, streams, fish, wildlife, and related environmental values from the adverse impacts of surface coal mining operations and provide mine operations with a regulatory framework to avoid water pollution, and the long-term costs associated with water treatment.” There are several potential hazards that could occur after disposal of mining operations waste on adjacent land and water sources including alterations to stream ecosystems and degraded water quality. Changes in selenium concentrations, for example, are of concern because selenium exposure can be problematic for a variety of animal species and humans. Selenium is an important element for the human diet because small quantities facilitate optimal health but larger quantities can be toxic. Repeal of the rule will eliminate required monitoring to ensure timely detection and correction of changes in selenium concentration and other chemicals in mine waste. Supporters of repealing the rule cite increased coal production costs and a potential loss of jobs. The absence of monitoring can result in increased costs to remove toxic contaminants and medical treatment for people who become ill.
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