Session

Twists and turns; public health issues in perspective in the US

Jim Wohlleb, MA, MS, APHA Medical Care Section, 1018 N Arthur, Little Rock, AR 72207-6302

APHA's 2018 Annual Meeting & Expo (Nov. 10 - Nov. 14)

Abstract

Police Power and Public Health: Excessive Use of Force as Friend and Foe of U.S. Public Health in the 20th Century and Today

Christine Mitchell, MDiv Harvard T.H. Chan School of Public Health, Medford, MA

APHA's 2018 Annual Meeting & Expo (Nov. 10 - Nov. 14)

Public health professionals today are calling for police violence to be addressed as a public health problem, for data on police killings to be collected by public health departments, and for researchers to be taking this disparity in violence seriously. Interestingly, as this paper will show, a field that once utilized police violence to force people to make decisions in response to public health problems is now calling for police violence to be addressed as a public health problem in itself. Through the context of epidemic diseases in the late 19th and early 20th century, and through the conversation on compulsory vaccinations and quarantines, this paper explores the tension between individual rights and the public health, probes both the definition of and the limits on “police power,” and suggests alternative pathways to law enforcement to protecting public health. Most importantly, this paper serves as a call to those in the field of public health to acknowledge the field’s historical complicity with police violence on vulnerable populations for the “common good” and strategize for how to address this tension while protecting the public’s health in contemporary practice.

Advocacy for health and health education Diversity and culture Other professions or practice related to public health Provision of health care to the public Public health or related laws, regulations, standards, or guidelines Social and behavioral sciences

Abstract

Agency Responses to Mental Health Issues Related to HIV/AIDS in the early 1980s in New York

James Walkup, Ph.D., Rutgers University, Piscataway, NJ

APHA's 2018 Annual Meeting & Expo (Nov. 10 - Nov. 14)

Soon after AIDS arrived , an October 1982 article in Gay Community News alluded to psychology/psychiatry viewing gay sex as disordered when it reminded readers: it wasn’t so long ago that “the words ‘gay’ and ‘disease’ were merely redundant,” alerting them how press coverage was once again linking the two terms. Subsequent struggles to define responsibility for psychological services for New Yorkers with HIV both reproduced, and scrambled, pre-existing divisions about the legitimacy of psychological/psychiatric expertise. In the face of the initial inaction by NYC’s public/nonprofit clinical settings, Gay Men’s Health Crisis (GMHC) created a volunteer force, drawing largely from the gay community, including some psychologists (involved in programming/training). Despite suspicion by some that reliance on psychological ‘expertise’ to design prevention and support programs could re-link gay sex and disorder, skyrocketing demand for services, and a conviction that public systems could not be counted upon, soon convinced GMHC to “professionalize” services. The GMHC-model soon received state support, and was a building block for programming. The subsequent all-hands-on-deck push for state interagency coordination initially found directives ran afoul of the state Office of Mental Health’s legislatively mandated, historically-rooted, tight focus on those with psychiatric disabilities and severe mental illness (SMI). The number of people living with HIV/AIDS(PLWHA) who might fall in that category was unknown and, presumably, a small minority. Efforts to investigate epidemiology and design integrated services for the intersection of HIV/SMI ushered in new role for psychiatry/psychology in the AIDS era.

Administration, management, leadership Program planning Provision of health care to the public Public health or related public policy Social and behavioral sciences Systems thinking models (conceptual and theoretical models), applications related to public health

Abstract

Public Demonstrations, Bold Experiments, and Self-Experimentation: Historical Practices Predating Ethical Guidelines

Jan Carney, MD, MPH, Larner College of at the University of Vermont, Burlington, VT

APHA's 2018 Annual Meeting & Expo (Nov. 10 - Nov. 14)

Introduction: The National Act (Public Law 93-348) of 1974 created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, followed by federal regulations. Prior to these, research practices were largely unregulated until a series of experiments raised substantial concerns about practices on humans. One interesting historical perspective is the use of public experimentation and testing on self and on family to enhance public credibility and acceptance of research findings. Methods: Literature review and research with focus on primary sources, including newspaper accounts. Results: Public demonstrations of early vaccine safety were common among political figures and their families, including Frederick II of Prussia, King Louis XIV of France and Catherine II of Russia; other examples include variolation of Lady Mary Wortley Montagu’s children against smallpox in England in 1718 and of two daughters of the Princess of Wales in 1722. Pasteur’s public experiment with anthrax vaccines at Pouilly-le-Fort, in 1881, boldly demonstrated his new vaccine against the pervasive animal killer. Robert Koch, in his controversial tuberculosis treatment, published in November 22, 1890, tested his “remedy for tuberculosis” first on himself then on healthy volunteers, describing his own pain, breathing difficulty, vomiting, and fever following his self-experimentation. In 1900, Drs. Reed, Carroll, Agramonte and Lazear of the U.S. Army Yellow Fever Commission conducted experiments to determine the etiology of yellow fever and transmission by mosquitos. Dr. James Carroll intentionally let a mosquito bite him during the experiments and contracted yellow fever several days later, but survived, providing credibility for their theory of disease transmission. Ethical concerns arose with the Tuskegee study, hepatitis experiments at the Willowbrook School, and development of the HeLa cell line. Published experiments were also conducted to study immunity to cancer by injecting cancer cells into ill and hospitalized patients, and later, into healthy prisoners. These controversial experiments came to light in 1964; during the experiments, some researchers refused to inject themselves, the lead investigator refusing to take “even the little risk.” Conclusions: Before research protections, history provides examples of efforts to enhance credibility and public acceptability of new research findings by public experiments, self-and- family experimentation, and use of new treatments on famous political figures. However, in contrast to efforts of scientists to enhance research credibility with self- experimentation, a public refusal to experiment on oneself revealed just the opposite, fueling concerns about safety of the conduct of such research.

Clinical medicine applied in public health Ethics, professional and legal requirements Public health or related laws, regulations, standards, or guidelines Public health or related public policy Public health or related research

Abstract

History of Medicare and its role in addressing healthcare disparities across age groups

Walid El-Nahal, MD Health System, Charlottesville, VA APHA's 2018 Annual Meeting & Expo (Nov. 10 - Nov. 14)

Prior to the enactment of Medicare, health equity across age groups was a major issue. Disparities in healthcare coverage between younger employed populations and the elderly retired population were striking. Some estimates suggest that half of seniors were uninsured prior to the enactment of Medicare. Today, that number is on the order of 2 to 3 percent. While a third of people above 65 lived in poverty in the 1960s, that number is now closer to 10%, matching rates among the middle-aged population. While this was undoubtedly multifactorial, decreases in out-of-pocket healthcare expenditures are thought to have contributed significantly to this. Addressing that disparity continued after the enactment of Parts A and B, with the later enactment of Part D, which estimates suggest has decreased out-of-pocket drug costs by 20% for enrollees. Although coverage for the elderly has become easy to take for granted, it is important to be mindful of the significant disparity that a program like Medicare addressed, as we move forward in trying to approach disparities across other patient populations.

Public health administration or related administration