public health

Originally published March 17, 2015

Media stories about measles outbreaks in California and Arizona have featured prominent politicians weighing in with conflicting messages. Should vaccination be required for all children with few exceptions? Are vaccines safe? Should parents have a choice – when refusing vaccines can put their own and other people’s children at grave risk? The stories are dramatic, but scholars and public officials warn that it is dangerous to turn vaccination into a political football. Other widely publicized controversies reveal that the insertion of politics into media coverage can be hard to reverse, as it may undermine public trust in doctors and public health officials.

Political Controversy Sticks

Our research examines two recent politically charged health controversies – the 2009 dust-up over mammography screening guidelines and the 2006-2007 debate over whether middle schools should require girls to get vaccinated against infections by the human papillomavirus (“HPV” for short). Specifically, we found that local and national media coverage did not start with a focus on political controversy. But once news stories started to highlight partisan arguments among political leaders, political controversies became the focus of subsequent coverage. more...

Originally posted June 29, 2016

In early September 2015, Blanca Borrego, an undocumented Latina immigrant accompanied by her two daughters, arrived at a women’s health clinic in Texas for a routine gynecological exam. Sitting in the waiting room for nearly two hours, Blanca’s anxiety and impatience grew to the point where she almost walked out of the office. Eventually, Blanca was met by local law enforcement officials who escorted her out of the clinic in handcuffs for allegedly using a forged driver’s license during patient intake. Blanca’s eight-year-old daughter watched in tears while her mother was taken away and a deputy told Blanca’s eldest daughter that their mother would face deportation. Blanca remains in county jail on a $35,000 bond.

Scenarios like Blanca’s – highlighting the impact of race, class, and immigration status on reproductive rights – are not always brought to the fore. Although reproductive rights activists say they advocate for all women, difficulties faced by white, middle-class, heterosexual women get more attention than those experienced by women of color, immigrant or transgender women, or those with disabilities. However, a movement for reproductive justice has emerged by and for women of color that offers new possibilities to bring previously neglected issues to light. Key challenges include tackling the reproductive experiences of Latinas – and looking for ways to do more to address their needs in reproductive health care and policy.A movement for reproductive justice has emerged by and for women of color.

Latina Realities

Understanding Latinas’ reproductive lives requires understanding how many forms of disadvantage intersect and create reinforcing disadvantages. more...

A very large number of Americans are held in jails and prisons – some 762 out of every 100,000 residents. Although the United States has only five percent of the world’s population, it holds one quarter of all the world’s prisoners. However, the social burdens occasioned by so much imprisonment are not borne equally by all segments of the American population. According to recent estimates, one of every 15 black men is held in jail or state or federal prison, compared to one of every 106 white males. This racial disparity has a big impact on the life fortunes of white and black men – contributing to gaps in many domains, ranging from jobs and family life to health and mortality.

But the social reverberations of mass incarceration do not stop with the prisoners themselves. The consequences can be even greater for children, family members, and associates attached to those who are imprisoned. A burgeoning research literature suggests that having a family member sent to prison damages the mental and physical health of those left at home. The imprisonment of a family member means one less person to contribute to household support, increasing stress and making everyone less economically secure.The social reverberations of mass incarceration do not stop with the prisoners themselves.

Although researchers have documented these indirect social impacts from imprisonment, they have been unable before now to estimate how many adult women and men are connected to an inmate – and therefore, have not been able to specify the scope of negative consequences faced by people tied to America’s prisoners. Now, for the first time, data from the 2006 General Social Survey make it possible to estimate the reach and wider social impact of the U.S. prison system. We use this data and build on previous studies to explore the impact of imprisonment on the family members and associates of black and white prisoners. more...

Health care providers who perform abortions routinely use ultrasound scans to confirm their patients’ pregnancies, check for multiple gestations, and determine the stage of the pregnancies. But it is far from standard – and not at all medically necessary – for women about to have abortions to view their ultrasounds. Ultrasound viewing by patients has no clinical purpose: it does not affect the woman’s condition or the decisions health providers make. Nevertheless, ultrasound viewing has become central to the hotly contested politics of abortion.

Believing that viewing ultrasounds will change minds, opponents of abortion – spearheaded by the advocacy group Americans United for Life – have pushed for state laws to require such viewing. So far, eighteen states require that women be offered the opportunity to view their pre-abortion ultrasound images, and five states actually go so far as to legally require women to view their ultrasound images before obtaining an abortion (although the women are permitted to avert their eyes). In two of the five states that have passed such mandatory viewing laws, courts have permanently enjoined the laws, keeping them from going into effect.Ultrasound viewing by patients has no clinical purpose: it does not affect the woman’s condition or the decisions health providers make.

As the debates continue to rage, both sides assume that what matters for an abortion patient is the content of the ultrasound image. Abortion opponents believe the image will demonstrate to the woman that she is carrying a baby – a revelation they think will make her want to continue her pregnancy. Ironically, supporters of abortion rights also argue that seeing the image of the fetus will make a difference. They say this experience will be emotionally distressing and make abortions more difficult. Paradoxically, such arguments from rights advocates reinforce assumptions that fetuses are persons and perpetuate stigma about abortion procedures. more...

Activists, political leaders, and the general public view the Americans with Disabilities Act as one of the most important pieces of U.S. civil rights legislation. The law unquestionably improved the lives of people with disabilities in many ways, especially by enhancing their access to businesses and public places. But it has fallen short of one of its major goals: to boost employment and earnings. Twenty-five years later, the employment rate among people with disabilities is still considerably lower than among those without disabilities; and when people with disabilities do find jobs, they earn substantially less than those who have no disabilities.

My colleague Michelle Maroto and I have looked into why the Act fell short in this important respect, especially given that similar legislation, including the Civil Rights Act, accomplished more in reducing discrimination in the workplace.

Why Did the Act Fall Short?

In the scholarly literature and public documents and testimony, there are two hypotheses about why the Americans with Disabilities Act failed to improve employment and earnings. The unintended harms perspective argues that, by requiring workplaces to make changes for employees with disabilities, the law unintentionally discouraged hiring. And the judicial resistance perspective faults Congress for leaving much of the law’s enforcement in the hands of the courts, whose actions or delayed actions undermined effectiveness.There are two hypotheses about why the Act failed to improve employment and earnings: the unintended harms perspective and the judicial resistance perspective.

Both of these possible explanations presume that institutional contexts – the market economy, the court system – influence how legal intentions get translated into real-world outcomes. Scholars who pay close attention to the influence of institutions believe that labor market outcomes (and other economic outcomes) are shaped by more than just supply and demand. Federal and state legislatures, enforcement agencies, and the courts engage in activities that also influence economic outcomes that policymakers have tried to affect. Thus, proponents of the judicial resistance argument, for instance, suggest that court decisions distorted Congressional intentions and often undercut the role of the Equal Employment Opportunity Commission in applying the Americans with Disabilities Act to various workplaces.

What Our Research Shows

My colleague and I sought to untangle the roles of legal requirements, state and federal institutions, and individual characteristics in shaping trends in employment and earnings among people with disabilities from 1988 to 2012. We used nationally representative data about workers from the U.S. Current Population Survey, and also examined Supreme Court decisions and state-level data on complaints about disability issues registered with the Equal Employment Opportunity Commission. Our study cannot shed light on what would have happened if the national law had never been passed, but we can use comparisons across time, across types of workers, and across the states to establish some trends and explanations.

In 2012, adults with disabilities had an employment rate that was 40 percent lower than adults with no disabilities, even after we took into account differences among people in education, family situation, and other characteristics that could influence employment.

• Employment gaps between people with disabilities and others increased both during periods of economic slowdown and times of economic growth.
• People with disabilities earned about 33 percent less than people without disabilities in 2012, even after taking into account other relevant characteristics – and the earnings gap has remained largely unchanged over twenty-five years.
• Better-educated individuals with disabilities fared better than others in both employment and earnings. Having a college degree seems to have had a protective effect for people with disabilities, helping them to overcome possible negative perceptions among employers.
• Earnings among people with disabilities were greater in unionized workplaces and those with health benefits.

Patterns of enforcement mattered – in states, courts, and the federal bureaucracy:

• Higher levels of enforcement activity by the courts and the Equal Employment Opportunity Commission were negatively associated with employing people with disabilities.
• States also legislated against discrimination. Regardless of economic conditions, employment rates for people with disabilities were reduced by 4.4 percentage points in states that were slower to act.
• Earnings were not affected by enforcement, and only slightly affected by state legislation.

Moving Forward

Our analysis showcases the importance of thinking about the politics following the passage of landmark legislation, not just the politics leading up to it. Our data lend some credence to both the unintended harm and judicial resistance arguments about why implementation of the Americans with Disabilities Act failed to markedly improve employment and earnings. In 2008, Congress took note of these shortfalls by passing amendments intended to strengthen the impact of the original law. Future research needs to monitor the impact of these amendments. In the process, close attention should be paid to how legal provisions and rulings influence ongoing decisions by employers. In addition, our study underlines the importance of reducing educational barriers for people with disabilities, doing all that can be done to help them gain training and degrees. So far, educational gains have done the most to help Americans with disabilities overcome barriers in the labor market.So far, educational gains have done the most to help Americans with disabilities overcome barriers in the labor market.

Chronic diseases and injuries are the leading causes of premature death and preventable illnesses in the United States and around the world. Injuries cause many unnecessary deaths among young adults and children. Traffic crashes hurt 50 million worldwide each year, and firearms and alcohol are also leading threats. Meanwhile, half of all Americans suffer from chronic conditions like heart disease, diabetes, and cancer that account for seven out of every ten deaths and eat up three-quarters of health care dollars. By 2030, chronic diseases will cause more than three quarters of deaths worldwide, costing some $47 trillion over the next two decades.

Conventional wisdom attributes the growth of injuries and chronic illnesses to seemingly inevitable causes such as population aging and changing lifestyles. Such forces are at work, of course, but it is the task of public health scientists like me to probe more deeply.

A closer look reveals that many unnecessary injuries and chronic health problems are spurred by what might be dubbed the “corporate consumption complex” – a network of consumer products companies, financial institutions, trade associations, and public relations firms that deliberately urges people to buy unhealthy foods and unsafe products. In 1961, President Dwight Eisenhower warned that the military industrial complex posed a danger to our democracy and well-being. Today, the consumption complex constitutes a similarly grave threat. more...

U.S. health care is in the midst of a major transformation. With the implementation of the Affordable Care Act, tens of millions of Americans are getting health insurance coverage for the first time. Expanded coverage will bring a tsunami of new demand, and current transformations underline the truth that insurance is not the same thing as access to appropriate health care. Across the nation, front-line providers of primary care – safety net providers – risk becoming overwhelmed by the arrival of millions of people newly insured or enrolled in Medicaid, including many vulnerable people with special needs. As happened after the start of Medicare in 1965, the United States faces the prospect of tremendous strain on the vital primary care infrastructure – with the risk that many people could still go without adequate care.

Bolstering safety net services will be essential to meet the needs of the newly insured – as well as the needs of millions who will still remain uninsured (either because Affordable Care does not include them or because they live in conservative states that refuse to expand Medicaid). more...

The debate over same-sex marriage – or “gay marriage” – has been contentious in national and state politics for nearly twenty years. After voters in many states rushed to ban same-sex unions, the tide turned. In recent years, sixteen states and the District of Columbia have legalized same-sex marriage and another three states have approved civil unions or domestic partnerships that include full spousal rights for lesbian, gay and bisexual couples. Despite this progress, as of the end of 2013, only 37% of Americans live in a state with marriage equality; and many lesbian, gay, and bisexual people still do not enjoy the full rights and benefits associated with marriage. This is unfortunate for moral and economic reasons. Equally important, a growing body of public health research documents the many health benefits associated with legal same-sex marriage. more...

The United States imprisons more of its people than any other nation – currently one out of every 31 Americans. Lots of prisoners naturally leads to a steady flow of people leaving prison. Each year more than 700,000 U.S. prisoners are released to their communities. These men and women often have little education and poor prospects for finding jobs or establishing stable homes – and to make things worse, their health often deteriorates right after they leave prison.

About four out of every five newly released people suffer from chronic medical, psychiatric or substance abuse problems – but only about one in five visits a physician outside of hospital emergency departments during the first year after release. Imprisoned patients are often released without adequate follow-up instructions, medications, or access to health insurance coverage. Many let problems fester until they end up in hospital emergency rooms – inflating costs in U.S. health care and forcing taxpayers or insured Americans to foot bills the ex-prisoners cannot pay. An obvious solution is to ensure continuous good health care for people leaving prison. more...

As the debate over immigration reform heats up, a number of contentious issues are front and center – including competition over jobs, border security, and the very meaning of U.S. citizenship. Politicians and pundits have plenty to say about these topics, and no doubt there will also be fierce debates about which public benefits should be available to new citizens or people on a “path to citizenship.” At what point, if any, should formerly undocumented residents gain access to welfare benefits, unemployment insurance, or the new protections included in the recently enacted health reform law?

One important topic that may not get enough attention is how the basic health of immigrants themselves could be affected by reforms. Will reforms make it easier for all migrants to get timely and adequate health care, not just for sudden problems like injuries in an accident but also for chronic diseases? The answers matter not just for the wellbeing of newcomers themselves, but for the health and prosperity of all Americans, the neighbors and co-workers of immigrants. more...