Public Health Journalism this Week

Families demand action against midwife after multiple deaths | 12news.com & 1016132 (youtube.com)

How marijuana reclassification could impact Arizona dispensaries – Axios Phoenix

Kris Mayes to investigate Steward Health Care’s bankruptcy (azcentral.com)

Here’s what Arizonans need to know about the FLiRT COVID-19 variants. (azcentral.com)

Fake drug and alcohol treatment centers cause a big scandal in Arizona : NPR

Arizona facing third wrongful death lawsuit related to Medicaid fraud (azcentral.com)

 

Former ADHS director recalls scope of practice changes for midwives

See: Families demand action against midwife after multiple deaths | 12news.com

Will Humble was the state’s health director when the scope of practice for midwifery was expanded. Midwives used to be prohibited from conducting VBAC births, or vaginal birth after cesarean delivery, in Arizona.

There was a strong push to change that. Humble recalls it wasn’t an easy decision.

We had the home birth enthusiasts and the midwives pushing for an expanded scope of practice to include VBAC. And on the other side, we had OBGYNs who had spent years in medical school and then a residency practicing how to manage births, including VBACs,” Humble recalled. “And they thought it was just outrageous that midwives, who had almost no medical training, really hadn’t been a medical school, that they would be allowed to do this practice.”

Ultimately, after extensive research, Humble said the state sided with midwives. They did, however, add additional criteria and limitations for VBACs to try to minimize risk.

“If the midwife doesn’t follow those criteria, the risks go from manageable to extreme. Same goes for the agency. If the state agency isn’t doing a good job overseeing the midwives, those risks go from manageable to really, really bad,” Humble said.

Humble said transparency from the health department is critical to ensure parents are making the best and safest decision for their family.

The health department has two-fold responsibility. Number one, to hold the midwives to the letter of their regulations and to ensure that there’s disciplinary action when those criteria aren’t being met. The second piece is to make that information known,” Humble said.

Biden Administration to Allow States to Include Adult Dental Services as an Essential Health Benefit

Last week HHS finalized a new rule allowing states to include adult dental services in the list of designated essential health benefits required to be covered by most health plans under the Affordable Care Act.

States that add adult dental to their benchmark plan would also guarantee coverage for people on the state’s Medicaid program.

When the ACA was passed in 2010, children’s oral health services were included in the statutory language within the ten categories of services that were required to be considered…  but adult oral health services were excluded. The new HHS rule removes that long-standing prohibition and allows states to include adult oral health services as a standard benefit.

If states take the option presented in this new rule and update their benchmark plans to include adult dental services, all qualified health plans will be required to incorporate adult dental services either within the medical plan or via a contract with a standalone dental plan issuer. States that wish to add dental coverage will have to go through the process of updating their benchmark plan to specify the inclusion of adult dental services as an essential health benefit.

Governor Hobbs’ executive order last week around Arizona’s essential health benefits around reproductive health didn’t mention anything about oral health…  but this new rule provides a fresh opportunity to advocate for adult oral health to be incorporated as a benchmark essential health benefit.

 

Note: Back in 2014, Governor Brewer picked the AZ State Employee ‘EPO’ Plan as the benchmark for Arizona’s Marketplace plans. Ever since then, Marketplace plans have needed to cover (at a minimum) the same benefits as the state employee plan. Other commercially available plans need to be “substantially equal” to the state employee benchmark plan in scope, limitations, and exclusions (e.g. visit limits).

At the time, I opined on my ADHS Blog that the choice was a good one because it had a robust behavioral health component with fewer limitations, restrictions and exclusions than most other options- and already covers behavioral health services at parity (meaning behavioral health has the same level of coverage as physical health). To my knowledge, the Ducey administration never made any changes to that benchmark plan.

AHCCCS Preparing Reimburse for Doula Services: Comment Thru June 10

A doula is a trained professional who provides physical, emotional, and informational support to a woman throughout her pregnancy, childbirth, and postpartum period. Doulas act as a facilitator between the laboring women and her physician by ensuring that the mother gets the required information to make informed decisions.

Several studies have shown that moms who have doula services during their pregnancy and delivery have fewer cesarean sections and epidural, reduced preterm birth and higher rates and longer duration of breastfeeding.

Doula care reduces healthcare costs by lowering the rate of pre-term and C-section deliveries to the tune of about $1,000 per doula-supported birth

Good news!

AHCCCS has filed a State Plan Amendment that will add coverage and payment for doula services effective October 1, 2024!  Comments are being accepted publicinput@azahcccs.gov through June 10, 2024.

We encourage you to send comments to AHCCCS in support of this evidence-based initiative that both improves birth outcomes and reduces delivery costs.

Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery – PubMed

Doula Care Reduces C-sections, Pre-term Birth & Cuts Birthing Costs by a Net $1,000

Leveraging Doulas to Improve Birth Outcomes

Doula Services Improve Maternal and Child Health Outcomes

Who’s a Doula?

Is H5N1’s Jump to Cattle a Big Deal? (Updated May 24)

I’m sure you’ve heard that the H5N1 avian influenza strain has been recently discovered to have jumped to cattle and has been detected (by PCR) in raw milk in at least 59 cattle herds among 9 states. No herds are known to have been infected in Arizona as of yet (that we know of).  What are the public health implications and what’s being done to investigate and intervene?

Background

Let’s start with a quick history of how the H5N1 avian influenza virus got started.

In 2020 it appears that there was some reassortment (aka gene-swapping) between dually infected domestic poultry and wild bird influenza viruses that resulted in the new ‘HPAI’ H5N1 influenza virus.

In February 2022 the USDA discovered this new version of the influenza virus rifled through a US commercial turkey facility, marking the first known commercial outbreak of the virus in the US.

The H5N1 avian virus is shed in the saliva, mucous, and feces of infected birds. It spreads rapidly through poultry flocks and among wild birds and is quite lethal for poultry.  An estimated half a billion farmed birds have been slaughtered in efforts to contain the virus.

For the most part the virus has just been making birds sick – but there have been detections of the virus in all kinds of mammals as well – ranging from sea lions to mink to polar bears.

New Regulations after Some Cattle Became Infected

Last month, the USDA found that the virus had begun to infect domestic cattle…  although the symptoms and virulence in cattle is much lower than in birds. While infected cattle had some symptoms, they haven’t been serious nor lethal (in contrast with the effect of the virus on birds).

The USDA is the regulatory authority for the testing, investigation, and control measures for both the birds and the cattle. USDA has several new regulatory measures already in place that you can see here: aphis-requirements-recommendations-hpai-livestock.pdf (usda.gov)

Virus Surveillance & Investigations

So far all of USDA’s testing in actual meat from cattle is clear of the virus, but it’s showing up in high concentrations in the milk of infected dairy cows.

The vast majority of milk on the shelf is pasteurized and not a threat at all because if the virus is in the milk, the heat of pasteurization kills it. Raw milk (legal in Arizona) of course is a theoretical risk for humans but is unlikely to cause severe illness unless the virus changes dramatically from where it is today.

Note: It’s legal to sell raw milk that’s not pasteurized but it must meet specific standards in ARS 3-606. The Arizona Department of Agriculture (ADA) is the regulatory authority (not ADHS). Raw milk producers need to get a separate license from the ADA and comply with detailed regulations that cover sanitation, handling, and labeling. Raw milk must be specifically labeled indicating that it’s not pasteurized and summarizing the potential health threats from consuming raw milk.

Workers close to infected cows and birds haven’t been becoming sick – except for a couple cases of ‘pink eye’ where workers got an eye infection from splashes while milking cows.

The meat that has been tested at retail sites in the 9 states that have found infected dairy cows has so far all been negative. USDA is testing meat at licensed slaughterhouses (using PCR), but the results aren’t out yet.

A hamburger study is underway at the slaughterhouses too. No results yet – but there will likely be results by next week.

Here are the results so far: Updates on H5N1 Beef Safety Studies | Animal and Plant Health Inspection Service 

USDA still doesn’t know exactly how the cows are getting it from the birds – but that’s under investigation. My bet is that it’s because some farmers feed dairy cattle chicken feces (they call it litter), which could be infecting the cows.

Bird flu outbreak: Arizona farms haven’t detected any cases

If that turns out to be the case the intervention is simple – order farmers to stop feeding chicken feces to cows. Whether they’d comply is another matter.

Future Implications

As for the H5N1 virus mutating in cows and jumping to people in a much more virulent form…  yeah it’s theoretically possible but has never been observed before.

The normal pathway for new virulent influenza virus (pandemics) is birds > pigs > humans. That’s the long-term pattern including H1N1 back in 2009. Why? Because believe it or not pigs are close to humans on the biological tree and have similar respiratory receptors.

New strains almost always come from China because in rural China humans, pigs and birds (usually geese) all live together.  Cattle are far from humans on the mammal tree so it’s unlikely the H5N1 virus would mutate and become a virulent human strain in a bovine.

May 23, 2024 Update:

USDA’s Food Safety and Inspection Service collected 30 samples of ground beef from retail outlets in the states with dairy cattle herds that had tested positive for the H5N1 influenza virus at the time of sample collection. The samples were sent to APHIS’ National Veterinary Services Laboratories (NVSL) for PCR testing. NVSL reported that all samples tested negative for H5N1.

USDA’s FSIS, APHIS, and Agricultural Research Service (ARS) are working on three separate beef safety studies related to avian influenza in meat from dairy cattle.

  1. Samples of ground beef obtained at retail in the affected States test negative: Samples were collected at retail outlets in the States in which dairy cattle herds have tested positive for H5N1 influenza virus. The samples were analyzed by APHIS using polymerase chain reaction (PCR), to indicate whether any viral particles were present. No virus particles were found to be present.
  2. Beef muscle sampling of dairy cows at select FSIS-inspected slaughter facilities: FSIS has completed collection of muscle samples at from cull dairy cattle that have been condemned for systemic pathologies. The samples are currently being analyzed by APHIS using PCR to determine presence of viral particles. The results are forthcoming and will be posted as soon as they become available.
  3. Ground beef cooking study: ARS inoculated a very high level of a HPAI virus surrogate into 300 grams ground beef patties (burger patties are usually 113 grams) to determine whether FSIS recommended cooking temperatures are effective in inactivating H5N1 virus The burger patties were cooked to three different temperatures (120-, 145-, & 160-degrees Fahrenheit), and virus presence was measured after cooking. There was no virus present in the burgers cooked to 145 (medium) or 160 (well done) degrees. Even cooking burgers to 120 (rare) degrees, which is well below the recommended temperature, substantially inactivated the virus.

Kelli Donley Williams Named Deputy Director of Maricopa County Department of Public Health

Good news for Arizona’s public health system folks. Our Immediate Past President Kelli Donley Williams announced at our last Board meeting that she’ll be beginning a new job as the Deputy Director for the Maricopa County Department of Public Health in late June.

For the last few years Kelli has been serving as the director of human services at the Maricopa Association of Governments.

Her primary responsibility at MCDPH will be assisting Director Fowler with planning and management of the operations of the department. This includes oversight of three divisions: Health Outreach, Partnership and Equity; Child and Maternal Health; and Organizational Support and Community Operations. 

In addition to serving several years on the AZPHA board including terms As Vice President, President Elect, President and now Immediate Past President, Kelli is a proud UArizona Mel & Enid Zuckerman College of Public Health graduate. She found her passion for public health while volunteering with the Peace Corps in Africa in 2000.

Kelli is a native Arizonan and the author of four novels, Under the Same Moon, Basket Baby, Counting Coup, Desert Divide.

Kelli lives with her husband Jason, animals, and unruly vegetable garden in Mesa, Arizona. She blogs at: www.africankelli.com.

Oral Arguments Monday in Petersen v. Hobbs Agency Director Nominations Case

After Sen. Hoffman’s failure to hear nominations for several of Governor Hobbs’ nominees to direct state agencies (and his bizarre behavior during the very few “Director’s Nominations” Committee hearings that did occur), it became clear that Hobbs’ nominees to lead state agencies wouldn’t be getting a fair shake at confirmation from the Committee or the Senate.

See: Senate committee doesn’t ‘vet’ nominees. It sabotages them

We posted a blog back then arguing that the Governor should use provisions in state law to get her nominees onto more stable ground: Time to Play Hardball with Agency Director Nominations? Here’s a Playbook. Hobbs ended up going with Option 3 in that blog post as outlined in Governor Hobbs Letter to Senate President Petersen. Hobbs first withdrew the 13 nominations of the agency directors that she had previously sent to the Senate.

See: Governor Katie Hobbs Pulls Nominees from Partisan Political Circus Created by Extremist Jake Hoffman
See: 38-211 – Nominations by governor; consent of senate; appointment

Hobbs appointed Ben Henderson as the Interim Director for each of the agencies. Mr. Henderson proceeded to name the person who had previously been nominated to be agency director to the title of Executive Deputy Director.

State Senate President Petersen sued Governor Hobbs in Maricopa County Superior Court last year, challenging Hobbs’ end-around the Senate.

Judge Blaney will hear the first round of oral arguments in court Monday at 10am in the Maricopa County Superior Court building (Room 411).

See: Civil Court Case Information: Petersen v. Hobbs Maricopa County Superior Court Case Number CV2023-019899/

My sense is this case will ultimately be appealed regardless of what Blaney decides – so it may be several months to more than a year before we have a final resolution in this important policy matter.

If the State Senate flips to the Dems or is 15-15 tie after the November election, things could change rapidly, and the case could end up being dismissed once a new Senate president is sworn in and Hoffman is discharged from the Director Nomination Committee (or it’s abolished).

I hope to be able to get a seat in the courtroom on Monday and provide an update next week.

AZPHA’s Potential Positions on November Ballot Propositions: Part 5 – Arizona for Abortion Access Act

Every cycle the Arizona Secretary of State generates a publicity pamphlet to help educate voters ahead of the general election. The pamphlet includes arguments in support of and against citizens’ initiatives and legislative referral. It’s a feature of the Clean Elections voter initiative from several years ago. The publicity pamphlet is a key educational resource for voters to use before voting.

As Arizona’s independent voice for public health, we’ve played a key role in helping voters to understand the public health implications of the various ballot measures. One way we do that is to send arguments for and against ballot propositions focusing on the good and bad public health impacts. Last cycle AZPHA placed arguments for or against 4 of the 10 ballot propositions.

This cycle the window for getting arguments filed is May 20th – June 20th. The arguments are posted in order they are received so it’s a good idea to get arguments early so voters see our stuff first.

There are already 6 ballot measures set for the 2024 ballot (not including the upcoming voter-driven Arizonans for Abortion Access). Three have direct impacts to public health / public health policy and a 4th will the AZ for Abortion Access initiative.

Our Public Health Policy Committee will be recommending arguments for the publicity pamphlet to our Board of Directors for consideration at our May 17 Board Meeting. If approved, I’ll be authorized to submit our arguments for the publicity pamphlet.

Anybody can turn in an argument. Simply write up an argument (300-word limit) and submit it to the General Election Ballot Measure Argument Portal along with the $75 fee. Portal is open from May 20 to June 20.

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View a summary and our draft argument FOR the Arizona for Abortion Access Act
See Our Draft Argument (For)

This voter driven constitutional amendment would establish the fundamental right to abortion that the state of Arizona may not interfere with before the point of fetal viability unless justified by a compelling state interest (e.g. improving or maintaining the health of the individual seeking abortion care that does not infringe on that individual’s autonomous decision making).

AZPHA’s Potential Positions on November Ballot Propositions: Part 4 – Locking in Partisan Primaries

Every cycle the Arizona Secretary of State generates a publicity pamphlet to help educate voters ahead of the general election. The pamphlet includes arguments in support of and against citizens’ initiatives and legislative referral. It’s a feature of the Clean Elections voter initiative from several years ago. The publicity pamphlet is a key educational resource for voters to use before voting.

As Arizona’s independent voice for public health, we’ve played a key role in helping voters to understand the public health implications of the various ballot measures. One way we do that is to send arguments for and against ballot propositions focusing on the good and bad public health impacts. Last cycle AZPHA placed arguments for or against 4 of the 10 ballot propositions.

This cycle the window for getting arguments filed is May 20th – June 20th. The arguments are posted in order they are received so it’s a good idea to get arguments early so voters see our stuff first.

There are already 6 ballot measures set for the 2024 ballot (not including the upcoming voter-driven Arizonans for Abortion Access). Three have direct impacts to public health / public health policy and a 4th will the AZ for Abortion Access initiative.

Our Public Health Policy Committee will be recommending arguments for the publicity pamphlet to our Board of Directors for consideration at our May 17 Board Meeting. If approved, I’ll be authorized to submit our arguments for the publicity pamphlet.

Anybody can turn in an argument. Simply write up an argument (300-word limit) and submit it to the General Election Ballot Measure Argument Portal along with the $75 fee. Portal is open from May 20 to June 20.

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View a summary and our draft argument AGAINST the Partisan Primaries Regardless of Party Affiliation Amendment
See Our Draft Argument (Against)

This measure (referred to the ballot by the legislature) would require partisan primary elections for partisan offices; prohibits primary elections where all candidates, regardless of political party affiliation, run in the same primary election, such as top-two, top-four, and top-five primaries; and provide that the state’s direct primary election law supersedes local charters and ordinances.

AZPHA’s Potential Positions on November Ballot Propositions: Part 3 – Open Primaries

Every cycle the Arizona Secretary of State generates a publicity pamphlet to help educate voters ahead of the general election. The pamphlet includes arguments in support of and against citizens’ initiatives and legislative referral. It’s a feature of the Clean Elections voter initiative from several years ago. The publicity pamphlet is a key educational resource for voters to use before voting.

As Arizona’s independent voice for public health, we’ve played a key role in helping voters to understand the public health implications of the various ballot measures. One way we do that is to send arguments for and against ballot propositions focusing on the good and bad public health impacts. Last cycle AZPHA placed arguments for or against 4 of the 10 ballot propositions.

This cycle the window for getting arguments filed is May 20th – June 20th. The arguments are posted in order they are received so it’s a good idea to get arguments early so voters see our stuff first.

There are already 6 ballot measures set for the 2024 ballot (not including the upcoming voter-driven Arizonans for Abortion Access). Three have direct impacts to public health / public health policy and a 4th will the AZ for Abortion Access initiative.

Our Public Health Policy Committee will be recommending arguments for the publicity pamphlet to our Board of Directors for consideration at our May 17 Board Meeting. If approved, I’ll be authorized to submit our arguments for the publicity pamphlet.

Anybody can turn in an argument. Simply write up an argument (300-word limit) and submit it to the General Election Ballot Measure Argument Portal along with the $75 fee. Portal is open from May 20 to June 20.

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See a summary and our draft argument FOR the Arizona Eliminate Partisan Primaries Amendment
See Our Draft Argument (For)

This voter-driven amendment would eliminate partisan primaries and replace them with an electoral system where individuals may vote for the candidate of their choice, regardless of the party affiliation of the voter or the candidate.

AZPHA’s Potential Positions on November Ballot Propositions: Part 2 – Signature Distribution Requirement for Voter Initiatives

Every cycle the Arizona Secretary of State generates a publicity pamphlet to help educate voters ahead of the general election. The pamphlet includes arguments in support of and against citizens’ initiatives and legislative referral. It’s a feature of the Clean Elections voter initiative from several years ago. The publicity pamphlet is a key educational resource for voters to use before voting.

As Arizona’s independent voice for public health, we’ve played a key role in helping voters to understand the public health implications of the various ballot measures. One way we do that is to send arguments for and against ballot propositions focusing on the good and bad public health impacts. Last cycle AZPHA placed arguments for or against 4 of the 10 ballot propositions.

This cycle the window for getting arguments filed is May 20th – June 20th. The arguments are posted in order they are received so it’s a good idea to get arguments early so voters see our stuff first.

There are already 6 ballot measures set for the 2024 ballot (not including the upcoming voter-driven Arizonans for Abortion Access). Three have direct impacts to public health / public health policy and a 4th will the AZ for Abortion Access initiative.

Our Public Health Policy Committee will be recommending arguments for the publicity pamphlet to our Board of Directors for consideration at our May 17 Board Meeting. If approved, I’ll be authorized to submit our arguments for the publicity pamphlet.

Anybody can turn in an argument. Simply write up an argument (300-word limit) and submit it to the General Election Ballot Measure Argument Portal along with the $75 fee. Portal is open from May 20 to June 20.

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Below is a summary and a draft argument AGAINST the Arizona Signature Distribution Requirement for Initiatives Amendment
See Our Draft Argument (Against)

This proposition (referred to the ballot by the legislature) adds a new signature distribution requirement to get citizen initiatives on that ballot. It would require organizers of future voter initiatives to gather 10% of votes cast for governor from each of the 30 legislative districts in order to qualify for the ballot. For constitutional amendments voters would need to collect 15% from each legislative district.

Future voter initiatives designed to address public health threats (such as the Arizona Abortion Access Act), the Smoke Free Arizona Act, the Predatory Debt Collection Protection Act and the voter initiative that expanded Medicaid to 100% of poverty would be MUCH harder time making it to the ballot if voters approve this measure.