When it comes to substance abuse disorders, public health and the public at-large are hardly on the same page — in fact, they’re not even reading the same book. And that’s a serious problem for sustaining and strengthening efforts to treat addiction and advancing effective public health policy.
“We already know quite a bit about public attitudes toward mental illness and we were interested in learning more — especially in the context of prescription (painkiller) drug abuse — about what the public thinks about issues related to drug addiction,” Colleen Barry, who recently co-authored a study on how the public views drug addiction versus mental illness, told me. “The attitudes of the public can be linked in important ways to broader support for policy action.”
In the study, which was recently published in the journal Psychiatric Services, Barry and colleagues surveyed a representative sample of more than 700 U.S. adults, asking a variety of questions about stigma, social distancing and the acceptability of discrimination. For example, researchers asked questions such as: Would you be willing to have a person with mental illness/drug addiction marry into your family? Would you be willing to have a person with mental illness/drug addiction start working closely with you on a job? Do you favor or oppose requiring insurance companies to offer benefits for the treatment of drug addiction/mental illness that are equivalent to benefits for other medical services? And do you agree that landlords should be able to deny housing to a person with drug addiction/mental illness? Overall, the study found that respondents held significantly more negative views of drug addiction than of mental illness.
Specifically, researchers found that 62 percent of respondents said they’d be willing to work with someone living with a mental illness, but only 22 percent would be willing to work with someone living with addiction. Twenty-five percent said employers should be able to deny employment to people with mental illness; 64 percent said the practice should be allowed regarding drug addiction. Twenty-one percent of respondents opposed offering insurance parity for mental illness, while 43 percent opposed such parity for patients with drug addiction. Fifty-four percent thought landlords should be allowed to refuse housing to people with drug addiction, while 15 percent had a similar view about people with mental illness. Overall, researchers found higher opposition to public policies aimed at helping people struggling with drug addiction when compared to policies in support of people with mental illness. However, respondents did seem to agree in one area: About one in three believe that recovery from either drug addiction or mental illness is impossible.
Study co-authors Barry, Emma McGinty, Bernice Pescosolido and Howard Goldman write:
Less sympathetic views may result at least in part from societal ambivalence about whether to regard substance abuse problems as medical conditions to be treated (similar to other chronic health conditions, such as diabetes or heart disease) or personal failings to be overcome. More so than mental illness, addiction is often viewed as a moral shortcoming, and the illegality of drug use reinforces this perspective. It is likely that socially unacceptable behavior accompanying drug addiction (for example, impaired driving and crime) heightens society’s condemnation.
“It was surprising to me how negative the attitudes were,” said Barry, an associate professor in the Departments of Healthy Policy Management and Mental Health at Johns Hopkins Bloomberg School of Public Health. “From a policy perspective, we tend to roll mental illness and addiction together…but the way the public thinks about them is very different — more different than I would have expected.”
In efforts to reduce societal stigmas around drug addiction, Barry called for better public information about the treatability of drug addiction and media coverage that more accurately portrays the face of addiction. For example, many people might automatically associate drug addiction with the image of a strung-out drug user living on the streets. But that image misconstrues the growing reality of drug addiction and the idea that drug addiction can happen to anyone and in all walks of life, Barry told me. In fact, such a stereotypical image of addiction could significantly impact public support for policy action at a time when public health practitioners are struggling to contain increases in prescription painkiller and heroin-related deaths and overdose. In addition, such societal attitudes often prevent those who need treatment for addiction from seeking help. Barry noted that currently, less than 10 percent of people with an addiction disorder seek any treatment at all.
“We have a whole new population that needs treatment that is not going to get into treatment in the context of broader social attitudes,” she said, referring to the prescription painkiller abuse epidemic. “So this is a huge issue. …Public support plays a major role in determining which public policies get advanced and which don’t. When we look at the state of the substance abuse treatment system, it’s terribly underfunded and part of that has to do with an underlying lack of support among the public.”
To address the problem, the study calls for “portraying addiction or mental illness as treatable.” In this realm, Barry noted that with advancements in mental health treatments, such as the availability of selective serotonin reuptake inhibitors (SSRIs) to treat depression and anxiety, people became more comfortable talking publicly about their struggles with mental illness and thus, stigmas around mental health begin to break down. Unfortunately, on the addiction side, we’re behind in both treatment and public acceptance, she noted.
However, the arrow between public opinion and policy change is bidirectional, Barry tells me. In other words, policy can help shift public attitudes as well. She’s talking about the Affordable Care Act, which now requires insurance companies participating in the new health insurance marketplace to cover mental health and substance abuse services as essential benefits. Such a high-profile policy change could go a long way in mainstreaming mental health and addiction treatment, Barry said. Still, public attitudes on drug addiction seem far from the public health perspective that considers addiction a chronic disease.
“We need to transform the stories of addiction in our country,” she said. “We need to be more involved in communicating a more true face of what addiction looks like in the U.S. and how treatment can benefit individuals, and that includes influencing how the news media covers these issues as well as how politicians talk about this issue. We need to change the narrative to one of a chronic disease that can benefit from ongoing, effective treatment.”
To read more about the study, visit the Johns Hopkins Bloomberg School of Public Health.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Expanding the right to know: California workers gain additional access to workplace toxics information as new hazards emerge
“If the California Public Health Department had been able to find out that my company was using a chemical that was killing people, I might never have gotten so sick that I had to have a lung transplant,” Ricardo Corona told a California Judiciary Committee last April, testifying in favor of California Senate Bill (SB) 193 that Governor Jerry Brown signed into law on September 29th. The law, which amends California’s Hazard Evaluation System and Information Service (HESIS), will become the first in the country to require companies that manufacture and distribute toxic chemicals to provide a government agency – in this case the California Department of Public Health – with information about where those chemicals are being shipped. While this sounds more bureaucratic than groundbreaking, Corona’s testimony illustrates vividly how this law could change lives for the better.
As Corona explained to the California Senate committee, he began work in 2006 at a California company that makes food flavorings. His job was to make butter flavorings. As he described during the hearing, in the course of his work, Corona “was exposed to a lot of dust and powder” and breathed the compounds into his lungs as he worked. He did so without having been given respiratory protection or any training about the hazards of this dust. Not long after, Corona started having trouble breathing and a doctor diagnosed asthma. But Corona’s breathing worsened. Eventually, he lost a reported 80% of his breathing capacity and required a lung transplant. Similarly affected and waiting for a lung transplant at the time of the April 2013 California Senate hearing was Corona’s co-worker Irma Ortiz.
The chemical to which Corona and Ortiz had been exposed was diacetyl. It’s used to give microwave popcorn and other snack foods a buttery taste. Diacetyl is also used in baked goods, candy, pet food and other products. Exposure to it is linked with serious respiratory illness including bronchiolitis obliterans – the irreversible obliteration of the small airway passages in the lungs. “My employer did not warn me about the very toxic effects on my lungs of this butter flavoring chemical. The label didn’t have anything on it,” Corona told the California Senate committee. “If my employer and the workers in our company had been told right away that diacetyl was causing dangerous lung problems, I would not be sitting here today with a transplanted lung,” said Corona.
“Workers like me me need SB 193 so we can get the right information from our employers when the California Health Department learns about a serious problem,” explained Corona. The law, he said, “could have kept me from being exposed to toxic chemicals that caused permanent damage. And it could have helped my doctors to figure out that the chemicals at work were killing me. The doctors could have given me information on how to be protected.”
Limitations, caveats and new hazards
As Frances Schreiberg, attorney with the Oakland, California-based law firm Kazan, McClain, Satterley & Greenwood explains, SB 193 – which will take effect on January 1, 2016 – advances the availability of vital workplace chemical hazard information but it does so with limitations. It will require that, upon request and when there there new scientific or medical evidence indicating that a substance may pose serious new or previously unrecognized occupational hazards, companies provide HESIS with the names and addresses of businesses and places of employment in California that have purchased the substances in question. Companies will so be required to tell HESIS the quantity of the chemical purchased, even when it’s part of a mixture. This information will be used to carry out HESIS’ work and won’t be published publicly unless another law requires such disclosure. And the new law won’t apply to chemicals used in consumer products or to other sellers of these chemicals.
With this downstream data in hand, HESIS can ask an employer how it is using a toxic chemical and how the firm is protecting workers, explains Schreiberg. This information will also help HESIS work with employers to find safer substitutes for hazardous chemicals and help HESIS develop and issue hazard alerts –ideally before workers like Ricardo Corona and Irma Ortiz get sick.
“There’s nothing exactly comparable at the federal level,” says Schreiberg.
The law is limited to new scientific and medical information about a chemical’s health effects, which could include hazards not detailed on material safety data sheets (MSDS) in use when the law becomes effective. Take the case of 1-bromopropane – a solvent used as an industrial cleaner for electronics, metals, optics, with adhesives used in manufacturing foam cushions, in aircraft maintenance, asphalt and synthetic fiber production as well as in dry cleaning, among other applications. The material safety data sheets (MSDSs) currently available online from Science Lab and SigmaAldrich, for example, contain no information indicating that 1-bromopropane might be carcinogenic to humans. The National Toxicology Program’s just released 13th Report on Carcinogens, however,describes 1-bromopropane as “reasonably anticipated to be a human carcinogen based on sufficient evidence of carcinogenicity from studies in experimental animals.”
The 13th Report on Carcinogens (RoC) also lists o-toluidine – used primarily to make rubber chemicals, herbicides, dyes, pigments and some medical products – as a “known” human carcinogen. Current MSDSs list it as a “possible” carcinogen. Similarly, the 13th RoC newly lists cumene as “reasonably anticipated to be a human carcinogen” while existing MSDSs for cumune include no indication of such carcinogenicity. While cumene is a naturally-occurring component of petroleum, tobacco smoke and coal tar, it is also used in manufacturing acetone (a solvent) and phenol, both of which are widely used in plastics production.
Meanwhile there’s additional new chemical hazard information in the updated ChemSec Substitute It Now or SIN list (produced by the Göteburg, Sweden-based International Chemical Secretariat) released on October 8th that added 28 chemicals to the existing list of more than 800. Thirteen of these chemicals have been added because they’ve been identified as persistent, bioaccumulative toxins, five because they’ve been identified as carcinogens, mutagens and/or reproductive toxicants and 10 were added because of their endocrine disrupting properties. Among the SIN list additions are flame retardants, plasticizers, chemicals used as food packaging coatings, waterproofing agents, lubricants, solvents, and in inks, paper and textiles among other products. It’s worth noting that endocrine disruption – interference with hormones that regulate a host of vital body systems, including metabolism and reproduction and also play an important role in maintaining neurological, cardiovascular, developmental and immune system health – is typically absent from toxicological information included on MSDSs.
How effective California’s new law will prove in protecting workers like Richard Corona and Irma Ortiz from chemical hazards remains to be seen. But workers and employers alike will now have a legally enforceable tool that will enable them to ask where chemicals with newly identified health hazards are being used throughout California. While but a drop in the bucket of workers exposed to toxic chemicals worldwide – and still constrained by confidential information provisions – it at least offers a way to share this information and prompt worker protection that might be adopted and expanded elsewhere.
Elizabeth Grossman is the author of Chasing Molecules: Poisonous Products, Human Health, and the Promise of Green Chemistry, High Tech Trash: Digital Devices, Hidden Toxics, and Human Health, and other books. Her work has appeared in a variety of publications including Scientific American, Yale e360, Environmental Health Perspectives, Mother Jones, Ensia, The Washington Post, Salon and The Nation.
“A Red Dirt Town,” which placed second in the Yale Environment 360 Video Contest, examines the legacy of pollution in Anniston, Alabama, the former home of a Monsanto chemical factory. The video, produced by Spenser Gabin, tells the story of how PCBs from the Monsanto plant contaminated the town’s waterways and taint the fish that are popular with local anglers.
Watch the video.
“Yes, you can use my name because it doesn’t matter. They have already done everything they can do to me.”
Those are words from Eliceo, a former dairy farm worker in upstate New York. Earlier this year, Eliceo, 36, decided to speak up and share his story with local advocates who are tirelessly working to improve conditions on New York dairy farms and end persistent reports of workplace safety violations, preventable work-related injuries, wage theft, exploitation and in some cases, worker deaths. His story of dangerous farm conditions, inadequate to nonexistent safety training and an employer apathetic to his medical needs is unfortunately not uncommon. In fact, Carly Fox, an organizer at the Worker Justice Center of New York who connected Eliceo with a workers’ compensation lawyer, tells me it’s not unusual for farmworkers to say that employers are more concerned with the health and safety of their cows than the health and safety of their workers.
“Greek yogurt has increased demand for dairy and the state is excited about it and celebrating its growth, but the invisibility of the Latino workplace is really problematic,” said Fox, who’s part of a larger coalition working to organize dairy farm workers and push policy-makers to intervene on behalf of worker safety. “It’s such a successful industry right now and production is increasing so fast, but we’re not giving credit as to why. These workers work incredible hours, they’re afraid of getting fired and their immigration status is used to keep them in fear. …It’s a very troubled industry that we’re celebrating. This isn’t dignified work. It’s substandard.”
In New York state, dairy production is booming, with much of it driven by consumer demand for Greek yogurt. According to the U.S. Occupational Safety and Health Administration, while the number of New York dairy farms during the past few decades has decreased, the amount of milk produced has gone up by the billions of pounds, resulting in an increase in hiring outside labor. On the surface, the situation seems like a bright spot in a struggling economy. But underneath the idyllic stereotype of the family farm, workers are increasingly coming forward to report hazardous working conditions, wage violations and employer neglect. In response, dairy farm workers in partnership with local worker advocates have begun organizing to improve working conditions, strengthen government oversight and shed light on a situation that is hardly idyllic at all.
“The workers themselves are saying we deserve better — they’re saying we’re working in horrible conditions and we deserve dignity,” Fox told me.
As part of their efforts to bring visibility to the problem, Fox and fellow advocates are collecting the stories of New York’s dairy farm workers, a large proportion of whom are immigrants unaware of their labor rights and fearful of retaliation for speaking out or demanding medical care for injuries sustained on the job. While some data report that New York dairy farms employ about 2,000 Hispanic workers, Fox says those numbers are terribly outdated. She and her colleagues estimate it’s much higher — probably between 5,000 and 10,000. One of those workers is Eliceo, 35, who came to the United States in 1996, working on chicken farms and in construction in North Carolina before moving to New York in 2009 and finding work within the state’s booming dairy sector.
In 2012, Eliceo began working at a large dairy farm about an hour outside of Rochester. He had multiple job duties, taking care of the animals, cleaning stalls and milking cows. He worked eight hours a day, six days a week — and he and his fellow workers were constantly working, milking upward of 4,000 cows within an eight-hour shift. In February 2013, having already been at the farm for about five months, a bull that was among a group of milking cows attacked Eliceo as he was herding cows from the barn into the milking parlor. He said his employers never alerted him that he may encounter bulls on the job, though he soon realized the fact for himself, and he never received training on how to protect himself from an attack. The injuries Eliceo sustained during the incident affect him until this day.
“(The bull) charged me and hit me in the right foot and I fell,” he told a worker advocate. “Then he hit me from behind. In that moment, I passed out and when I came to the bull was still attacking me. I screamed for help. There were so many cows and I was thrown to the ground. My co-workers couldn’t see where I was even though I was yelling. After, the same animal attacked me outside. I managed to get up and get myself out of there. I barely escaped because if I hadn’t, he would have killed me.”
In the immediate aftermath of the attack, Eliceo couldn’t lift his arm or walk, there were bruises all over his body from the bull’s multiple hits. Neither his employer nor supervisor offered to take him to receive medical care. The next morning, Eliceo found his own ride to the hospital, though his supervisor had expected him back at work and was upset at having to find someone to fill in. Eliceo eventually saw a specialist, who recommended he rest for a week to let his injuries heal and gave him a note ordering him not to return to work without a doctor’s authorization. Eliceo says he gave the note to his supervisor, who said it was invalid, fired Eliceo and kicked him out of the house where he was living. (Farms often provide worker housing, which has a long history of substandard, unhealthy conditions.)
Fortunately, Eliceo had met Fox prior to being evicted from his house. Fox connected him with La Casa, a local organization that provides transitional housing for migrant farmworkers, where Eliceo stayed for three months and recuperated from his injuries. Still, Eliceo wasn’t able to work for a year and continues to suffer from chronic pain that affects his ability to make a living. He’s currently working with a lawyer to access workers’ compensation.
“We don’t know that there are people who advocate for us,” he said. “We are made blind to the truth, as if our eyes were closed. We think that we don’t have any support or the same rights as everyone else. If I hadn’t met (Fox), I would have gone back to Mexico hurt. The first thing we do is take off running for Mexico. What happened to me was incredible, that I crossed paths with (Fox). Now I know my rights, thanks to (Fox).”
Agriculture is among the most dangerous industries in the nation, with a fatality rate nearly seven times higher than for workers in the overall private sector. In the dairy sector, in particular, hours are typically long and wages are typically low. According to the National Center for Farmworker Health, a survey of Hispanic dairy farm workers in New York found that most worked an average of 62 hours a week for an average wage of $7.51 per hour. Nationwide, dairy workers experience a higher occupational injury and illness rate than other workers in the private sector and on New York dairy farms alone, there have been 55 fatalities since 2006. However, OSHA’s ability to enforce safer working conditions is filled with gaps.
Typically, OSHA’s presence on dairy farms is in responding to reports of fatalities, not in preventing them from happening in the first place. For example, a 2013 regional OSHA notice listed four completed fatality inspections since 2007: a worker run over by a feed truck, a worker asphyxiated by methane, a worker crushed by cows and a worker struck by the bucket of a skid steer. This major gap in OSHA oversight is a top priority for the recently launched New York State Dairy Workers Organizing Campaign, which is aimed at improving conditions on New York’s dairy farms and empowering workers to make a difference.
“We want to create a movement of workers who are not afraid to say ‘we need laws, we need protection,’” said Rebecca Fuentes, a lead organizer with the Workers’ Center of Central New York. “We’re finding more and more in interviews that workers want to band together.”
Last year and in response to the stories advocates were hearing during farmworker education and training outreach, the Workers’ Center of Central New York in partnership with the Worker Justice Center of New York launched the statewide campaign to raise awareness about the injustices dairy farm workers face and to strengthen OSHA oversight. Listening to Fox and Fuentes talk about the conditions and dangers dairy farm workers face on a daily basis, it’s shocking to realize that OSHA has such restricted jurisdiction — currently, dairy farms with 10 or fewer employees are completely exempt from OSHA regulations unless the farm operates a temporary labor camp.
Fox tells me that dairy farm workers face a litany of harmful and stressful working conditions: dangerous animals, hazardous chemicals, old machinery, extreme temperatures and little access to protective equipment and safety training. Workers often work long, irregular hours, sometimes with no break at all. The day I spoke with Fox she had just interviewed a worker who reported working six hours on, six hours off on a continuing basis for 15 months with only one full day away from work. Most of the workers Fox and Fuentes work with are Hispanic and speak little English, making them highly vulnerable to workplace abuses. In addition, dairy farm workers often live in migrant housing, which means their employer is also their landlord.
“This is the stuff we hear all the time,” Fox said. “Not every farm is like that, sometimes you hear really good things. But at the end of the day, it’s an industry that’s basically unregulated.”
As part of their organizing efforts, advocates and workers began meeting with local OSHA officials and pushing for a “Local Emphasis Program,” an enforcement strategy designed and implemented at the regional level to address hazards or industries that pose a particular risk to workers in the office’s jurisdiction. The strategy was a success, with OSHA agreeing to launch random, unannounced inspections on New York dairy farms with more than 10 employees beginning this past July. Unfortunately, the inspection program ended in September, though advocates hope the effort will be renewed. Still, OSHA’s action made a difference. Fox said that since the OSHA announcement, she’s heard from workers who report receiving safety training for the first time.
In addition to the OSHA success, the farmworker campaign also organized an 11-day speaking tour in April that visited churches, community centers and universities across the state. The tour, which made 23 stops, was organized to raise awareness among the public, broaden support for worker rights and cultivate new partnerships. The tour’s featured speaker was Jose Cañas, an immigrant farmworker who has worked on upstate dairy farms for more than three years and who witnessed as well as experienced work-related injury and illness. Fox reports that speaking out in public was an empowering experience for farmworkers — “putting a face to this problem is radical in and of itself,” she said.
“We wanted to educate people that health and safety is a right not only for dairy workers, but for all workers,” Fuentes told me.
One of those workers is “Jorge” (he asked me not to use his real name), 36, who’s been working on a dairy farm in upstate New York for nearly 12 years. He’s a milker, working seven days a week — noon to 6 p.m. four days a week and 8 p.m. to 2 a.m. three days a week. He and his co-workers milk 850 cows in six hours and he doesn’t get a break during his shifts. (Fox, who translated the interview for me, tells me that’s normal.) Seven years ago during one of his shifts, a forklift hit him in the head, splitting his forehead open. When he regained consciousness, he was in an ambulance on the way to the hospital, where he received 12 stitches. His employer took him back to the farm, where Jorge lived in farmworker housing, the same day and asked him to start working again just two days later.
For a month, Jorge tells me, his head felt numb — “I couldn’t feel my head.” His employer had said he would take Jorge back to the doctor to have the stitches removed; instead, the employer’s wife removed the stitches and Jorge was never taken for follow-up care. Seven years later, Jorge says he still has problems with his left ear — he doesn’t hear as well — and struggles with chronic headaches.
Jorge tells me he’s never received any workplace safety training, even though he’s exposed to chemicals on the job. In fact, he says when management is handling the chemicals, they’re wearing protective gear — “but for us, they just give us gloves,” he said.
“We are also human,” Jorge tells me. “Just because we’re undocumented doesn’t mean we don’t have rights. We are equal. …We came just to work, we didn’t come to take anyone’s job. We see that Americans don’t want to do the work we’re doing. Please don’t forget about us.”
Moving forward, Fox, Fuentes and their colleagues will continue to help workers organize, lodge formal complaints with OSHA, recover stolen wages and access workers’ compensation. They’re also working to collect 100 interviews from 100 different workers and develop a survey instrument tool they hope to eventually use to grow the worker movement and foster worker leaders.
“Law or no law, we are going to organize and the workers will become a movement.” Fuentes said.
To learn more about the New York State Dairy Workers Organizing Campaign, visit the Workers’ Center of Central New York.
(Special thanks to Carly Fox who connected me with workers and translated interviews.)
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Last week, the American Academy of Pediatrics published a “Contraceptives for Adolescents” policy statement that advises pediatricians to consider long-acting reversible contraception (LARC) methods as first-line contraceptive choices for adolescents. LARC methods include contraceptive implants that can be inserted into the upper arm (which can remain in place for three years) and intrauterine devices (with different versions approved for three or five years).
Unlike condoms or birth-control pills, which require repeated correct use, LARCs only need to be administered once. They have failure rates of less than 1%, compared to 9% for combined oral contraceptive pills and 18% for condoms — and those two may be higher among adolescents than in the adult population that’s most often used in contraception studies. (These are all figures for “typical use” as opposed to “perfect use,” because in practice some of us forget to always have a condom or take a pill every day at the same time.) “The most effective methods rely the least on individual adherence,” the statement explains.
The AAP statement covers LARCs in a broader context, and gives advice on adolescent confidentiality and parental involvement; sexual history-taking; and counseling about both abstinence and contraception. On that last topic, the statement advises:
Abstinence is 100% effective in preventing pregnancy and STIs and is an important part of contraceptive counseling. Adolescents should be encouraged to delay sexual onset until they are ready. However, existing data suggest that, over time, perfect adherence to abstinence is low (ie, many adolescents planning on abstinence do not remain abstinent). Therefore, pediatricians should not rely on abstinence counseling alone but should additionally provide access to comprehensive sexual health information to all adolescents.
Additional sections summarize the range of contraceptive options for adolescents, provide considerations for special populations, and stress the importance of frequent follow-up to maximize adherence.
Then come 14 recommendations, which include educating patients about all contraceptive methods that are safe and appropriate for them; encouraging consisent and correct use of condoms with every act of sexual intercourse; knowing about laws on minor consent and confidentiality and how best to meet patients’ needs while following them; allowing sufficient visit time for discussing contraception with adolescent patients; and being aware of subsidized insurance programs and clinics that provide confidential and free/low-cost reproductive health services. The specific recommendations on LARCs are:
2. Pediatricians should be able to educate adolescent patients about LARC methods, including the progestin implant and IUDs. Given the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents. Some pediatricians may choose to acquire the skills to provide these methods to adolescents. Those who do not should identify health care providers in their communities to whom patients can be referred.
5. Pediatricians should be aware that it is appropriate to prescribe contraceptives or refer for IUD placement without first conducting a pelvic examination. Screenings for STIs, especially chlamydia, can be performed without a pelvic examination and should not be delayed.
Following these recommendations will let pediatricians help their adolescent patients choose the best contraception methods for their needs and avoid unintended pregnancies. Research suggests that teens will choose LARC methods when barriers to their use are reduced or eliminated. Vox’s Sarah Kliff recently interviewed Gina Secura, who until her recent retirement directed the CHOICE Project at the Washington University in St. Louis School of Medicine. Between 2007 and 2013, that project gave nearly 10,000 women no-cost birth control. When they had free access to a wide range of contraceptive options and knowledgeable providers to help them make informed decisions, the majority of participants preferred LARCs. The New England Journal of Medicine has just published CHOICE Project results on adolescents; of 1404 teenagers enrolled in the study, 72% chose a LARC.
The Affordable Care Act requires that insurers make all FDA-approved forms of contraception available without cost-sharing to all women with reproductive capacity, so cost should no longer be an impediment to LARCs for many women. (Plans don’t have to offer cost-sharing-free coverage of every single contraceptive available, as long as they’re covering one of each type of contraceptive — e.g., a woman might still have to pay a co-pay for her current birth-control pill, as long as there’s another brand she could take that doesn’t require a co-pay.) As Secura told Kliff in their interview, though, cost is not the only issue to be addressed:
… what we found was that it’s not simply cost that is the barrier to birth control. There are all these other barriers that aren’t so simple and obvious. If the clinic manager doesn’t want to insert an IUD that day for example, and wants you to come back, that’s a road block. There’s nothing like somebody making a decision and acting on it right then. So unless clinics can afford to stock these more expensive methods, we’re going to have women and hopefully teens saying, “I heard about this and I would like it,” and if it’s not available that’s going to a problem. How do we get those existing providers trained, comfortable, and confident?
These kinds of barriers, and the need to overcome them, were also the subject of a recent commentary by Carol S. Weisman and Cynthia H. Chuang of the Penn State College of Medicine in the journal Women’s Health Issues (disclosure: I’m the journal’s managing editor). In “Making the Most of the Affordable Care Act’s Contraceptive Coverage Mandate for Privately-Insured Women,” Weisman and Chuang note that women may be uncertain about what their plans cover or unaware of various methods’ attributes, while their primary-care providers may not be trained to provide LARCs.
To address these challenges, Weisman and Chuang recommend clear communication with the public and private-plan enrollees about what the ACA requires and what individual plans cover; training of primary-care providers on LARCs, and seamless referral arrangements from primary-care providers who can’t offer these methods to providers who can; and the “design, assessment, and dissemination of woman-centered information and decision tools to help women make optimal contraceptive choices in the context of their own life circumstances and preferences.”
The AAP’s new policy statement is in line with these recommendations — it advises pediatricians to be ready to discuss all the available contraceptive options with their adolescent patients, and either acquire the skills to provide LARCs or be ready to refer patients to colleagues who can. With knowledgeable providers helping young women choose and access the best forms of contraception for their needs, we can avert more unintended pregnancies.
It was too late for textile workers Grover Hardin and Louis Harrell to be helped by OSHA’s cotton dust standard. By 1978 when the rule was issued, both men suffered from byssinosis (a.k.a., brown lung disease) and would die from it. Harrell’s face and Hardin’s words, however, would have meaning for other textile workers and possibly help them be protected from the consequences of breathing cotton dust.
Harrell and Hardin, along with images of other textile workers taken by photojournalist Earl Dotter, appeared in the OSHA booklet “Cotton Dust: Worker Health Alert.” It was issued in the final year of the Carter Administration. Soon after, the booklet was ordered to be destroyed.
The story of what happened to the cotton dust booklet when the Reagan Administration took office is told in the latest issue of the journal New Solutions. It’s a special open-access edition to mark the 100th anniversary of the American Public Health Association’s Occupational Health and Safety Section (until 1955 known as the Industrial Hygiene Section.) Glenn Shor, PhD, MPP tells the tale, explaining that orders to destroy the booklet came from Reagan appointee OSHA chief, Thorne Auchter, during his first week in office. Shor’s article includes the March 1981 memo which reads:
“Assistant Secretary Auchter has indicated that the following publications no longer represent agency policy and should be withdrawn from circulation and destroyed (including warehouse stocks): Cotton Dust: Worker Health Alert (#3065), Cotton Dust Standard: Management’s Role (#3066) and Cotton Dust Can Destroy Your Lungs Poster (#3064).
It wasn’t just the cotton dust booklets that irked the anti-labor Reagan Administration. Shor explains that three worker-centered films commissioned by President Carter’s OSHA chief, Eula Bingham, PhD, also incensed the Reaganites. Auchter directed OSHA staff to “recall” the films. Shor writes that Auchter
“threatened to withhold funding for union health and safety programs that did not return the films.”
Gladly, not everyone complied. The films Auchter wanted abolished, “Worker to Worker” and “Can’t Take No More,” were saved by some and now appear on YouTube. They are some of the most popular offerings on Mark Catlin’s YouTube collection of worker health and safety films.
How did Auchter explain his decision to destroy the cotton dust booklet? Shor, who is Secretary of the APHA OHS Section and member of its 100th anniversary commemoration committee, tracked down a statement from the former assistant secretary. As reported in April 1981 by Jeff Nesmith of the Cox News Service, Auchter said:
“That photo makes a dramatic statement that clearly establishes a biased viewpoint in the cotton dust issue…While I certainly understand and sympathize with the victims of cotton dust exposure, I do not believe it’s fair and proper to lend the weight of the government on one side or the other in such a controversial area.”
I don’t know how, or if, Auchter was pressed to explain what he meant by a “biased viewpoint.” There was substantial scientific evidence that exposure to cotton dust was associated with disabling and deadly lung disease. And “lend[ing] the weight of the government on one side” —in other words, protecting workers’ health — is what Congress intended when it passed the OSH Act in 1970.
Shor’s article includes a reprint of the 8-page booklet. See for yourself the OSHA booklet that was banned—-an act that set the stage for what would come during the Reagan-era OSHA.
Link to articles in the special, open-access edition of New Solutions (here)
Read the interview.
Washington Post reporter Lydia DePillis investigates the factors behind increasing workplace fatality rates among Latinos, even while overall workplace deaths in the U.S. are on the decline. DePillis starts with the story of Abdón Urrutia, a construction worker who injured his back while working on a project in Tysons Corner, Virginia.
On the day of his injury, after Urrutia lifted himself up the floor, he says, the staff at the company where he worked gave him eight ibuprofen, and he was able to go back to work. And he was back at work the next day, too — on lighter duty, without carrying heavy things.
“That’s how they are. They say it’s nothing big, keep working,” Urrutia said.
About a month later, his back still in pain, Urrutia went to a doctor — but couldn’t afford the MRI she recommended. Urrutia doesn’t have health insurance, saying the company’s coverage is too expensive.
“I just take these pills every day. They work real good,” Urrutia says, holding out a bottle of Naproxen, a powerful painkiller. “It hurts, but I just deal with it, just to get the job done.”
Urrutia says he later told the company he was worried about the number of pills he was taking, not wanting to get addicted. The company gave him some papers to sign, which Urrutia says he thought at the time were an acknowledgement of the dosage. He didn’t read them closely, however — and in fact, the company says, the forms certified that he hadn’t been injured at work.
DePillis goes on to explore the contributors to high rates of work-related fatality and injuries among Latino workers, such as fears of retaliation for speaking up and incomplete data being reported to OSHA. In addition, Latinos are over-represented in dangerous occupations — for example, about one in every three workers in construction and natural resource extraction were Latino in 2013, up from about 24 percent a decade earlier. She writes:
Rachel Micah-Jones, executive director of the migrant worker aid group Centro de los Derechos del Migrante, observed the uptick in Latino worker fatalities. She most often hears about widows seeking help to get the bodies of their husbands across the border — 527 of those who died on the job in 2013 were foreign-born, mostly from Mexico.
“A lot of employers suggest to workers that they go back and their wife will make them soup and everything will get better,” says Micah-Jones. “And then they have a really difficult time getting workers compensation or any kind of help.”
To read the full story, visit the Washington Post.
In other news:
Sacramento Business Journal: California Gov. Jerry Brown signed new legislation requiring hospitals to develop comprehensive plans to address workplace violence. Among its measures, the law requires hospitals to evaluate the association between low staffing levels and risk of workplace violence as well as other factors, such as the availability of security personnel. Reporter Kathy Robertson writes that while hospitals opposed the bill, the California Nurses Association applauded the move. In related legislative news, Robertson reports that Brown vetoed a bill that would have made hospital employees who contract difficult-to-treat staph infections eligible for workers’ compensation.
The Washington Post: Abby Phillip and Roberto Ferdman write about the first transmission of Ebola outside of West Africa — a nurse at a hospital in Madrid, Spain, who was caring for a patient with the virus. The article reports that Spanish officials are investigating what went wrong, while health workers raise concerns that current protective gear isn’t adequate and blame the nurse’s infection on substandard equipment. Another article in the Guardian reports that “staff at the hospital where she worked told El País (a daily newspaper in Spain) that the protective suits they were given did not meet World Health Organization (WHO) standards. …Staff also pointed to latex gloves secured with adhesive tape as an example of how the suits were not impermeable and noted that they did not have their own breathing equipment.”
NIOSH Safety Blog: Blogger Gregory Wagner, a senior advisor to the NIOSH director, writes about predictive analytics and its usefulness in reducing risk, injury and disease in the workplace. Wagner posits that predictive analytics hold significant potential for helping researchers pinpoint areas of high risk, more precisely deploy limited resources and more effectively prevent work-related health issues. In addition to writing about possible applications, Wagner also discusses barriers to implementing predictive analytics, such as a lack of data. Wagner is calling on readers to weigh in on the benefits and barriers to predictive analytics — go to the article to post a comment.
The New York Times: In “The Upshot,” writer David Leonhardt discusses the “Great Wage Slowdown,” noting that the “typical American family makes less than the typical family did 15 years ago, a statement that hadn’t previously been true since the Great Depression.” Leonhardt writes about the possible reasons why the wage slowdown may take a turn for the positive, such as stabilizing energy costs and rising numbers of college graduates, however he also writes that the forces behind wage stagnation may still be too strong to overcome anytime soon. Leonhardt writes: “Either way, the great wage slowdown, or the end of it, will help set the tone for American life in the coming decade.
Houston Chronicle: The U.S. Bureau of Labor Statistics lists the 10 deadliest jobs in America. At the top? Logging workers, who experience workplace fatalities at a rate of more than 91 per 100,000 full-time workers.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.