Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CONTENTS
Medicaid ................................................................................................................................................. 3
Medicare ................................................................................................................................................. 4
Ethnicity and Differential Access to Care for Eating Disorder Systems ....................................................................... 12
Health Disparities Persist for Men, and Doctors Ask Why .......................................................................................... 13
HIV............................................................................................................................................................................... 14
Kant Readings.............................................................................................................................................................. 22
Health and Working Conditions: Hotel Room Attendants in Los Vegas ..................................................................... 23
Immunization coverage among children born to HIV infected women in Rakai District, Uganda: Effect of voluntary
testing and counseling (VCT)....................................................................................................................................... 27
Federal Safety Net for Workers .................................................................................................................................. 27
Market Failure and the Creation of a National Health Information Technology System ........................................... 29
Kindig Reading............................................................................................................................................................. 33
Factors Contributing to Disparities in Preventative Health Care Among Lesbian Women ......................................... 34
Trends of Gonorrhea and Chlamydial Infection Among Active Duty Soldiers ............................................................ 40
Health and Access to Care for Children of US Migrants and Immigrants ................................................................... 43
Patterns of Cancer Incidence, Mortality, and Prevalence Across Five Continents ..................................................... 46
Safety and Health of Working Women: Poultry Processing in the Rural South .......................................................... 54
How (and how not to) Battle the Flu – A Tale of 23 Cities .......................................................................................... 58
Even though health care may be a limited resource, we treat it as though it is limitless because we are faced with
the moral dilemma that it is a human right to receive health care!
• almost everyone went to medical care, and talked about limits around money
• the only way to get medicine is to have money… are these assumptions correct?
• How do we invest in HC, and what do we get back? Can we make a cycle of investments so the outcome
we get back is growing faster than what we put in.
o If we can do this, we have a limitless system… it isn’t market based or commodity based.
Disability
• what is the definition of disability? By SS, it is a physical or mental impairment which prevents an
individual from engaging in any substantial gainful activity, and which has lasted or is expected to last for
12 months or result in death
• Disability is determined by the disability determinant act.
• Income limit Medicaid is 798 dollars. They look at income, assets, and health status.
NC HAS…
Medicaid for Aged (65) and older Blind and disabled, Medicaid for Long Term Care
Medicaid for women and children…
SCHIP
AAF
You can be enrolled in the Medicaid program but never receive a dollar of Medicaid service. You have to pay your
share first. Transferring money to family member = sanction
What is her spend down? 958 dollars… which will qualify her for coverage for the 6 months beginning at the point
the application was approved.
What happens if it takes her 5.5 months to pay 958 out of pocket? Then Medicaid covers half a month, then she
has ANOTHER 958 dollar spend down.
Higher costs at beginning because entering the system with higher rate of infection
Poor people give up care to pay their bills before going to government even if it means it hurts their health. If we
know that people who are minorities are more highly represented in lower income status, then what are the
implications of the law racially? What kind of biases/assumptions were made?
Medicare Part D is biggest policy issue of last couple of years – a great step forward in universal care, but huge
costs!
Medicare
• incremental strategy
o populations that are high status couldn’t afford health insurance
o Elderly
Sympathy
Agreement to keep medical system as is for AMA
Focus on burden of hospital care assumed status quo (fee for service)
Limited number of days covered to begin with
AMA powerful force in the agreement, upset about Medicaid, Medicare paid them off
Objectives
• Payment of mainstream rates to providers to provide care to the elderly so to increase amount of needed
care.
o Relieves pressure of retiring and not having work covered insurance
Medicare Structure
• >65
• Disabled and receiving Soc Sec benefits
• End stage renal disease
• Not means tested, benefits after 2 years of disability determination
Medicare A
• Hospital Insurance
o Room and board 90 days
o Nursing
o Home health
o Payroll funded primarily – by employer and employee
o Hospice care
$$$$
• payroll tax – everyone works and everyone pays, DEMOCRATIC PROCESS
• co pays with hospitalizations – different amount at different point in hospitalization
• deductible - $$$ before receive any services
• patient cost sharing hits at different point depending on services accessing
Medicare Part B
• supplementary health insurance
• Voluntary, vast majority sign up for it- monthly premiums
• Physician (diagnostic and surgical facility based) and outpatient care
o Federal tax subsidies
o Monhly premiums deducted from checks
o $100 deductible
o Medicare pays 80% UCC, patient other 20%
o Physicians may or may not decide to accept Medicare rates
If they do, they bill medicare directly and recipient pays balance
If not, they can change 115%
Limits?
• Catastrophic care – that extends beyond time limits
• Meds – no coverage until Medicare+ choice and now “D”
• Long term care
Pitfalls
• policies increase in premium as beneficiary ages, costing more as risk increases and more over time than
the more steady priced plans
• catastrophic only coverage
rd
• selection by 3 party coverers
• HMOs proliferation – increase in choice, decrease out of pocked costs premium variance by age (O)
Satisfaction surveys: bias, those disenroll are often not caught in the surveys… allow the safety valve for those not
satisfied
Physician Containment
• pressure from hospitals through PPS
• limits on balance billing (amount over UCC)
• increases in beneficiary cost sharing premiums, deductibles, co pays
PURPOSE
• assess impact of pollution of community health residents in SRI LANKA
BACKGROUND
• neither area had public water supply or public sewage disposal
• control area similar to industrial zone in other areas
Health Implications
- 15% lacking coverage have disabling chronic illness
- Vets age 25-64 without coverage 5X more likely to refuse treatment/medication than those covered
Empiricism
• the doctrine that knowledge derives from experience
• medieval practice and advice based on observation and experience in ignorance of scientific findings
Colsilience
• the agreement of two or more inductions draw from different sets of data.
st
21 century plagues
Blood versus feces
Virus vs. bacteria
Roles played by environmental degradation, war, travel, population changes, TRAVEL is scariest.
People are getting in contact with isolated populations that may have disease, but now all populations are
combining and spreading disease
Political price to pay by raising people’s awareness of disease, who reports the disease.
st
21 century plagues
• chronic disease epidemics
• how do we provide treatment for a long period of time?
London 1854, talks about the night soil men who clean out the cesspools and men that dispose of dead bodies as a
thriving business that developed on its own, that actually paid very well.
Talked about how waste was recycled, or put back into the soil to yield more crops and consequently more people
that they can feed. Then on a larger basis how one organisms waste is another’s fuel. All thanks to
microorganisms... we are completely reliant on bacteria and have a symbiotic relationship with them. Talked
about why in rainforests that’s why by the time you get to soil there aren’t a lot of nutrients… they all get
absorbed/used by the life in the higher levels. Square cm skin 100,000 bacteria
People often linked the odors of cesspools, filth with disease, which isn’t always the case. Dickens and Engels tied
corpses with malignant diseases. (Craven’s field) With cholera it was tied to the stink in the air.
Thomas and Sarah Lewis had baby Lewis that was first sick with cholera, broad st, 1840’s sick in 1854, outbreaks
48-49 (50,000 lives)
Henry Whitehead- clergyman went to Oxford – was first thinking about socioeconomic factors, like what floor
person lives on, looking at theory that people succumb to fear of disease, but knew someone with incredibly
strength and courage, can’t be that, he made connection between drinking Broad street water and getting sick
days later, but also skeptical because had seen people get better by drinking broad street water. Stuck to
elevation theory… was skeptical of removing pump handle.
Cholera: bacterium with a single cell that harbors DNA. No organelles or cell nuclei. Need between 1 million and
100 million to be infected. A cup of water could have 200 without being cloudly. They take up house in the small
intestine, protein called TCP helps reproduce really quickly, release toxin that causes cells to release water rapidly,
so person dies of dehydration really quickly. Waste products accumulate in blood. Means “roof gutter” didn’t do
well in past because humans live so far apart and don’t come in contact with each others waste
John Snow successful English doctor, acted as investigator, ether/chloroform in operations. Noticed you could be
with infected people and not get sick, or completely avoid them and get sick, so there must have been another
cause. Came up with waterborne theory of spreading in first outbreak, that it must be some agent that is
swallowed and not miasma theory – people get sick from stench. He went around and asked people about their
water, and took samples. Not sure if he led people on to his theory in talking to them… a bias. DIDN’T investigate
drinking habits of residents who had SURVIVED the outbreak,
Looked at houses supplied by Lambeth vs S&V water
Wanted to make connection between drinking/not drinking from pump and dying/living
The sewer men were like canary in the mine – couldn’t have been smell because these guys were really healthy!
William Farr: revolutionized statistic use in public health, published in weekly publication, calculated deaths by
elevation and concluded that more people on higher floors die, so it must be the smells! Very stubborn in his
views… helped bring about the practice of getting rid of cesspools and disposing of in Thames… even through
cholera outbreak highly supported this, which led to mix of disease and water that hurt the city… he stuck to view
that smell made people sick, distributed Clorox/bleach to deal with
Edwin Chadwick: in public health, responsible for big government today… said that all smell is disease, and made
elaborate plan to basically deliver cholera bacteria into mouths of londoners
Edmund Cooper first drew street map with black bar by death at each house to disprove that came from Plague pit
where corpses where disposed… presented to Board of health, but connection between pump and deaths was lost
because there was TOO much data. Then snow made his map after, came up with veronai diagram, cells with
points. Map played role in convincing Whitehead to investigate waterborne theory, and figure out that it was baby
lewis
Questions I have:
We’re a lot more technologically advanced now, but what are common views/things that are accepted in out
health system that we are either wrong about, or looking at in the wrong way, or can be greatly improved in some
way?
Interesting the conflicting interests of cities – great for implementing something like a waste disposal system
because we have more people closer together, but not so great in terms of terrorism.
3 Issues
Found
• incinerators in predominantly black neighborhoods
• mini incinerators as well
• all 5 landfills in predominantly black neighborhoods
Did they look at who is operating or working for landfills? Is it possible the landfill brought the people?
Predominantly white people making decisions, didn’t want it in THEIR neighborhood. What about real estate
prices?
Emerging Disease: Infections that are appearing for the first time, rapidly increasing in incidence and range
• when germs and humans come together
Bunyaviruses
Spread by contact with infected insect or animal
o mosquitoes
o ticks
o rodents
Filoviruses
Reservoir of diseases isn’t known
o person to person contact
o contaminated needles and syringes
o sexual contact
o contact with nonhuman primates
Flaviviruses
Insects responsible
o mosquitoes
o ticks
HIV
• Gay bars, PDF was illegal… 1969 Stonewall riot, then sexually more accepted in 70’s, emergence gay
neighborhoods in cities, and sexual liberation bath houses
• Epidemiologists missed that HIV was also appearing in intravenous drug users and women and infant
(partners)
• Took until 82 or 83 to figure out that was blood borne and sexually transmissive
• Retrovirus: HIV is first that we know of, it inserts viral RNA into hosts cells DNA, so all of daughter cells has
HIV in new cells, becomes virus factory
o Immune system amounts a response, but it isn’t strong enough to win in lifetime
o Policy issue about what to do with American blood supply, should donors be screened?
Blood banks didn’t want to spend money
• Ari Rubenstein noticed infants were being born and dying with immune system failure… they would start
out healthy and rapidly decline, 1984
• Frame, Luke Monenue, IDd retrovirus responsible for HIV
• Robert Gallo in US sure that was variant of leukemia causing retrovirus
o Once discovered could create test to screen
o Development of AIDS takes 4 years, then live 12-18 months and die of infection/cancer
1986: Senate passes Ryan White care Act: designed to bring resources to most affected cities
Title I grants/funds
AZT: added other titles. (Title II) and AIDS drug assistance program, ADAP
• III impact on women and children grew, created new title for them,
• IV created early intervention clinics (before gets chronic)
Trend
• find vaccine
• push for treatment drugs by advocacy of affected populations
• there was action by the local communities, they were stigmatized, but politically powerful (educated,
wealthy)
• Were we spending money on prevention? Started in 1985, but prevention messages are messy. They
didn’t want kids in HS learning about condoms, safe sex, intercourse, etc.
o Didn’t want to teach drug users safe injection
o Mistaken belief: EDUCATION = PERMISSION
Theories that HIV was present in regions of Africa and people were immune
• When drugs came out, prevention was for people who can’t afford treatment attitude
• Problem of epidemic: expression is different in every patient, immune systems fail in different ways
because of different exposure from birth
o So disease is not predictable
o We have treatment failures because there isn’t anything more to treat with
o Drugs demand high level of adherence, most humans aren’t that adherent to therapy
HUBRIS moments:
• thought we had conquered infections diseases before HIV
• stigma against population affected, homosexual men, so harder for researchers to see other people
affected
• some public policy officials took stand that HIV is “god’s revenge”
• how we manage, test, look for viruses has changed because of HIV, our understanding cell function,
classification of viruses,
• found HIV virus all come from same family
• POLICY INNOVATIONS
• idea that we can distribute drugs to large population, create public attitude that people need wrap
around services, linking people up with care resources
• specialists vs generalists:
• politically, pub pol, scientifically, there are similarities between cholera and HIV. With Cholera we could
engineer a response: clean water and sewer systems. It is hard to engineer response for behaviorally
linked infection.
What are HC services that are purely necessary? (everyone should have)
Immunizations (MMR)
Emergency Room/Urgent Care
Pre-natal care
Eye Correction
Psychiatry
MEDICARE PART II
Federal program
Universal
Doesn’t have federalist flavor like Medicaid
Implemented with medical providers input
HC providers less dissatisfied working with Medicare than Medicaid patients – we have the same system
everywhere, it is safe stable payer system
Late 90’s government cut Medicare distribution rates, hospitals start going out of business
Done to contain costs
Medicare lowered reimbursements to around costs of services – hospitals had been using extra to
subsidize care to uninsured.
Hospitals like Medicare because it is predictable, does a lot of services, one system, reimbursement flow is
reasonable.
Medicare Choice
Late 90s (1997) attempt to contain costs, managed care – Medicare Advantage
HMO system for Medicare, employees, that has pharmaceutical coverage
It was under utilized, and lower out of pocket costs, volume is important, but people didn’t jump on it
For older population, limiting provider choice was emotional… people want to go to their doctor
Part D
Physician Containment
Many employers are using case management to help employees with high costs
Recommendations
• grant to get background of uninsured and explore policy options
o realized not one option would address full problem or satisfy all stakeholder groups
o Decided on: market-based reform efforts, private-public partnerships, and public initiatives
There is conflicting interest between providing care for more uninsured AND restraining
health spending for employers, uninsured families, gov
• Thought about limited benefit packages and cost sharing
GOAL: All NC residents have health insurance that meets their basic healthcare needs
Five Priority Recommendations
1 Additional state funding to support and expand the healthcare safety net, to
provide healthcare services to the uninsured;
2 Promotion of personal responsibility for leading a healthy lifestyle and the
inclusion of healthy lifestyle promotion in state policies;
3 Development of a limited-benefit Medicaid expansion for low-income parents;
4 Creation of a subsidized health insurance product targeted to small employers
with 25 or fewer employees, low-income sole proprietors, and low-income
individuals who had not previously offered health insurance coverage; and
5 Creation of a high-risk pool for individuals with pre-existing health conditions.
Question: I’ve been thinking a lot about the balance between individual and local or government
responsibility towards an individuals health. And obviously you want to have programs that encourage healthy
behavior on an individual level, and I’m not sure there is an answer to this question, but what is the distribution of
the individual’s responsibility to take care of her or himself versus the government’s responsibility to do it.
Because I feel like with all the technology and medicines etc we are moving more away from prevention of a lot of
diseases, which maybe can be prevented with a healthy lifestyle, towards the government being responsible for
treating the disease, that arguably could have been prevented if the individual took better care of him or herself.
Do you think that the accessibility and availability of a medicine or service as a quick fix to so many
diseases that result from poor lifestyle choices decreases an individual’s incentive for healthy behavior that might
prevent the disease in the first place? And thus increases costs and skyrockets demand?
• Have to provide context for people to make best personal choices (not get HIV, diabetes) it is
responsibility of society and individual
• How do we provide access to HC resources that enables better decision making?
Objectives
• understand the multidimensional nature of local policy options for covering the uninsured
• Understanding structure and dynamics of financing care for the uninsured
• Analyze local policy options within the context of
o Multiple stakeholder interests
o State/federal policy directions
Chapter 1
There isn’t a good correlation between expenditures and health, so spending more won’t necessarily make us
healthier
Managed care programs, and consolidation of health care services. Maybe what we are going through
now is HC reform, just without the legislation behind it.
Presentville 2007:
• Financed privately and publicly
• Rising number of people uninsured
• Moving towards hospital systems and group practices over individuals
• We are measuring costs and quantity, but not quality
Healthopolis 2020:
• health benefits paid in annual capitation based on need/health status
• benefits to health care systems that improve over time
• all health care systems are finished consolidating
• payment made to health plans is based on HALE (health adjusted life expectancy)
• ? – is this book like a policy proposal?
• Ineffective programs have been reduced, and there is substantial cost savings
• This money given to small business employers… number of employees without health benefits dropped
close to zero
• Private-public dialogue = health outcome trusts, established to allocate resources effectively
A Realistic Vision
• current system is very political, new system will be purchasing population health framework
Structure: basic inputs (materials, etc) needed for health care services
Process: is procedures and intervention for converting structure into health care outcomes
Outcome: ultimate achievement of system
So when we are trying to judge health care quality, we are paying too much attention to process and too little to
outcome.
• Socioeconomic Determinants
o Higher socioeconomic status = lower morbidity
• Impact of lean staffing and increased service demands/higher level of competition on health of workers.
Nobody has looked at the quality of life of these workers, and asked if it could be an better
o Increased physical workloads
o Low income
o Low skill utilization and job control
o Little chance of skill advancement
• Housekeeping/service jobs is biggest growing sector – can’t be outsourced
o Low wage
o 75 billion dollar industry
o 1.1 million workers
Study Goals
• guest room attendants play huge role in designing study – so it meets their specific needs
o they have largest incentive to improve their quality of lives!
• there is an association between poor working conditions, poor health, and elevated levels of pain
In summary: time pressure, high workload, low job control, high psychological demand, and high job stress
increase the risk of health or severe pain in employees at Las Vegas hotels
REAL STORY
• OSHA takes credit for any distinguishable favorable trend in the data, but the real story is a grim one.
• It has currently been an issue addressed in the media, so it is finally getting some attention
• There IS an increasing trend of workplace death in the immigrant population
o CAUSES
Lack of knowledge about safety and health hazards
Language barrier
Exploitation (we make immigrants do most dangerous work)
Intimidation (fear of the migra, and won’t know to call OHSA)
• OK, so OHSA has been trying to “reach out” to Hispanic workers, form groups for communication, etc.
• They claim that more information is available to Hispanics about work safety, heath hazards, etc, and
training course through the web and similar publications
o OK, there is info on the web, but how available is it to the workers?
o Printed materials are outdated, and given sometimes only to employers
o A lot of Spanish people can’t actually read Spanish (or English)
o The only training being done is through a program that Bush is trying to eliminate
• Hispanic workers are not familiar with government agencies that could assist them
• Hoffman Plastics decision: undocumented immigrants are not entitled to back wages
o But everyone is entitled to safety, regardless of status!
• so there isn’t any link between OSHA research/work and the small trend in dropping Mexican immigrant
worker deaths
o maybe Mexican born workers have been in the US longer and have experience and aren’t as
willing to take risks as they were before?
What can OSHA and others do to improve plight of immigrant workers in the United States?
• Establish building grants program for community based organizations, so that workers can get local,
personal training
o The main issue is trust
o Workers go to co-workers, friends and family more often than employers
o These organizations would speak their language and not turn them in the MIGRA
o OSHA needs to be funding these organizations! But they are ignoring them
• do more research, public hearings, and establish a clearinghouse for information!
o OSHA needs to hire more people that speak a foreign language
• problem is preventing punishment/retaliation against immigrant workers that attempt to use their OSHA
rights.
o Should be fines for health/safety violations and criminal activity
Bottom Line: more money and more innovative programs by OSHA to hire more immigrant employees from
foreign countries.
February 20, 2007
• Does knowledge of HIV status affect immunization rates among children (with HIV positive versus
negative numbers)
• Outcomes
o Fully immunized
o BCG
o Etc
• Mine Safety and Health Administration (MSHA): mine workers most dangerous profession in country.
Make a lot of money, so union is more powerful
• scientists figuring out how much is bad for you, recommend equipment
o they set recommended exposure level
o then OSHA makes a permissible exposure level, that is usually higher than recommended
exposure level
• Congress setting laws, companies, employers, insurance companies, advocate groups, all working
together to decide on levels of exposure
o Insurance companies want levels to be high so they don’t have to file claims for people who are
injured
• There is a federal OSHA act, but each state has the option for creating its own plan
• A lot of people don’t have a choice about their jobs
How do our fatality rates compare with the rest of the world?
Number fatal work injuries, latinos: 1992: 275 deaths/year. Now 625. But there are a lot more latinos in the
country in general, BUT when we account for increases in population, trend holds.
• is there a decrease in death rates for non-latino (white workers, etc)
• service sector is increasing (lots of latinos)
• OSHA celebrating, rates went down 2004-2005, BUT rates of Hispanic and black workers killed in 2005
fatalities INCREASED
• Contract workers may not be counted in numbers, how can we even trust the numbers? A single event
can skew the numbers!
• It seems like we need an open access system that can bring up any individual’s information with
o There would be large start up costs, and then low marginal costs, and huge benefits!
Cost of building national HIT system: 276 billion (so this would have been a percentage of what we’ve wasted in
Iraq, right?)
Solutions for Government… because it’s a big player in Health care, purchases ½ US HC
• Mandatory conversion of all government-payer transactions to systems based on new clinical data
standards
• Parallel mandatory conversion of providers transactions with government payers to systems based on
new clinical data standards
• Safe harbor for hospitals purchases of the new system for physicians
Inadequate transmission of patient information across a continuum of care environments precedes a fatal
outcome
• this paper did a cost benefit analysis of a fully standardized electronic system
o value over year is 77.8 billion
Overview of Study
Data and Methods
• used literature review, experts, analytic framework, software model, and projection of costs.
• Basically, the costs outweigh the benefits in implementing a HIEI Health care electronic information
exchange and interoperability
o Limitations? HC organizations aren’t used to this system now
o A lot of costs might be inaccurately predicted
Overall Message: the government needs to step in to really make this happen!
• women made comment that the smell was so awful, job was terrible and she wanted to quit, but she
stayed for money for her family- this is something we talked about in class
o also another woman stated that she was single with two kids and she would deal with
harassment
Guest Speaker
HIT
Group 2:
Fragmentation
• 40,000-50,000 medical errors per year lead to death
• Medicine as an art and science standardization
• Standards of care and not telling HIV patients that they have Hepititis C
Surveillance/research/inter-exchange of information
A difficulty for small practices, already know their patients well must hire person
Focus on Egypt
The Study
Does access to family planning services have an effect on use of interuterine devices (IUDs)
Why Egypt?
• Population growth rate down from 3%... how can they attribute the access to family planning care?
• How is it a disparity?
• Empower women, over 1/3 not educated and 58% from rural areas
KINDIG READING
Health Determinant: Something that helps to set or direct your level of health function (demographic, genetic,
behaviors, education, social, environmental, and social factors) All of the things that when combined with me,
facilitate or inhibit my health status.
Education in the 80’s was a BAD thing for HIV. A lot of education is based on political things
Social class is another health determinant: higher class feels entitlement to HC. Class is how others perceive you
as well, people make assumptions about behaviors, ability to pay, etc.
Biological: what are you born with? Energy level, likelihood of heart disease, every single person has a different
set of health determinants than everyone else. What is it that exists in my biological, behavioral, social construct
that creates a structure that my health lives in? Some health determinants we don’t want to share with people!
Paper must show I understand something in each domain…
Health is status in which we function in our lives… NOT medical status
- 2 million lesbians in US
- Goal of study to figure out WHY disparities exist, and change for future
Implications
- Responsibility of system and HCP’s to change the environment
Tuberculosis
KINDIG CONTINUED…
• Shift away from fee for service – instead we pay for health
• More social and environmental awareness
• Current cost containment efforts cut costs but don’t say anything about health
• Emphasizes addressing outcomes of system in general, holding providers accountable for outcome
measured by health
• Measure by standardizing – HALE – gives each person a score that determines whether or not to provide
health care. Looks at outcomes as far as function.
• Target health care delivery to people who have the least – but we don’t see it that way
o What motivation does he propose for us to take care of these people?
Cost effectiveness
Reward for health outcome improvements
• If you can improve health of subpopulation over time, we’ll give you more
money! MARKET BASED INCENTIVE to provide better health care to
populations that start with worst health status.
So resources distributed away from wealthier populations to lower health status populations
• ? What is the moral response that HC is being rationed away from those who need it the most, to those
who may not get as much benefit ?
March 20, 2007
NH is smoke free!
• Minor’s access
• Advertising
Cessation Activities
Prevention Activities
Clean indoor air
Regulation/liability
Price/Economic
Assessment
• Monitor ID problems
o Water, diabetes, disease screening and immunizations
• Diagnose and investigate
o Medical examiners, TB, HIV
• Evaluate services
o Data management, health needs assessment
Policy Development
• Develop
o Housing, health, safety
• Enforce laws and regulations
o Food, license, hazardous material inspections
• Research for new solutions
o Recycling, health needs survey/assessment, observe other programs
Assurance
• Connect people and HC
o Early screening programs,
• Assure PH workforce
o Bio-emergency meetings, food service worker safety course, training
• Inform, educate, empower people about health issues
o Education and programs
• Mobilize community partnerships
collaborate with business, HC providers, etc
Introduction
Social Contract:
• rule of law
• peace among citizens
• protect human life
Surgeon’s General’s Workshop on Violence and Public heath (1985) encouraged health professionals to respond to
violence
the numbers are growing, so research and policy is necessary to strengthen our nation
TRENDS OF GONORRHEA AND CHLAMYDIAL INFECTION DURING 1985-1996 AMONG ACTIVE
DUTY SOLDIERS AT A UNITED STATES ARMY INSTALLATION
Silverman
What are the police powers that the government should hold over health?
(and why)
Differences in health status among distinct segments of the population, including differences in gender, race,
ethnicity, education, disability, etc,
• seasonal flu: what comes every winter, respiratory illness, vaccine available
• avian (bird) flu: H5N1
• Pandemic flu: global outbreak, easily spreads from person to person
Group Assignment
th
Look at response plans, look for gaps, condense work into 10 minute presentation: April 10
Avianflu.gov
My group: Group 2
Plan
• Steeper gradient for women than men with obesity and job status
• Obesity = socioeconomic disadvantage
• Obesity = low levels of education as well
• People doing manual labor have MORE likelihood of being obese
• Reasons for trend:
o Uncertain about productivity of obese workers
o Men run hiring processes, looking for attractive women
• We have history of removing poor children – we apply our standard, even if the person might be living
better than they ever had!
• Treating patients in clinic everyday doesn’t have as large effect as actually going in and informing policy
members what needs to be changed in living conditions, etc. There is a connection between policy and
clinical medicine… use research as a TOOL to answer questions of policy makers.
• We select for health by immigration – so we pull out the healthiest group (over time develop illnesses)
• They start to think differently about own health
• Salmon hypothesis: immigrants come to country and when get older, will go back to country of origin
• Infant mortality is low amongst Hispanic women compared to African American, but likely due to
selection.
April 2, 2007
• we look at medicine as somehow inferior to expensive procedures (because it is old fashioned?), but this
isn’t the case!
• Drugs work on the entire circulatory system, while angioplasty just works where operated
• Angioplasty is one of 10 most common procedures in hospitals
• Interventional cardiologists get paid 500,000 per year, largest increase in salary… so do they have
incentive to do surgery even if drugs could have equal effects?
• But we don’t like idea of leaving an artery just blocked!
Introduction
• number and rates of incidence
• mortality,
• prevalence of cancer
Methodology
• statistical analysis pre-existing data, 2002
• identified regional disparities
Results
• number of new cases in each region
• highest incidence of specific cancers
• lung cancer
• breast cancer
Reasons
• lung cancer
o cigarette smoke
o occupational hazard
o indoor exposure
o genetic susceptibility
• breast cancer
o screening
o chemoprevention
o treatment
Solutions
• behavioral interventions
o education
o increase screening and early detection strategies
o Vaccinations against HPV and HBV
• Public health policy
o Occupational safety
Epidemiology takes rigorous quantitative methods and does detective work/logical thinking to try and figure out
what is causing unusual patterns of disease.
• surveillance systems
• CDC is national coordinating industry
• Outbreak investigations
April 3, 2007 Public Health Reading
• 20% of population experiences mental health illness during year, and there are treatments!
o Mental illnesses rank first amongst causing disability in US
o But they are STIGMATIZED and face disparities
o The problem is that they aren’t looked at as legitimate illnesses
• Challenges
o Financing
o Quality of care
o Psychiatric hospitals
o Developmental disability centers
o Alcohol and drug rehab centers
o Private agencies have expanded in past decade
• Public Consulting Group determined that 4 hospitals beyond saving, and should be replaced by new ones,
580 million dollar project
o Wanted to move towards county operated model
• original model created in 1960’s had federal-local partnership that bypassed states.
o Reagan transferred funding to states, and now states had dominant role.
o States slowly downsized
o Problems like Medicaid made it harder, financing is tough
o PCG = ?
o LME = local management entity: purchase services from broad array of providers- so we shifted
to privatized care!
o MD/DD/SAS: state division of mental health, developmental disabilities, and substance abuse
services
• new legislation, reform, passed by Dept Health and Human services 2001
The Promise and Pitfalls of mental Health Reform in NC: Managing a Privatized System
• Privatization (LME’s)
o increase administrative efficiency
separates management and oversight from admin. Of services
private sector providers want to be more efficient so they are going to want new
technologies, etc. = increased competition = weed out bad ones = low cost and high
quality care
• There are low reimbursement rates and high demands, so little time for training – hard to get expertise
and resources
Enhanced Provider Quality
• want to enhance quality by making providers compete on value, not price – but it’s hard to keep track of
which providers have good quality AND it is arguable there won’t be competition for under-funded
services
• it is inconvenient for a consumer to have to switch between providers, and may be disruptive
Leadership
Psychiatrists
th
• 1/10,000 people! We rank 20
• We’ve done well in the past keeping this ratio because we have a lot of in state residency programs,
recently the trend has started to decrease, so we’re starting to fall behind.
• So the closer to the medical centers we get, the better the psychiatrist ratio… the trouble is when we
move farther out.
• In last decade, 2/3 counties in NC have lost all of or had significant decrease in number psychiatrists
• Psychiatrists go to metropolitan areas because there are more people!
• Without psychiatrists, burden of managing mental illnesses falls on primary care or other health services
• 24% decline child psychiatrists past decade
April 5, 2007
You can’t understand health disparities unless you understand health determinants
Results
• no signs of discrimination
• There is discrimination in practice after being admitted to hospital because there isn’t a system to
monitor policy within population
o Quality of treatment…
o Lack of seriousness of patient consent (patient tested without knowledge)
Problems
• too small a sample
• nature of those interviewed
• doctors still don’t have knowledge about HIV/AIDS… think they will get it from getting close to people.
o There’s still a fear of condom use!
• still stigmatized to sex workers, gay men, etc.
• Cancer is leading cause of death for 25-44 and 45-66 years of age! Others leading cause is heart disease.
• Asians have more cancers of infectious origins
o Eating more red meat cancer colon
• Asian Americans have lowest screening rates
• Language is also a barrier
HEALTH DETERMINANTS
All stereotypes are built into the HC system… society is built to provide HC easiest, etc to white men.
Every person has a concept of race put upon them that is a determinant of health
We moved from publicly funded into privatized market based model with LME’s – the old system had serious
problems (stretched beyond capacity) had 39 entities each governed by own mental boards, and very different
(levels of program planning, values, goals, organization, Medicaid billing, etc) completely separate from hospitals.
Money goes from state local communities in LME’s, they assure that are adequate services, that providers
following guidelines, etc.
Huge problem with recruitment contracted agencies, those that DO want to provide services don’t have business
plan, strategy, lots of times goes through entire funding in a couple of months
A DIFFERENCE IN DISPARITIES: COMPARISON OF TYPE I AND TYPE II DIABETES
Hispanics have poorer blood glucose control and are more severely medicated
SAFETY AND HEALTH OF WORKING WOMEN: POULTRY PROCESSING IN THE RURAL SOUTH
NIOSH
• branch of CDC
• does internal research
OSHA: regulatory
NIOSH: research
Safety and Health of Working Women Project (SHOWW)
• focused on how work contributes to health disparities
Work is good…
• health insurance
• money
• retirement benefits
• responsibility
• self worth/esteem
• less welfare burden
• increases tax base
• African Americans have harder time finding work, more hazardous, pay less
Poultry Processing…
• live birds get there, crated, hung on shackler, shot, throats cut, feathers removed, feet removed, rehung,
remaining feathers removed, then inspected at 90 birds a minute
• guts taken out, put into chiller, packaged as whole birds or cut up and packaged as parts, then ready to be
shipped to grocery stores
Morbidity
• from repetitive motion
• acute injury risk
• upward trend in mortalities – fire where 25 workers died
Is this kind of employment good? What is the community gaining? Why are so many people LEAVING
employment?
There isn’t OSHA standard for ergonomics, even though we know its an issue
Created exposure variable that was index of cumulative exposure over time.
Also interested in depression (pain related to depression)
14% lost to followup
Recruited 290 women in other jobs
Analyzed data to compare changes in plant, how do poultry workers look compared to other women? Followed
over time, factors depicting development of disease over time.
99% African American, single, employed 2 months – 30 years
What department was person 30 year experience employed in?
What is a $10 copay represent to someone who makes 8 dollars an hour before taxes?
So do the poultry workers have a higher prevalence of musculoskeletal symptoms than other women in their
community? YES, 2X higher
Research around these issues is difficult, potential to affect profit margin of business = TENSION
• Influenza of 1918 hit in summer, and was rampant among military camps
• Hit Philadelphia in September
• Rampant because city allowed public gatherings
o World War I parade/loan drive
o 4 months, 12,000 Philadelphians dead
o 719/100,000
o Prevented public gatherings in St. Louis, only 347 / 100,000 deaths
o EARLY ACTION SAVED LIVES
• Effective prevention program can implement controls and then control the epidemic, worry is that once
controls are lifted, epidemic will start again
o This is what happened in St Louis… reopened schools after 3 days influenza rates declining and
second wave epidemic started and children 30 to 40 percent of infections
• Study examined epidemic in 23 cities, Kansas City had most effective prevention, weren’t too late or too
early
• Most successful interventions in communities where political and health authorities broadly agreed on
what needed to be done and got significant cooperation from the public
• Tune intervention so single peak of minimal size is the result
• It is a mix between vaccine development and preventative measures
• Question of whether society is up for responsibilities that come with these measures, limitations
TEENS AND SUBSTANCE ABUSE TREATMENT IN TENNESSEE
Racial and Gender Differences in Utilization of Medicaid Substance Abuse Services among Adolescents
Health disparities are population level differences that result in different health outcomes
So we have to ID population, and population we are comparing it to
In differences to access, use, outcome
Implications
• differences in willingness of different HC professionals when have problem
• different ways of dealing with them
• how diagnose and treat a problem