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Posts Tagged ‘public health’

China’s Public Health Challenges

November 14th, 2009 No comments

China’s political and environmental challenges are often chronicled, but less attention has been paid to the public health issues that the nation’s move to developed nation status has caused.

That’s starting to change. In a good summary article in Yale Public Health, (pdf. of Fall issue on right side of linked homepage), Christina Larson offers a succinct account of the many issues confronting public health researchers and policy-makers in a nation with more than 170 cities of at least one million people (that’s right). As in any rapidly developing nation, China finds itself with a spike in chronic disease problems, while infectious disease issues have to an extent been dealt with. Today, the country is dealing with a high incidence of lung cancers (caused by a just silly smoking rate and by environmental toxins); diabetes; and — yes — obesity. Those iconic Beijing bikes are quickly giving way to cars, with the host of predictable negative health consequences you might expect.

The article goes on to explain that China is really a host of sub-populations, flung over a vast expanse and with wildly different problems. Interventions need to be carefully targeted to stand any chance of improving public health outcomes, but that targeting is itself challenging because of the dynamic, quickly changing nature of the nation and its people. Trying to glean useful data that screens out the “noise” is always a challenge for epidemiologists, but even more daunting under these conditions.

Steps are being taken, including the bellwether move of banning smoking in certain bars, but it will be vital for local, state, and global public health officials to “get smart” about the challenges they face, and soon. Time’s not on their side.

With these issues in mind, a contingent of health law professors from our law school is traveling to Southwest University in Chongqing next month, there to discuss, among other topics, global public health. Our expert on these issues, Michele Forzley, is a global public health expert with ties to WHO and the U.S. Department of Commerce; she is to speak on training legal and public health experts on confronting emerging issues. Her work is vital.

The Public Health Peril in Oklahoma’s Anti-Abortion Obsession

October 18th, 2009 1 comment

Nan Hunter has just run a good summary of recent legislation in Oklahoma that, taken as a whole, is designed to prevent women from having abortions altogether. The state’s determination shows that, Roe v. Wade not to the contrary, there’s plenty that states can do to restrict what the Court has declared to be part of a fundamental right to self-governance, privacy, and autonomy.

The state’s zeal, though, shows that ideologues on a mission can wreak havoc with settled public health principles, thereby jeopardizing the public’s trust in health care — just in case there’s any such trust left. There are at least two recent examples of this misguided approach.

First, a recent piece of legislation — later declared unconstitutional — required women to undergo an ultrasound (vaginally in the case of early pregnancies) before an abortion could be performed. Such coerced invasion of the body has typically been required only in cases of epidemic; even there, often the resisting party can usually forego vaccination and pay a fine, or suffer the less objectionable deprivation of liberty. This would have been the first case I’m aware of where an unwanted, invasive procedure would have been made a prerequisite for a procedure that someone has a legal right to have, and where that first procedure isn’t needed for some other medical reason. In other words, this is quite different from requiring a biopsy before surgery to remove a tumor.

Laws educating women about fetal development (although also typically a smoke-screen for restricting access to abortions) are OK with me, at least in principle. This weird law, on the other hand, is creepy and offensive, and it’s lucky that the legislators blew it through a technicality (shoving too many subjects into a single piece of legislation).

The second, and more recent example, is a law currently under challenge. This one  would set up publicly available, web-based reports on anyone who obtains an abortion. The information would have to be reported to doctors, who would then be required to pass it on to public health officials. This is a very, very bad idea. I don’t even need to talk about abortion (thankfully!) to explain why.

This law will drive a wedge between physicians and their patients. Many people have distrust of the medical and public health professions, and won’t be warmly encouraged to make that next visit to their provider — or to any other — when they’re met with a battery of identifying questions that can then be used to pick them out of a probably hostile community. As a flimsy subterfuge for the laws’ true intent, names aren’t required — but, as a lawyer from the Center for Reproductive Rights has pointed out, names won’t be needed to identify someone from sufficiently small communities, especially when so much other identifying information is exposed. According to this article, quoted extensively by Hunter, there will be “answers to 34 questions including…age, marital status and education levels, as well as the number of previous pregnancies and abortions. Women are required to reveal their relationship with the father, the reason for the abortion and the area where the abortion was performed.”

It’s clear that the legislators are trying to slap a different kind of scarlet “A” on these women, hoping that the shame and ostracism of expected discovery will keep them from carrying out their intended abortions. It might have this effect, but the more sweeping result will be a lack of trust that will penetrate relationships between patients, doctors, and public health practitioners. Patients will learn how to lie their way around the obviously unenforceable law (some of the facts sought depend on patients’ willingness to disclose, such as “reason for seeking the abortion” and, often, the number of previous pregnancies), and doctors may be less than forthcoming with public health officials if they see them as interfering with the MD/patient relationship. And any public health official with good training will despise and, one thinks, try to circumvent the law.

Even in states that require doctors to report HIV infection to public health, the goal is partner notification and contact tracing to eliminate an established risk. These laws are controversial, but they at least have arguments to recommend them — and the results aren’t published on public websites.

With this level of identifying information, the Oklahoma statute looks more like the sex-offender laws (which have their own problems, btw) than anything else. What more do you need to know?

Sotomayor: Abortion as a Public Health Issue

July 15th, 2009 1 comment

I no longer listen or watch raptly as Supreme Court nomination hearings proceed. They’re mostly for show, and a little goes a long way.

In Judge Sotomayor’s case, the little I’ve seen —  except for the moving sight of her mother in the audience, fighting back tears of joy and pride — has been as scripted as have been recent hearings. Republicans are cautiously on the attack, recycling the few pieces of ordnance they have (will anyone ever again refer to herself as “a wise Latina”?) and at times revealing their embarrassing ignorance of all things judicial. Democrats work on the hagiography while pre-emptively blocking any efforts to suggest that the nominee might actually have a heart. (Chuck Schumer’s references to cases where Sotomayor had ruled against sympathetic plaintiffs were noteworthy in this regard, if a little…odd.) And the nominee herself, determined to give them nothing (especially since she’s reputedly such a Latina hothead!), is plodding along in a performance that is measured — at times even boring — by design.

But I did stop what I was doing and listen attentively to a brief exchange between Judge Sotomayor and Sen. Lindsey Graham of South Carolina. The discussion concerned the nominee’s work as a Board member for the Puerto Rican Legal Defense and Education Fund (“PRLDF”). Having served on the board of a legal advocacy group my own self, I can tell you that even the lawyers among us had approximately zero input on the cases the organization chose to take, and even less on the legal arguments and strategy the organization pursued.

Nonetheless, there’s something to Sen. Graham’s line of questioning, because Board members are generally committed to the goals and philosophy of the organization, even if they might have quibbles about details. If Equality Advocates, on whose board I sat, had suddenly decided, for example, not to take cases involving transgender rights, I would have known about that decision, and protested it. Sotomayor said as much, noting that Board members did care about fidelity to the organization’s broad mission statement.

So Graham pressed Sotomayor on briefs that the PRLDF had filed arguing that denying poor women the right to a government-funded abortion was the moral equivalent of slavery. Sotomayor claimed, quite plausibly, to have known nothing of this, but then she did speak to the overall goals of the organization in the same way I would have felt comfortable describing the work of Equality Advocates. She said that the Fund (which contains the word “Education” in its title) was interested in issues of “public health,” as were other advocacy groups.

Aha! Graham had what he perceived as an opening. “So you think abortion is a public health issue?” he asked.

Somehow, she managed to avoid answering the question directly — but she shouldn’t have. Here’s the exchange (beginning shortly before 4:00):

Abortion is a public health issue, and this description of it shouldn’t be seen as controversial. Graham was doubtless proceeding from the presumption that those who see abortion as a matter of public health are on the extreme end of the pro-choice side.

It’s true that one argument in favor of abortion rights has been that, on a population-wide basis, safe and legal abortions lead to better health outcomes; illegality and the lack of regulation predictably compromise women’s health. But that doesn’t mean that the argument is decisive from a public health point of view, nor does it mean that the public health perspective is the only perspective from which to consider the issue.

Recently, those opposing abortion rights have argued that abortions have their own public health consequences, including increased incidence of breast cancer and adverse mental health outcomes for women who terminate their pregnancies. There’s not a lot of evidence in support of these theories, but that didn’t stop Justice Kennedy, in his 2007 Supreme Court decision in Gonzales v.  Carhart, from reciting supposed psychological consequences in support of his ruling that a law restricting late-term abortions was constitutional.

And public health, properly understood, isn’t a purely utilitarian calculus, anyway: Properly understood, it incorporates a respect for persons and autonomy that has both long- and short-term effects on health and well-being. In short, to recognize the issue as one with a public health dimension is to add a useful prism through which to view this complex and probably irresolvable issue.

But not the only prism. Saying that an issue has an important public health dimension isn’t ruling other perspectives out of order. Questions of rights and morality can’t and shouldn’t be read out of the issue. The challenge is to hold all of these perspectives before us as we strive for some kind of legal and social rules that we can live with, if not totally embrace. That goal sometimes  seems impossible to achieve, but I’m optimistic that public health talk can take some of the heat out of the discussion and enable sensible compromise.

Repeat: Abortion is a public health issue.

Delhi Order: Equality, Sliced Thick

July 6th, 2009 No comments

As many readers know, last week the High Court in Delhi, India, sided with an HIV/AIDS services organization in ruling that the state’s prohibition on consensual, “unnatural” sexual acts violated the Indian Constitution. Nan Hunter has a brief summary of the ruling in Naz Foundation v. Government of NCT of Delhi, which apparently applies throughout the country unless and until reversed by the Supreme Court.

The long decision is noteworthy for many reasons, most obviously because it adds India to the ever-growing list of nations that have taken important steps towards recognition of the basic equality of their LGBT citizens. I recommend reading the entire decision (it’s long!), which you can find linked to The Times of India  (which also quotes some of the court’s soaring rhetoric about discrimination, equality, and dignity).

Here, I want to focus on just a couple of points. First, the two state ministries that weighed in on the law differed; the Ministry of Home Affairs supported the law, while the Ministry of Health and Family Welfare sided with those challenging the law. The conflict draws into sharp focus the question of whether “morals legislation” is valid when it’s contradicted by public health and welfare considerations. In sum, the court said “no.” Home Affairs conceded the privacy argument for throwing out the law, but thought that it should be overborne by considerations of “public safety and protection of health as well as morals….” But the evidence strongly supported the contrary view of Health and Family Welfare, to the point that public health considerations argued strongly in favor of removing the legal prohibition against consensual sexual acts.

As someone who writes and teaches about the connections between public health and law, I was surprised and heartened to see the court undertake a direct and compelling public health argument in favor of throwing out this artifactual statute.  In a ten-page section of the opinion entitled “[The Law] as an Impediment to Public Health,” the court details the high social and epidemiological cost of the closet, which is powerfully reinforced by the criminalization of same-sex relations. As we know, criminalization of same-sex relations and the accompanying stigma (as well as the potential for blackmail, apparently still real in India) drive the epidemic underground, making it much more difficult to reach people with disease prevention messages and strategies.

To the Home Affairs counter that criminalization was the right response to the HIV epidemic, the court noted that this view ran counter to well-understood views of homosexuality and the effect of criminalization. Siding with international and national public health authorities (including Health and Family Welfare), the court stated the prevailing view that criminalization doesn’t stop the behavior, but simply drives it underground. Not a good place to be, from a public health perspective. In addition to leading to preventable cases of STDs, including HIV, criminalizing homosexuality has more subtle effects. It adversely “shapes an individual’s identity and self-esteem. These laws “serve to embed illegality within the identity of homosexuals.” They “reinforce public abhorrence of lesbians and gays resulting in an erosion of self-esteem and self-worth.”

The other point worth mentioning is that the court, like many courts addressing broad issues of human dignity and civil rights, looked not only to its own law but also to the laws of other nations, as well as to international declarations of rights. Lawrence v. Texas received prominence of place, with the New Delhi court quoting Justice Kennedy’s majority decision declaring that banning same-sex intimacy violated the couple’s fundamental liberty interest, as well as Justice O’Connor’s equality-based concurrence. But decisions from South Africa, Canada, Australia, and the European Court of Human Rights were also discussed, as were the Universal Declaration of Human Rights and the European Convention on Human Rights.

I can’t resist concluding this post by remembering Justice Scalia’s dissenting screed in Lawrence, relevant to both points. First, he liked that, pre-Lawrence, the prohibition on same-sex intimacy could be — and was — used to support the unequal treatment of gays and lesbians in other areas of law. A couple of the cases he cited favorably upheld: the use of a police department questionnaire asking potential applicants about past homosexual (but not heterosexual) activity; and expanded security clearance for gay and lesbian job applicants only. He left out the worst case of all, in which a job offer to a lesbian who was set to begin working in the Georgia State Attorney General’s office was withdrawn after the AG found out about her commitment ceremony; in the view of this later-to-be-determined adulterer, her status as a lesbian was enough to presume she’d engage in illegal conduct. Begin making room in the closet.

Scalia also reddened at the Lawrence majority’s invocation of — not reliance on — foreign (pronounced: “fer’n”) sources of law. He quoted favorably from an earlier opinion by Justice Thomas objecting to the Court’s imposing “foreign moods, fads, or fashions…” on Americans.

Dignity, equality, and application of sound public health findings: “Moods, fads, and fashions.”