A few of the recent pieces I’ve liked:
Andrea Elliott in the New York Times: Invisible Child: Dasani’s Homeless Life
Matthieu Aikins in Wired: The Surge: “In 1988 there were 350,000 cases of polio worldwide. Last year there were 223. But getting all the way to zero will mean spending billions of dollars, penetrating the most remote regions of the globe, and facing down Taliban militants to get to the last unprotected children on Earth.”
Maryn McKenna at Superbug: MRSA in UK Turkeys Raises Questions of Communication, Transparency and Risk
Elizabeth Weise in USA Today: Diseases on the move because of climate change
Al Shaw, Theodoric Meyer, and Christine Thompson at ProPublica: Federal Flood Maps Left New York Unprepared for Sandy – and FEMA Knew It
A coalition of public-health organizations, including the Robert Wood Johnson Foundation (RWJF) and Campaign for Tobacco-Free Kids, has released a report criticizing most U.S. states for under-investing in smoking prevention and cessation. Broken Promises to Our Children: The 1998 State Tobacco Settlement 15 Years Later calculates that states over the past 15 years, states have collected a total of $391 billion from tobacco settlements and tobacco taxes, but spent only 2.3% of that amount on tobacco prevention programs.
The report compares states’ tobacco-prevention expenditures to the levels recommended by CDC, and finds that only North Dakota and Alaska are spending what the agency recommends. Twenty-four states are spending less than half of what CDC advises. The $481 million states are spending on tobacco prevention this year is far lower than the $717 million they spent in FY 2008, before recession-associated cuts began. “These cuts mean more kids starting to smoke, fewer smokers quitting, and more disease, death, and health care costs from tobacco use,” the authors write. And, they remind us, tobacco prevention programs do get results:
Florida, which has a well-funded, sustained tobacco prevention program, reduced its high school smoking rate to just 8.6 percent in 2013, which is one of the lowest rates ever reported by any state.2 A December 2011 study in the American Journal of Public Health found that between 2000 and 2009, Washington state saved more than $5 in health care costs for every $1 spent on its tobacco prevention and cessation program by reducing hospitalizations for heart disease, strokes, respiratory diseases and cancer caused by tobacco use.
This is just one example of cuts to public health programs that allow for short-term balanced budgets but increase costs in future years. We’ve also written about “penny wise, pound foolish” cuts to poison control centers, STD screenings, programs addressing lead poisoning (here, too), and the infrastructure to identify and address foodborne illness outbreaks. These are all programs that save money in the long run, but face cuts when states and counties face declining revenues or increased expenses in another area.
Preventing health problems from occurring is often more cost-effective than treating the problems, and it also improves quality of life. In the US, however, we spend just three percent of our healthcare dollars on disease prevention. Since 2008, over 52,000 state and local public health jobs have been lost (through layoffs and attrition), and many health agencies have reduced the services they provide.
The incredible shrinking Prevention and Public Health Fund
The Affordable Care Act took a step toward improving prevention funding with the Public Health and Prevention Fund, which was supposed to contain $18.75 billion between fiscal year 2010 and FY 2022 and $2 billion per year thereafter. Fund dollars are supporting state and community programs to prevent tobacco use, obesity, heart disease, stroke, and cancer; strengthen the public-health and primary-care workforce; build public-health infrastructure; and conduct prevention-focused data collection and research. (You can see what kinds of Prevention Fund grants your state has received at the HHS website.)
The amount of money in the Prevention and Public Health Fund keeps shrinking, though, as Congress and the Obama administration decide to spend those funds on other things. As this American Public Health Association fact sheet shows, the $1.5 billion funding level originally legislated for FY 2014 has shrunk by one-third, to $1 billion. Assuming past cuts are neither reversed nor deepened, the FY 2015 amount will be $1 billion rather than $2 billion. Money has been shifted from the Fund to stave off scheduled cuts to Medicare physician payments and support enrollment in the new health insurance exchanges.
In the case of the Prevention and Public Health Fund, Congress and the Obama administration have been shifting money from public health to healthcare. Spending money on healthcare isn’t a bad thing, but taking that money from things that could lead to population-wide health improvements is not helpful in the long run.
Dedicated funding — and more of it
Earlier this year, the Institute of Medicine released the RWJF-funded report For the Public’s Health: Investing in a Healthier Future. The report notes that despite spending far more per capita on healthcare, the US lags behind other high-income countries in life expectancy and other indicators of health status. The authors state that in the US, “fixation on clinical care and its delivery eclipses attention to population-based activities that offer efficient and effective approaches to improving the nation’s health.”
The IOM committee offers 10 recommendations to improve US public-health funding. They suggest that as the ACA reduces the need for state and local agencies to spend money on clinical care, these governments should redirect those funds to disease prevention. They also urge Congress to “double the current federal appropriation for public health” and “authorize a dedicated, stable, and long-term financing structure” to generate the necessary revenue. Specifically, they recommend “enacting a national tax on all medical care transactions to close the gap between currently available and needed federal funds.”
Those are bold recommendations, and it’s the kind of thinking we need to achieve a future in which disease prevention is on par with disease treatment.
I spent Sunday morning in the ER of my local community hospital in Hays County, Texas. While my husband lay on the gurney having an IV line inserted, I distracted his attention by conversing with the nurse. I can’t recall what prompted it, but the nurse, Elizabeth, offered her experience with this year’s influenza season.
“I’ve been an ER nurse for 10 years. When it comes to the flu, this year was a lot different. We’ve only seen a handful of cases.”
Like many U.S. hospitals, it’s used by the community for primary care.
I asked Elizabeth if she had any ideas to explain why they’re not seeing patients with influenza.
“A lot more kids do the Dracula cough,” she said. “You know, coughing into their elbow. The schools really emphasize it with the kids, and it’s getting to be the norm.”
Elizabeth and I quickly rattled off a few more possibilities:
- Did more people get a flu shot this year compared to previous years?
- Did it have something to do with this year’s four-strain vaccine?
- Are those strains less virulent?
- Is it just an anomaly in our locality?
The flu season will continue for several months. Elizabeth and her fellow ER nurses may eventually see more cases as the season continues into next year. By June 2014, the CDC’s National Respiratory and Enteric Virus Surveillance System will answer some of our questions. They’ll likely report on the virulence of the strains and percentage population vaccinated. We’ll have to wait for other researchers to examine the impact of the Dracula Cough.
California Governor Jerry Brown was one of the moving forces behind a new agreement among three Western states and British Columbia to align their policies to combat climate change. Under the pact, signed on Oct.
28 by Brown and the governors of Oregon and Washington, the states and the province agreed to a series of actions, including putting a price on carbon and adopting a low-carbon fuels standard. Yale Environment 360 spoke with Brown and asked him five questions about the pact and overall efforts to tackle climate change.
There are few factors that shape a person’s health as strongly and predictably as income. And while enforcing wage and labor laws may at first seem outside the purview of public health agencies, Rajiv Bhatia adamantly disagrees. In fact, he says that public health may wield the most persuasive stick in town.
Bhatia is the director of environmental health at the San Francisco Department of Public Health (SFDPH) and is behind an innovative policy change that uses the agency’s existing regulatory authority to prevent wage theft and support basic labor rights among restaurant workers. Begun in response to community demand, the agency now routinely employs its authority to revoke or suspend restaurant permits to help enforce official wage theft findings and ensure that employers carry adequate workers’ compensation insurance. The permitting authority has a direct and immediate financial impact on employers, “so we probably have the strongest stick in town to get a restaurant to act,” Bhatia said.
“Instead of developing a public health agenda from within an institutional box, we said we’re going to use our power to support the goals of social movement groups,” he told me. “What we’ve done if fairly unique and it’s certainly replicable, but it’s not replicable without a struggle.”
Bhatia co-authored an article about the agency’s experience — “Protecting Labor Rights: Roles for Public Health” — that was published in the current supplement issue of Public Health Reports. In the piece, he and co-authors Megan Gaydos, Karen Yu and June Weintraub note the connections between labor conditions and health, writing that “income is a prerequisite for nutrition, housing, transportation and leisure and is associated positively with health outcomes, including longevity.” They added that with the decline in enforcement capacity at federal and state labor agencies — the number of workplaces is up while the number of investigators is down — cross-agency collaboration could go a long way in protecting workers. They write:
Interagency collaboration among local, state, and federal government agencies — as well as collaboration with community-based organizations and the private sector — is a promising mechanism of efficiently meeting regulatory commitments in a resource-constrained environment. Local health departments can support compliance with labor laws by monitoring working conditions, educating workers and employers, using existing enforcement authorities, and recognizing exemplary businesses. Improving working conditions should be viewed as a key function of public health.
In San Francisco, the Office of Labor Standards Enforcement (OLSE) monitors violations of local wage laws (the city’s minimum wage is $10.74 an hour as of January) and mediates complaints of wage theft. About one-third of OLSE cases involve restaurants, and the city is no stranger to the problem of wage theft. In one study conducted by the Chinese Progressive Association, half of restaurant workers in the city’s Chinatown neighborhood were not receiving minimum wage. The conditions made restaurants the perfect test subjects for a cross-agency approach to wage law enforcement.
The process works like this: An OLSE investigation finds an employer guilty of violating wage laws and orders an employer to pay back wages and penalties. Unfortunately, the employer doesn’t always comply — that’s where the San Francisco Department of Public Health comes in. As part of its inspection duties, the public health agency can suspend or revoke a restaurant’s permit for failing to meet food safety standards. But it can also suspend or revoke a permit if a business is breaking any other local, state or federal laws — including wage laws. In other words, by engaging public health authority, the labor office is able to significantly expedite compliance and in the long run, hopefully prevent wage theft in the first place.
“We were able to rapidly quicken the enforcement process,” Bhatia said. “Even from a food safety perspective, we have a common interest because businesses that violate some laws are more likely to violate other laws. …There’s probably nothing more important to health than income, so I see this as public health demonstrating its commitment to the social determinants of health.”
Since the effort began a handful of years ago, there’s only been about a dozen instances in which the public health agency has threatened to sanction a restaurant’s permit, Bhatia said. But in every instance, the move has worked and the restaurant has complied with the enforcement order.
Expanding to insurance monitoring
After the wage theft success, Bhatia and his colleagues wondered if they could use their regulatory authority to improve other workplace conditions as well. They knew from previous assessments that although restaurants are legally required to carry workers’ compensation insurance, many either don’t have coverage at all or underestimate their workforce numbers. Inadequate insurance causes significant barriers for workers seeking care for work-related injuries or disability benefits. So in 2010, Bhatia decided to integrate routine insurance monitoring into the permitting process. Now, restaurants are required to show proof of workers’ compensation insurance or risk their permit renewal. According to the Public Health Reports article:
Of businesses in the first sample, 10% did not have workers’ compensation insurance prior to SFDPH’s request for proof of coverage. While some acquired insurance after this request, 4% did not provide proof of coverage until SFDPH threatened to suspend their permits. After being compelled to attend public hearings, all businesses except one provided proof of insurance coverage.
On the surface, the work Bhatia describes may seem like a natural fit for public health. But he said it didn’t come without a struggle. In fact, he said it was restaurant inspectors who put up the most resistance, raising concerns that the new measures would draw attention away from food safety and muddy their relationships with restaurant owners. (On a side note, a similar labor tactic was proposed in New York City, but local health officials argued it would water down its food safety focus and the legislation eventually died.)
Even though the San Francisco model seems like an easy, low-cost way to support workers, Bhatia said he isn’t entirely optimistic that many public health agencies would follow San Francisco’s lead on their own.
“It has to come from an organized political movement demanding that the public health agency take on a broader set of roles,” he said.
For a full copy of the Public Health Reports article, click here.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
“I played by the rules. I worked to support my family. The unregulated industry virtually destroyed my life. These chemicals that are used on food in large-scale production must be tested, and proper instructions and labels supplied with their sale.”
Those were the words of Eric Peoples at a congressional hearing in 2007. He testified about his experience working at a food-manufacturing plant where he was exposed to flavoring chemicals including diacetyl. Those exposures led to severe lung damage. At the time of his testimony, Peoples was awaiting a lung transplant.
Eric Peoples became one of the public faces in 2007 of our nation’s ineffective systems for protecting workers, consumers and the environment from chemical hazards. For his part, Peoples brought to light several key problems with our federal public health agencies. Workers are exposed on-the-job to a smorgasbord of chemicals, for which too little information is known about their health effects. Very, very few of the chemicals in commerce—including those used as food flavoring agents—-are subject to workplace safety regulations. Many chemicals used as food additives, including the ones to which Mr. Peoples was exposed, are considered by the Food and Drug Administration (FDA) as “generally regarded as safe” (GRAS). FDA may consider them GRAS to ingest, but some of them are clearly not safe when workers (or even consumers) inhale their vapors. A new paper to be published in the American Journal of Industrial Medicine reinforces this disturbing reality.
Dr. Kay Kreiss with CDC’s National Institute for Occupational Safety and Health (NIOSH) describes an investigation at a flavoring manufacturing plant in Indiana. Kreiss and colleagues have conducted other studies (here, here, here, here) involving workers exposed to food flavorings, most notably those involved in microwave popcorn production. In this study, the NIOSH researchers evaluated 369 spirometry results of 112 food-flavoring production workers which were performed between 2004-2009. The exams were conducted to ensure the workers were well enough to wear respirators. Workers in the plant were involved in a variety of tasks from R&D and quality control, to packaging. Workers with the highest exposure to the butter-flavoring agent diacetyl had job titles related to “dry blend, extract and distillation, liquid compounding, process flavors, and spray dry.” The researchers compared the prevalence of “abnormal restrictive pattern of spirometry” in the exposed workers to that expected in the U.S. general population, controlling for demographic traits, BMI and smoking history. Here’s some of what Kreiss reported:
- “For non-smokers (n=38), the mean decline in FEV1 was 81.3 ml/year, and the mean decline in FVC was 94.8 ml/year.” (FVC is a value applied to an individual’s maximum forced expiratory effort.)
- “Of 70 employees with two or more spirometry tests…19 precent were identified as having excessive FEV1 declines.” (FEV1 is a value applied to the volume of breathe exhaled by an individual at the end of the first second of forced expiration.)
- Of the 25 employees who had serial measurements of lung function and abnormal restrictive spirometry results, eight of the 25 had excessive declines in lung function.
- “Of production employees, 37 percent had either abnormal spirometry or abnormal declines in spirometry or both, with the predominant abnormality being a restrictive pattern. Restriction was about 3.12 times more common than expected compared to the general United States population, after adjusting for potential contributing factors such as smoking, overweight and obesity.”
Kreiss offers a litany of flavors produced at this one Indiana plant including those mimicking butter, buttermilk, cheese, coffee, fruits, beef, chicken, and fish. The trade association for these flavoring producers is the Flavor and Extract Manufacturers Association (FEMA). Kreiss notes in her paper that the group published a list of chemicals used in flavor production that are considered respiratory hazards.
Why do food manufacturers use chemicals to flavor their products knowing the compounds can cause severe lung damage to exposed workers? Because they can. None of the compounds on FEMA’s list are regulated by OSHA. They are also shielded by FDA’s GRAS designation.
When Mr. Peoples’ and other lung-damaged workers’ experiences became public it seemed like there was momentum to address the serious risk to respiratory health of food-flavoring agents. OSHA indicated in 2008 that it intended to initiate a rulemaking. The FDA indicated that a petition calling on the agency to revoke the GRAS designation of diacetyl-containing substitutes was “under active review.” FDA added:
“Although it is highly unusual for the FDA to contemplate food ingredient regulation on the basis of inhalation, we have not ruled out any regulatory option.”
OSHA has long since moved to its back burner a regulation to address the health risk to workers of food-flavoring agents. Actually, not so much the back burner, but off the stove and out the door altogether. Perhaps, however, there’s a slim chance that FDA—an organization that insists it is a public health agency—will address the issue. Clearly, a food additive that can cause irreversible lung damage when inhaled cannot in any public health context be “generally recognized as safe.”
Dr. Kay Kreiss’ paper reminds me to ask FDA for the status of their “active review.” A letter is in the mail.
On the shopping day known as “Black Friday,” activists held protests at Walmart stores across the country to protest the company’s low wages. In one of the eight press releases the company issued in the 24 hours between Thanksgiving Day and the close of the November 29 “Black Friday,” shopping day, Walmart corporate communications vice president David Tovar stated:
“For our part, we want to be absolutely clear about our jobs, the pay and benefits we offer our associates, and the role retail jobs play in the U.S. economy. Walmart provides wages on the higher end of the retail average with full-time and part-time associates making, on average, close to $12.00 an hour. The majority of our workforce is full-time, and our average full-time hourly pay is $12.81 an hour. We are also proud of the benefits we offer our associates, including affordable health care, performance-based bonuses, education benefits, and access to a 401K.”
According to protest organizers – the coalition of labor and other workers’ rights advocacy groups that have come together under the banners of Making Change at Walmart and OUR Walmart (Organization United for Respect at Walmart) – there were about 1500 November 29 protests that resulted in 110 arrests for civil disobedience. Communities where protests took place included Chicago; Dallas; Sacramento; Seattle; Secaucus, NJ; St. Paul, MN, the San Francisco Bay Area, southern California, Massachusetts, Virginia and Washington, DC. In which of these communities can one live on $12.81, let alone $12.00 an hour?
Doing the math
As Walmart spokesperson Kory Lundberg explained in a phone call, typical hours for a full-time Walmart employee are 37 to 38 hours per week, 52 weeks a year. That comes to between $24,646.44 and $25,312.56 annually at the $12.81/ hour rate. Drop to $12/ hour and you’re taking home $23,088 to $23,712 a year. From a monthly perspective, which is how many of us budget expenses, on the high end we’re looking at $2,053.87 to $2,109.38 or between $1,924 and $1,976 on the lower $12/hour end. (If $12 and $12.81 are being presented at “average” wages that means there are also people making less than that.) But working with the average, some back-of-the-envelope math suggests how living on such a Walmart wage might pencil out. It also offers some perspective on how much one might have at the end of the month to contribute to the 401K plan that Lundberg said “many” employees participate in (Walmart matches worker contributions up to 6%) or to put toward the company health insurance that begins at $18 per 2-week pay period (Walmart covers the first $250 in medical costs).
With the federal poverty level for a two-person household at $15,510 for 2013, a single parent of one child earning an average Walmart wage would be well above that poverty level and expect to pay federal taxes. Using the IRS withholding calculator and the Tax Policy Center’s payroll tax calculator, we can see that head of household with one dependent who earns an annual salary of $23,088 can expect to pay somewhere between $2300 and about $2400 or so in taxes each year, which works out to about $200 per month. That would drop a $1,924-per-month paycheck to $1,724. (An actual budget would, of course, have to be refined to factor in any local taxes and tax credits.)
Looking at rents around the country where the Walmart “Black Friday” protests took place, an average one-bedroom within 10 miles of Chicago now goes for about $1500 or more a month ($950 if you’re further out), in the DC area for $1375, while the average one-bedroom rents for $1005/month in Dallas, $760 in Sacramento, $890 in Ontario, CA, between $810 and $1060 in Seattle, and $975 in St. Paul. Clearly if you live within 10 miles of central Chicago (or another high-rent community) you’re going to have to have a rent paying roommate, partner or family member but on the low end, let’s look at Sacramento. If your monthly after-tax pay is $1724 (at the $12/hours for 37 hours a week rate) after paying the rent, you have $964 left for the month.
It is from this sum you’ll be paying an average utility bill of about $150/month, and if in Sacramento a transit pass of about $100. (A Chicago monthly pass will also cost $100 while in DC a month of bus passes costs $64 but a monthly Metrorail pass between $140 and $230.) If you have opted to go without a landline telephone and manage to find a $50/month cell phone plan after paying rent and these utilities, you’re left with $664 to cover the rest of your monthly expenses, including food.
Using US Department of Agriculture (USDA) figures for monthly groceries, you might spend between about $165 if you are on the USDA “thrifty plan” to about $300 on the “liberal plan” for a single person. Split the difference and estimate $232.50 for a single person. If you are also feeding a six-year-old child, add in another $202.40 and remaining spending money for the month drops to $229.10. (Without a child to feed you’d have $431.50 left to work with.) Add a child’s monthly bus pass to your budget at $50 and you’re at $179.10. If you take advantage of Walmart’s health insurance plan and pay $18 twice a month, your remaining spending money for the month is $143.10 If you need to pay for a preschooler’s daycare at going commercial rates, you’re out of luck, as that’s going to cost you at least $550 a month.
So in a lower cost-of-living city like Sacramento, a single person would be spending about $1,292.50 and a parent and child about $1,545.90, for bare-bones expenses each month. Shift this to a higher-cost community, like Chicago, while utilities, food and public transportation costs will be similar, housing costs will mean you almost certainly need to be sharing rent.
So after paying for housing, utilities, transportation, food – and Walmart’s most basic health insurance – a single person living in a relatively low-cost community would have about $395.50 to cover the rest of the month’s expenses; a parent with a 6-year-old, about $143.10. For the parent and child household this works out to about $36 a week, or about $5 a day – and this budget includes no toiletries, clothing or other household purchases. It also does not include any kind of savings to build up any financial cushion, money to take classes at a community college or take other steps that can improve an individual’s longer-term financial outlook.
If you’d managed to save up for a home computer or other internet-enabled device, you might want to try and cover a basic service of about $40 a month that would reduce your monthly available spending money to $103.10 and weekly spare cash to about $26. Not much room for emergencies or education costs, let alone savings or a 401K contribution. Sure, you could put yourself on the “thrifty” USDA food budget and put more spending money back in the budget but spending less than $70 a week to feed mom and a six-year-old, will take some serious budgeting, planning, and figuring out what to do without, at current food prices.
This is the the kind of challenge facing at least half of Walmart’s 1.3 million US employees. So while Walmart said the company would be providing its “associates” with “holiday pay equal to an additional day’s work” and “a 25 percent discount on an entire basket of goods for their extraordinary efforts” on Thanksgiving and Black Friday, that’s unlikely to make up for the chronic penny-pinching necessary to meet basic household needs.
The crunch of numbers
At the same time, other numbers released by Walmart aimed to cast doubt on the involvement of company workers in the protests. Walmart spokesperson Lundberg said that fewer than 20 “associates” were involved in the November 29 protests and no more than six of these Black Friday protests included any Walmart employees. Protest organizers say this assessment isn’t accurate. “It’s not a fair argument to make given the high level of risk for employees who protest,” noted Alex Barrios, spokesperson for California State Senator Norma Torres who attended a November 29 Walmart protest in Ontario, California. What Barrios was referring to is the retaliatory action Walmart took against workers who joined similar protests in 2012, action that included threatening, disciplining, firing and having employees “surveilled,” all of which the National Labor Relations Board said last week was not legal.
“Across the country, there are countless Walmart workers who are paid poverty wages, cannot get enough hours, and have erratic work schedules that make it difficult to survive,” said US Senators Sherrod Brown (D-OH) and Ed Markey (D-MA), and Representatives Jan Schakowsky (D-IL), Judy Chu (D-CA), William Lacy Clay (D-MO), Gwen Moore (D-WI), and Jim McDermott (D-WA), in a statement released to coincide with the Black Friday protests. “We stand with the courageous Walmart workers who are demanding better wages and an end to illegal retaliation,” they said. “Walmart, the largest private employer in the United States, has a responsibility to their employees and our country to respect workers and their rights. No one should have to fear losing their jobs just for speaking up.”
“The company can do better,” said Rep. Schakowsky’s spokesperson in a phone call.
“Of course, we have entry-level jobs and we always will. The real issue isn’t where you start. It’s where you can go once you’ve started.” wrote Walmart on “Black Friday,” touting its advancement and promotion records. Right now, however, more than half a million employees of the United States’ largest retailer, with net sales of more than $450 billion, can’t get very far. Their current wages will barely cover one extra Chicago roundtrip transit fare and a dollar cup of coffee to warm their hands while waiting for the bus.
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, TheAtlantic.com, The Washington Post, Salon and The Nation.