Bailus Walker

The Changing Landscape for the Elimination of Racial/Ethnic Health Status Disparities

The elimination of racial/ethnic health status disparities is a compelling national health objective. It was etched in sharp relief by the 1985 report of the U.S. Department of Health and Human Services Secretarys Task Force on Black and Minority Health and considerable attention has been devoted to the problem since that report. But the problem persists, disparities are not fully explained and effective policies to reduce them have been elusive, a situation presenting both opportunities and challenges. Important advances towards reducing racial/ethnic health disparities may be made by better understanding the complex bidirectional relationship between and among the multiple factors, biological and non-biological, influencing morbidity and mortality. The landscape in which these influences are felt is anything but static. In this paper selected components of the landscape that are critical to the elimination of racial/ethnic health status disparities are reviewed. These factors underscore the importance of adopting and maintaining a perspective on health disparities that encompasses a broad array of health determinants.

CURRENT CONCEPTS: ORGANOPHOSPHATE TOXICITY

Recent cases of nosocomial poisoning associated with the treatment of patients contaminated with organophosphate (OP) insecticides and the increasing potential for exposure to these chemicals elevate into sharper focus the continuing clinical and public health problem of pesticide poisoning. Despite a number of reports on the multiple aspects of OPs insecticides and their health effects, the general public and health services professionals, broadly defined, remain confused and misinformed about this class of chemicals. In this article we examine sources of exposure and current knowledge of health effects of OPs. The protection of health care workers is also discussed.

Public Health in a Managed Care Environment

As the health care system moves in a new direction, toward managed care, the critical role of public health in societys efforts to mitigate illness and the realization of health become more apparent. Indeed, the public health problems of this era will not yield to simple solutions. They require a multitude of resources, both human and material, and a myriad of services derived from these resources. Public healths role is to serve as the governments presence in assessing health status, developing policy, evaluating the effectiveness of policy implementation, and assuring access to and quality of comprehensive health services. Increasingly, public health must coordinate a wide array of systems in both the private and public sectors to fulfill its purpose.

medical education in the 21st Century

This commentary is a reaction of medical educators and health practitioners to the Josiah Macy Jr. Foundation’s recently released report, Revisiting the Medical School Mission at a Time of Expansion. The report is a fresh assessment of what more medical schools must do to prepare students for 21st century challenges and opportunities to improve the health status of the population including underserved groups.

The Microbiome: A Contributor to Health and Disease

As the 21st century unfolds there is substantial evidence that biological research is experiencing extraordinary scientific and technological advances. Prominent among these advances are the completion of the Human Genome Project, which laid the foundation for the second advance, the Human Microbiome Project. Emerging from these advances are two overarching conclusions: a) genomics is no longer the sole domain of the geneticist, and b) we each are hosts to trillions of microorganisms. Genomics and other technologies have enhanced efforts to characterize the structure, composition, and functions of the microbiome. This characterization has fueled progress in understanding the role of the microbiome in health and disease. In this review, we highlight developments that have helped illuminate the microbiome-health connection. This information can improve an understanding of connections and relationships among multiple factors (or determinants) of health.

Respecting and protecting the beloved community, especially susceptible and vulnerable populations.

T Introduction discusses the public health and ethical challenges of responding should a pandemic influenza event reach the United States and suggests a framework that public health professionals and faith leaders can use to address those challenges. Critical to such a response is how emergency preparedness strategies can effectively target vulnerable populations. Ethical and programmatic principles and practices of population-based disease prevention and health promotion and protection must prioritize service to those who are habitually underserved. Vulnerable populations are the neediest; thus professionals in the public health and faith communities must afford them special attention. The public health and faith communities must come together to respond to a possible pandemic flu episode by effective emergency preparedness as an ethical mandate.* While there is no consensus on the best definition for ethics, for the purpose of this manuscript ethics is defined as a set of rules, principles, values, and ideals of a particular group.1[p.60] Paying special attention to vulnerable populations is a central ethical challenge for those making hierarchical decisions in times of public health crisis. There are several

Race, Genomics and Chronic Diseases: What Patients Have to Say—A Commentary

E abounds that developments in genomics are gaining increased attention, as more and more biological discoveries drive eff orts to elucidate the role of genetic variation and mutation in predisposing humans to disease. Multiple dimensions of genomic science have been the focus at many levels in both the public and private sectors. For instance, the National Human Genome Research Institute1 has called for more genomic research of Africans, and people of the African diaspora. Under the headline, Genomics is Failing on Diversity, Popejoy and Fullerton2 discuss how a complex web of historical, cultural, scientifi c, and logistical factors are sustaining an embarrassing bias in genomics. Their fi ndings indicate that the proportion of individuals included in genomewide association (GWAS) studies, (the preferred tool for discovering the genetic factors in common diseases) who are not of European descent has increased to nearly 20%. Much of this rise is the result of more studies being done in Asia on populations of Asian ancestry. It prompted warning that a much broader range of populations should be investigated to avoid genomicmedicine being of benefi t merely to a “privileged few.” Additional evidence of increased focus on genomics includes genomeediting technology which has tripped an alarm among bioethicists and other members of the scientifi c and lay communities. Recently, researchers called for restraint in genomic editing as concerns intensifi ed about the possibility of genetically engineered human beings. Although many European countries ban germline genetic engineering in humans, the United States and China do not have such laws.3 Still another metric of advances in the science of genomics is the growth of the body of literature. It has increased greatly both in monographic and periodic publications. In fact, genomic medicine permeates not only the medical literature but the press, and the economy as well, prompting Greely to observe “Genomics is just too many things: It is omnipotent and irrelevant; unchangeable or acutely responsive to its environment. It is about health and disease as well as human enhancement. It can be used as a tool for tracing ancestry from our ethnic forebears to more recent family and it has become a key to criminal identifi cation.”4[p. 1446] In this issue of the Journal, Horowitz and colleagues5 add to the growing literature regarding multiple dimensions of genomics and chronic disease. The researchers report a novel approach to exploring information required to aid the translation of genomic discoveries into the health care of patients.

The need for diversity in the environmental health workforce.

Epidemiologic evidence makes clear that the likelihood of exposure to environmental contaminants increases in most poor and underserved communities. Despite progress in reducing a number of environmental risk factors for disease, serious environmental problems persist, and those remaining problems are highly complex. Their solution requires meaningful community engagement as well as a diverse environmental health workforce. Demographic data, and related social and economic developments, strongly indicate that such a workforce must include underrepresented minorities. While the problem has not been solved, select programs have made impressive contributions to meeting this need, an example of which is described in this paper.

Preface—Symposium on Air Quality and Alternative Transportation Fuel

Long-standing concern about the health effects of inhaled toxicants has increased as epidemiological and toxicological studies have strengthened the link between air pollution and respiratory and cardiorespiratory abnormalities. An important source of these toxicants is emissions from motor vehicles, including light-duty vehicles (LDVs, also referred to as passenger cars), light-duty trucks (LDTs), heavy-duty vehicles, and motorcycles used for transportation on the road. Indeed, since the earliest periods of the Clean Air Act (CAA), mobile sources have been recognized as one of the most important sources of air pollution and there has been a persistent need to address this problem through increasingly tight and wide-ranging regulation. At the same time, human behavior and other social factors, such as vehicle miles traveled (VMT), appear to have offset many of the gains achieved from imposition of technological control. Another contributing factor, according to the National Academy of Sciences–National Research Council’s Committee on Air Quality Management in the United States, was the difficulty in identifying and repairing the high emitting vehicles. In this setting, evidence abounds that despite the nation’s significant progress in improving air quality, the problems posed by pollutant emissions in the United States have not been solved and human exposure to airborne toxicants continues to be a risk factor for disease, disability, and premature deaths. It is also clear that further improvements in air quality are needed, particularly to attain new ambient air standards for fine particulate matter and ozone concentrations. In earlier efforts to attain ambient air standards in compliance with the CAA, mobile-source emission control was approached through technological changes to engines and exhaust systems. With the exception of lead, fuel was not regulated for emissions control. Beginning in the late 1980s, however, a more balanced strategy began to take shape that combined regulation of vehicle performance with regulations of fuels used by those vehicles. These developments were followed by a surge of interest in both the public and private sectors in alternative fuel. This interest has also been intensified by a range of political, social, and economical development, including oil and biofuel economy, at the national and global levels. In response, governors of a number of states began to unveil plans for increased production and use of renewable fuels. In 2006, the presidential State of the Union address further spurred interest in biofuels and gave new impetus to the identification of biofuel crops as a source of energy. Even before the speech, public health specialists, energy experts, economists, farmers, and numerous businesses and industrial groups had focused attention specifically on biodiesel and its potential for improving air quality and, in the process, reduce risk factors for respiratory abnormalities. The essential interplay of these factors provided a rich context for a discussion of the production and use of alternative fuel as an approach to reducing human exposure to airborne toxicants and alternative transportation fuel and related public health issues. Thus, in September 2006, the American Lung Associations of the District of Columbia, the Upper Midwest, and of the Southwest, voluntary health organizations dedicated to the prevention of respiratory diseases, convened a one-day symposium in Washington, DC. The objectives were to (a) review the state of knowledge of the health effects of air pollutants and (b) discuss the opportunities for further improvements in air quality by the development and widespread use of alternative fuels. Attention of the discussants was primarily on biodiesel because the Department of Energy’s data showed that this plant-based product (“green chemistry”) was the fastest growing alternative fuel. Growth doubled to 150 million gallons in 2006 from 75 million gallons in 2005. Consumption of biodiesel was expected to reach 250 million gallons by the end of 2006. In summary, trends in biodiesel had strong momentum, and were part of the matrix of what might be called “biofuel mania.” Although there are a number of approaches for controlling the release of toxicants from mobile and stationary sources, the symposium approached these topics with the recognition that a fundamental toxicant control principle is “substitution or elimination”—that is, substituting materials that do not produce toxicants or restricting the amount of key chemical elements available for production of pollutants.

Impacts of the Red Book

With the publication by the National Research Council of Risk Assessment in the Federal Government: Managing the Process (called the Red Book) we crossed a border on the route to a better understanding of the challenges of determining the potential adverse health effects resulting from human exposure to hazardous agents or situations. In the process the Red Book has had concrete and far-reaching consequences, a subset of which is reviewed in this essay.