January 2015—Public Health Law News

Public Health Associate Program application period open. CDC’s Public Health Associate Program (PHAP) is recruiting recent graduates for the 2015 PHAP class. Applications will be accepted until January 16, 2015. Visit PHAP’s webpage for more information about qualifications and how to apply.

Law and individuals with special needs conference [PDF 59KB]. The University of Arizona College of Medicine Phoenix and the American Society of Law, Medicine, and Ethics are hosting The Law and Ethics of Those with Special Needs. The conference will take place February 18–20, 2015. Find more information and register for the conference.

State laws for e-cigarette sales to minors. CDC’s Morbidity and Mortality Weekly Report (MMWR) published State Laws Prohibiting Sales to Minors and Indoor Use of Electronic Nicotine Delivery Systems—United States, November 2014, MMWR Vol. 63, No. 49, Dec. 12, 2014.

Nine public health advocacy victories in 2014. The American Public Health Association released a list of 9 health advocacy victories in 2014.

NACCHO Annual Conference 2015 and call for abstracts. The National Association of County and City Health Officials (NACCHO) Annual Conference Workgroup seeks sharing session abstracts for the 2015 NACCHO Annual Conference, set for July 7–9, in Kansas City. The conference theme is “Envisioning the Future: Creating Our Path.” Register on or before June 4, 2015, for early bird rates.

State death investigation systems resources. At the request of the National Center for Health Statistics, CDC’s Public Health Law Program (PHLP) assessed coroner and medical examiner laws across the 50 states and the District of Columbia. The resulting resources provide information on death investigation systems, coroner training requirements, medicolegal offices, death investigation and autopsies, and more. These resources are useful to law and policy makers interested in how death investigation systems are structured and death investigators’ scope of practice.

American Indian and Alaska Native Communities ACA resources. [PDF 270KB] PHLP published The Affordable Care Act & American Indian and Alaska Native Communities: Selected Readings and Resources, a list of readings and resources that describe the Affordable Care Act and the Indian Health Care Improvement Act’s impact on American Indian and Alaska Native communities. The list includes summaries of the laws, scholarly articles, and resources on enrollment and exemptions.

Health Department Billing for Immunization Services: A Menu of Suggested Provisions. [PDF 434KB]  A menu of state law provisions that impact the health department’s authority to bill third parties for services provided. The menu was created by PHLP in cooperation with the National Center for Immunization and Respiratory Diseases.      

State Ebola protocols. PHLP and CDC’s Office of the Associate Director for Policy compiled a table of state-by-state Ebola protocols to help law and policy makers prepare for and respond to Ebola-related situations.

Alaskan Tribes Added to the Indigenous Law Portal. Alaska has been added to the Library of Congress’s Indigenous Law Portal. The Portal is a free collection of digitized materials from the Law Library of Congress, including links to tribal websites and other primary source materials.

US court upholds NY State vaccination requirement for students
Reuters   (01/07/2015)   Daniel Wiessner

On January 7, 2015, the US Court of Appeals for the Second Circuit ruled that New York’s state law requiring children to be vaccinated in order to attend public school does not violate parents’ religious rights under the US Constitution. The three-judge panel further ruled that children who have not been vaccinated may be barred from attending public schools during disease outbreaks.

Three New York City parents brought the suit, arguing that their First Amendment right to religious freedom superseded the state’s interest in preventing spread of disease in schools. Two of the parents received religious exemption from vaccinations, but sued when their children were barred from attending school during a chicken pox outbreak. The third plaintiff was denied a religious exemption because school officials determined that her objections to vaccines were health-based rather than on a sincerely held religious belief.

[Editor’s note: Read Phillips v. the City of New York, 2nd Circuit US Court of Appeals No. 14-2156-cv. and learn more about vaccines and immunizations and vaccine safety. Also read PHLP’s Health Department Billing for Immunization Services: A Menu of Suggested Provisions [PDF 434KB].]

FDA favors ending blanket ban on gay blood donors
USA Today   (12/23/2014)   Doug Stanglin

In 1983, the US Food and Drug Administration (FDA) instated a ban on blood donations from men who had engaged in sex with other men. In December 2014, the FDA recommended moving to a less restrictive policy, dropping the blanket ban and allowing gay and bisexual men to donate blood if they had not had sex with another man for at least a year.

The current ban was established in the height of the AIDS epidemic. FDA commissioner Margaret Hamburg says the proposed policy would “better align the deferral period with that of other men and women at increased risk for HIV infection.”

The FDA’s recommendation comes after extensive scientific studies, epidemiologic data, and a vote by a panel of blood safety experts convened by the US Department of Health and Human Services (HHS). In November 2014 the HHS panel recommended moving to a one-year ban, barring male donors who have had sex with other men.

For some activists, the recommended policy changes are still inadequate. “Some may believe this is a step forward, but in reality, requiring celibacy for a year is a de facto lifetime ban,” said a statement from Gay Men’s Health Crisis, a New York-based nonprofit that supports AIDS prevention and care.

Patient groups that rely on safe blood supply, the Red Cross, the American Association of Blood Banks, and America’s Blood Centers, have all voiced support for dropping the ban, with the latter three organizations calling the ban “medically and scientifically unwarranted.”

[Editor’s note: Read the FDA’s statement, Blood Donations from Men Who Have Sex with Other Men Questions and Answers.]

California: Cage-free egg production law aims to reduce salmonella contamination
Egg prices likely to rise amid laws mandating cage-free henhouses
Los Angeles Times   (12/28/2014)   David Pierson
[Editor’s note: Read California’s Proposition 2.]

Colorado: State launches campaign on responsible, legal recreational marijuana use
Colorado says ‘it’s good to know’ about marijuana
USA Today   (01/05/2015) Trevor Hughes
[Editor’s note: Learn more about Colorado’s Good to Know campaign and marijuana laws.]

New York: Medical reality shows bring patient privacy questions
Dying in the ER, and on TV without his family’s consent
New York Times   (01/02/2015)   Charles Ornstein
[Editor’s note: Read more about the Health Insurance Portability and Accountability Act.]

Washington: Ballot measure requires broader background checks for gun buyers
Fight on guns is being taken to state ballots
New York Times   (01/02/2015)   Jennifer Steinhauer
[Editor’s note: Find more information and read Washington’s Universal Background Checks for Gun Purchases, Initiative 594 [PDF 180KB].]

National: Spending bill includes provision decriminalizing medical marijuana
Congress quietly ends federal government’s ban on medical marijuana
Los Angeles Times   (12/16/2014)   Evan Halper
[Editor’s note: Read Consolidated and Further Continuing Appropriations Act, 2015 Title IV § 583 [PDF 2.07MB].]

National: Study finds e-cigarette use higher than tobacco cigarette use among teens
E-cigarettes top smoking among youths, study says
New York Times   (12/16/2014)   Sabrina Tavernise
[Editor’s note: Read the National Institute on Drug Abuse’s Monitoring the Future 2014 Survey Results.]

National: Local bans on hydraulic fracturing oil extraction tested in local courts
Heavyweight response to local fracking bans
New York Times   (01/03/2015)   Jack Healy

National: PREP Act declaration would provide some legal  immunity for Ebola drugs
HHS Secretary issues declaration under PREP Act to support development of Ebola Vaccines
Infection Control Today   (12/09/2014)  
[Editor’s note: Read the Public Readiness and Emergency Preparedness (PREP) Act and the HHS Secretary Burwell’s press release.]

National: Brief examines how states have implemented federal health reforms
Implementing the Affordable Care Act: state approaches to premium rate reforms in the individual health insurance market [PDF 987KB]
The Commonwealth Fund   (12/29/2014)   Justin Giovannelli, Kevin W. Lucia, and Sabrina Corlette

National: Listeria-tainted caramel apple outbreak leads to voluntary recalls
Latest facts: Listeria caramel apple outbreak
Food Poison Journal   (01/04/2015)   Bruce Clark
[Editor’s note: Learn more about the Listeria outbreak from the FDA.]

International: International Monetary fund policies considered in Ebola risk factors
Ebola crisis made worse by IMF austerity plans for Africa: Study
The Huffington Post   (12/30/2014)   Michelle Faul
[Editor’s note: Find more information and read The International Monetary Fund and the Ebola outbreak, published in The Lancet Global Health on January 4, 2015. Also read the International Monetary Fund’s (IMF) Deputy Director, IMF Fiscal Affairs Department, Sanjeev Gupta’s response to the article.]

International: Village chief first to be convicted under Sierra Leone Ebola laws
First conviction in Sierra Leone under Ebola laws
Yahoo! News   (12/24/2014)  

Randy Hanzlick

Title:
Professor of Forensic Pathology and Director of Forensic Pathology Training, Emory University School of Medicine; Chief Medical Examiner, Fulton County, Georgia

Education: 
Bachelors of Arts, Zoology, Ohio State University; Doctor of Medicine, Ohio State University College of Medicine

PHLN: Please describe your career path. 

Hanzlick: To be a forensic pathologist, one must complete medical school, general pathology residency (3–5 years), and then do a one-year forensic pathology fellowship. Graduates must pass the general pathology board certification examination (anatomic pathology at a minimum, and many also do clinical pathology), and then the forensic pathology board certification examination offered by the American Board of Pathology or international equivalent. 

PHLN: What is forensic pathology?

Hanzlick: “Forensic” is derived from the Latin “forensis” which means “forum” or “public.” The Latin “Pathos” means “suffering,” and “ology” means “the study of.” Suffering is typically caused by disease or injury. Thus, “forensic pathology” is the study of disease and injury that is of interest to the public.

Typically, forensic pathology deals with mortality (fatal cases, deaths), although some engages in “clinical forensic pathology,” which deals with non-fatal injuries, such as those that occur in child abuse or other types of cases with inflicted injuries.

PHLN: What drew you to forensic pathology?

Hanzlick: When I was doing my pathology residency, hospital autopsies and coroner autopsies were done in the same autopsy room. One of my favorite pathology professors did autopsies for the coroner, and he informed me about forensic pathology, showed me some of his cases, and aroused my interest in becoming a forensic pathologist.

PHLN: What are your day-to-day job responsibilities as a professor and as Fulton County, Georgia’s chief medical examiner?

Hanzlick: My day-to-day duties involve office administration; teaching pathology residents medical students, and forensic pathology fellows; and occasional autopsy performance. Our office is accredited by the National Association of Medical Examiners (NAME), and we have a forensic pathology fellowship accredited by the Accreditation Council on Graduate Medical Education (ACGME). I have to ensure compliance with NAME standards and ACGME requirements. I report to the Fulton County management and commission, as well as the chairman of pathology and laboratory medicine at Emory. Much of my job involves quality assurance and review of work done by others in the office. I oversee a staff of 36 employees, which includes administrative staff, records and documents personnel, medical examiners, forensic technicians, and death investigators.

PHLN: Do you perceive yourself as working in public health law?

Hanzlick: No. I need to know public health law that impacts on my work, and abide by it, such as the reporting of certain notifiable conditions. I have written multiple articles about medical examiners’ and coroners’ roles regarding public health, epidemiologic research, and surveillance, and have done much work with CDC, but I do not consider myself as “working in public health law.” 

PHLN:  Can you please describe the difference between a coroner and a medical examiner?

Hanzlick: Although there are exceptions, coroners are usually elected and are not physicians. They have the legal duty to investigate and certify deaths, but in general, they do not perform autopsies and must rely on forensic pathologists to perform autopsies for them and advise about the cause and manner of death. Coroners still exist in about half of the states. In some states, every county has a coroner. In others, coroners exist, but there is also a state medical examiner who oversees their activities. Other states have combinations of medical examiners and coroners. Medical examiners are usually appointed by a local or state government, almost always physicians, and usually forensic pathologists. In a medical examiner system, the medical examiner does what a coroner would do, but also performs the autopsies and certifies deaths. I have written a text on this subject for students and the public that describes death investigation systems and procedures.

PHLN: Do the differences between coroners and medical examiners affect public health? If so, how?

Hanzlick: In my opinion, medical examiners are probably more likely to be knowledgeable of public health issues and interact with various public health agencies, although this will vary by state. 

PHLN:  What does “medicolegal death investigation” mean?                                                            

Hanzlick: “Medicolegal” has to do with the practice of medicine as it relates to law. So, medicolegal death investigation involves the investigation of deaths in compliance with state death investigation laws to determine the cause, manner, and circumstances of death. Manner of death in most states is either homicide, suicide, accident, natural, or undetermined. Medicolegal death investigation involves review of relevant medical history, circumstances of death, scene investigation, and postmortem examination with relevant laboratory testing. All of these are needed for a complete medicolegal death investigation in most cases and involve medical decision-making. 

PHLN: You have been a practicing medical examiner for over 30 years; how have the coroner and medical examiner systems changed and how do you expect the systems to evolve in the coming years?

Hanzlick: This is a topic I have written about extensively. In the last half of the 20th century, many jurisdictions abolished their coroner system and replaced it with a medical examiner system. This trend basically came to halt by the year 2000, and few systems have changed since then. It is difficult to establish a medical examiner system in rural areas because case load and tax base are inadequate to do so. In a sense, the areas of the United States that are conducive to medical examiner systems have developed medical examiner systems. I foresee a trend to establish regional medical examiner offices, with or without coroners, to improve access to services involving trained and qualified investigators and forensic pathologists. The National Research Council report on strengthening the forensic sciences [PDF 3.45MB] recommends that all death investigation offices become accredited, and that all death investigation personnel be certified in their specialty area. This will require the evolution of death investigation systems in a direction that they are more professional. 

PHLN: What types of deaths require investigation?

Hanzlick: State laws vary, but in general, they require investigation of deaths that are known or suspected to involve external causes (injury or poisoning); deaths in custody of law enforcement or state or local institutions; deaths that are unusual or involve public health threats; and deaths that are sudden, unexpected, and unexplained.

PHLN: Can you give a few examples of why it’s important for a medical examiner to oversee medicolegal death investigations?

Hanzlick: Many deaths involve complicated medical issues or involve combinations of external causes and disease. Medical knowledge is required to evaluate such cases and direct the investigation to obtain necessary information. Death certification (completion of the death certificate) involves medical conditions and quality death certificates should be completed by a physician trained in death certification. Often, medical testimony is needed in criminal and civil legal proceedings, and a medical examiner-physician-forensic pathologist is trained for this and is best qualified to provide such testimony and expert opinion. Physician medical examiners are likely to be aware of public health issues and reporting requirements.

PHLN: How many practicing medical examiners do we have currently practicing in the United States and how many would we need to meet our population’s needs?

Hanzlick: There have been only about 1,500 people certified in forensic pathology since 1959. Our best estimate is that there are about 500 board certified forensic pathologists in the United States practicing full time. We estimate that an additional 500 would be needed to achieve a service level in which forensic pathology services are available on a similar level throughout the United States and to conduct autopsies at a rate beneficial the needs of the courts, public health, and public safety needs. 

PHLN: What factors have contributed to the shortage of medical examiners?

Hanzlick: There are only 35 training locations in the United States, and many of these programs have only one training position available per year. Of approximately 80 approved training positions, only about 50 have funds available. Because many forensic pathology jobs are government funded, the pay is low compared to other physicians’. The net result is that we produce about only 40 forensic pathologists per year, which is barely enough to keep up with attrition due to retirement and death. Also, only about two-thirds of those trained go on to practice forensic pathology full time, and some do not practice it at all. 

PHLN: In instances when medical examiners must investigate and respond to public health threats, what kinds of enabling laws are important?

Hanzlick: Medical examiners and coroners operate under state death investigation statutes. Many states have specific provisions that require the medical examiner or coroner to investigate deaths that are a possible threat to public health. Other states lack this specific provision, but there is usually wording to allow investigation of “unusual” deaths, which can be interpreted to include deaths of public health importance. When new entities emerge, such as the Ebola issue, it is important that medical examiners and coroners understand the state public health director’s authority and how his or her authority and decision making would impact on death investigation activities such as disposition of deceased bodies. In general, I believe the laws in virtually all states would allow the medical examiner or coroner to investigate deaths of public health importance, especially those that have not come to the attention of a medical institution that has made a diagnosis. It is important that medical examiners and coroners follow applicable guidelines established by health departments and other entities such as CDC. They should also be familiar with the types of services that might be available to assist in such investigations. 

PHLN: What other kinds of laws are important for carrying out medicolegal death investigations?

Hanzlick: The primary law of importance is the state’s death investigation statute and any other local laws or regulations that apply to death investigations in the area. Knowledge of anatomical gift and organ/tissue donation laws is also very important, as are laws regarding who the state allows to perform autopsies. Laws about evidence and testimony are also relevant.

PHLN: What other projects are you currently working on?

Hanzlick: I am currently serving on the National Commission on Forensic Science’s Medicolegal Death Investigation Subcommittee, which is specifically working on issues related to accreditation, certification, electronic networking of medicolegal offices, and increasing the supply of forensic pathologists in the United States. I am involved in activities of the surveillance and data taskforce of the national alliance for suicide prevention, CDC’s unexplained death project, and Georgia’s newly emerging sudden death in the young program. I recently headed a NAME project to prepare draft best practices guidelines for the CDC’s National Violent Death Reporting System. I also continue to author regular articles relating to systemic death investigation and forensic pathology issues.

PHLN: Can you describe one of your most memorable investigations?

Hanzlick: Probably the most memorable is one that took considerable time and effort by numerous agencies, including public health and law enforcement, both local and federal. It literally dragged out for years, and I was challenged repeatedly about my analysis and conclusions. Briefly, it was a case of alleged assassination with a toxin, for which we could not find any evidence. It was very challenging.

PHLN: If you weren’t working in forensic pathology, what would you likely be doing?

Hanzlick: I would probably try to work on projects with NAME and/or federal entities, such as CDC, the National Institute of Justice, or the National Institute of Standards and Technology on projects that relate to medicolegal death investigation. Preferably, of course, this would be on a paid basis(!) as a consultant or advisor. I do not want to work as a consultant on criminal or civil law cases. I have testified enough in court to last me a lifetime, and never having to do it again would suit me just fine.

PHLN: Have you read any good books lately?

Hanzlick: Actually, no. I am not much of a reader of novels. I do like to refresh myself now again on classic literature and historical events, but most of my reading is done to gain background information for things I am writing, and it’s pretty boring to others. I am not much of a conversationalist with people who talk about their latest read, the most recent movie they saw, or what television shows they watch. I just don’t do that stuff for some reason. In contrast, my wife is an avid reader and she keeps me updated on quality books and their plots and themes.  

PHLN: What are your hobbies?

Hanzlick: I play a few instruments well enough to be entertaining, but not well enough to do it for a living. I used to write a lot of songs but do not do that much anymore. In recent years, I have enjoyed boating and fishing in north Georgia and have developed an interest in lake and river science and water management issues. One thing I really like to do is write poems (usually limericks) about people when they retire or when special events occur. In general, however, I love to write, whether it is something like a lyric, a scientific article, an opinion, a report, or some other document. Writing makes me think much as reading would, and for me, writing has replaced my need to read except as described above. 

PHLN: Would you write a limerick for the Public Health Law News, please?

Hanzlick: 
We know there are Public Health Laws
That were written for probable cause.
    When law and medicine meld
    We are often compelled
To acknowledge their multiple flaws.

PHLN: That is great! Thank you! Is there anything you would like to add?

Hanzlick: I think I have covered it, but I would like to reiterate that I have always appreciated the efforts of public health entities and have done what I can to raise awareness about them among medical examiners and coroners, and to personally work on projects of public health importance. Thank you for the opportunity to answer your questions.

The first reader to correctly answer the quiz question will be given a mini public health law profile in the February 2015 edition of the News. Entries should be emailed to PHLawProgram@cdc.gov with “PHL Quiz” as the subject heading. Entries without the heading will not be considered. Good luck!

Public Health Law News Quiz Question: January 2015

What kind of poem did Dr. Randy Hanzlick write for the January 2015 edition of the Public Health Law News?

Colleen DeLizza

December Question: Name one of the “take home messages” Dr. Jono Mermin took from his work in the Epidemic Intelligence Service.

Winning response: 
“One take home message from Dr. Mermin’s overseas work in Tajikistan is that reptiles living with humans is not healthy, i.e., their poop poses health issues, especially when ingested.

Employment organization and job title:
I am a clinical pharmacist and currently work at First Databank Inc., a drug knowledgebase vendor. Previous to this position, I had a long career as a clinical pharmacist in both a community hospital and the Veterans Administration hospital in Palo Alto, California.

A brief explanation of your job: 
I work in the Disease Decision Support group. We create databases of clinical drug information that is used to guide electronic medication prescribing in various patient settings. I am a member of our state pharmacy professional organization that participates in public health fairs as well as a member for the county medical volunteers for disaster response.

Education:
I did some undergraduate study at State University of New York, Stony Brook, then received my pharmacy degree from Northeastern University, Boston. I have taken several computer classes at Foothill College, a local community college.

Favorite section of the News:
The interview is what attracted my attention this time. I have an interest in general in many aspects of drug therapy and also issues surrounding vaccination, vaccination rates, and vaccination reformulation.

Why are you interested in public health law?
I am interested in the use of information technology in assisting public health measures. Just as health education and general education are vital to improving our overall health and well-being, I try to follow the guidelines provided by public health policies that support public health educational efforts.

Do you have any hobbies?
I enjoy cooking, hiking, and am an avid cyclist for both commuting and exercise. I help out at a local bicycle organization that repairs and fixes donated bicycles to various local charities.

Federal: Court declines to order additional cage-related labeling on egg cartons
Compassion Over Killing v. FDA
United States District Court, Northern District of California
Case No. 12-cv-01385-VC
Filed 12/19/2014
Opinion by District Judge Vince Chhabria

Federal: Challenge to nudity ban fails O’Brien free expression test
Hightower v. City and County of San Francisco
United States District Court, Northern District of California
Case No. C-12-5841 EMC
Filed 12/24/2014
Opinion by District Judge Edward M. Chen

Federal: Statements regarding food safety were not ‘objectively false’ 
In re Yum! Brands, Inc. Securities Litigation
United States District Court, Western District of Kentucky, Louisville
Civil Action No. 3:13-CV-00463-CRS
Filed 12/23/2014
Opinion by Senior District Jude Charles R. Simpson, III

Federal: No broad public safety exception to state’s economic loss doctrine 
Schwabe North America, Inc. v. Cal-India Foods International, Inc.
United States District Court, Eastern District of Wisconsin
Case No. 14-CV-235
Filed 12/23/2014
Opinion by Chief District Judge William C. Griesbach

Quotation of the Month: Health and Human Services Secretary Sylvia M. Burwell

“My strong hope in issuing this PREP Act declaration in the United States is that other nations will also enact appropriate liability protection and compensation legislation. As a global community, we must ensure that legitimate concerns about liability do not hold back the possibility of developing an Ebola vaccine, an essential strategy in our global response to the Ebola epidemic in West Africa,” said Health and Human Services Secretary Sylvia M. Burwell of the declaration under the Public Readiness and Emergency Preparedness (PREP) Act to facilitate the development and availability of experimental Ebola vaccines.