Janet Golden, PhD
Today’s piece, the fourth in our ongoing race and health series, is by Janet Golden, a historian of medicine and public health. She writes about the teaching of race and health, and connections between past and present.
- Michael Yudell
As a medical historian, I find the subject of race and health to be both the easiest and the hardest to present to my students. It’s easy because there is so much data to analyze, from W.E.B. DuBois’ Philadelphia Negro (1899) to more recent work from the National Institute on Minority Health and Health Disparities. This agency, which is part of the National Institutes of Health, has been around in one form or another since 1990, and today has the mission of leading “scientific research to improve minority health and eliminate health disparities.” That is the challenge.
Economic disparities and racism are the foundation of a significant portion of health disparities. They are linked to factors like living in neighborhoods filled with environmental hazards such illegal lead smelters and in homes with lead-based paint, not to mention the cockroaches that have been linked to asthma. Poverty is tied to the lack of access to good food, good jobs, good education, and good health services. Neighborhoods matter. Health is not an individual issue; it is a collective concern.
The infant mortality rate, an index of national well being used around the world, shows how far we have come since 1900, when the death rate for infants was 100 out of every 1000 live births. And a look at the infant mortality rate today shows we have a long way to go. As pediatrician and historian Jeffrey Brosco has demonstrated, “deaths among African-American infants have remained double the national average” for more than a century.
That’s the crux of our nation’s problem and of the problem in my classroom. We aren’t talking about something that can’t be substantially remedied; we are talking about a situation that reflects the ongoing problem of race and inequality.
The horrifying explosion at a fertilizer plant in West, Texas is a painful reminder that workplace safety is a crucial part of public health. As former U.S. Labor Secretary Hilda Solis noted in a Memorial Day speech in 2012 “Every day in America, 12 people go to work and never come home. Every year in America, nearly 4 million people suffer a workplace injury from which some may never recover. These are preventable tragedies that disable our workers, devastate our families, and damage our economy.”
In 1911, a fire at the Triangle Waist Factory in New York City, took the lives of 146 people in a mere 18 minutes, a horrific tragedy that is documented in news reports, survivor interviews, photos and documents compiled by Cornell University.. The victims suffocated or burned inside or jumped to their deaths to escape the flames. “They hit the pavement like rain” recalled a fire chief. In the wake of this tragedy, New York State created a Factory Investigating Commission. The owners of the factory were charged in criminal court. The full transcript of the trial is here. But rather than read it, why not listen to poet Robert Pinsky read his moving poem about the fire, “Shirt.”
States enacted factory inspection laws before and after the Triangle Fire, although safety enforcement was not always rigorous and small workplaces often escaped from regulation or avoided inspection. Widespread federal oversight of workplaces did not begin until 1971, with the creation of the Labor Department’s Occupational Health and Safety Administration (OSHA) following passage of the Occupational Safety and Health Act of 1970.
Workplace safety measures are attacked by critics of the “Nanny State,” who assert that the federal government is trying to legislate private behavior. They point at warning labels on tools and decry the government effort to disseminate what they view as common sense. Businesses facing regulation claim that OSHA rules don’t make workplaces safer and merely drive up costs for consumers.
Michael Yudell, Associate Professor, Drexel University School of Public Health
What interests you: Disease sleuthing? Global bioethics? Protecting the food supply? Protecting yourself when you travel?
A new ranking of the top 30 public health blogs places The Public's Health at No. 14. The complete list is below. Lots of interesting stuff.
And if you want to go beyond reading about public health, join us at 6 p.m. Friday for “Blogging and Beer: Public Health in Philadelphia.” Also with us will be our editor at the Inquirer, public health writer Don Sapatkin, and some of our regular contributors. There is no cover charge for what we hope will be a lively discussion at Rembrandt’s Restaurant in Fairmount, one of several health offerings at the Philadelphia Science Festival that we mentioned last week.
Best Public Health Blogs
1. The CDC Public Health Blogs are the primary blogs of the Centers for Disease Control and Prevention. The CDC blog serves the same purpose as the organization, to help keep people safe by educating them on potential risks and risk management not only to do with disease, but many other issues related to public health.
Highlight: Special Needs and Tornados, a Joplin Story
Bette Begleiter and Mazvita Nyamukapa
In his 2013 State of the Union Address, President Obama emphasized the need to give our kids a chance by making high quality-preschool available to every child . His message echoed that of Former President Lyndon B. Johnson, who in his 1964 State of the Union address resolved to begin the War on Poverty and from this birthed the Office of Head Start. From a public health perspective, resolving to invest in our future by increasing access to early childhood education for all children, is a good thing supported by both data and our values as a society.
Sadly, however, hopes for universal pre-school have been dashed for the moment.
Sequestration, the budget-slashing result of both parties’ failure to reach a more palatable deficit-cutting compromise, has led to 5% funding cuts for all current Head Start programs, not to mention the President’s proposed expansion. This particular sequestration cut translates to the projected loss of $11.6 million in Head Start funding from Pennsylvania’s economy and more than 200 Head Start-related jobs. Worst of all, up to 2,300 commonwealth children will lose access to Head Start and Early Head Start services. New Jersey will be cut by $7.6 millionand a loss of access for 1,300 children (nationwide, Head Start will cover 70,000 fewer children).
Early childhood education is important because it forms the foundation for the growth and development of well-adjusted and productive individuals by focusing on cognition; language; social and emotional development, and physical health at a critical time. And it is a key determinant of health in a child as well as in the adult that he or she will grow up to be. The association between education and health as well as those between education and income is well-documented -- early childhood education is an imperative.
During his State of the Union address last month, President Obama challenged the assembled lawmakers to tackle comprehensive immigration reform. The issue has proven a divisive one in our national political discourse, and most of the discussion focuses on the political ramifications. Pundits have discussed how immigration reform might impact the Latino vote, as well as what types of immigrants would be eligible for citizenship, and what the role of border security is, to name a few hotly-contested questions in the current debate. Amid this political maelstrom, few have considered how comprehensive immigration reform might affect the nation’s health. Understanding the health implications of immigration reform may contribute to the public discourse on the topic, and may also provide insights that are relevant to the equally divisive health reform debate. Remember that undocumented immigrants are explicitly excluded from Obamacare.
To examine this question carefully, I’ll first discuss what we know about the demographics of undocumented immigrants in the United States. Then I will review the available evidence describing the health of this population and their health care use. First, however, I would like to acknowledge the challenges to studying this vulnerable population and the potential inaccuracies of the resulting data. It is widely known that Census reports include small numbers of undocumented immigrants. It is just as hard to assess the health status of this population as it is to count their numbers. Undocumented immigrants are also under-represented in most large health surveys, with a few exceptions presented below. As a result, our knowledge about the health of undocumented immigrants and their use of the health-care system is limited.
According to the best available evidence, there are 11.1 million undocumented immigrants residing in the U.S. — more than one-quarter of the nation’s total immigrant population. It is estimated that there are 550,000 undocumented immigrants living in New Jersey, the fifth-largest of any state, and 160,000 in Pennsylvania, many of whom work in restaurants and have fueled the recent food renaissance in Philadelphia. At the national level, most undocumented immigrants are Latinos — 82 percent, to be exact. Because Latinos constitute the overwhelming majority of the nation’s undocumented immigrants, let’s focus on Latinos when reviewing the medical literature and discussing the impact of immigration reform on the nation’s overall health.
Studies have consistently demonstrated that undocumented Latino immigrants use less health care than U.S. citizens who are either Latino or white. One survey study based in California and Texas — traditional centers for Latino immigration and Nos. 1 and 2 in the state rankings — reported that undocumented Latino immigrants were less likely to see a doctor than a national sample of Latino U.S. citizens. The same study showed that undocumented Latinos who saw a physician had approximately half the number of doctor visits as Latino citizens. A recent study using a large sample representative of California’s population compared the health care use of undocumented Latinos to that of U.S.-born Latinos and whites. This study found that 87% percent of U.S.-born whites had visited a physician in the previous year, compared to 83% of U.S.-born Latinos and just 64% of undocumented Mexican immigrants. Emergency room visits were also less common among undocumented Latino immigrants than among Latino or white citizens. Although low health care utilization among undocumented immigrants may be related to access barriers or fear of deportation, the final study reported the same principal finding after controlling for socioeconomic factors, insurance, and need.
On Friday if Congress and the president do not act, what is known as the budget sequestration-- automatic cuts to a wide range of government programs– will kick in.
This spells public health disaster.
The first to feel the massive cuts to public health programs will be mothers and young children. The youngest are like canaries in a coal mine – the most sensitive to any change in the political winds, and thus the best human indicators of how well our policies are working. Cuts are scheduled to hit Head Start, childcare subsidies, special education, and mental health services, to name just a few.
One area that will be particularly painful relates to families’ most basic needs: good nutrition. The Special Supplemental Nutrition Program for Women, Infants & Children (WIC) provides supplemental foods, health care referrals, and nutrition education for pregnant and lactating moms and their children under five. WIC serves 53% of all infants and 25% of all pregnant women in the United States – more than 9 million mothers and young children each month.
If sequestration is allowed to go forward on March 1, WIC will be slashed by 5.1%. Sound small? It is the equivalent of dropping 600,000 mothers and young children from the program.
By Janet Golden
Did you know that sometimes there is a free lunch — or, more precisely, free money?
If not, then let me guess: You haven’t finished reading the 900+ pages of the Affordable Care Act, even though this was one of your New Year’s resolutions. And maybe you’ve woken up in the middle of the night wondering: What’s in it for public health?
Okay, I realize that is not a likely scenario. But should you be curious, a summary of the key public health provisions can be found here.
Erin Cusack and Bette Begleiter
On Monday, Ohio Gov. John Kasich, a conservative Republican, said “yes” to his state receiving billions of federal dollars to increase health-care coverage through Medicaid expansion. The following day, Republican Gov. Tom Corbett, in an unsurprising but still disappointing turn of events, announced he was “not recommending” that Pennsylvania accept this money at this time – a statement that could leave hundreds of thousands of uninsured families out in the cold.
Since 2010, the public debate on health reform – plagued by myths, political ideology, and not a few unfounded claims – has devolved from a conversation about solving the problem of the uninsured, to a game of partisan bickering and infighting. Now, with election season behind us and the implementation of most important provisions of the Affordable Care Act (ACA) less than a year away, Pennsylvania faces the largest public policy decision regarding Medicaid in decades, as does New Jersey: Should the state expand Medicaid and health coverage as part of landmark health care reform?
In 1965, when President Lyndon B. Johnson amended the Social Security Act to enact Medicaid, the federal government promised an unprecedented state-federal partnership that would provide health insurance to millions of uninsured Americans. Although all 50 states would eventually join the program by 1982, only six would set the precedent by joining Medicaid in its inaugural year. Pennsylvania was one of them. As a result, thousands of uninsured Pennsylvanians had access to life-saving health care for the first time.
Today, one in five residents in Pennsylvania receives health coverage through Medicaid. In addition, almost half of all births in Pennsylvania, and 35% of children, are covered by this critical program. While Medicaid and the Children’s Health Insurance Program (CHIP) together provide a strong base of health coverage for low-income children and pregnant women – as Medicare does for the elderly – eligibility for low-income adults ages 18 to 64 remains extremely limited. And pregnant women’s coverage ends almost immediately following birth.
By Nan Feyler
Lead poisoning of children continues to be a serious health problem – and one that science has linked to lower and lower levels of exposure even as government has opted for greater and greater cuts in prevention programs.
Each year, thousands of children in the Philadelphia region alone are poisoned, most often from deteriorated paint and dust in older homes where lead paint remains under layers of newer lead-free paint. Chipping and peeling paint due to age, overdue or poor maintenance, unsafe remediation or wear and tear on well-used areas like doors and windows can create poisonous lead dust that, while often invisible, accumulates on surfaces throughout the house, putting young children and babies at risk.
Philadelphia’s new Lead Paint Disclosure and Certification Law, which went into effect on Dec. 21, is intended to reduce the risk of lead poisoning in children who live in older rental properties in the city. Section PM-305 of the Philadelphia Property Maintenance Code already requires landlords to correct any peeling paint, cracked or loose plaster, decayed wood, and other defective surface conditions in a rental unit. Yet each year hundreds of children in Philadelphia are poisoned from exposure to lead paint and lead dust in the homes that their families rent.
JoAnne Fischer and Bette Begleiter
JoAnne Fischer is executive director, and Bette Begleiter deputy executive director, of the Maternity Care Coalition, a Philadelphia nonprofit that works to improve maternal and child health and wellbeing through the collaborative efforts of individuals, families, providers and communities.
By JoAnne Fischer and Bette Begleiter
Each year, Americans spend an average of more than $7,500 per person on healthcare and over $10,000 per birth. This is more than in any other country in the world. Does this expense lead to improved health outcomes? In terms of maternal mortality it is totally counterintuitive. The United States has some of the best economic development, nutrition, technology, and medical institutions in the world. We’d expect that mothers would no longer die in childbirth. We have made steady improvements over the past 80 years. Nonetheless, we are losing ground. And if we don’t make important changes in our health and our health-care system, the trajectory is grim.
The U.S. ranks a dismal 50th in maternal mortality – dead last in the developed world and behind numerous other countries, from Turkey and Saudi Arabia. About 1,000 women across the country die each year from pregnancy-related complications, a rate of 14.5 deaths per 100,000 live births in 2007, the most recent data available from the Centers for Disease Control and Prevention. Another 34,000 women experience “near misses” that often result in chronic illness such as diabetes and hypertension. And the trend in recent decades often has been toward more deaths, not fewer. In Pennsylvania, for example, the maternal mortality rate rose from 9.7 per 100,000 live births in 2005 to 14.5 in 2010. These women do not have to die. Many of the complications are preventable with better access not only to prenatal care but to healthcare in general for women of child bearing age.
The harsh fact is that young women today are arriving to pregnancy in poorer health than their mothers. The obesity epidemic has impacted teens and young women, with over 50 percent of women giving birth in Philadelphia overweight or obese according to the Philadelphia Department of Public Health. Obese women are 50 percent more likely to have a surgical (Cesarean) birth and to experience more complications such as preeclampsia (1.5-3 times the risk) and gestational hypertension (2-3 times the risk). These complications dramatically increase their chance of dying.