Quick, Effective Public Health Measures

I'm freshly back from the annual meeting of the Public Health Law Research program, sponsored by Robert Wood Johnson.

At most academic meetings, I prefer schmoozing in the halls to listening to the talks. That's part personal vice, and part stage-of-career: at this point, it matters more who I talk to than whose paper I hear. This conference was different, though--perhaps because I'm new to it. A very large percentage of the papers (and posters!) repaid close attention.

But the best session of the conference, to my mind, was the "Critical Opportunities" session. The session, which is apparently an annual affair, is presented as a competition: a handful of public health law scholars are invited to present their best ideas for high-impact, evidence-based public health interventions that have a chance at actual enactment. The audience votes on which one they think is (to put it roughly) most worth peddling to health-policy folk under the banner, "Do it now!"

This year's choices: a proposal for corn masa flour fortification for the prevention of neural tube defects, made by the CDC's Erica Reott, MPH, LCDR S. Kinzie Lee, MPH, and Amy Cordero, MPA; a proposal for legal reforms to prevent opioid overdose from Corey Davis of UNC Chapel Hill; a proposal from Adam Finkel, Sc.D., of UPenn Law, to make "smart disclosure" rules, like nutritional content labels, more complete and accurate; a proposal to put decals on the cars of teens subject to "novice drive" license restrictions, from Allison Curry, PhD, MPH, of Children’s Hospital of Philadelphia; a proposal for better (and better supported) local governance of public health institutions from Scott Hays & Janine Toth of the University of Illinois at Urbana-Champaign; and a set of proposals for gun-control laws from Marvin Swartz, MD, of the Duke University School of Medicine.

All of the proposals were terrific and important, but I want to take a bit of time to mention a few that might surprise my blogging audience, as they surprised me. I leave aside the Hays/Toth proposals about public health governance, though they were completely sensible and apt to have immense impact over time; and I leave aside the gun control measures, as you're all apt to be reading a great deal about them these days; and, finally, I leave aside the superb presentation on labeling and "smart disclosure" rules, as I have the sense--perhaps wrongly--that we are all aware that many disclosures, mandated as a substitute for regulation on the grounds that people can decide for themselves when adequately informed, do not in fact inform adequately.

I shall instead mention the three options that, for different reasons, gobsmacked me. In each case, I'm relying entirely on data from the presenter's own slides, which I've obtained from the PHLR folks (Thanks, Bethany!)

I present, first, corn masa flour fortification. (This ended up being the crowd's favorite.) Neural tube defects like anencephaly and spina bifida affect about 3000 pregnancies per year. NTD's affect the Hispanic population more profoundly than the rest of the population. This is likely because flour is enriched with folic acid, which helps prevent NTD's, but corn masa flour (widely used in the Hispanic community) is not fortified. Flour fortification has reduced NTD rates by more than a third. A similar rate among Hispanics would prevent 40 NTD's a year. Given the high cost of NTD medical treatment, the public health intervention saves $100 for each $1 spent. And here's the kicker: there is but one major manufacturer of corn masa flour in the US, and this firm has in fact joined public health groups in petitioning the FDA for permission to fortify.

Second, legal reforms to prevent opioid overdose. Did I know that prescription pain-killer overdoses had passed automobile crashes and gun accidents as the number one accidental cause of death in America? No, I did not. 100 a day die from prescription painkiller overdoses--more than die from heroin overdoses and cocaine overdoses combined. There's a drug called Naloxone, which, if administered nasally to someone who's OD'd, will actually interfere with a prescription opioid's effects on the body, and prevent the OD from being fatal. Ambulances and first-responders carry it, but physicians are reluctant to co-prescribe it to people to whom they prescribe pain-killers. This is mainly because the Naloxone is apt to be administered to their patient by someone with whom they don't have a doctor-patient relationship (a relative, or bystander). Docs worry about liability for prescribing a drug to X which is mainly to be administered by not-X. But of course, isn't that how epi-pens are used? Maybe law could be used to create a standard of care that involves co-prescribing the emergency cure with the problematic pain-killers. Next, bystanders often fail to call 911 because they fear arrest. The solution here is a relatively simple, narrow, legal grant of immunity to people who telephone first-responders from the scenes of drug overdoses. Turns out that police--who, after all, have a lot of depressing experience in finding the dead bodies of prescription drug overdosers--don't even mind granting that limited sort of immunity. They'd rather let a few druggies get away than pick up another body. Me, too.

And third, putting decals on cars whose teenaged drivers are subject to various license restrictions, such as not having any non-family members in the car. As the father of a 15 year old, I like this idea. Yes, it makes your car into a police target. That's, um, the idea. Your kid knows s/he's a police target, and caution (or at least obedience to the license-restriction regulations) ensues. Some folks worry that predators will use the decals to make their search for vulnerable teens easier, but really, how hard is it for a predator to look at the driver? And predators, unlike cops enforcing license-restriction rules, aren't picky about the driver's exact age. Here's the main punchline, though: New Jersey put the decals on, and 1600 crashes per year were prevented. Driving is apt to be the most dangerous thing one's teen will ever do, and the decal law helps cops clamp down on teens who evade the sensible rules. In New Jersey, graduated driver's license enforcement rose by 14% after the decals went on. That means, teens who were breaking the rules by driving with their friends in the car were cited, and teens who were driving after dark were cited. As a dad, I'm all in favor.

So: fortify that corn flour! Co-prescribe that antidote! Label those teens! And save lives.