hey, judy, wherever you are – the president signed the FDA tobacco bill. i think you’d be pleased with most of it.

miss you.

i always feel some embarrassment when former professors or other people i’m familiar with are publicly called out for wrongdoing, justifiably or not. such is the case with tee guidotti, former department chair at GWU SPHHS. a review panel found that “inattention to detail,” rather than interference from DC’s water utility, led him to the central conclusion in a published article that

there had been no identifiable health impact from the unprecedented concentrations of lead in [DC's] water from 2001 to 2004

subverting research for money, i can understand (but abhor). sloppy research? from a professor? inexcusable.

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the draft of kennedy’s HELP bill currently circulating (his answer to health care reform) prohibits health insurers from excluding pre-existing conditions from coverage. it also limits what characteristics insurers may consider when setting premiums, to “family structure” (although i wonder if that means they could charge higher rates for same-sex couples), community rating area (minimum size set by HHS), actuarial value of the benefit, and age (with limitations).

because insurers are also prohibited from excluding potential enrollees or placing annual or lifetime limits on benefits, (“each health insurance issuer that offers health insurance coverage in the individual or group market in a State must accept every employer and individual in the State that applies for such coverage”) this could force a greater pooling of risk – causing some premiums to rise, and others to fall – although i suspect the actual outcome would be that insurers would simply offer a wider variety of clinical coverage options, and charge more for more comprehensive plans.

the bill does set out minimum coverage requirements for all plans, which must include preventive services rated “A” or “B” by the US preventative services task force (such as regular mammograms for women age 40 or over, cervical cancer screening for sexually active women, cholesterol & blood pressure screening, and certain disease screening for pregnant women. all other OB-GYN screening guidelines are interestingly currently under revision.), immunizations, and non-adult preventive care and screenings in guidelines promulgated by HRSA.

(at page 40 of 615 they started talking about health insurance gateways, and lost me completely.)

and of course, it goes on and on, and is currently being marked up in committee. best quote so far, by barbara mikulski (paraphrased): “some call this bill a combination of rube goldberg and karl marx. well, the current system is a combination of adam smith, darth vader, and invasion of the body snatchers.”

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update OH! and i totally forgot – my favorite public health news story of the week – yesterday’s news that a smoking ban is being rolled out in virginia’s prisons. in unsurprising republican fashion,

“I don’t have any problem with prisoners being denied the right to smoke,” said House Majority Leader H. Morgan Griffith (R-Salem). “The only question I have is what effect it would have on control.”

go figure.

earlier this month, maryland authorities issued a warning against consuming rockfish and bluefish caught in coastal atlantic waters (according to their chart, this doesn’t extend to rockfish caught in the chesapeake, but the chart hasn’t been updated since may ‘07).

the warning says that

pregnant women, women of childbearing age, nursing women and children under 6 should not eat rockfish or bluefish caught in the Atlantic by amateur fishermen. People not in those groups may eat one meal of rockfish, also called striped bass, from the Atlantic every month, and one meal of bluefish every other month.

note that it only applies to fish caught by amateur fishermen. not to commercially-caught rockfish or blues from the same area. why? well, it’s not because commercially-caught fish are safer. it’s because commercially-caught fish fall under federal jurisdiction.

when i have a spare moment, i’m going to check the feds to see if they’re also warning against eating those fish. it’s not like PCBs discriminate by type of fisherman.

update: a quick search on the fish & wildlife service website yields nothing; the FDA is equally useless. USDA?

i was browsing through the google analytics, curious about what search parameters bring people to this blog, and i came across this question buried in the list. it struck me that i’ve never really thought about it.

first, there are the definitional questions. what did the searcher mean by “worth it”? and – don’t laugh – what did he or she mean by “be”? is this a cost-benefit analysis? a worldview question? is my existence defined by my advanced academic degrees? (the short answer to that one is a resounding “no,” by the way.)

i grew up in a public health household, and the most fulfilling work i’ve ever done has been in that field. i decided to earn an mph for entirely economic reasons, though – the added income from the degree. there was very little offered in the coursework that i either hadn’t already studied, or hadn’t learned at the dinner table or in the field. (obviously this wouldn’t be the case for most people, but i remember looking at maps of central american countries with my father when i was in 7th grade, as he determined the catchment areas of rural health posts. the broad street pump was practically a bedtime story. in fifth grade, i made a presentation to my class on contraceptive methods, much to my language arts teacher’s dismay. imagine explaining vaginal suppositories to your teacher when you’re ten years old…)

the mph was “worth it” in the sense that i completed my coursework while working full time, and saw a satisfying bump in my income. but it didn’t do much to change the way i looked at the world, or analyzed problems. it was really just academic and professional recognition of something i already knew.

the jd on the other hand – now that is a completely different story.

i went to law school – several years after earning my mph – simply because i could. i scored well on the LSATs; international trade law and health law issues were directly pertinent to my work, and unlike public health, it was not something i could learn from my parents or on the job. i never had any interest in practicing law in the courtroom or for a firm. i just wanted the additional analytical tools. and from that perspective, earning the jd was definitely “worth it.” i loved law school. i didn’t have much exposure to the socratic method, but it was thrilling in the classes where the professor used it. hypos were essentially big puzzles to which case law, statutes, and regulations could be applied – fitting the pieces together to determine possible answers. i learned more about the u.s. government than i had before (growing up overseas and having a narrow academic interest in college can stunt one’s civics education), and my appreciation and respect for the rights and responsibilities of individuals grew enormously, challenging my generally-unquestioned collectivist public health mindset. my public health positions have been somewhat altered by my legal education, both reinforcing some beliefs and leading me to question and reject others. i think these are all good things.

i “am” an mph jd in the sense that those letters come after my name on my business cards. i currently work for an organization whose primary focus is the law, and in an issue area that happens to be health (but not public health as its usually construed). when i read the newspaper, i naturally gravitate toward health and law reporting in areas that interest me, and i think i’m more likely to question assumptions i come across than i was before my degrees. but the mph/jd doesn’t define all of me. a quick search through this blog gives a much better picture of who i “am” than five letters on cardstock, or the diplomas gathering dust at the back of my closet.

i’ve found many benefits to having an mph/jd, and given the opportunity, i would likely do it again. one drawback, though, is that i’ve educated myself out of the type of jobs (and beyond the expected income level) that i like – at least for the moment. i’m an analyst at heart. show me a forest, and i’ll start cataloguing the trees and wildlife, and developing theories about pretty much anything i’m asked about. the big picture – the policy decisions, the strategic planning, the long-term outlook – these are things in which i have no particular interest. if i agree with them, i’ll happily work to support them, but i’d rather leave the development to someone else.

so there you go. a more introspective post than i’ve written in some time. and it probably won’t help the person who originally posed the question one bit. because what “worth it” and “be” mean to me may be entirely different than what they mean to him or her.

the interwebs are a great and marvelous thing. and i’m loving what people are doing with the medium. media? whatever.

at any rate, this video (can’t embed, you’ll have to click through) is one of the best short explanations of the meaning and importance of public health that i’ve ever seen.

although i doubt we’ll become “the healthiest nation in one generation”¹ as they hope; remember the alma-ata declaration in 1978? and here we are, 31 years later…² granted, alma-ata was global; this is “merely” national. but we’re going to be years digging out of the current economic crisis, and unless we start focusing on our public health infrastructure now, our next generation will be worse off than we are today.

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i’m anthropomorphizing my office supplies. behold: sad stapler.

____________________
¹ ah, slogans. like “health for all by the year two thousand” and “babies don’t thrive in smoke-filled wombs” and “click it or ticket.” catchy, memorable, but effective? how useful are those marketing tools?

² in an email exchange (and i’m assuming it’s OK for me to reprint it), my most constant reader pointed out that “over the last 31 years (god – has it been that long?!), governments like Kazakhstan have spent more time on trivial matters like changing the spelling of city and country names and building new capital cities as monuments to colossal political egos than in reversing the lowering life expectancy from alcoholism and failure to vaccinate children.” that, unfortunately, is the all-to-common political legacy of public health – and one of the reasons i am skeptical of campaigns with due dates.

despite having a startling similarity in appellation, i’m pretty sure that janet napolitano is no relation to johnette napolitano. which kills any chance of hearing the DHS secretary sing joey anytime soon.

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in reproductive health news, it’s looking likely that the FDA will be making it easier for 17-year-olds to buy plan B. the u.s. district court for the eastern district of NY has told them to, at least. (PDF of the memo & order in tummino v. von eschenbach)
i like the judge’s straightforward approach:

…the gravamen of plaintiffs’ claims is that the FDA’s decisions regarding Plan B – on the Citizen Petition and the SNDAs – were arbitrary and capricious because they were not the result of reasoned and good faith agency decision-making.

Plaintiffs are right.

…

Indeed, the record is clear that the FDA’s course of conduct regarding Plan B departed in significant ways from the agency’s normal procedures regarding similar applications to switch a drug product from prescription to non-prescription use, referred to as a “switch application” or an “over-the-counter switch.” For example, FDA upper management, including the Commissioner, wrested control over the decision-making on Plan B from staff that normally would issue the final decision on an over-the-counter switch application; the FDA’s denial of non-prescription access without age restriction went against the recommendation of a committee of experts it had empanelled to advise it on Plan B; and the Commissioner – at the behest of political actors – decided to deny non-prescription access to women 16 and younger before FDA scientific review staff had completed their reviews.

somehow i don’t think the rank & file up in rockville are too broken up about the district court’s decision.

really, just a solid science blog: cocktail party physics.

the post that caught my eye, of course, was on the MMR-autism “link.” it’s worth a read (and a watch).

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maybe i’ll eventually get around to blogging about why i think the wyeth v. levine SCOTUS decision was right, even though the original outcome at trial was likely wrong.

one of the side effects of the wyeth decision has been the proliferation of doomsday cries from such venerable sources as the wall street journal and AEI asserting that the decision spells certain doom for the pharmaceutical industry. in addition to calling for explicit FDA preemption of state causes of action, some – like the manhattan institute – would like the feds to indemnify drug companies that adhere to the minimum FDA warning label requirements, and create a federal drug injury compensation program, similar to the national vaccine injury compensation program.

i think this is a horrible idea on a number of levels, and i’ll sketch out a few thoughts to flesh out later:

* the VICP was established after a series of personal injury lawsuits awarded high damages to plaintiffs and several manufacturers halted production of the vaccines in response to their high liability costs. this is similar on its face to the greater drug situation, post-wyeth, but until we see a flood of wyeth-inspired lawsuits, reports of big pharma’s demise are premature. companies aren’t going to stop developing new drugs just because case law has now clarified what the FDA had maintained for decades: that the post-market surveillance of drugs requires both regulation and litigation. (either that, or we need to seriously beef up the FDA’s budget and give it back its fangs – something i don’t see the “free-market” manhattan institute favoring.)

* drug companies don’t have a very good track record of self-policing once their products have been approved. (vioxx, anyone?) removing one of the few incentives to keep on top of new data (lawsuits) will further reduce the companies’ interest in assuring the safety of their products.

* vaccines protect the whole population against epidemic disease. the rest of the drug pantheon… well, while they do serve a social good, i don’t consider lifesaving – but ultimately individual-supporting – drugs to have the same social value. it’s the difference between funding a city sewer system and funding a program to install self-cleaning toilets in every home. (no telephone sanitizer jokes, please.)

* there are 23 vaccines covered by the VICP. in contrast, the physician’s desk reference lists more than 2,400 drugs.

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and on a completely unrelated note, kashi frozen dinners are really, really yummy. the one i’m currently noshing on – black bean mango – is a little high on the sodium (430 mg), but impressively flavorful and texturally varied. it’s also vegan. go figure.

the colorado senate recently passed a bill, 32 to 1, requiring pregnant women to submit to HIV testing. the lone dissenting vote came from a republican who believes that the measure would “remove the negative consequences that take place from poor behavior and unacceptable behavior.”

apparently the senator believes that living with the consequences of untreated HIV appropriately punishes poor behavior. on the other hand, the rest of the state’s senators apparently believe that a fetus’ medical needs outweigh a woman’s right to privacy. according to one of the bill’s sponsors, “What this bill will do and why it’s so important to test the woman when she is pregnant — if she is HIV-positive, treatment is started immediately to protect the baby, the unborn baby.”

now, don’t get me wrong – i think HIV testing is a good idea. it’s a good idea if you’re sexually active and if there’s a possibility you could be exposed to HIV. it’s a good idea if you’re a pregnant woman who wants to make the most informed choices about health care for yourself and your fetus. so it’s a good idea to require doctors to offer the test, and to either require health insurance to cover it, or to pay for it out of government coffers. but requiring women to get tested – which is the likely outcome of an opt-out system – bothers me. interjecting the government anywhere in a woman’s reproductive health care bothers me, because in this country, it’s a quick jump to measures that limit reproductive choice, and that impinge on a woman’s right to conduct her life as she sees fit.

i believe the wording of the bill is highly problematic, even though it’s basically the existing syphilis law with HIV tacked on:

25-4-201. Pregnant woman to take blood test. (1) Every licensed health care provider authorized to provide care to a pregnant woman in this state for conditions relating to her pregnancy during the period of gestation or at delivery shall take or cause to be taken a sample of blood of the woman at the time of the first professional visit during the first trimester for testing pursuant to this section. The blood specimen obtained shall be submitted to an approved laboratory for standard serological test for syphilis and HIV. Every other person permitted by law to attend pregnant women in this state but not permitted by law to take blood samples shall cause a sample of blood of each pregnant woman to be taken by a licensed health care provider authorized to take blood samples and shall have the sample submitted to an approved laboratory for a standard serological test for syphilis and HIV. A pregnant woman may decline to be tested as specified in this subsection (1), in which case the licensed health care provider shall document that fact in her medical record.

(2) If a pregnant woman entering a hospital for delivery has not been tested for HIV during her pregnancy, the hospital shall notify the woman that she will be tested for HIV unless she objects and declines the test. If the woman declines to be tested, the hospital shall document that fact in the pregnant woman’s medical record.

25-4-203. Birth certificate – blood test. In reporting every birth and stillbirth, physicians and others required to make such reports shall state on the certificate whether a blood test for syphilis and HIV has been made upon a specimen of blood taken from the woman who bore the child for which a birth or stillbirth certificate is filed and the approximate date when the specimen was taken. In no event shall the birth certificate state the result of the test.

first, they’re requiring a sample of blood to be taken for the purposes of the HIV test, whether a woman agrees to be tested or not. then, the bill allows women to opt out, rather than requiring affirmative assent to the procedure, which would provide more protection for the woman. nothing will prevent a provider from taking the blood and “oops!” either “forgetting” to give the woman the option to decline the test, or “losing” any documentation of her refusal. finally, if they do offer her the option to decline, and she does, the fact of her refusal must be documented. why? and how will that information be used down the line? will providers be allowed to refuse to treat women who decline the test? will health insurers refuse coverage to women – or their infants – who have not tested negative? and what is the purpose of recording the fact or absence of the test on the child’s birth certificate?

the legislation is broadly written to cover all providers treating women for “conditions relating to … pregnancy.” this would require that a woman seeking an abortion must go through the HIV rigamarole. and to what end?

while this legislation might have evolved from good intentions, the potential for abuse seems very high, and the rationale behind requiring the testing, flimsy at best. i can only hope the house shows better sense than the senate and defeats it.

earlier this month, the VA state legislature passed what is (IMO) a pretty pathetic compromise clean indoor air bill. perhaps to show they can come up with meaningful legislation, they’ve just passed a bill to expand the death penalty.

you read right. once the ink dries, a whole new category of people will be eligible for capital punishment: those who assist in a murder, but don’t actually kill anyone.

yay richmond.

the news is telling us that the economic stimulus package is expected to receive final approval and head to obama’s desk. few of the news reports have any detail as to what’s actually in the bill, so i headed over to thomas to find out.

what struck me immediately was not so much what’s in it, but what’s been removed from it. (assuming i’m reading the strikes and italics correctly.)

for example:

the entirety of the transparency and oversight requirements. there had been requirements for a whole host of stimulus-package information to be published on the recovery.gov website. information like:

• Each Federal agency shall publish (1) a plan for using funds made available in this Act to the agency; and (2) all announcements for grant competitions, allocations of formula grants, and awards of competitive grants using those funds.
• detailed data on contracts awarded by the Government for purposes of carrying out this Act, including information about the competitiveness of the contracting process, notification of solicitations for contracts to be awarded, and information about the process that was used for the award of contracts.
• printable reports on funds made available in this Act obligated by month to each State and congressional district
• links to and information on how to access job opportunities created at or by entities receiving funding under this Act, including, if possible, links to or information about local employment agencies; state, local and other public agencies receiving funding; and private firms contracted to perform work funded by this Act.

heaven forbid the public is advised of how the money is actually spent, or where it is actually going. i suspect that would just be too dangerous for the congresscritters who are constantly running for re-election, or for the ones who oppose the package, and yet stand to profit tremendously from it (politically).

so that’s a glimpse at what was cut. but what’s still in the bill?

on the health care side, there seems to be more than a billion dollars earmarked for clinical effectiveness research, presumably to guide future government involvement in attempts to reduce health care costs (or perhaps as a precursor to universal coverage); the current language sets out:

the funding appropriated in this paragraph shall be used to accelerate the development and dissemination of research assessing the comparative clinical effectiveness of health care treatments and strategies, including through efforts that: (1) conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions and (2) encourage the development and use of clinical registries, clinical data networks, and other forms of electronic health data that can be used to generate or obtain outcomes data

there’s also $118M for “energy conservation and investment” for military construction projects – something that is sorely needed, as new buildings seem to be going up on bases (at least in this area) without any consideration for green construction or energy efficiency (the new child development center on fort myer is an egregious example of this). $336M for the construction of child development centers, across all services. $481M for warrior transition complexes. (no army funding for barracks, though. interesting.) $1.3B for VA medical facilities, and $145M for VA benefits claims processing.

as i read through this, it’s an awful lot of government spending. i’m not sure how it’s supposed to result in jobs creation, though. food for thought.