February 2017—Public Health Law News

Webinar: Education as a Social Determinant of Health: The Role of Laws and Policies. The Network for Public Health Law and the Public Health Law Program (PHLP) are cosponsoring a webinar about the role of law in addressing education as a social determinant of health. This webinar, featuring speakers from CDC, the Network for Public Health Law, and the Health Policy Institute of Ohio, will discuss the new federal Every Student Succeeds Act, as well as innovative legal and policy approaches at the state and local levels. This free webinar will take place February 23, 2017, from 1:00 to 2:30 pm (EST), and will include a live question and answer session.

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Webinar: Improving the Health Status of Your Community. The American Bar Association is hosting a continuing education legal webinar at the Health Landscape 2017 conference about the role of law as the key components of the healthcare legislation reform are implemented. This free webinar will feature a speaker, (Montrece Ransom, JD, MPH, team lead for Public Health Law Training and Workforce Development, Public Health Law Program (OSTLTS) who will discuss how audience members can gauge the health literacy of their communities; conduct community health assessments; evaluate demographics; and understand federal, state, and local community benefit regulations and reporting. The webinar will take place February 24, 2017, from 12:30 to 2:00 pm (EST), and will include a live question and answer session.

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Final Rule for Control of Communicable Diseases: Interstate and Foreign. CDC published the final rule for the Control of Communicable Diseases on January 19, 2017. The rule includes amendments to the current domestic and foreign quarantine regulations for the control of communicable diseases. These amendments were made in response to public comments received regarding the notice of proposed rulemaking published on August 15, 2016. This rule will become effective on February 21, 2017.

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Archived CDC Grand Rounds—Addressing the Unique Challenges of Opioid Use Disorder in Women. January’s CDC Grand Rounds discussed the increasing rates of opioid overdose deaths in women and how biological difference could have profound effects on treatment and prevention. The presentation and slides are available for free download.

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State Screening for Pregnant Women with Hepatitis B Virus (HBV). The “Assessment of State Perinatal Hepatitis B Prevention Laws” article published in the American Journal of Preventive Medicine evaluates state screening and reporting laws for HBV. The standard of care is to screen universally for HBV in pregnant women to prevent mother-to-child transmission, premature death, and chronic liver disease.

Zika: Selected Law and Policy Resources. This Public Health Law Program web page offers resources that describe and comment on law and policy responses to the Zika virus outbreak.

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WHO Health Law Website. The World Health Organization (WHO), supported by the European Union-Luxembourg-WHO Universal Health Coverage Partnership, has created a new website containing guidance and information about universal health coverage law reform.

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Advancing the Right to Health: The Vital Role of Law. This report, published by WHO, discusses the role that public health law reform can play to advance the right to health and create conditions for people to live healthy lives. It describes issues and requirements to be addressed during the development of public health laws. It also includes case studies and examples of legislation from various countries with successful public health legislation. WHO, the International Development Law Organization, the O’Neill Institute for National and Global Health Law at Georgetown University, and Sydney Law School, The University of Sydney, Australia collaborated to create this report.

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Key Findings From 50-State Assessment of Evidence-based Policymaking In an effort to assess evidence-based policy making, Pew-MacArthur Results First Initiative has identified five states (Washington, Utah, Minnesota, Connecticut, and Oregon) as models that developed both an efficient process and tools to make policy decisions.

National: Travelers with nut allergies clash with airlines
The New York Times (01/26/2017) Roni Caryn Rabin

Most airlines serve peanuts as part of their services to passengers, but this can be life-threatening to travelers with nut allergies. There are no regulations about how airlines should handle these situations. In the absence of legal guidance, airlines have responded in a variety of ways, including implementing nut “buffer zones,” avoiding distributing peanuts on flights, and in extreme cases, removing passengers with allergies or removing people who continue to eat nuts even after being told not to from planes and refusing to stop serving nuts.

Passengers and advocacy groups like Food Allergy Research and Education are pursuing discrimination lawsuits because of policies prohibiting passengers with allergies to pre-board to safeguard their seats from exposure. Some lawsuits claim that passengers are treated differently because of a perceived disability when they are barred from flights. Others argue that passengers with nut allergies are not accommodated or are singled out for different treatment and should be allowed to pre-board as are other passenger groups so they can safeguard their seats from exposure.

In the past, airlines have allowed passengers to pre-board to clean trays and armrests, reducing the likelihood of nut contact. Recently, pre-board privileges have been revoked because the primary concern has shifted from passengers who suffer from nut allergies to the inconvenience to the airline. Matt Miller, an American Airlines representative, stated that “We cannot guarantee customers will not be exposed to peanuts or other nuts during the flight . . . and preboard can create a false sense of security.” American Airlines in particular has a peanut policy that denies any special requests for people with allergies, but that causes passengers to avoid self-reporting allergies, potentially increasing allergic-induced medical emergencies.

Although airlines caution against hosting allergic passengers, a 2013 study published in the Western Journal of Emergency Medicine found that “allergic reactions make up fewer than four percent of all in-flight medical emergencies.”

Even without formal regulation, however, airlines including Jet Blue, Southwest, and Delta have taken the initiative to establish nut free “buffer zones,” and avoid or prevent the service of nuts altogether thereby reducing the incidence of emergencies in the air.

[Editor’s note: Read the Federal Aviation Administration’s guidance for the management of passengers who may be sensitive to allergens [PDF - 114KB] and learn more about food allergies.]

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Virginia: House panel in Virginia OKs bills targeting opioid crisis
Chicago Tribune (01/21/2017) Megan Schiffres, AP

Last November, Virginia’s governor and state health commissioner declared the state’s opioid crisis a public health emergency. Virginia’s House of Delegates is now considering seven bills with a variety of strategies intended to address this crisis.

Three of these bills seek to make naloxone, an opioid overdose antidote, easier to access. One authorizes pharmacists to dispense naloxone without a patient-specific prescription. Another states that people who have received specialized training may dispense it and train others to use it. HB 2163 takes a different approach, mandating that naloxone (a short-term emergency drug) must be prescribed whenever physicians prescribe buprenorphine, a drug that relieves withdrawal symptoms and is intended to make long-term addiction recovery more successful.

The other four House bills focus on changing physicians’ opioid prescribing practices. HB 1885 limits opioid prescriptions to a seven-day supply. Another bill seeks to eliminate prescription fraud by requiring electronic opioid prescriptions. Two others want to change broader prescribing guidelines, one through creating a workgroup to establish educational guidelines for physicians and the other through changing official rules set by medical boards.

These bills have already passed through a House committee, and similar bills in the Senate have received unequivocal support.

[Editor’s note: Read Virginia bills related to addressing opioid overdoses: HB 1885, HB 2165, HB 1750, and HB 2167.]

California: Laguna Beach looks at banning smoking in all public places
The Los Angeles Times (01/25/2017) Bryce Alderton

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California: Measles outbreak grows in LA’s orthodox Jewish community despite California’s strict new vaccination law
Los Angeles Times (01/21/2017) Soumya Karlamangla
[Editor’s note: Read about California’s childhood vaccine programs and school immunization laws.]

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California: San Francisco sues Trump over executive order targeting sanctuary cities
Los Angeles Times (01/31/2017) Maura Dolan
[Editor’s note: Read Executive Order: Enhancing Public Safety in the Interior of the United States and the City and County of San Francisco’s Complaint for Declaratory and Injunctive Relief.]

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Hawaii: Hawaii bill would classify homelessness as medical condition
AP (01/26/2017) Cathy Bussewitz
[Editor’s note: Read the proposed Hawaii Senate concurrent resolution.]

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Iowa: Iowa considers broadening opt-outs for child vaccinations
Chicago Tribune (01/26/2017) Linley Sanders

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Massachusetts: Mass. legislation would sharply curb marijuana law
Boston Globe (01/20/2017) Joshua Miller

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National: FDA warns parents again to not give children homeopathic teething tablets
WCMH-TV Columbus (01/31/2017)
[Editor’s note: Read the US Food and Drug Administration’s warning against the use of homeopathic teething tablets and gels.]

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National: As more voters legalize marijuana, states left with regulatory hurdles
StateLine (01/27/2017) Sarah Breitenbach

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National: EPA accuses Fiat Chrysler of secretly violating emissions standards
The New York Times (01/12/2017) Hiroko Tabuchi
[Editor’s note: Learn about the US Environmental Protection Agency’s notice to Fiat Chrysler Automobiles for diesel vehicle violations.]

Canada/Deline Got’ine: Guardians of a vast lake, and a refuge for humanity
New York Times (02/07/2017) Peter Kujawinski
[Editor’s note: Learn more about the UNESCO designation of the Tsá Tué Biosphere Reserve located in Canada’s Northwest Territories and the Deline Got’ine government.]

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Cuba: Dumping medicine, faking patients: Cuban doctors describe a system that breeds fraud
Miami Herald (01/17/17) Jim Wyss

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France: France bans free soda refills in attack on obesity
The New York Times (01/27/17) Kimiko de Freytas-Tamura

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Russia: Putin signs law reducing punishment for domestic battery
CNN (02/07/2017) Clare Sebastian and Antonia Mortensen

Interview with José T. Montero, MD, MHCDS, CDC Deputy Director

Title:
Director, Office for State, Tribal, Local and Territorial Support and Deputy Director, Centers for Disease Control and Prevention

Education:
MD, Universidad Nacional de Colombia, Bogotá, Colombia; Family Medicine: Universidad del Valle (Colombia). Epidemiology: Universidad Javeriana (Colombia). MHCDS, Dartmouth College

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Public Health Law News (PHLN): Please describe your career path and what drew you to medicine and to public health.

Montero: I went to medical school in Colombia because I was interested in the brain, behavior, and what that you could do with and to the brain. There, students go to medical school right after high school, and it’s a six-year process, with a social service year after that. I did the social service in a rural community, where I was the director of the local community health center. Instead of leaving after just one year, I stayed and became the regional director for that area and then the director for that state health department a couple of years later.

My experience in the social service changed my perception of how we can use medicine. I loved being a doctor. I loved patient interaction, but I thought I could have greater impact by trying to modify the systems or manage or design changes, and that’s what moved me into the public health field.

When I moved to the United States, I did clinical work in western New York, but I was craving a public health job. I became the chief of disease control at the New Hampshire Department of Health, then the state epidemiologist, and finally the New Hampshire state health officer. Then I went to work at a hospital and focused on population health, trying to answer the same questions I’ve always been trying to answer: How do you connect patient and population health and disease care needs and their environment to get better health outcomes and better health systems? How do we apply a population health and a public health philosophy to the design of care delivery? And here at CDC, I still continue to work on developing and implementing these concepts.

PHLN: What insights into public health have you gained through your most recent career experiences as vice president of population health and health systems integration at Cheshire Medical Center/Dartmouth Hitchcock Keene, New Hampshire, and public health director for the New Hampshire Department of Health and Human Services?

Montero: Regardless of where we sit, public or private, public health or healthcare delivery, we are all trying to do what is best for people. Some of us try to do it at an individual level, some try by applying the latest and greatest technology, and some try by changing the systems and conditions in which people live, play, and receive their services. It’s hard―and will continue to be hard―to identify where each of these approaches adds the most value and where and how they should allow other parts of the system to interact or take the lead. We are in this together and should understand and respect each other’s roles. 

We are in a health pathway, not just health care or public health. It’s about health. We need to appreciate and integrate differing points of view and expertise for the best possible results.

PHLN: What are your day-to-day job responsibilities as director of the Office for State, Tribal, Local and Territorial Support (OSTLTS)?

Montero: CDC’s mission would be impossible without collaboration and bilateral support from state tribal, local, and territorial (STLT) partners. OSTLTS connects CDC with the external world, ensuring STLTs and CDC engage effectively. My role is to create, manage, and improve relationships with all of the different administrative levels of STLTs, as well as with our partners. We want to work towards a health system, creating more integrated public health system with a better and more functional relationship with the healthcare delivery system.

PHLN: Please describe OSTLTS’s role and relationship with STLT jurisdictions?

Montero: OSTLTS is where health departments can come to better understand how to navigate CDC. OSTLTS is a partner, listening to their needs and translating those needs to the rest of CDC. We look at things in integrated and systematic ways, not just illness-, disease-, or risk factor-based, but all across the board. That is why we are here and how we add value to the interaction between CDC’s centers and the field.

PHLN: How do partnerships with STLT governments, federal agencies, non-governmental agencies, and other public health stakeholders affect OSTLTS’s mission and activities?

Montero: Our mission is to partner with them; it is not just that it affects our mission, it is our mission. As we look at how we advance US public health, we know we cannot achieve our mission alone. We have incredible expertise at CDC, but we need to be able to guide the public health enterprise. It’s a two-way street, though. We listen and we bring the partners’ voices to CDC to help the agency adapt and improve. We need to be responsive to the needs of our communities and people across the US who come to us, translated through our partnerships.

PHLN: How does your background as an epidemiologist influence your approach as director of OSTLTS?

Montero: I like to be clear about what problem we are addressing, asking the right questions and measuring the impact of the solutions we propose and implement. Presenting the data in a transparent and clear manner is important as well so communities see the value and impact of what we propose.

PHLN: How do you hope to support STLTs to help improve public health outcomes?

Montero: We have the Preventive Health and Health Services Block Grant, we support accreditation, we provide support to the tribes, we do legal epidemiology, and we perform other types of public health law support. We support the Public Health Associate Program that allows us to place and train people in the field. But we are doing all of those things with one goal in mind: advance the performance and capacity of the public health system and improve its agility and resilience. Things will happen, diseases will happen. We can evaluate and change how we help STLTs be prepared, flexible, and adaptable to respond to those events. That’s part of growing, this “modernization” that really means becoming a more flexible organization.

PHLN: What do you think the greatest public health challenges will be in the coming decade?

Montero:  Challenges can be described from many different perspectives. As a nation, we are aging and that creates a set of challenges and opportunities. We also have clear differences within our population in the way people have access to services and to improved quality of life. CDC just released this incredible MMWR supplement, the first of a series about rural health. We have groups in our population who are not being properly served. They are poor, they can be of any race, but they share the fact that they will suffer more through their lives and will die earlier for many different reasons.

We also have to address the increase in chronic diseases—conditions that might be exhibited in the environments we create through policy, through the way that we design our communities and common living spaces, the things we produce, the types of jobs accessible to these groups, and through access to education.  

We must work together to address these issues as a nation, focusing on where the biggest needs are, whether in rural or urban settings. Our challenge is how to identify and make accessible the appropriate resources to effect the greatest change.

PHLN: You have unique expertise, experience, and understanding of domestic and international public health. How is international public health related to public health in the United States?

Montero: We’re all interconnected. Just look at infectious diseases. It’s a shared priority because we can just jump in an airplane and cross continents in a matter of hours. That component of influence—the travel interactions of our mobile societies—is increasingly relevant to public health. International public health, facing and controlling risk factors before they cross our borders, is incredibly important, so we need to better understand what’s going on in other countries. We also need to understand social characteristics of migratory populations to better develop and plan for our growing, changing population.

PHLN: How is law related to public health?

Montero: It’s a key component of public health. When we talk about public health, we are talking about the general agreements of a society and how to create the conditions to make us healthy. Law is the common language that our society created to make things fully defined and stable. So, law is a key component in the way that we think about, design, implement, and maintain public health strategies.

PHLN: How does public health law relate to your previous work experience?

Montero: Public health law has been the foundation of my career. People tend to forget that law is the way that we codify our interactions, formalizing and memorializing the necessary agreements for society to function. So, just going to medical school, being able to practice, and performing my activities as a physician were all allowed by codified laws.

From across all three branches of US government, we created and consented to many societal agreements, but unless you codify those agreements, they are kind of weak. For example, if you have a tobacco-free policy, but don’t make it a law, it’s not going to stick, and it isn’t going to be enforceable. From codifying the clinical access to codifying structural determinants, you see law being the language that unifies and defines it.

PHLN: How does public health law help OSTLTS improve the capacity and performance of the public health system?

Montero: It is incredibly valuable being able to show other parts of the STLT public health system   different approaches that have been taken and the historical value of particular pieces of legislation from across the country. Also, when our state health officers need to go―as I did—to their respective state legislatures, it helps to have an understanding of what is happening elsewhere, what has been successful, what type of language has been used in another state that shares some of their state’s characteristics. The analysis that the Public Health Law Program can provide is incredibly important to understanding what’s going on across the country.

PHLN: What’s your favorite part of your job so far?

Montero: Getting to know the team has been incredible. We have very talented people who are committed to the mission.

I also enjoy being instrumental in rekindling some relationships with states. I have the luxury of already knowing many of the health officers, but changing the way that I relate to them—not as a state or local health officer, but as their CDC counterpart—has been quite interesting. I’ve enjoyed learning how to work more with tribes, how we can improve the health for our rural population, and how we can continue to have ongoing public health improvement. It’s only been three months, but it has been great.

PHLN: What are the greatest challenges you face in your position?

Montero: It’s a great organization, but the depth and breadth of CDC is incredible—realizing how to put all of the many components of CDC together in the way that I interact with STLTs is challenging.

At the same time, there are many things that are not in CDC but are happening in the STLT services that I’m constantly learning about. Anticipating those events as they come so that I can support the health officers in their day-to-day performance and connect them with the right researchers at CDC is challenging. How do we manage this going forward? We’ll figure it out as the new administration comes in and as new priorities and approaches are set.

PHLN: What would you be doing if you weren’t working in public health?

Montero: I always wanted to be an artist, but I’m lousy at it. I’m a physician by training, so I could continue to see patients. My definition of “public health” is really broad, so I don’t see how what I would be doing would not be related to public health. As a clinician, if I do it right, I’m working for public health. From being a hospital administrator in the past, I can explain that role as someone who was trying to do public health from the hospital. And, fortunately, I had the CEO’s support to do that—to build that population health approach from within the hospital administration. So, given my professional training, I would be doing that.

PHLN: Have you read any good books lately?

Montero: I recently finished reading The Quartet by Joseph J. Ellis, which is about the birth of this country from a different perspective. How did we move from the Federalist Papers and the initial Declaration of Independence to the US Constitution, the actual creation of this as a country, not just a federation? The process that took place then, how it was written, and the politics of how it was codified are actually quite timely for this type of conversation we’re having here. It is an amazing book, and it explains so many things about today’s United States, how we developed the organizations and systems we have, the human components and expectations of each of the players in the quartet. Other than that, I’m reading Tom Clancy and some other thrillers and science fiction stuff.

PHLN: If you could travel anywhere in the world, where would you go and what would you do?

Montero: I love to travel. I would love to visit Egypt and the pyramids, but not just to look at the architecture. I’d also like to learn more about the ancient cultures. How did they get to where they were, what happened, and how did they fall?

PHLN: Do you have any hobbies?

Montero: I like music a lot—I like classical music, but also all types of Latin American music. I enjoy theater and the arts in general. I try to keep reading. I tried to learn to play the violin, but I don’t have the skills for that. I tried to paint, but it requires too much patience and I lack the discipline to sit down and perfect the art. I also love hiking, and I’m trying to figure out where in Georgia I can go.

The first reader to correctly answer the quiz question will be featured in a mini public health law profile in the March 2017 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: February 2017

What book did Dr. Montero recently read and enjoy?

Janice Wood

Question: What country would Debra Gee like to visit?

Answer: Spain

Employment organization and job title:  
Tompkins County Public Health Department, Environmental Health Division, Support Staff, Keyboard Specialist

A brief explanation of your job:
Support tech staff by answering phone calls from the public, processing mailings, including food service permit renewals. I keep records of pets vaccinated at our rabies clinics. 

Education:
 Associate degree in accounting from Tompkins Cortland Community College.

Favorite section of the News: 
The interviews are interesting. They give me insight into different areas of public health and how each interacts with the public and with those in official capacities.

Why are you interested in public health law? 
I have worked in the Tompkins County Public Health Department for 20 years. The various subjects in the News show how health issues are affecting the public we serve.

What is your favorite hobby?
I love reading and gardening.

Federal: Court upholds temporary restraining order on Executive Order, “Protecting the Nation from Foreign Terrorist Entry into the United States”
States of Washington and Minnesota v. Donald Trump, President of the United States, et al. [PDF - 444KB]
United States Court of Appeals for the Ninth Circuit
Case No. 2:17-cv-00141
Filed 02/06/2017
Opinion by Judge James L. Robart

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Federal: Court is unpersuaded that the efficiencies generated by Humana Aetna merger will be sufficient to mitigate the transaction’s anticompetitive effects for consumers in the challenged markets
United States of America v. Aetna INC.,et al.
United States District Court for the District of Columbia
Case No. 16-1494 (JDB)
Filed 01/23/2017
Opinion by Judge John D. Bates

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Federal: Court adopts HHS Secretary’s proposed corrective action plan for settlement with two additions; original settlement regarded an “additional and illegal condition of coverage”
Jimmo v. Burwell
United States District Court for the District of Vermont
Case No. 5:11-cv-17
Filed 02/01/2017
Opinion by Chief Judge Christina Reiss

“It is paradigm shift for sure, but the single best thing we can do today is to allow physicians and health care providers in general to write prescriptions for housing,” said Hawaii Senator Josh Green about how to better address homelessness.

[Editor’s note: This quote is from Hawaii bill would classify homelessness as medical condition, published by The Denver Post, 01/28/2017.]