Will Humble Professional Development, State Legislature, Wills Blog

Learn How the Arizona State Legislature Works with this Engaging Podcast

The Arizona State Legislature will meet on Monday, January 8, 2024. Many legislators will hit the ground running with bills that they already have in the hopper. See the bills that have been pre-filed so far

That means we need to be ready to fight for good bills, fight against bad bills, and be prepared to advocate for adjustments for bills somewhere in the middle right out of the box.

You can prepare your advocacy chops before the legislative session starts by listening to the Arizona Common Ground podcast, an eight-episode educational podcast series that gives a behind the scenes glimpse of the state legislative system and learn how bills can become laws. The Consumable Podcast Series is Available as:

Krista Romero-Cardenas, MPH, a former senior instructional specialist for the Western Region Public Health Training Center and alumna of the Mel and Enid Zuckerman College of Public Health is the creator and host of the Arizona Common Ground podcast – an eight-episode educational podcast series that will take you through the process of how bills are passed in Arizona.

This is a must-listen to podcast for anybody interested in learning how the Arizona State Legislature makes the sausage!

ARIZONA COMMON GROUND
By AzPHA Member Krista R. Cardenas, MPH 
The podcast series is available as ARIZONA COMMON GROUND on Apple Podcasts
ARIZONA COMMON GROUND | Podcast on Spotify
Will Humble Professional Development, Public Health Law, Wills Blog

Arizona Legislative Session Begins Monday, January 13: Here’s Our Advocacy Approach

January 13 marks the beginning of the 2025 legislative session. The kickoff will be the Governor’s address to the legislature where she’ll outline what she sees as priorities.

AzPHA will follow the session closely and express our support or opposition to bills based on a simple core principle…  we support bills that will have a positive impact on public health especially when they are evidence-based or evidence-informed.  We will oppose bills that are likely to have a negative impact on public health. 

Our support or opposition to bills is located on the https://www.azleg.gov/ site under RTS Current Bill Positions. We have a host of Resolutions that also guide our advocacy which are posted on our website.

The fact that we have Resolutions on so many core public health priorities make it easy for us to be swift with our support or opposition. Our Resolutions go all the way back to the 1930s. They are initiated by either the Board or our members and all resolutions have been voted on and approved by our members.

Our Public Health Policy Committee has a discussion board on Basecamp and that’s also where we post information, research and documents related to public health policy.  Let me know if you’d like to sign up for that Basecamp site at willhumble@azpha.org.

Our policy committee also has conference calls Fridays at 2pm starting January 17. Details are in our policy committee basecamp (email me at willhumble@azpha.org to get access to the members policy committee Basecamp).

Will Humble Public Health, Wills Blog

Transforming Public Health Practice With Generative Artificial Intelligence

Transforming Public Health Practice With Generative Artificial Intelligence | Health Affairs

Abstract: Public health practice appears poised to undergo a transformative shift as a result of the latest advancements in artificial intelligence (AI). These changes will usher in a new era of public health, charged with responding to deficiencies found during the COVID-19 pandemic and managing investments required to meet the health needs of the twenty-first century.

In this Commentary, we explore how AI is being used in public health, and we describe the advanced capabilities of generative AI models capable of producing synthetic content such as images, videos, audio, text, and other digital content.

Viewing the use of AI from the perspective of health departments in the United States, we examine how this new technology can support core public health functions with a focus on near-term opportunities to improve communication, optimize organizational performance, and generate novel insights to drive decision making.

Finally, we review the challenges and risks associated with these technologies, offering suggestions for health officials to harness the new tools to carry out public health goals.

Three Applications for Generative AI Models in Public Health

Public Communication

Organizational Performance

Novel Insights

Public health has the potential to rapidly evolve with the advent of new technologies. But ultimately, AI, including generative AI, is just a tool, similar to a vaccine or genomic surveillance.

Public health practitioners will need to master the new tools and learn to use them as part of a larger public health strategy. This discussion reviews the use of AI and presented three early use cases for generative AI related to communications, organizational performance, and generating novel insights that align with three of the eight core capabilities defined in the Foundational Public Health Services framework.

Transforming Public Health Practice With Generative Artificial Intelligence | Health Affairs
Will Humble Disease Control, Public Health, Wills Blog

H5N1 Influenza in Valley Wastewater: Does it Matter?

Yesterday brought an unexpected detection of H5N1 ‘avian’ influenza RNA in wastewater from three cities in Maricopa County—Phoenix, Tempe, and Surprise. H5N1 mostly affects wild birds, domestic poultry, and a handful of mammal species (including mild infections among human agricultural workers. But, with no human-to-human transmission and urban Maricopa County not being super agricultural, its presence in wastewater raises intriguing questions about the source. Let’s explore why and the implications.

What is H5N1?

H5N1 (aka avian influenza) is a strain of avian influenza virus that has caused severe outbreaks among wild birds and domestic fowl. Infections in mammals have been rare and mostly mild. Some agricultural workers with close contact with infected birds or cattle have been infected, but with mild symptoms and with no documented human-to-human transmission.

The Wastewater Detections

The ADHS State Laboratory confirmed the presence of H5 RNA in wastewater samples collected from Phoenix, Tempe, and Surprise. The finding was surprising because these cities are not known for large-scale poultry farming (where such a virus might be expected in domestic wastewater).

Also, all three cities say that their stormwater systems (which collect rainwater and runoff) are completely separate from their wastewater systems (which handle sewage). This separation means that the virus’s presence can’t be attributed to wild birds contaminating street drains and then getting into domestic wastewater.

Where’s it Coming From?

So, where is the H5 RNA coming from? After consulting with public health experts, the most plausible explanation points to backyard chicken flocks. Backyard poultry keeping has grown in popularity, and infected chickens could easily introduce the virus into wastewater through improper disposal of chicken tissue via household sinks.

Note: ARS 11-820.04 prohibits counties from adopting laws or regulations prohibiting residents from keeping up to six fowl in their backyards.

While it’s theoretically possible the source of the detections of H5 in wastewater are human infections, it seems like a longshot since no human-to-human transmission of H5N1 has been documented.

What’s Next?

As part of normal annual influenza surveillance, randomly selected specimens from human influenza infections (which is increasing quickly right now) are routinely sequenced – and if some of them are H5 (rather than the ubiquitous H1N1 and H3N2 strains) we should know shortly.

Note: The ADHS State Lab (which confirmed these detections) is finishing its validation protocol for the H5N1 wastewater validation test, with certification by the CDC expected soon. ADHS’ H5N1 assay for human infections IS validated.

Should We Be Concerned?

For now, there’s no need for alarm. Human cases of H5N1 remain rare, mild and there’s is no evidence of human-to-human transmission. However, these detections underscore the importance of vigilance, proper biosecurity measures for backyard flocks, and ongoing surveillance of both human and animal health.

We’ll continue to be on top of local and national developments – but for now there’s nothing to freak about.

Will Humble Public Health, Wills Blog

Association v. Causation: A Key Distinction when Developing Public Health Policy

One of the key aims of public health is to assess the cause of disease or bad outcomes so we can design interventions.  In order to do that, we need to be able to tell the difference between when something is actually “causing” an outcome and when the exposure or condition is simply “associated” or “correlated” with an outcome. 

Whether something causes or is simply associated with a bad outcome is a key factor when we design interventions.  The following examples may shed some light on the relationship between risk factors, outcomes, and the difference between association and causation.

A study in the American Journal of Pathology “…persons with tattoos appear to die earlier than those without”.   The study found that people in the study group with a tattoo died 14 years earlier than people without a tattoo (p = .0001).

This study doesn’t conclude that having a tattoo actually causes people to die earlier.  Rather, it suggests that having a tattoo may be associated or correlated with other independent factors that might lead to an earlier death (e.g. people with tattoos may be more likely to have risk-taking behaviors).

In order to conclude that an exposure or condition actually causes an outcome, researchers randomly divide study participants into groups by assigning them to the exposure or condition they’re studying (experimental group) while making sure that another group doesn’t have the exposure or condition (control group). 

If the expected outcome is observed within an experimental group and not in the control group, it’s likely that exposure actually caused the outcome.

For example, if researchers were to expose one randomly-selected group of people to poison ivy via direct contact with poison ivy leaves – while not exposing the control group to poison ivy – they would most likely be able to establish that poison ivy actually caused the rash.  It’s this random assignment to conditions that make experiments sophisticated enough to detect actual causation.

Judging the causal significance of an association or causation is both a science and an art.  The gold standard for determining what is an association and what is actual causation is described in a 1964 Surgeon General’s Report on this topic.

Some of the research you read about shows a correlation or association between variables, not causation.  When you’re reading scientific studies, make sure you look for whether the study is talking about an “association or correlation” or whether they are talking about causation.

Editorial Note: Mr. Robert F Kennedy Jr appears to need an in-depth tutelage on the difference between anecdotes and stories and the difference between association & causation. Time and again Mr. Kennedy bases his opinions on spurious reports, anecdotal stories and some articles that draw conclusions about the association between various stimuli and outcomes rather than focusing on causation.

That mind-set is relatively benign when it’s held by a private sector lawyer with a famous name – but it’s potentially dangerous when the person is in charge of nearly 30% of the U.S. federal budget, health care for the majority of the country and comprehensive regulatory authority of drugs, food and medical devices, and the US publicly funded research mission.

RFK Jr. as HHS Secretary: His Shift Away from Evidence Puts Public Health in Peril – AZ Public Health Association

RFK Jr. as HHS Secretary? Why It Could Mean the End of Evidence-Based Public Health Policy – AZ Public Health Association

Will Humble Assurance & Licensure, Public Health, State Legislature, Wills Blog

The Real Danger of State Agency Sunset Reviews: Ineffectiveness During Unified Government

Arizona’s sunset review process is designed to hold state agencies accountable, ensuring they fulfill their missions effectively and efficiently.

However, the current debate over whether these reviews are being ‘weaponized’ in our divided government misses a critical point: the real risk isn’t that sunset reviews are too harsh under divided government, but that they’ve been toothless and ineffective during unified government.

During periods of divided government, as we have now, the legislature tends to actively scrutinize agency performance. Auditor General reports are taken seriously, and legislative committees hold agencies accountable for their shortcomings.

This fosters oversight and ensures state agencies run transparently and efficiently. But, when the same party controls both the executive and legislative branches (as we saw during the Ducey administration) the sunset review process becomes a formality, with little to no meaningful oversight.

The Arizona Auditor General’s Office (an arm of the state legislature) plays a vital role in finding agency deficiencies. Their reports are comprehensive and independent. For example, Auditor General reviews revealed systemic failures in the Arizona Department of Health Services’ nursing home complaint investigations during the Ducey era.

Their 2019 report highlighted unacceptable delays in investigating complaints, putting vulnerable residents at risk. The follow-up review found that the agency had reclassified 98% of high-risk complaints as low risk to give the appearance they had making process and performance corrections.

Despite the severity of these findings, the legislative review process during the Ducey administration largely ignored these issues (although a hearing was held), allowing the problems to persist unchecked (until the next administration took office).

Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Ducey Administration

This lack of accountability during unified government is a systemic issue. The legislative review committees, dominated by the governor’s party, often dismiss Auditor General findings as unimportant or inconvenient. Instead of using these reports to drive meaningful reform, they rubber-stamp agency operations, creating a dangerous lack of oversight.

In contrast, divided government forces a more rigorous review process. Legislators from the opposing party are motivated to scrutinize the executive branch’s performance, often shining a spotlight on agency performance.

For example, recent debates over agencies set to expire in 2025, as reported by the Arizona Capitol Times, show how divided government can lead to shorter leashes for underperforming agencies.

Agencies set to expire in 2025 will likely get ‘shorter leashes’ | Arizona Capitol Times

To strengthen the sunset review process and ensure it works effectively regardless of the political landscape, Arizona needs structural reforms like mandatory legislative hearings on Auditor General findings (regardless of the political composition of the government) independent oversight boards to review agency performance, and increased funding for the Auditor General’s Office.

The real danger of Arizona’s sunset review process isn’t that it’s too harsh under divided government—it’s that it becomes a rubber stamp under unified government.

Without robust oversight, agencies can fail the very people they’re supposed to serve. Ensuring meaningful accountability should be a bipartisan priority, safeguarding the public interest no matter who holds power.

Will Humble Firearm Safety, Injury Prevention, Suicide Prevention, Wills Blog

Leading Causes of Death in AZ in 2024 – Heat Deaths up 350% in Last 5 Years; COVID Continues its Drop in 2024

As you recall, our resident AZPHA epidemiologist Allan Williams PhD did a deep dive into the leading causes of death in Arizona during the pandemic and discovered we were the only state where COVID-19 was the leading cause of death during the first couple years of the pandemic.

AzPHA Data Brief: Arizona is the ONLY State in the U.S. In Which COVID-19 Is the Leading Cause of Death During the Pandemic

We asked Allan to run the cause-of-death numbers again for 2024 for the period January-Sept. While COVID-19 was still the 4th leading cause of death in Arizona during 2022, it dropped out of the top 15 this year.  

Meanwhile, we continued to have far more heat related deaths than we had just a few years ago – had another dramatic jump in heat-related deaths in 2023 – moving that cause of death up to number 12 (742 deaths in 2024).

An even deeper dive into the heat-related death data found that heat related deaths have increased 350% in the last 5 years (tracking the affordable housing crisis & housing waiting lists for folks with a serious mental illness resulting in homelessness).

The rest of the chart looks pretty stable over the last few years, with heart disease and cancer continuing their dominance as the leading causes of death as it is in the rest of the country.

Main strategies to prevent heart disease and cancer are to stop smoking if you smoke. Make sure to go to your annual checkup where you can learn about things like high blood pressure or early signs of diabetes & take actions to prevent bad a bad outcome.

While you won’t find firearms as a primary cause of death in our charts – they remain a primary mechanism for suicide and homicide deaths and some of the accidents. Over 60% of the suicide deaths included the use of a firearm.

Accidents were the 3rd leading cause of deaths – with accidental poisonings from fentanyl a large component of that category along with car collisions.

Here’s a thumbnail of the leading causes of death in Arizona and some basic individual prevention tips:

1. Heart Disease (11,064)

  • Don’t smoke
  • Exercise regularly
  • Manage blood pressure
  • Manage cholesterol levels
  • Lower salt/alcohol use
  • Better nutrition

2. Cancer (10,021)

  • Don’t smoke
  • Eat well balanced diet
  • Physical activity
  • Get routine screenings
  • Use sunscreen/protect skin
  • Get regular checkups

3. Accidents (4,258)

  • Buckle up
  • Drive a safe car with airbags
  • Don’t drive under the influence
  • Avoid recreational use of pills (fentanyl)
  • In home fall prevention strategies
  • Physical activity/balance

4. Chronic Lower Respiratory Illnesses (2,754)

  • Don’t smoke
  • Worker safety protection
  • Keep up to date with vaccines
  • Exercise

5. Stroke (2,425)

  • Don’t smoke
  • Manage blood pressure
  • Lower alcohol use
  • Better nutrition
  • Seek treatment medication for AFIB (atrial fibrillation)
  • Regular checkups

6. Alzheimer’s (1,950)


7. Diabetes (1,806)

  • Manage the disease
  • Physical activity/nutrition
  • Don’t smoke
  • Manage blood pressure/cholesterol
  • Modest alcohol use

8. Liver Disease (1,154)

  • Getting vaccinated for Hepatitis A and B
  • Practicing good hygiene
  • Drinking alcohol in moderation
  • Use medications as directed
  • Get routine checkups with blood tests
  • Practice harm reduction if you’ve had Hep C

9. Suicide (1,082  >60% from firearms)

  • Depression screening
  • Seek behavioral health help
  • Improve social connectedness
  • Identify persons at risk
  • Evidence based responses
  • Enhance life skills and resilience

10. Hypertension (800)

  • Get regular checkups & take medicine as directed
  • Don’t smoke
  • Lower salt intake
  • Improve physical activity & nutrition
  • Limit alcohol

11.  Parkinsons (745)

12.   Influenza/Pneumonia (725)

  • Stay up to date on all vaccines including influenza, COVID-19, RSV, pneumonia etc.
  • Get routine checkups

13. Heat (742)

  • Strategies to reduce homelessness
  • Increase affordable housing
  • Limit outdoor exposure to extreme heat
  • Stay hydrated

14. Nutritional Deficiency (seniors – usually protein deficiency) 616

  • Eat healthy diet with enough protein
  • Manage diet as you age
  • Sufficient nutrition

15.  Kidney Disease (607)

  • Stay active
  • Manage diabetes
  • Take medication as directed
  • Eat a healthy diet
  • Reduce salt intake
  • Don’t smoke
  • Check and control your blood sugar and blood pressure as part of your regular checkups
  • Get your kidney function checked if you have one or more of the ‘high risk’ factors: diabetes, hypertension, obesity, a family history.

Preventing Child Fatalities in Arizona: The Case for Firearm Safety Reform – AZ Public Health Association

Will Humble Public Health, Wills Blog

Public Health Journalism this Week

Arizona faces $2.8 billion class action lawsuit over alleged negligence in AHCCCS fraud scheme – Navajo Times

Indigenous families sue Arizona over human cost of sober living fraud

Medicaid funding cuts could put thousands of Arizonans in peril

Katie Hobbs: Arizona abortion reports are ‘government surveillance’

Lack of coordination hinders state response to maternal mortality

Agencies set to expire in 2025 will likely get ‘shorter leashes’ | Arizona Capitol Times

Will Humble Behavioral Health, Medicaid, State Legislature, Wills Blog

The High Stakes of Medicaid Cuts: What Arizona Stands to Lose (and a simple solution)

Some in congress and the incoming administration have suggested they’ll be making major changes to Medicaid this congressional session – especially those elements that were associated with the affordable care act like the expansion population – in particular how the expansion population was funded (persons between 100% and 138% of poverty).

While Arizona did expand Medicaid to that population the legislature made the expansion contingent on the federal government paying at least 80% of the cost of the expansion population.

Importantly, the legislature also tied the hospital assessment, which pays the state match for the more than 450,000 childless adults to the federal government continuing to pay at least 80% of the expansion population. In other words, the childless adult coverage (made possible by the hospital assessment) would end if the fed’s stop paying for at least 80% of the expansion populations costs.

The Human Costs of Rolling Back Medicaid in Arizona

Medicaid is a lifeline for more than 2.5 million Arizonans, including nearly 500,000 childless adults who regained coverage through a $570M assessment on hospitals which pay for the state match to the feds to fund coverage for childless adults. Thousands of who face significant behavioral health challenges, including serious mental illnesses.

The funding for this population hinges on a critical provision: the federal government must cover at least 80% of the costs for the Medicaid expansion population.

If this threshold isn’t met, AHCCCS coverage ends for both the expansion population and childless adults because AHCCCS would no longer be able to collect the hospital assessment that pays for the state portion to cover childless adults.

Behavioral & Public Health Impacts

For childless adults, access to Medicaid often means access to life-saving care, including treatment for substance use disorders, mental health counseling, and medications. Without this coverage, many individuals with SMI would face a grim reality: untreated illnesses, emergency department visits, and increased rates of homelessness and incarceration. And yes, death.

Behavioral health services aren’t just a moral imperative; they’re a cost-saving measure. Research consistently shows that access to Medicaid reduces uncompensated care costs for hospitals and lowers overall healthcare spending by addressing health issues before they escalate.

The Financial Reality

Arizona’s Medicaid expansion is funded through a $570M hospital assessment that covers the state’s share of costs. However, this funding mechanism is tied to the federal government maintaining at least 80% coverage of the expansion population. If federal funding drops below this threshold, the hospital assessment would no longer be valid.

The state would then face two choices:

  1. Decouple the hospital assessment from the expansion population 80% requirement: This would allow Arizona to continue cover the 500K ‘childless adults’ using the hospital assessment as the state contribution.
  2. Cover the $570 million state match through the general fund: Given Arizona’s budget constraints, this scenario is unlikely, leaving hundreds of thousands without coverage.

Losing Medicaid coverage for childless adults would strain Arizona’s healthcare system and social services. Hospitals would see an increase in uncompensated care, driving up costs for all Arizonans. Public safety systems would also bear the burden, as untreated behavioral health issues often lead to incarceration, repeated hospitalizations, homelessness & death.

AZPHA urges the Arizona State Legislature to proactively protect coverage for childless adults this legislative session by decoupling the hospital assessment from the requirement that the federal government pay at least 80% of the costs for the distinctly different expansion population.

See the statute authorizing the Hospital Assessment which pays for covering ‘Childless Adults’ (ARS 36-2901.08)

Failure to proactively act to decouple the hospital assessment from the expansion population match requirement would jeopardize the health and well-being of our most vulnerable residents and strain our healthcare infrastructure beyond repair… and it’s a simple fix – simply eliminate ARS 36-2901.08(E) – let’s call it the Childless Adult and Behavioral Health Protection Act:

36-2901.08. Hospital assessment

E. The administration shall not collect an assessment for costs associated with service after the effective date of any reduction of the federal medical assistance percentage established by 42 United States Code section 1396d(y) or 1396d(z) that is applicable to this state to less than eighty per cent.

AZPHA has been doing some pre-session work to ensure that such a bill is filed this session. More to come when we know the bill’s number.

Medicaid funding cuts could put thousands of Arizonans in peril
Medicaid Expansion is a Red and Blue State Issue | KFF
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