Tag: Public Health

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Clinical General Healthcare Costs Healthcare Disparities Law Public Health Quality Improvement

On Public Charge

A step forward or a step back from self-sufficiency?

By: Souma Kundu

At the start of 2020, I remember the Trump administration celebrating what it saw as a victory for “self-sufficiency,” and “protecting law-abiding legal citizens from undue tax burdens”. Following a battle in the lower court, in a much-anticipated Supreme Court ruling, the court sided 5-4 with the administration, allowing enforcement of the 2019 expansion of the Public Charge rules.

This court ruling on Public Charge marks only the latest iteration of a policy dating back to the 1882 Immigration Act. While the definition and enforcement has varied over time, the essence of the law remains true to its origins: immigrants who are deemed unable to take care of themselves without becoming dependent on public assistance are unsuitable for American citizenship and therefore denied entry. Historically, public charge was determined by a holistic review of an applicant’s circumstances including age, health, financial status, education and skills. The use of public benefits for cash assistance and long-term institutionalization could be considered in this review, but other programs such as nutritional/housing assistance or public insurance were not included. In 2019, the United States Citizenship and Immigration Services (USCIS) expanded on the existing criteria to consider public benefits such as supplemental nutrition assistance, Medicaid or public housing. Additionally, it stipulated that the use of any of these public benefits for more than twelve months within any 36 month period may classify an applicant as a “public charge” effectively making them ineligible for permanent residency.

At the heart of this policy’s long-standing history is a deep-rooted belief that self-reliance is inextricably linked to the worth of an individual. It also posits that requiring public assistance is not only a burden to society, but one that is unlikely to be paid off or utilized for eventual gain.

But is this policy, and its predecessors really helping us increase self-sufficiency? Or is it robbing the US of its vast current and future population of contributing citizens? Even more pressing in 2020, is the impact of enforcing public charge during a pandemic leading to an underutilization of health care and resources only to increase morbidity and mortality across the nation?

From the lens of a healthcare worker, the general concern that efforts to rehabilitate lead to dependence baffles me. In medicine, from a sprained ankle to a surgery, achieving ultimate goals of “returning maximum function” all depend on how we can aid the healing process along the way. Generally, the use of a brace to offload the weight of a broken foot is not contested. Neither is the need for physical therapy to retrain our muscles after injury. But when it comes to rehabilitation of a person, our nation is much more skeptical of the process.

The abundance of research in the US and other countries on long-term effects of various welfare programs such as cash assistance, nutrition, and housing, point to the overwhelming benefits to the health of the recipients. Interestingly, benefits can also be seen towards community, by way of increased rates of labor participation, education attainment, employment status and productivity (Banerjee, Blattman, et. al). In a 2019 study on long-term economic impacts of childhood Medicaid, researchers found Medicaid-eligible children had higher wages starting in their twenties with wages increasing as they age. By the time these children reach age 28, their expected annual tax on earnings will return 58 cents for each Medicaid dollar spent to the government (Brown 2020). Providing basic human needs can be life changing – and it seems not just an ethical imperative, but a sound investment.

As many physicians, policy makers, immigration lawyers and researchers have feared, the changes to public charge determination is adding fear and confusion, resulting in underutilization of services available to immigrant families. Even programs such as the Children’s Health Insurance Program (CHIP), which is exempt from public charge review, have experienced a decrease in utilization.  An early impact study of public charge since enforcement began in February 2020, showed a 1% increase in the US’ noncitizen population that was associated with a 0.1% drop in child Medicaid use, estimated as a decline in coverage of 260,000 children. Researchers attribute this drop in enrollment to the fear and misinformation spreading amongst immigrants around public charge (Barofsky 2020).

As a medical student in San Diego where roughly two-thirds of our county’s population is Spanish-speaking, the impact of fear-mongering could not be more clear. Since the start of the pandemic, our once overflowing children’s hospital emergency department has been eerily quiet. Parents are worried for the safety of their families at the cost of health consequences from delays in care. At a time when access to medical care is imperative, our patients without documentation fear being turned away, or worse, turned in.

Meanwhile, disenrollment affects more than just immigrant families foregoing public assistance. Safety-net hospitals which rely heavily on Medicaid and CHIP payment are estimated to be at risk for a loss of $68 billion in health care services for Medicaid and CHIP enrollees (Raphael 2020). A drop in Medicaid enrollees will lead to increases in uncompensated care, lower Medicaid and CHIP revenue, alongside the cost of complications and emergencies secondary to foregoing early/preventive care. The fear and reluctance that public charge has created is not a simple reduction in federal spending, but rather a shifting of the burden with downstream financial havoc.

With the ample evidence that negates the assertion that the use of public assistance dooms one to a lifetime of dependency, and evidence to the contrary, that foregoing use has downstream effects on society, I urge us to rethink the dominant narrative around welfare and its implications for our nation. If we reject the belief that we must limit the use of public resources in favor of nurturing our communities most in need, we are much more likely to manifest our nation’s values of self-sufficiency and unlocking its potential. I’m not asking you to give up on self-reliance, I’m asking you to invest in it.

References:

  1. Blattman C, Jamison J, Green E, Annan J. The returns to cash and microenterprise support among the ultra-poor: a field experiment. SSRN Journal. Published online 2014.
  2.  Banerjee AV, Hanna R, Kreindler G, Olken BA. Debunking the stereotype of the lazy welfare recipient: evidence from cash transfer programs worldwide. SSRN Journal. Published online 2015.
  3. Brown DW, Kowalski AE, Lurie IZ. Long-term impacts of childhood medicaid expansions on outcomes in adulthood. Review of Economic Studies. 2020;87(2):792-821.
  4. Barofsky J, Vargas A, Rodriguez D, Barrows A. Spreading fear: the announcement of the public charge rule reduced enrollment in child safety-net programs: study examines whether the announced change to the federal public charge rule affected the share of children enrolled in medicaid, snap, and wic. Health Affairs. 2020;39(10):1752-1761.
  5. Raphael JL, Beers LS, Perrin JM, Garg A. Public charge: an expanding challenge to child health care policy. Academic Pediatrics. 2020;20(1):6-8.
Categories
Clinical General Healthcare Costs Innovation Quality Improvement Technology

Let Me Be Brief: Principles of Value-Based Health Care

A series of briefs by Texas Medical Students

By: Sanjana Reddy, Tsola Efejuku, and Courtney Holbrook

In the seminal 2006 text, Redefining Health Care, Harvard Business School professors Michael Porter and Elizabeth Teisberg describe a healthcare market with a “positive sum” game; a market where all professional and economic incentives are aligned towards the maximization of “value,” defined as the “the quality of patient outcomes relative to the dollars expended.”1 Value in health care is the measured improvement in a patient’s health outcomes for the cost of achieving that improvement.1 Value-based care transformation is often conflated with cost reduction methods, quality improvement, or even evidence-based care guidelines. Rather, the goal of value-based care is to enable healthcare systems to improve health outcomes for patients over the full cycle of care. Tiesberg further elucidates three key dimensions (the Triple C’s) for measuring patient outcomes: capability (the ability for patients to do what is important to them), comfort (relief from emotional and physical suffering), and calm (reducing the chaos of navigating the healthcare ecosystem).2

In the U.S., improving patient-centered outcomes has become a highly discussed topic with ABIM’s Choosing Wisely program3, American College of Physicians’ High Value Care initiative4, and even major publications like the American Journal of Medicine’s recurring column on high-value care practice.5 In response to escalating healthcare costs, the Centers for Medicare & Medicaid Services (CMS) and other payers have shifted from traditional fee-for-service payments to value-based reimbursements such as the CMS Merit-Based Incentive Payment System (MIPS).6 Value-based health care empowers the clinician-patient relationship, places care delivery decisions at the expertise of a coordinated clinical team, and focuses on outcomes that matter most to patients.

The leadership of professional organizations, such as the Texas Medical Association (TMA), is invaluable to the process of defining and upholding the principles of value-based health care for systems and individual practitioners. Current TMA policy recognizes the need to advocate for high-value care principles in undergraduate and graduate medical education (Res. 201-A-18)7 and the adoption of the Choosing Wisely campaign (265.023).8 Although the evidence-based model (265.018.)9 previously adopted by the TMA does not encompass the full principles of the value-based decision making model, TMA resolutions on Cost Effectiveness (110.002)10 and Cost Containment (110.007)11 reinforce the need for cost-effective utilization of care.

On the federal level, exceptions to key legislation have been enforced recently to further advocate for value-based healthcare options. In November 2020, the CMS and Department of Health and Human Services Office of the Inspector General (OIG) released new exceptions to the Anti-Kickback Statute and the Stark law, effective January 19, 2021. These exceptions now allow more providers to participate in coordinated and value-based care arrangements that can improve quality and outcomes, lower costs, and increase health system efficiency, without the fear of severe criminal or civil legal backlash.12

The practice of value-based health care, although strong in theory, is not without flaws. The primary weakness of this system is that physicians are often responsible for things out of their control, such as referred providers’ costs and pre-existing conditions.13 This system requires widespread buy-in from all providers in order to collectively reduce costs and increase quality of care—effectively changing the culture of health care. Notably, this system inherently disincentivizes caring for patients of low socioeconomic status, particularly minorities, who inevitably generate higher costs due to health disparities.14 Weinick et al. emphasize adding a metric to the value-based healthcare system that addresses equity in health care. Their guide illustrates how to utilize value-based health care to reduce racial disparities, primarily by appending equity in pay-for-performance models.15

Goals of the Medical Student Section include staying informed about current policies regarding value-based health care since these policies are constantly changing and significantly affect reimbursement rates. Medical students are afforded the opportunity to learn about the principles of value-based health care from the very beginning of their training. Knowing the alphabet soup of value-based care (MIPS, APM, MACRA, etc.) will benefit patients and providers alike by improving outcomes, reducing costs, and maximizing reimbursements. In an effort to emphasize value-based health care early in the practice of medicine, the American Board of Internal Medicine sanctioned the Dell Medical School Value Institute for Health & Care’s STARS (Students and Trainees Advocating for Resource Stewardship) program. Over the past few years, student representatives across the country have met to learn about the principles of high-value care, review the Choosing Wisely campaign, and start their own initiatives at their respective medical schools. In Texas, students at UTHSC San Antonio’s Long School of Medicine created an ongoing Value-Based Health Care elective and degree distinction pathway. Dell Medical School offers online instructional modules and is a leader in patient-centered outcomes research. Medical students have a tremendous opportunity to impact high-value care through education, research, and student-led initiatives.

References:

  1. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006. Boston, MA: Harvard Business School Press.
  2. Liu TC, Bozic KJ, Teisberg EO. “Value-based healthcare: person-centered measurement: focusing on the three C’s.” Clin Orthop Relat Res. 2017;475:315–317.
  3. https://www.choosingwisely.org/
  4. https://www.acponline.org/clinical-information/high-value-care
  5. https://amjmed.org/advancing-high-value-health-care-a-new-ajm-column-dedicated-to-cost-conscious-care-quality-improvement/
  6. https://www.cms.gov/newsroom/fact-sheets/quality-payment-program
  7. Texas Medical Association. Policy Compendium. Evidence-Based Medicine 265.018.
  8. Ibid. High-Value Care in Undergraduate and Graduate Medical Education 200.054.
  9. Ibid. Choosing Wisely Campaign 265.023.
  10. Ibid. Cost Effectiveness 110.002.
  11. Ibid. Cost Containment 110.007. 
  12. Modernizing and Clarifying the Physician Self-Referral Regulations Final Rule (CMS-1720-F). CMS. Accessed May 27, 2021. https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-final-rule-cms-1720-f.
  13. Burns, J. “What’s the downside to value-based purchasing and pay for performance?” Association of Health Care Journalists. September 6, 2014. https://healthjournalism.org/blog/2014/09/whats-the-downside-to-value-based-purchasing-and-pay-for-performance/.
  14. “Value-Based Health Care Must Value Black Lives,” Health Affairs Blog, September 3, 2020. DOI: 10.1377/hblog20200831.419320
  15. Weinick, Robin & Rafton, Sarah & Msw, & Walton, Jim & Do, & Hasnain-Wynia, Moderator & Flaherty, Katherine & Scd,. (2021). Creating Equity Reports: A Guide for Hospitals.
Categories
Clinical Community Service Emotion Empathy General Healthcare Disparities Opinion Public Health

Let Me Be Brief: Community Leadership

A series of briefs by Texas Medical Students

By: Fareen Momin, Sereena Jivraj, and Melissa Huddleston

In the ever-evolving field of medicine, it is no surprise that the idea of leadership in medicine has changed over the years. Some physicians have engaged in additional leadership in the context of politics. In fact, several physicians signed the Declaration of Independence.1 Today, physician community leadership extends much further. Physicians can engage with their communities and beyond via virtual platforms. Physician “influencers” use social media to provide quick answers to patients, and physician-patient interactions on Twitter alone have increased 93% since the onset of the COVID-19 pandemic.2 With physician voices reaching ever-larger audiences, we must consider the benefits and ramifications of expanding our roles as community leaders.

Medicine and politics, once considered incompatible, are now connected.3 There is a long list of physician-politicians, and community members often encourage physicians to run for political office, as in the case of surgeon and former representative Tom Price.4 Physicians are distinctly equipped to provide insight and serve as advocates for their communities.5 Seeking to leverage this position, a political action committee (PAC), Doctors in Politics, has an ambitious desire to send 50 physicians to Congress in 2022, so they can advocate for security of coverage and freedom for patients to choose their doctor.6-7 There are dangers, however, when physicians take on this additional leadership role. For example, Senator Rand Paul (R-Ky.), an ophthalmologist, has spread medical misinformation, telling those who have had COVID-19 to “throw away their masks, go to restaurants, and live again because these people are now immune.”8

It is not practical for even those medical students who meet age requirements to run for office. What we can do is use our collective voice to hold our leaders accountable, especially when they represent our profession. We can create petitions to censure physicians who have caused harm and can serve as whistleblowers when we find evidence of wrong-doing perpetrated by healthcare professionals. We can also start engaging in patient advocacy and policy-shaping with the American Medical Association (AMA) Medical Student Section and professional organizations related to our specialty interest(s).

To avoid adding to confusion, statements by physicians should always be grounded in evidence. Dr. Fauci’s leadership is exemplary in this regard. He has worked alongside seven presidents, led the National Institute of Allergy and Infectious Diseases (NIAID) since 1984, and has become a well-known figure due to his role in guiding the nation with evidence-based research concerning the COVID-19 pandemic.9 Similarly, Dr. John Whyte, CMO for WebMD, has collaborated with the Food and Drug Administration (FDA) to advocate for safe use of medication and to educate those with vaccine apprehension.10 Following these examples, we should strive to collaborate with public health leaders and other healthcare practitioners and to advance health, wellness, and social outcomes and, in this way, have a lasting impact as leaders in the community.

  1. Goldstein Strong Medicine: Doctors Who Signed the Declaration of Independence. Cunningham Group. Published July 7, 2008. Accessed February 2, 2021. https://www.cunninghamgroupins.com/strong-medicine-doctors-who-signed-the-declaration-of-independence/
  2. Patient Engagement with Physicians on Twitter Doubles During BusinessWire. Published December 17, 2020. Accessed February 2, 2021. https://www.businesswire.com/news/home/20201217005306/en/Patient-Engagement-with-Physicians-on-Twitter- Doubles-During-Pandemic
  3. WHALEN THE DOCTOR AS A POLITICIAN. JAMA. 1899;XXXII(14):756–759. doi:10.1001/jama.1899.92450410016002d
  4. Stanley From Physician to Legislator: The Long History of Doctors in Politics. The Rotation. Published May 15, Accessed February 2, 2021. https://the-rotation.com/from-physician-to-legislator-the-long-history-of-doctors-in-politics/
  5. Carsen S, Xia The physician as leader. Mcgill J Med. 2006;9(1):1-2.
  6. Doctors in Politics Launches Ambitious Effort to Send 50 Physicians to Congress In 2022. BusinessWire. Published May 27, 2020. Accessed February 2, 2021. https://www.businesswire.com/news/home/20200527005230/en/Doctors-in-Politics-Launches-Ambitious-Effort-to- Send-50-Physicians-to-Congress-In-2022
  7. Doctors in Accessed February 2, 2021. https://doctorsinpolitics.org/whoweare
  8. Gstalter Rand Paul says COVID-19 survivors should “throw away their masks, go to restaurants, live again.” TheHill. Published November 13, 2020. Accessed February 2, 2021. https://thehill.com/homenews/senate/525819-rand-paul-says-covid-19-survivors-should-throw-away-their-masks-go-to
  9. Anthony Fauci, M.D. | NIH: National Institute of Allergy and Infectious Diseases. Published January 20, 2021. Accessed February 2, 2021. https://www.niaid.nih.gov/about/anthony-s-fauci-md-bio
  10. Parks Physicians in government: The FDA and public health. American Medical Association. Published June 29, 2016. Accessed February 2, 2021. https://www.ama-assn.org/residents-students/transition-practice/physicians-government-fda-and-public-health
Categories
Clinical General Law Public Health

Let Me Be Brief: Politics in Medicine

A series of briefs by the Texas Medical Students

By: Shubhang Bhalla, Chelsea Nguyen, and Alejandro Joglar

There are only two possible scenarios: either the Mayans were inept seers, or they ran out of stone. In any case, the predicted end of the world missed its appointment by exactly eight years. With nearly three million deaths globally, COVID-19 has quickly assumed its standing as one of the leading communicable causes of mortality.1 Despite the novel therapeutics to combat the pandemic, recent scientific models and  health information now report that masks could have prevented nearly 12% of mortality associated with SARS-CoV-2.2 Surprisingly, this simple piece of personal protective equipment has become politicized, with some opponents claiming that masks are an infringement on human liberty. In the current sociopolitical climate, we are amid two pandemics: one of SARS-CoV-2 and another of misinformation—both equally harmful. Much like the historical precedent set in 1918 with the formation of     the Anti-Mask League, public health leaders of the twenty-first century must face the challenge of juggling objective science, pandering politics, and devastation left in the wake of the SARS-CoV-2 pandemic.

Public health has been consistently linked to leading political efforts of the time. From the development of environmental regulations, seatbelt laws, and smoking zones, to the contentious debate over mandatory vaccinations, efforts to improve public health sometimes impinge on various political ideologies and interests.3 Often, these debates can be broken down to the fundamental balance of individual autonomy and communal benefits. This intricate relationship between public health and politics has become increasingly strained during the current pandemic. Many critics of the pandemic response argue that by “flattening the curve,” individual autonomy has been infringed upon. Undoubtedly, the pandemic has catalyzed the transformation of established social operations: business closures, online education, and disruptive daily living. However, among what some call “liberty-depriving” mandates, the mandatory mask  usage remains a significantly contentious proposal. Wearing a mask serves to fulfill two broader, complementary goals: individual responsibility and adherence to a common, public paradigm to eradicate the pandemic. Despite its complementary nature, the wearing of masks has become a catalyst for political conflict, becoming a form of divisive political symbolism for the American public.

Today, only twenty-five states currently mandate face masks in public;4 however, as restrictions begin to  lift due to mounting public pressure, it is critical to understand that the origins of the mask resistance is the consequence of inconsistent scientific recommendations, actions of political figures, and America’s long-standing principle of liberty. The argument of wearing masks is simple: viruses are transmitted via droplets, and properly constructed masks can prevent the spread of infected droplets. According to the CDC, this is called “source control.”1 However, the delivery of this message has been muddled. In April, the World Health Organization (WHO) instructed the public not to use masks, while the CDC recommended the opposite. In June, the WHO adjusted its guidance to state that the public should wear nonmedical masks only in specific instances of high risk of infectivity. However, the CDC director touted universal mask wearing as “one of the most powerful weapons” to curb the rates of COVID-19.5 The net  result of conflicting recommendations was a divided population who sought concrete guidance from political figures.

Yet, political figures further allowed for festering sentiments against masks to transform into a symbolic ideology. Initially, the conflict arose with protest against government mandates, cited by some as “extensive governmental reach into individual action,” but as the debates shifted towards masks, a new conflict—one of the “culture war”—reigned.6 In this battle, masks were described as “muzzles . . . restricting His [God’s] respiration mechanism.”6 As these views gained popularity, politicians’ action indirectly supported these protests. Top officials, such as Donald Trump and Mike Pence, sought to erroneously show strength by limiting mask usage or outright denying the need for the equipment. In Montana on September 14, 2020, former Vice President Mike Pence stood in front of a large crowd to support the state’s Republicans. However, many individuals who attended the event, including Mike Pence, were not wearing a mask despite a mask order that was in effect for the surrounding county.7 Furthermore, at the national level, Congress denied passing the Masks for All Act of 2020, an initiative to provide high-quality masks for all individuals.8 Contradictions between the scientific community, state policy, and actions of key figures downplayed the severity of the virus, influenced public’s perception, and shifted support towards the anti-mask masses.

As of May 19th, approximately 125.5 million people in the United States have been fully vaccinated, either  by the two-dose series by Pfizer and Moderna or Johnson & Johnson’s single-dose vaccine.9 Per the CDC, it is predicted that 90% of the total US population will be vaccinated by July 12th.9 Despite this incredible progress, it is still important to continue following mask-wearing protocols as new research is being developed about effectiveness of the vaccine. For example, it is still unknown whether fully vaccinated individuals can transmit COVID-19 to unvaccinated individuals.10 Additionally, the rise of new variants of COVID-19 may influence the effectiveness of vaccines and the spread of COVID-19 among susceptible individuals. The uncertainty surrounding the vaccines and COVID-19 means it is essential to continue following public health mandates, including mask wearing if unvaccinated, social distancing, and following travel and local guidelines regardless of vaccination status. Dr. Anthony Fauci even mentioned during an interview with CNN that it is “possible” that Americans will be wearing masks in 2022.11

As medical students, we can play an important role by engaging with and educating our communities about the most effective methods of maintaining safety during the pandemic. It is important that we talk with our friends and family about why unvaccinated individuals should continue to wear a mask and follow certain precautions and remaining guidelines (ex: wearing masks on public transport) as well as recommending trusted resources for more information, such as the CDC. As new research develops and guidelines change, being a clear and comprehensive line of communication between science and the public is more important than ever before.

  1. Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC. Centers Dis Control Prev. Published online 2020:1-4. Accessed May 9, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
  2. Matuschek C, Moll F, Fangerau H, et Face masks: Benefits and risks during the COVID-19 crisis. Eur J Med Res. 2020;25(1). doi:10.1186/s40001-020-00430-5
  3. Bekker MPM, Greer SL, Azzopardi-Muscat N, McKee M. Public health and politics: How political science can help us move forward. Eur J Public Health. 2018;28(suppl_3):1-2. doi:10.1093/eurpub/cky194
  4. Markowitz Does Your State Have a Mask Mandate Due to Coronavirus? AARP. Published 2021. Accessed May 9, 2021. https://www.aarp.org/health/healthy-living/info-2020/states-mask-mandates-coronavirus.ht ml
  5. CDC and WHO offer conflicting advice on masks. An expert tells us why. Accessed May 9, 2021. https://abcnews.go.com/Health/cdc-offer-conflicting-advice-masks-expert-tells-us/story?id= 70958380
  6. Dyson, (2020). Are they masks or muzzles? Two discussions highlight different opinions | Latest News | starexponent.com. Free Lance Star. https://starexponent.com/news/are-they-masks-or-muzzles
  7. The Mask Hypocrisy: How COVID Memos Contradict the White House’s Public Face | Kaiser Health Accessed May 9, 2021. https://khn.org/news/mask-wearing-hypocrisy-how-covid-white-house-memos-contradict-ad ministration-coronavirus-defense-policy/
  8. Masks for All Act of 2020 (2020; 116th Congress S. 4339) – GovTrack.us. Accessed May 9, https://www.govtrack.us/congress/bills/116/s4339
  9. Covid-19 Vaccinations: County and State Tracker – The New York Times. Accessed May 9, https://www.nytimes.com/interactive/2020/us/covid-19-vaccine-doses.html
  10. Center for Disease Control and Prevention. CDC Issues First Set of Guidelines on How Fully Vaccinated People Can Visit Safely with Others. Accessed May 9, 2021. https://www.cdc.gov/media/releases/2021/p0308-vaccinated-guidelines.html
  11. Fauci: “Possible” Americans will be wearing masks in 2022 to protect against Covid-19 – Accessed May 9, 2021.
Categories
Clinical General Public Health

Let Me Be Brief: Vaccine Hesitancy

A series of briefs by the Texas Medical Students

By: Grayson Jackson, Kate Holder, and Whitney Stuard

Vaccine hesitancy refers to when an individual refuses or delays receiving an available vaccine, primarily due to misinformation, lack of health literacy, or fear.1 This issue—especially in the setting of the COVID-19 crisis and growing misinformation about science and medicine nationwide—is of great importance for medical students as future physicians and scientific communicators. Widespread vaccine refusal may result in untold public health consequences, including outbreaks of vaccine-preventable infectious diseases and rising healthcare costs. Vaccine hesitancy is often observed by quantifying nonmedical vaccine exemptions from state-mandated immunizations. In Texas, these exemptions have tripled since the 2010–11 school year.2 Data compiled by the Centers for Disease Control show that during the 2018–19 school year (the most recent available), Texas reported 2.2% of kindergarteners with a nonmedical exemption, amounting to 390,000 exempted children second only to California.3

The ongoing health crisis caused by COVID-19 has placed tremendous hope on vaccine compliance as the most practical way to stifle the global pandemic. Scientific facts have become increasingly politicized, and vaccines represent one of the key topics in which such facts have become distorted and polarized. Some questions (i.e., whether vaccines cause autism) have persistently circulated among vaccine-hesitant groups for years, whereas the COVID-19 crisis has heightened the risk of disinformation as vaccines by Pfizer, Moderna, and others are rolled out nationwide. It is incumbent upon us as future physicians to engage in the responsible dissemination of correct information about vaccines’ safety and efficacy. However, one should also avoid rushing to condemnation or judgment of vaccine-hesitant patients and parents which may only intensify their opposition.4

The Texas Medical Association (TMA) has worked to actively combat vaccine hesitancy and problems with vaccine availability throughout the state. The TMA has been working to support vaccinations including influenza, HPV, MMR and others throughout its history. TMA’s current vaccine advocacy agenda is still working to advocate for flu shots during the ongoing COVID-19 pandemic. The TMA Medical Student Section (MSS) has also continually supported vaccine availability to all Texas residents and promoted Be Wise Immunize chapters throughout the medical school within the state. In addition to TMA’s Be Wise Immunize program, TMA has published a variety of policies supporting vaccinations to increase overall vaccination rates. Policy such as 135.012 Immunization Rates in Texas, 260.072 Conscientious Objection to Immunizations, and 135.022 Adolescent Parent Immunizations all work to increase vaccination rates within the state, promote the Texas Vaccines for Children Program and the Adult Safety Net Program, as well as combat vaccine hesitancy. In addition, during the COVID-19 pandemic TMA has encouraged the #ThisIsOurShot campaign to combat vaccine hesitancy.

The TMA Medical Student Section supports widespread vaccine availability in a prompt and timely manner to all Texas residents. The MSS supports incorporation of the COVID-19 vaccine into the mandatory vaccine category once it is federally authorized beyond emergency use. This may become increasingly important as we see young people and college students, who deny the vaccine due to not fearing the less negative COVID-19 health outcomes, become the population disproportionately responsible for COVID-19 spread.

As a medical student, you have probably heard countless friends and family members discuss their hesitancy to receive the COVID-19 vaccine. Many people have vehemently opposed the COVID-19 vaccination simply because they have fallen victim to false information. As medical students and advocates, we should commit to broadcasting truth and combating misinformation in our local communities. We have the wherewithal and the voice to endorse the COVID-19 vaccine.

1 MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036

2 https://www.texmed.org/Template.aspx?id=55299#_ftnref1

3 https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/exemptions-reports/2018-19.html

4 Please visit https://www.ama-assn.org/delivering-care/public-health/3-ways-physicians-can-improve-vaccine-conversation.

Fast Facts

  • The COVID-19 vaccine cannot give you the coronavirus or make you test positive for the coronavirus.
  • Even if you have already recovered from COVID-19, you should receive the vaccine to prevent reinfection.
  • The COVID-19 vaccine will not alter your DNA or impair your ability to have children.
  • The COVID-19 vaccine is demonstrably safe and effective and tested through rigorous clinical trials.
Categories
Emotion Empathy General Humanistic Psychology Literature Opinion Patient-Centered Care Psychiatry Psychology Public Health Reflection

Book Review: Loose Girl by Kerry Cohen

Hi MSPress Blog Readers!
……
We didn’t have a blog post scheduled for this week, so here’s a book review instead 🙂 I read this book last week for my Adolescent Sexual Health MPH course and enjoyed it.There’s a lot of interesting tidbits on sexual health issues. I mention two.
Even if you don’t agree with everything the author says, I think memoirs can be helpful in showing you unique life perspectives based on true experiences that you may never have experienced yourself. Furthermore, reading memoirs can get you acquainted with potential resources to help others. Ever heard of bibliotherapy, anyone? 🙂
……
Your Blog Associate Editor,
Janie Cao

Categories
Opinion Public Health

Is health a moral responsibility?

L0070041 Public Health Centre

“The preservation of health is a duty. Few seem conscious that there is such a thing as physical morality.”
Henry Spencer (1)

We are in charge of our lives. We choose what job we go into, what friends we invite, what clothes we wear and what food we eat. This is what we tell ourselves every morning as we drag ourselves out of bed, every night when we gaze up at our ceilings and think back on our day with pride. After all, if we were mere puppets on a string, what would be the point of it all?

For the past few decades more and more money has been pumped into public health campaigns (1). Our health is not based solely on our wealth, our family or our doctor, but upon the choices we make, and public health campaigns aim to nudge our choices in healthier directions.

Knowing that we are responsible our health, how does it feel to have such a responsibility? How do we react to this immense control that we hold in our hands; this ability to decide how many years we will live, how quickly we will age – the knowledge that the health choices we make today may well have an impact five years down the line? And how much responsibility do we really have for our own actions, considering all of the external forces acting on us, many of which are acting at a subconscious level?

To illustrate my point, allow me start with an example. If I knew I was going to die of lung cancer in twenty years if I continued to smoke, would I be encouraged to give it up? This simple question illustrates how very complex our lives really are. Giving up a habit – whether it is smoking tobacco or eating fast food – is rarely simple. Some of us may well choose to place the responsibility upon the smoker, but such a simplification masks the more intricate webs of that person’s life: what made them start in the first place, what made them continue and where does their motivation now lie? Are they smoking as a way to escape their feelings? To chase after a certain persona? If we place responsibility at the person’s feet, then we ignore the more subconscious desires that have led them towards their supposedly autonomous choices. We all engage in risky behaviours to some degree. A quick glance at the past few days will highlight many ‘unhealthy’ decisions that we have all made on the spur of the moment. Are we to blame for our decisions?

The idea of being in charge of our health has become particularly popular in the mainstream media. A quick Google search will uncover articles on how to build the perfect body, ten-minute guides to eating more fruit and vegetables and quick tips to help us lead more healthy lives (2). Even closer to healthcare, the idea of patient-centeredness has become almost an ideology within healthcare circles; words that are repeated ad infinitum to both students and professionals. This idea of being responsible for our own bodies illustrates our desire to place the power to determine our health back into our own hands, as opposed to relying wholly on the modern medical apparatus to do everything for us.

The numbers back this up even more. The World Health Organization (WHO) has stated that lifestyle-related diseases accounted for 86% of deaths and 77% of disease burden within the WHO European Region. This includes diseases such as cardiovascular diseases, cancers, chronic respiratory problems and mental illnesses (3). Furthermore, leading geneticists have pointed out that the “current increase in obesity has nothing to do with genes and everything to do with how we live” (4). These statistics are further supported by the fact that prevention is far more cost-effective than any intervention that healthcare professionals can undertake; from health education within our schools to exercise regimens into our forties – these are the most impactful activities we can do to positively impact our health. And because these are activities that we choose to participate in, it follows that we are sitting in the pilot seat; we have the power to get off our sofas and put on those Lycra shorts.

So what would it mean if we believed that we are all 100% responsible for our bodies? On one end of the spectrum, it may encourage people to lead more healthy lives – to perhaps avoid that drive to McDonald’s on the way home, or to insist on an early morning run despite the rain pattering on the window outside. But at the other end of the spectrum you have those people who have simply stumbled down the black hole of unhealthy lifestyle, whether it is drugs, fast food or a sedentary lifestyle. And the more we push for a culture of individual responsibility, the more needless blame we may place upon those who ultimately need help and not judgment. Do you think you would treat a person differently if you believed their illness was entirely their choice?

By placing responsibility on individuals, we walk down the road of assuming that to be ill is to be guilty, thereby further stigmatizing the unwell. A good example of this is mental illness, which has a long history of blame ranging from the relationship with the mother to the relationships within an entire family, until eventually we decided to fall back upon neurobiological theories in an attempt to absolve people of blame altogether.

As human beings, we are creatures of habit; as much as we would like to believe that becoming healthy is as simple as creating a New Year’s Resolution, half of all individuals who begin an exercise regimen quit within six months (4). The environment in which we grow up as children has a profound influence upon our behaviours. The habits we learn from our parents and those closest to us, whether they be about smoking, exercise or eating unhealthily, can stay with us subconsciously (3). When we decide to stay at home and watch another episode of Game of Thrones rather than go out for a run, how much of that decision was ours? How much control do we have over our personalities, whether they be impulsive or habitual?

Health is more than just a decision. It lies at the center of many threads: genetic, environmental, social and psychological. Although we live in a world where six of the ten leading factors contributing to the burden of disease are lifestyle related (5), we must appreciate the fact that these are indeed factors, not a solid line that we can draw across other peoples’ lives to claim that they are wholly responsible for what happens to their bodies and mind.

So what do we do about these opposing forces acting on us? On one end of the spectrum lies the idea that we have a dictatorial control over and responsibility for our decisions, while on the other end there lies the more deterministic way of viewing things, where ‘whatever happens, happens – I can’t do anything to change it’ is the prevailing belief. Which one is right? Which one should we accept?

The answer, I believe, lies not within abstract philosophical questions about morality and free will. Rather, I believe the answer is different for each and every one of us. It is up to us to decide how we view our bodies, our minds and the world in which we live. Do we want to live healthily? Why? Are we doing it for ourselves? To be able to fit into our new wedding dress? To allow our children to live in a smoke-free house? We all have our own reasons for the choices we make, and no doctor can make these decisions for us. Instead, we need to take a step back and think about what is most important in our lives, and do what we can to realize our goals with that in mind.

“Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. [..] That is why I recommend that the Statue of Liberty on the East Coast be supplemented by a Statue of Responsibility on the West Coast.”
Viktor Frankl (6)

References

  1. The Lancet. Is health a moral responsibility? The Lancet; 1996. 347:1197
  2. Cappelen, A.W., Norheim, O.F. Responsibility in health care: a liberal egalitarian approach. Journal of Medical Ethics; 2005. 31:476-480
  3. Brown, R.C.H. Moral responsibility for (un)healthy behaviour. Journal of Medical Ethics; 2012. 10.1136
  4. Minkler, M. Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century’s End. Health Education & Behaviour; 1999. 26:121-141
  5. Resnik, D.B. Responsibility for health: personal, social, and environmental. Journal of Medical Ethics; 2007. 33:444-445
  6. Frankl, V. Man’s search for meaning: the classic tribute to hope form the holocaust; 2013. Ebury Digital.

Featured image:
L0070041 Public Health Centre by Wellcome Images