Global Climate Change Research Program Report

Profound Public Health Impacts Identified

The Global Change Research Act of 1990 mandates that the U.S Global Change Research Program deliver a report every 4 years to analyze the effects of global change on the natural environment, agriculture, energy demand, land and water resources, transportation, human health and welfare, human social systems, and biological diversity.  The statutory charge for the report is to “… inform decision-makers, utility and natural resource managers, public health officials, emergency planners, and other stakeholders by providing a thorough examination of the effects of climate change on the United States”.  The 2018 report was issued on the day after Thanksgiving. 

The Report issued last week focuses on the elements in their statutory mandate for 10 regions and 18 topics.  Chapter 14 focuses on public health.  Many of the public health challenges and impacts in the report are things readily observable today.  For example, one of the acute is the public health and policy struggles this year will be surrounding prioritization, use and conservation of increasingly limited water supplies here in Arizona.   As the Colorado River basin continues to have less snow pack and earlier melting- there’s no doubt that allocating a permanently reduced water supply.  We’re likely to see these negotiations play out at the national and state level in the coming months.

At first, I was planning to write my own summary of the public health chapter- but the Executive Summary of that chapter does a pretty good job- so I’ll paste that section for you instead:

Climate-related changes in weather patterns and associated changes in air, water, food, and the environment are affecting the health and well-being of the American people, causing injuries, illnesses, and death. Increasing temperatures, increases in the frequency and intensity of heat waves (since the 1960s), changes in precipitation patterns (especially increases in heavy precipitation), and sea level rise can affect our health through multiple pathways. Changes in weather and climate can degrade air and water quality; affect the geographic range, seasonality, and intensity of transmission of infectious diseases through food, water, and disease-carrying vectors (such as mosquitoes and ticks); and increase stresses that affect mental health and well-being.

Changing weather patterns also interact with demographic and socioeconomic factors, as well as underlying health trends, to influence the extent of the consequences of climate change for individuals and communities. While all Americans are at risk of experiencing adverse climate-related health outcomes, some populations are disproportionately vulnerable.

The risks of climate change for human health are expected to increase in the future, with the extent of the resulting impacts dependent on the effectiveness of adaptation efforts and on the magnitude and pattern of future climate change. 

Obviously, there is allot more in the report that really requires a deeper dive.  The report is certainly worth book marking in your Favorites section for reference as you conduct your public health work.

Approaches for Improving Oral Health

Poor oral health is a health disparity for low-income people and people with disabilities.  Dental illnesses significantly increase the risk of chronic health conditions, result in missed days of work and school, and negatively affect employability. According to an American Dental Association survey, approximately 33% of Americans who have income lower than 138% of federal poverty level struggle to get employed because of the condition of their mouth and teeth. 

Poor oral health can easily compound the effects of preexisting conditions and aggravate already fragile socioeconomic well-being, both at the individual and population levels. However, oral health care delivery and services can be improved through innovations in programming, financing, and workforce training. Using the population health framework, states can make significant strides towards improving their population’s overall health by improving dental care access and delivery.

Below are some examples of public health policy interventions underway in the U.S in various states to address this important health disparity.

Impact of Medicaid on Access to Oral Health Services

State Medicaid programs including AHCCCS are mandated to provide comprehensive dental coverage for Medicaid-enrolled kids – but aren’t required to offer dental coverage to Medicaid‐enrolled adults. Nationally there’s an uneven patchwork of dental care coverage that impacts access to dental services. 

Arizona provides emergency dental services to all enrolled adults up to a $1,000 annual cap. But coverage alone isn’t enough to actually get care.  Many dental providers don’t  accept Medicaid coverage and nearly 49 million people are living in dental health professional shortage areas (HPSAs) across the country (HPSAs are geographic regions, populations, or facilities that are lacking sufficient healthcare providers).

Many states have used Medicaid waivers demonstrations to improve dental care. For example, California developed a Dental Transformation Initiative to increase dental care access and address the specific oral health needs of children by providing incentive payments to dental providers for achieving state-defined targets.  Here are some examples that are being implemented across the country:

Alignment with Population Specific Services

Oral health programs or pilots can also be aligned with current services provided by the state for increasing access to oral health services for specific populations.  For example, New Hampshire created a pilot program held at local WIC sites to integrate preventative oral health care for low-income women and children into existing safety net programs. It included a weekly dental clinic at each WIC site at which dental hygienists and dental assistants provided preventative care and referred participants to local Medicaid-enrolled dental providers for follow-up care.

Workforce Innovation

Last legislative session Arizona lawmakers approved a new class of dental professionals called Dental Therapists who, over time, will be about to meet some of the workforce demands in Arizona’s rural and underserved areas.  The Board of Dental Examiners still needs to develop the Administrative Code (Rules), but dental therapists will be practicing on the horizon, providing a potentially important access point in rural and other underserved areas.

Care Delivery Innovations

Advances in telehealth can also be promising avenues for improving access to oral health care too. For example, Alaska used telehealth to address its oral health needs. Given the lack of access to oral healthcare that affects their rural residents, they established the practice of mid-level oral health providers known as dental health aide therapists. Telehealth (specifically live videoconferencing) allows these aides to connect with supervising dentists in hub locations who are then able to provide professional oversight and supervision virtually. 

New Physical Activity Guidelines

It’s no secret that obesity is a core public health challenge of our time- largely as a result of the lack of physical activity and poor nutrition.  In fact, 80% of US adults and adolescents aren’t getting enough physical activity.  Physical activity fosters normal growth and development and can make people feel, function, and sleep better and reduce risk of many chronic diseases.

A couple of weeks ago JAMA’s 2018 Physical Activity Guidelines Advisory Committee published a systematic review of the science supporting physical activity and health in HHS’ 2018 Physical Activity Guidelines Advisory Committee Scientific Report.  The HHS Physical Activity Guidelines for Americans Report (2nd edition) recommended the following:

  • Preschool-aged children (3 through 5 years) should be physically active throughout the day to enhance growth and development.

  • Children and adolescents aged 6 through 17 should do 60 minutes or more of moderate-to-vigorous physical activity daily.

  • Adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity. They should also do muscle-strengthening activities 2 days a week.

  • Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity a week.

The 2018 recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic and muscle-strengthening physical activity are beneficial.

The JAMA Committee concluded that the  Physical Activity Guidelines for Americans Report (2nd edition)   provides information and guidance on the types and amounts of physical activity that provide substantial health benefits. Health professionals and policy makers should facilitate awareness of the guidelines and promote the health benefits of physical activity and support efforts to implement programs, practices, and policies to facilitate increased physical activity and to improve the health of the US population. 

You can dive into the systematic review on the JAMA site. Their review largely validates the 2018 guidelines.

Sign Up for Our Professional Learning Communities

Over the next month, we’ll be setting up some Professional Learning Communities in our Basecamp where members with similar interests can share information with one another, update each other about actions that state and federal agencies are taking (or not taking), and share best practices that influence public health.

Lauren Savaglio (our Board Member for Professional Development and Academic Relations) has set up a tool so you can sign up to participate on one of 5 pilot Professional Learning Communities.  In order to sign up, simply go to our Survey Monkey Link and ask to sign up for one of our initial Communities in Basecamp.  Our pilot PLC’s will be in the areas of:

  • Behavioral Health

  • Public Health Nursing

  • Maternal and Child Health 

  • Oral Health

  • Nutrition & Physical Activities 

Also, let me know if you’d like to be added to our Public Health Policy Committee Basecamp site and I can get you all set up.  We have about 50 folks already set up on that site.

Participate in our Volunteer Event!

Please consider participating in our December Volunteer Event to hand-pack meals specially formulated for malnourished children! We still need 5 more people to help us hand-pack meals that will be sent around the world where they feed orphanages, schools, and clinics to break the cycle of poverty. 

When: Monday, December 10. 2018, 8:30 PM – 10:00 PM

Where: 1345 S. Alma School Rd, Mesa, AZ 85210

Register: https://www.fmsc.org/join-group?joincode=1931W2 

Group Name: Professional Development AZPHA  Join Code: 1931W2

For questions and/or an outlook calendar invite, please contact Lauren Savaglio-Battles at professionaldevelopment@azpha.org

2019 Legislative Session

The 2019 Legislative Session will begin on January 14.  The Session usually starts with a State of the State address by the Governor followed by a proposed executive branch budget. 

Here’s a PowerPoint RE 2019 Legislative Priorities that I put together.  Like other years, lots of things will come up during the session that we will support or be opposed to.  Our Public Health Policy Committee will share information and meet during the session as we prepare our positions and conduct our public health advocacy.

The party balance in the State Senate will remain 17-13; while the balance in the House will be 31-29 (a much closer party balance than there has been in recent years).

The President of the Senate will be  Karen Fann (R) LD-1 and House Speaker will be  Rusty Bowers (R) LD-25.  There will be 12 Senate committees and 20 House committees starting in January.  The Senate Health and Human Service Committee will be chaired by Senator Kate Brophy-McGee (Sen. Heather Carter will be Co-chair).  The House Health Committee will be chaired by Representative Nancy Barto (Rep Jay Lawrence as Vice Chair)

Senate Committees:

Appropriations: Sen. David Gowan (LD14), Chair

Commerce: Sen. Michelle Ugenti-Rita (LD23), Chair

Education: Sen. Sylvia Allen (LD6), Chair and Sen. Paul Boyer (LD20), Co-chair

Finance: Sen. J.D. Mesnard (LD17), Chair

Government: Sen. David Farnsworth (LD16), Chair and Sen. Sonny Borrelli (LD5), Co-chair

Health and Human Services; Kate Brophy McGee (LD28), Chair & Heather Carter, Co-chair

Higher Ed. & Workforce Dev: Heather Carter (LD15), Chair and Sen. J.D. Mesnard, Co-chair  

Judiciary: Sen. Eddie Farnsworth (LD12), Chair

Natural Resources and Energy: Sen. Frank Pratt (LD8), Chair

Rules: President-Elect Karen Fann (LD1), Chair  

Transportation and Public Safety: Sen. David Livingston (LD22), Chair  

Committee on Water and Agriculture:  Sen. Sine Kerr (LD13), Chair Sen. Frank Pratt (LD8), Co-chair

House Committees:  

Appropriations: Rep. Regina Cobb (LD5), Chair and Rep. Kavanagh (LD23), Vice Chair

Commerce: Rep. Jeff Weninger (LD17), Chair

County Infrastructure: Rep. David Cook (LD8), Chair

Education: Rep. Michelle Udall (LD25), Chair

Elections: Rep. Kelly Townsend (LD16), Chair

Federal Relations: Rep. Mark Finchem (LD11), Chair

Government: Rep. John Kavanagh (LD23), Chair

Health & Human Services  Nancy Barto (LD15), Chair and Jay Lawrence (LD23), Vice Chair

Judiciary: Rep. John Allen (LD15), Chair

Land & Agriculture: Rep. Tim Dunn (LD13), Chair

Military & Veterans Affairs: Rep. Jay Lawrence (LD23), Chair

Natural Resources, Energy & Water: Rep. Gail Griffin (LD14), Chair

Public Safety: Rep. Kevin Payne (LD21), Chair

Regulatory Affairs: Rep. Travis Grantham (LD12), Chair

Rules: Rep. Anthony Kern (LD20), Chair

Sentencing & Recidivism Reform: Rep. David Stringer (LD1), Chair

State & International Affairs: Rep. Tony Rivero (LD21), Chair

Technology:  Rep. Bob Thorpe (LD6), Chair

Transportation: Rep. Noel Campbell (LD1), Chair

Ways & Means: Rep. Ben Toma (LD22), Chair

2018 Child Fatality Review Report Published

The death of any child is a tragedy – for the family and for the community. Everybody wants to prevent childhood deaths. But making policy interventions to prevent childhood deaths requires information in order to develop effective policy interventions.  That’s where the Arizona Child Fatality Review State Team comes in.

More than 25 years ago the state legislature passed a law establishing the Arizona Child Fatality Review Program (A.R.S. § 36-342, 36-3501-4).  It’s a great example of establishing public policy designed to build data and evidence so policy makers can use evidence to build future interventions.

The State Team includes representatives from the Academy of Pediatrics and from the ADES Divisions of Developmental Disabilities and Children and Family Services, as well as from law enforcement and the ADHS. The team’s role is to review all childhood deaths in AZ and produce an annual report to the Governor and legislature with a summary of findings and recommendations based on promising and proven strategies regarding the prevention of child deaths.

In past years this focus has raised the awareness about child drowning and the importance of putting babies to sleep on their backs or making sure all children are always secured in car seats. Other recommendations included taking action to reduce the number of uninsured, decrease medical complications of pregnancy and increase safe sleep practices.

The 2018 Child Fatality Review Report was published last week- and as usual it provides a host of data and recommendations that are directly tied to evidence. Here are some examples from this year’s report.

Child suicides increased an astonishing 32% and accounted for 6% percent of all child deaths. A history of family discord was the most commonly identified preventable factor in suicides followed closely by a history of recent break-up, drug/alcohol use and an argument with a parent. 

Firearm deaths increased 19% from the previous report.  Suicides and homicides accounted for 88% of firearm-related deaths in 2017. Fifty-one percent of firearm related deaths were a result of suicide (n=22) and 37% of firearm related deaths were homicides (n=16).

Injury deaths increased 4% from the previous reporting period and comprised 23% of all child deaths. The leading cause was car crashes and 31% of the injury deaths were among kids less than 1 year old… and important piece of data considering Arizona has yet to adopt a law requiring kids under 2 years old to be in a rear facing car seat.

The number of unsafe sleep deaths increased 5% from the previous year.  60% were bed sharing with adults and/or other children. Child fatalities due to maltreatment decreased 4% and accounted for 10% of all child deaths in Arizona.   Substance use was a factor in 65% of maltreatment deaths.

Drowning deaths increased 30% over the period and accounted for 4% of all child deaths. 63% occurred in a pool or hot tub. Lack of supervision was a factor in 69% of drowning deaths.

Substance use was a factor in 17% of all child fatalities (n=136).  The majority of substance use related deaths involved the child or the child’s parent as the main user contributing to the death of the child. In 49% of substance use related deaths, the parent was misusing or abusing alcohol or drugs.

The full report covers each of these areas including some recommendations for policy and program interventions in each area.  Sometimes the recommendations are more related to increasing awareness but many are more policy based.

Lots of work went into this report- so if you’re somebody in a position to influence either lawmakers or agency officials to implement preventative policies in these areas- please get familiar with this   important research product – it will really help inform your advocacy efforts.

Research Published about Vaccine Exemption Policies

It’s no secret that many states including Arizona are struggling to maintain enough vaccination coverage to achieve “herd immunity”.  Herd immunity simply means that you have enough vaccination coverage to protect the entire community – including people that for medical reasons can’t be vaccinated and folks who’ve been vaccinated but still may be susceptible (because vaccines aren’t 100% effective).

Requiring kids in public school to be vaccinated is one of the most important public policy tools to ensure herd immunity.  Arizona does that through statutes labeled ARS-872 & ARS-873 – which require kids to be vaccinated if they attend public school (unless they have an exemption). In Arizona, there are medical, religious, and “personal” exemptions. The problem over the last few years is that more and more parents are exercising the personal exemption option.

Arizona’s immunizations rates continue to decline: 1) immunization rates have decreased across all age groups from 2012 to 2017; 2) personal exemption rates continue to be highest in charter schools, followed by private and public schools in 2017; and 3) overall personal exemption rates increased in the last year- going from 3.9% to 4.3% for pre-school; 4.9% to 5.4% for Kindergarten and 5.1% to 5.4% among 6th graders.

Of course- when looking toward interventions to stem the tide it’s important to look to the scientific literature to see what’s going on in other states.  A very informative article about personal vaccine exemptions was published recently entitled The state of the antivaccine movement in the US: A focused examination of nonmedical exemptions in states and counties.

The researchers conducted a detailed analysis of personal exemptions within each of the 18 states that allow nonmedical exemptions to their school vaccine requirements. Here’s a map of which states allow non-medical school exemptions.

The researchers found that several counties, especially those with large metropolitan areas, are at high risk for vaccine-preventable pediatric infection epidemics.  Since 2009, personal exemptions have risen in 12 of the 18 states that currently allow philosophical-belief exemptions.  On average, states that allow non-medical exemptions have 2.5 times higher exemption rates.

The also dove into the data and found that there is a direct correlation between higher personal exemption rates and lower vaccination rates.  That might be intuitive- but it’s important because it shows that personal exemption rates for school requirements is a good measure of real immunization rates.

The discussion portion of the article discusses the efficacy of interventions in various states, and basically found that more aggressive approaches – like eliminating personal exemptions entirely- are more effective at long term improvements in vaccination rates than softer approaches.

Definitely worth a read.

AZ Develops Pain & Addiction Curriculum for Clinicians

It’s no secret that getting a public health handle on the opioid crisis will take a multi-pronged effort for an extended period.  Part of the solution was the policy development, passage and implementation of the Arizona Opioid Epidemic Act.  Other elements include developing and implementing new Opioid Prescribing Guidelines and developing new regulations for pain management clinics.

Another huge element is changing the culture of pain and addiction care.  ADHS has completed a Arizona Pain and Addiction Curriculum that approaches pain and addiction in a new way – as complex, interrelated, public-health issues. 

The curriculum was jointly developed by Deans and Curriculum Representatives from every MD, DO, NP, PA, ND, DMD and DPM program in Arizona.  The program stresses not only the new evidence base of pain and addiction care.

Resources for programs consist of both a Pain and Addiction Curriculum and a Pain and Addiction Faculty Guide.  Because it was created and facilitated by public health, it’s accessible online at any time, to the appreciation of other teaching programs across the country.

Kudos to ADHS and the dozens of stakeholders for this novel work and especially AzPHA member Lisa Villarroel MD.  Work on this scale hasn’t been done before in the US – so kudos to our Arizona teaching programs for being so open and collaborative. This is another example of the stakeholder driven innovative work being done right here in Arizona that’s likely to be adopted as a best practice in other states.

Tucson Voters Lead the Way

Last week Tucson voters approved Proposition 407 approving $225M in Bonds for improving the outdoor built environment.  The funds will be used over the coming years for playgrounds, sports fields, pools, splash pads, recreation centers, pedestrian pathways, bike pathways, and pedestrian & bike safety infrastructure. 

The plan includes 25 new splash pads, 22 new playgrounds and 17 shade structures installed at city parks in the next several years.  Tucson will be reopening 2 city pools that have been closed and will make renovations the 22 other public pools.  Improvements are also planned for sports fields, 28 new walking paths in parks, 26 new ramadas, 19 new restrooms and an amphitheater.

Safety and mobility projects will connect people to parks, schools, shopping and transportation. New sidewalks, enhanced major street crossings, off-street biking and walking paths and residential street traffic calming are also slated in the plan which will provide more than 210 km of enhancements across Tucson.

The improvements won’t happen overnight though.  The $225M in improvements is spread over 9 years.  You can learn more about the proposed Parks and Connections projects using Tucson’s Interactive Story Map.

Congrats to the voters of Tucson for investing in their built environment and creating more opportunities for folks to enjoy the outdoors and get some exercise!

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