August 2015—Public Health Law News

Webinar Series on the Intersection of Public Health and Health Care—The Role of Law. The American Health Lawyers Association and the Public Health Law Program (PHLP) are co-hosting a six-part, free webinar series focused on legal issues at the intersection of public health and health care. The fourth webinar in the series, Implementing the ACA—Community Health Needs Assessments, will take place Friday, September 18, 2015, 1:00–2:30 pm (EDT). This webinar will describe federally qualified health centers and rural health clinics and give practical insight into the field.

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Student Mentorship Program. The Network for Public Health Law’s Student Network for Public Health Law is recruiting mentors for its Mentorship Program. This national program connects current students and young professionals pursuing careers in public health law with experienced professionals who can help build knowledge and develop skills relevant to the field. Mentors must be experienced in the field and should regularly work on public health policy and law issues and do not need to have a JD or an MPH. Applications will be accepted until August 21, 2014.

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FDA Seeks Comments on Proposed Nutrition Labeling Changes. The FDA issued two proposed rules and one supplemental proposed rule on updating the nutrition facts label. The rules are published in the Federal Register so that the public can review them and send their comments to the FDA. The FDA will consider comments on the original proposed rules and supplemental proposed rule before issuing a final rule. Comments are due October 13, 2015.

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Association of Healthcare Emergency Preparedness Professionals (AHEPP). A new professional association dedicated to advancing the field of disaster preparedness and response, AHEPP is accepting members and hosting its first national conference. The conference will help guide participants through the most important disaster concerns in various types of healthcare facilitates and will be on November 17–18, 2015, in Omaha, Nebraska. See AHEPP’s website for early bird rates, the complete conference agenda, and more information.

National Health Security Strategy. The Office of the Assistant Secretary for Preparedness and Response released the latest National Health Security Strategy and Implementation Plan (NHSS). The NHSS is intended to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies.

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Journal Article on Improving Hospital Support of Breastfeeding. Preventing Chronic Disease published “Implementing Legislation to Improve Hospital Support of Breastfeeding, New York State, 2009–2013.” The study, conducted by the New York State Health Department, reviewed breastfeeding policies of the 129 New York hospitals that provide maternity care services to see if they were in compliance with New York Law Public Health Law § 2505-a. The study was supported by the US Department of Health and Human Services, CDC, the Robert Wood Johnson Foundation, Public Health Law Research Program, the Maternal Child Health Block Grant, and the New York State Department of Health. Dennison BA, Hawke BA, Ruberto RA, Gregg DJ. Implementing legislation to improve hospital support of breastfeeding, New York State, 2009–2013. Preventing Chronic Disease 2015;12:150121.

SNAP restrictions can hinder ability to purchase healthy food: Stigma, payment options among issues

The Nation’s Health   (08/04/2015)   Lindsey Wahowiak

The Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, is a program to help low-income families have better access to food. Though overseen by the US Department of Agriculture, there are no federal guidelines about what foods beneficiaries can purchase with their benefits. Without federal rules about what kind of food SNAP beneficiaries may purchase, states have tried to implement their own guidelines.

Wisconsin considered legislation to limit what kinds of food SNAP beneficiaries may purchase. The Wisconsin Assembly passed a bill in May 2015 that would limit what beneficiaries may purchase. The bill excludes some items, like shellfish, altogether, but also includes a mandate that two-thirds of SNAP recipients’ spending must be on “healthy foods,” as defined by the state’s Supplemental Nutrition Program for Women, Infants and Children (WIC) guidelines. (WIC is a similar but separate federal program.)

Critics of the proposed guidelines point out that there were no apparent scientific or nutritional basis for what foods were considered “healthy foods.”

Executive director of the Hunger Task Force, Sherrie Tussler, said “The idea that people would be required to buy two-thirds healthy foods sounds good in theory, but we had to be oppositional to it because no one could define what healthy foods are. Why would we take [dried] beans off the list? Probably because we don’t grow them here. Wisconsin grows potatoes, so suddenly potatoes are a ‘healthy’ food . . .”

[Editor’s note: Read Wisconsin’s 2015 Assembly Bill 177, which was presented to the Wisconsin Senate June 10, 2015, but has not been voted on yet.]

California: Sacramento County approves new development code
Public CEO   (07/28/2015)  
[Editor’s note: Learn more about Sacramento County, California’s new Zoning and Development Code.]

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California: Pharmacies to begin prescribing birth control under new state law
The Sacramento Bee   (08/03/2015)   Jeanne Kuang
[Editor’s note: Read California’s Senate Bill No. 493, which was approved by the governor October 1, 2013.]

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Georgia: US seeks unprecedented life sentence for peanut executive in food safety case
ABA Journal   (07/27/2015)   Debra Cassens Weiss

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Maryland: The Baltimore looting has led to a problem that is very unusual for the DEA
The Blaze   (07/30/2015)   Cole Ellenbogen

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National: CareFirst doubles cost savings by sharing rewards with US doctors
Reuters   (07/30/2015)   Susan Kelly

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National: Drug prices soar, prompting calls for justification
New York Times   (07/23/2015)   Andrew Pollack

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National: FDA wants food labels to quantify added sugars
New York Times   (07/23/2015)   Catherine Saint Louis and Stephanie Strom
[Editor’s note: Read FDA’s Proposed Changes to the Nutrition Facts Label.]

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National: Marijuana cookie death highlights need for warning labels, CDC says
CBS News   (07/24/2015)   Bianca Seidman
[Editor’s note: Read the Morbidity and Mortality Weekly Report, Notes from the Field: Death Following Ingestion of an Edible Marijuana Product—Colorado, March 2014, which was published July 24, 2015.]

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National: Study finds state policies influence vaccination, disease outbreak rates
UGA today   (08/04/2015)   Stephanie Schupska
[Editor’s note: Learn more about state school and childcare vaccination laws.]

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National: Yelp adds health care statistics to medical business listings
Mobi Health News   (08/06/2015)   Aditi Pai

Interview with John Bilderback

Title:
Step ONE Program Manager, Chattanooga-Hamilton County Health Department, Chattanooga, Tennessee

Education:

• MS 2007 University of Tennessee at Chattanooga, clinical exercise physiology
• BS 2001 University of Tennessee at Chattanooga, exercise science

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Public Health Law News (PHLN): Please describe your career path.

Bilderback: After I graduated from the University of Tennessee at Chattanooga, I was lucky enough to land a part-time job with the health department implementing a locally funded grant from the Junior League of Chattanooga. The grant focused on nutrition education and childhood obesity prevention and was implemented by the Step ONE program. About two months after I started, my supervisor left for a job in the school system, and I was promoted to my current position.

PHLN: Were you always interested in public health? What sparked your interest?

Bilderback: No, but that was primarily due to a lack of exposure to public health. As an undergraduate, I knew I wanted to work in the health field, and I loved exercise and nutrition. The turning point for me was probably during graduate school when Dr. Greg Heath became our new Health and Human Performance Department head. He had spent the previous 20 or so years working at CDC, so it’s safe to say he had an influence on my career from the moment he arrived. The other thing that kept gnawing at me was the scope of the obesity epidemic and how little visible progress was being made reversing the trend through traditional methods.

PHLN: What is Step ONE?

Bilderback: The Chattanooga-Hamilton County Health Department collaborated with the mayor of Hamilton County and the Hamilton County Regional Health Council in 2004 to launch Step ONE (Optimize with Nutrition and Exercise). Our mission is “to create a culture in Hamilton County where residents choose to practice good nutrition and exercise regularly.” Over the past ten years, the program has evolved with the evidence-base focusing on the built-environment, policy, and systems with public health education while building partnerships with other government agencies, nonprofits, schools, local foundations, and residents to work toward accomplishing the mission.

PHLN: How did you become involved with Step ONE?

Bilderback: I was hired for the part-time position in August 2007 and then promoted to Step ONE program manager in January 2008. They say the third time is the charm and in my case that was true. I’d pursued the Step ONE position for some time. I’d interviewed for the job on three separate occasions. To me, Step ONE is an initiative that is uniquely positioned to reverse the obesity trend locally. Its mission to create “culture of health” while being community driven is the best approach for such a complicated public health challenge.

PHLN: What made Chattanooga-Hamilton County, Tennessee, realize it had a community obesity and nutrition problem?

Bilderback: In 2002 and 2004, the health department released its results from the Youth Risk Behavior Surveillance System and Behavioral Risk Factor Surveillance System, respectively. Both surveys showed our community had some serious concerns about obesity-related weight and health behaviors. Of course, it was known this was happening nationally and at the state level, but the local numbers brought a sobering reality that ultimately resulted in Step ONE’s creation.

PHLN: Why is this a community problem, rather than an individual problem?

Bilderback: In the past, the health field treated obesity solely as an individual problem needing a medical modal solution. The reality is that healthy eating and physical activity are individual choices that are profoundly influenced by access, policies, individual perceptions and knowledge, convenience, and other socioeconomic circumstances. Not only do these things influence health choices, they also have a substantial effect on people’s motivation, or lack thereof, to change health behavior. When we surveyed people in the past, they generally knew they need to eat more fruits and vegetables and get more physical activity. The solution to obesity lies in the space between choices. These spaces tend to be governed by culture and socioeconomic factors meaning population based interventions with a community driven focus can be successful.

PHLN: How did Step ONE and Chattanooga-Hamilton County Health Department begin addressing these issues? 

Bilderback: Step ONE, from its inception, has always understood reversing the obesity trend would happen though cultural change and that this kind of change takes decades to bear fruit. Our goals and objectives are outlined in the plan that was published in 2004 called “Healthy Eating and Physical Activity: A Community Approach.” While somewhat dated, this plan is a result of a lengthy and carefully executed public engagement process with much of its content still relevant today.

PHLN: Were there specific communities you focused on? If so, which communities and why? 

Bilderback: Step ONE is focused all on Hamilton County residents and its corresponding communities. To give you a sense of scope, Hamilton County has a land area of 542 square miles with a 2010 population of 336,463. Due to the sheer size of the county, Step ONE divided its focus into six environment-based categories: home/families, neighborhoods, faith-based institutions, schools, worksites, and healthcare providers/resources. Interest and commitment by groups, people, and organizations within each of these categories have steered the work done in each aspect.

PHLN: How did Step ONE receive a Healthy Kids, Healthy Communities (HKHC) grant, and how has that grant been used?

Bilderback: In 2008, with funding from the Robert Wood Johnson Foundation, Step ONE was selected by the National Association of Counties to conduct a community dialogue on childhood obesity prevention and the faith-based community. Our hope at the time was that it would energize our faith-based community about childhood obesity and Step ONE. Unfortunately, participation by the faith-based community was low, but the overall turnout was strong. The significant outcome from that stakeholder meeting eventually led to the creation of the Partnership for Healthy Living (PHL), and that network has been the foundation for all the work we have done since then. In December 2009, Step ONE and our partners from the PHL were awarded a HKHC grant. We committed to work together with residents of East and South Chattanooga on policy, systems, and built-environment changes designed to address health disparities in their neighborhoods. Ultimately, this collaborative will apply what we’ve learned to strategies across Hamilton County.

The HKHC grant was leveraged to help our partner organizations and residents apply for and receive additional funding for projects identified by the collaborative. Some of the successes from the HKHC grant have been the Hamilton County Board of Education approving an open use policy for all elementary school playgrounds, creation of the Chattanooga Mobile Market, installations of new bus shelters by Chattanooga Area Regional Transportation Authority, the revitalization of Milliken Park, intersection traffic changes in front of Orchard Knob Elementary School, and 36 garden grants.

PHLN: How was a shared use or, in the case of Chattanooga-Hamilton County, an open use policy part of the plan to improve community health?

Bilderback: One of the priority areas set by the East Chattanooga Leadership Advisory Council (ELAC), one of two resident-lead groups we organized, was to increase access to safe places for physical activity. The unpublished assessment conducted at the beginning of the grant by the Ochs Center for Metropolitan Studies in 2010 indicated there was a lack of green space—an estimated two acres per 1,000 people compared to the city’s 4.6—available in some of the target neighborhood zip codes. The initial approach was to identify elementary and middle schools for joint use agreements; however, this approach became very time consuming for our limited staff. While some schools were enthusiastic about the idea, others were not. Then James Elder, chairperson for ELAC at that time, asked a simple question, “What if we asked the school board to change the rule?” It was at that moment the entire conversation shifted from singular agreements at each school to a system-wide policy that would open all playgrounds.

PHLN: What role did the community play in designing and implementing the plan to improve community health?

Bilderback: From the very beginning, even as we were writing the grant, we included community residents. It was our intent to include them in every important decision and eventually to empower them as leaders through this for communities. Both community councils, ELAC and South Chattanooga Leadership Advisory Council (SLAC), worked to determine priorities, goals, strategies, and activities for each year, while Step ONE and our organizational partners provided technical assistance. In the long-term, we worked with them to develop their leadership capacity so each group would be sustainable. Match funding for the grant was set aside in the Healthy Living Fund we created at the Medical Foundation of Chattanooga. ELAC and SLAC each have $15,000 for use at their discretion aimed at activities to improve health in their communities.

PHLN: What were some challenges you faced when trying to implement an open use policy?

Bilderback: To be honest, we probably anticipated and prepared for more challenges than we actually faced. In hindsight, our preparation and the relationships developed between the community members and all the parties involved early on very likely helped us avoid quite a few challenges. Barriers we ran into were concerns over liability, vandalism, and additional maintenance due to use, all of which are valid. However, everyone agreed the playgrounds could and should get more use so long as the school keeps the first right of use.

PHLN: What’s the difference between an open use policy and a shared use agreement?

Bilderback: The shared use agreement is, basically, a contract between two or more parties to share responsibilities and set ground rules for using a school or other property. Our open use policy was passed by the school system’s board of education and includes all elementary schools with one action. There’s no contract, and the school board made clear the circumstances by which people and families can use an elementary school’s outdoor playgrounds and basketball courts. We did not include the middle and high school fields because of valid concerns for additional maintenance costs due to increased use. Shared use agreements fit the middle and high school situations better. The advantage to an elementary school open use policy is that most school systems have many more elementary schools than middle and high schools combined. In addition, most playground equipment is built to withstand heavy use, so maintenance costs are minimal.

PHLN: How did you and your organization respond to and resolve concerns about the open use agreement?

Bilderback: We listened to people’s concerns and involved them in writing the policy. By having PTA members, principals, school board members, the school facilities director, and a local foundation at the table with public health professionals, we could agree on comfortable language. This allowed all parties to be included from the first to the last draft of the policy. In the end, another benefit was the professional relationships and trust that was developed, which will be of great value in future efforts.

PHLN: How did collaborating with the community affect your program’s goals and outcomes?

Bilderback:Because of the way we structured the grant, the communities’ goals were our goals. Step ONE was able to build experience and identify methods that can be replicated in other parts of the county. The communities’ insight and ultimate ownership of the work was without a doubt the thing that legitimized and drove the work.

PHLN: How did ChangeLab Solutions help troubleshoot the open use policy?

Bilderback:ChangeLab’s resources were a great starting point. The trouble we were running into was that we could not find a model policy anywhere. Some of the language from joint use agreements was helpful but not necessarily at a policy level. ChangeLab provided additional technical assistance that helped us be more confident in the work we were doing. They are a tremendous resource, and I highly recommend them to anyone needing a legal perspective on policy and agreement development.

PHLN: How did you get buy-in from community members, school workers, and community leaders?

Bilderback: Buy-in is built in with this kind of approach. The community members and leaders were part of planning, decision-making, and even the grant writing. Building trust and transparency between the community members, our partners, and Step ONE was fundamental to success. Too often, people think respect is the most important part of this type of work, but I don’t think that goes far enough. You can respect someone, or an organization, but still not trust them. That was what we were hearing and seeing early on in the work. Respect was always there, but trust was usually missing. The school bought in because some of the community members were PTA members, and they trusted us. The respect and trust we all have for each other allows for the honesty necessary when negotiating policies and agreements. Ultimately, everyone bought in because it was genuinely everyone’s idea.

PHLN: The open use policy was implemented in February 2014. How’s it going?

Bilderback: I recently spoke with Principal Thirkill (principal of Orchard Knob Elementary School) who helped us with the policy work. He told me that he announced the policy at the principals’ meeting and it went over well. In June, Step ONE purchased new signs (two for each school) explaining the policy and making the public aware of when they can use the playgrounds. This fall, with funding from the Benwood Foundation, we’ll begin engaging the students and neighborhoods around the Howard High School feeder schools to see how they might want to improve the playgrounds. The objective here is to build awareness of the resource and increase use of the space during non-school hours.

PHLN:  Do you have other success stories from Step ONE’s interventions? If so, will you please describe them?

Bilderback: The thing that comes to mind is not something that shows up in statistics or quantitative measures. At the heart of the work done through the HKHC grant were two leadership councils, ELAC and SLAC. It has been just over a year since the grant ended, and both are still going strong with minimal support from Step ONE. They are adding members and identifying projects to work on. They are working on things like bus routes to grocery stores, neighborhood asset mapping, holding meetings with other community organizations to identify shared concerns on crime and safety, and, most importantly, they are sustaining many of the relationships created during the grant.

PHLN: What are the most important lessons you’ve learned throughout this process?

Bilderback: Control is an illusion in community work—embrace the chaos. All too often interventions are too constraining, leaving little or no room for midstream adjustments, which results in less than desirable outcomes. These constraints are necessary in many cases but come with the cost of limited buy-in from community members. Because of how we structured this grant, we were able to be flexible with opportunities as they arose and change course when a certain strategy wasn’t working. By giving up some control, we empowered those we aimed to help. In the end, we learned as much from them as we hope they did from us.

PHLN: What are some of the other projects Step ONE is focused on?

Bilderback: Right now Step ONE is finishing up a Healthy Eating, Active Living Index that will be a baseline and guide our partners with future interventions. We are also implementing a CDC 1305 Chronic Disease School Health grant awarded to us by the Tennessee Department of Health. Through this grant, we are continuing to promote open use policies and farmers/mobile markets, help daycares implement stronger physical activity/nutrition policies, and we have purchased a SPARK curriculum for all Hamilton County schools with kindergarten–6th grades. Step ONE will also be awarding our annual garden grants in the coming months.

PHLN: What advice would you give to other communities trying to implement similar changes?

Bilderback: While the approach we took takes longer to gear up, it’s fundamentally stronger from a sustainability and community buy-in point of view. In the end, I think answering the following four questions can help people find the path forward:

1. Why is the change we want necessary, and will it help people?
2. What is the reasoning behind the barrier, and is it valid?
3. Is there capacity to support this change and to scale it up?
4. Might there be a simpler solution to the problem?

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

Bilderback: I’d probably be working in health for nonprofit organizations, but my staff members think I’d be an executive chef or a graphic designer.

PHLN: Have you read any good books lately?

Bilderback: The most recent book I read was No Sweat by Michelle Segar. Her perspective on self-motivation and behavior change is spot on. Another good book that I found very helpful with our work was Toward the Healthy City: People, Places, and the Politics of Urban Planning by Jason Corburn. This is a “must read” for anyone in public health working in the built-environment.

PHLN: What are your hobbies?

Bilderback: I love to cook; I make my own hot sauce from my garden and dry herbs for rubs. I love University of Tennessee football and seeing my son fall in love with it, too! Mostly though, I just hang out with my wife Riann, my son Ben, and our three dogs.

PHLN: Is there anything you would like to add?

Bilderback: None of this work could have ever been done without our partners. Step ONE is a small three-person operation that owes much of its success to everyone who has been involved over the years. It’s humbling to see so many professionals and community members set aside egos and focus on solving problems.

[Editor’s note: Read more about Step ONE’s program innovations. Also, check out this video about the Chattanooga Mobile Market, a mobile grocery store that is reducing Chattanooga’s food deserts with every mile driven.]

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

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Public Health Law News Quiz Question: August 2015

Name one of the four questions John Bilderback encourages community organizers to ask themselves before implementing changes similar to the open policy agreement that Step ONE helped implement in Chattanooga-Hamilton County, Tennessee.

Perrianne Lurie, MD, MPH, FACPM

July Question: Name one of CAPT Carmen Clelland’s hobbies.

Winning response: 
Long distance running.

Employment organization and job title: Pennsylvania Department of Health, Bureau of Epidemiology, public health physician

A brief explanation of your job: I am the vaccine preventable disease epidemiologist for the Commonwealth of Pennsylvania.

Education: MD, New York Medical College; MPH in epidemiology, Columbia University School of Public Health

Favorite section of the News: Public Health Law Briefly Noted section

Why are you interested in public health law? It impacts every facet of public health.

What is your favorite hobby? I have two: reading science fiction and playing European strategy board games.

California: Procedures for nurses administering cardiac stress tests don’t meet guidelines
Nosal-Tabor v. Sharp Chula Vista Medical Center
Court of Appeals of California, Fourth District, Division One
Case No. D065843
Filed 08/03/2015
Opinion by Justice Cynthia Aaron

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Pennsylvania: Vacancy alone does not meet hardship threshold for zoning variance
Jenkins v. City of Philadelphia
Commonwealth Court of Pennsylvania
Case No. 1470 C.D. 2014
Filed 08/03/2015
Opinion by Judge Bonnie Brigance Leadbetter

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Federal: Company not obligated to defend against state’s prescription drug epidemic suit
Cincinnati Insurance Co. v. HD Smith Wholesale Drug Co.
United States District Court, Central District of Illinois, Springfield Division
Case No. 12-3289
Filed 07/28/2015
Opinion by District Judge Richard Mills

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Federal: Defendants violated the False Claims Act by not taking needed steps to repay claims 
Kane v. Healthfirst, Inc.
United States District Court, Southern District of New York
Case No. 11 Civ 2325(ER)
Filed 08/03/2015
Opinion by District Judge Edgardo Ramos

Quotation of the Month: Dr. Michi Shinohara, a dermatologist at the University of Washington.

"In the US the [Food and Drug Administration] has the authority to regulate inks, but is not currently doing so. Regulation of tattoo parlors and tattoo artists is left to the states, and the requirements for operating vary widely from very minimal [bloodborne pathogen training] to fairly complex [hundreds of hours of apprenticeship]," said Dr. Michi Shinohara, a dermatologist at the University of Washington in Seattle, of tattoo ink regulation in the United States.