Tag Archives: wellness

Vowing to jettison Obamacare, Republicans face immediate resistance and risks

The 115th Congress started work Tuesday with Republican majorities in both the House and Senate in agreement on their top priority — to repeal and replace the 2010 health law, the Affordable Care Act, also known as Obamacare.

“The Obamacare experience has proven it’s a failure,” House Majority Leader Kevin McCarthy, R-Calif., told reporters at an opening day news conference.

But that may be where the agreement among Republicans ends.

Nearly seven years after its passage, Republicans still have no consensus on how to repeal and replace the measure.

“It is risky business,” said Thomas Miller, a conservative economist and former Capitol Hill aide now at the American Enterprise Institute.

Republicans, he said at a recent AEI forum, are “very good at fire, aim, ready.” But with more than 20 million Americans getting coverage under the law, GOP lawmakers will have to tread carefully, Miller warned. “The hard one is when you’re trying to defuse what’s already been out there, cutting the wires on the bombs sequentially” so as to avoid a messy and destructive explosion.

Republicans are reportedly discussing a range of options for disassembling Obamacare, but analysts who have been involved in the intricacies of health policy for decades warn no replacement strategy will be easy.

The most immediate problem for the GOP is that even with majorities in both chambers of Congress, they do not have the 60 votes needed to overcome Democrats’ objections in the Senate. (There are 52 Republicans in the Senate now.) That means they won’t be able to pass a full repeal of the law on their own and it is unlikely eight Democrats would join to overturn President Barack Obama’s signature legislation.

Even if they did have the votes standing by, they don’t have anything teed up to replace the health law.

“It’s not that Republicans don’t have replace bills. They have a couple dozen,” said Douglas Badger, who oversaw health policy in the White House for President George W. Bush and worked for the Senate GOP leadership prior to that. “The problem is they don’t have consensus,” he said at the AEI forum.

Still, doing nothing, or even waiting, is not an option given that these lawmakers have been vowing to repeal the law almost since the day it passed in 2010.

“You have to pass something,” said Miller, “and whatever you pass you call repeal.”

The leading option under consideration is “repeal and delay.” The idea is to use the budget process to overturn the tax-and-spending parts of the law, but delaying the effective date to buy time for Republicans to agree on a replacement bill.

But there are problems with that strategy. One is political — Democrats are already crying foul.

“It’s not acceptable to repeal the law, throw our health care system into chaos and then leave the hard work for another day,” incoming Senate Minority Leader Charles Schumer, D-N.Y., said Tuesday.

Added Sen. Richard Durbin, D-Ill., “it’s not repeal and delay, it’s repeal and retreat.”

The plan also has raised concerns in the health industry. The goal of delaying the repeal date is to let people who have obtained insurance under the health law keep it while a replacement is formulated. But that is by no means guaranteed.

Insurance analysts have said that any more uncertainty in an already fragile marketplace could easily prompt insurers to leave the individual market, which would put at risk coverage for not just the roughly 10 million people who are purchasing plans there under the health law, but also the roughly 10 million people who previously had individual policies. (Another 10 million people have gained coverage under the health law through an expanded Medicaid program for those with low incomes.)

Without specific help for insurers from Congress, which would likely include insurance payments Republicans have called bailouts, “the market will begin to crumble” quickly, said Robert Reischauer, former president of the Urban Institute.

House Majority Leader McCarthy told reporters Tuesday that “no decisions have been made yet” on how Republicans might want to help stabilize the insurance market while they seek a replacement plan.

The individual insurance market could also be rattled if the incoming Trump administration decides not to appeal a lawsuit brought by congressional Republicans who argued that the Obama administration was illegally using money to pay insurers to subsidize health costs for some low-income customers buying individual plans on the health law’s marketplaces. If the new administration bows out of the suit and those subsidies, insurers would not get reimbursed for the expenses, and some analysts predict it could force companies to leave the market.

On the other hand, attempting to repeal and replace the law in a single bill also could pose problems.

Repealing and replacing together “looks less like repealing than fixing,” said Badger. “That could cause some angst” among the GOP base that wants Obamacare to be fully eliminated.

And Democrats point out that Republicans are equally guilty of overpromising the benefits of overhauling the health care system, albeit in a very different way.

The goals currently being talked about by Republicans — including making health care more affordable, covering more people, reducing government spending and giving states more flexibility — “are impossible to achieve,” within acceptable GOP budget limits, said Reischauer at the AEI event. “There are going to have to be some tradeoffs,” he said, as Democrats found when they tried to accomplish roughly those same goals.

Made available from Kaiser Health News under a creative commons agreement. KHN is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Minnesota is leading the rest of country in banning germ-killer triclosan

Minnesota’s first-in-the nation ban on soaps containing the once ubiquitous germ-killer triclosan takes effect Jan. 1, but the people who spearheaded the law say it’s already having its desired effect on a national level.

The federal government caught up to Minnesota’s 2014 decision with its own ban that takes effect in September 2017. Major manufacturers have largely phased out the chemical already, with some products being marketed as triclosan-free.

And it’s an example of how changes can start at a local level.

“I wanted it to change the national situation with triclosan and it certainly has contributed to that,” said state Sen. John Marty, an author of Minnesota’s ban.

Triclosan once was widely used in anti-bacterial soaps, deodorants and even toothpaste. But studies began to show it could disrupt sex and thyroid hormones and other bodily functions, and scientists were concerned routine use could contribute to the development of resistant bacteria. And University of Minnesota research found that triclosan can break down into potentially harmful dioxins in lakes and rivers.

The group Friends of the Mississippi River and its allies in the Legislature, including Marty, got Gov. Mark Dayton to sign a ban in 2014 that gave the industry until Jan. 1, 2017, to comply.

In September, the FDA banned triclosan along with 18 other anti-bacterial chemicals from soaps nationwide, saying manufacturers had failed to show they were safe or more effective at killing germs than plain soap and water. However, the FDA allowed the use of some triclosan products such as Colgate Total toothpaste, saying it’s effective at preventing gingivitis.

Marty and Trevor Russell, the water program director for Friends of the Mississippi River, acknowledged they can’t take direct credit for the FDA’s action because that rulemaking process began in 1978, though it didn’t finalize the rule until after a legal battle with the Natural Resources Defense Council.

However, the Minnesota men hope their efforts helped turn opinions against the chemical and are confident the state’s ban helped prod manufacturers to accelerate a phase-out that some companies such as Procter & Gamble and Johnson & Johnson had already begun.

Most major brands are now reformulated, said Brian Sansoni, spokesman for the American Cleaning Institute, a lobbying group. Soaps containing triclosan on store shelves are likely stocks that retailers are just using up, he said.

Russell noted he recently found Dial liquid anti-bacterial hand soap at two local Wal-Marts, two supermarkets and a Walgreens.

The industry is now submitting data to the FDA on the safety and effectiveness of the three main replacements, benzalkonium chloride, benzethonium chloride and chloroxylenol.

“Consumers can continue to use these products with confidence, like they always have,” Sansoni said.

By going first, Russell said, Minnesota can identify any issues with implementing the ban and share it with the rest of the country.

The Minnesota Department of Health will remind consumers and businesses of the ban’s start.

Trump action on health care could cost Planned Parenthood

One of President-elect Donald Trump’s first, and defining, acts next year could come on Republican legislation to cut off taxpayer money from Planned Parenthood.

Trump sent mixed signals during the campaign about the 100-year-old organization, which provides birth control, abortions and various women’s health services. Trump said “millions of women are helped by Planned Parenthood,” but he also endorsed efforts to defund it. Trump once described himself as “very pro-choice.” Now he’s in the anti-abortion camp.

The Republican also has been steadfast in calling for repeal of President Barack Obama’s health care law and the GOP-led Congress is eager to comply.

One of the first pieces of legislation will be a repeal measure that’s paired with cutting off money for Planned Parenthood.

While the GOP may delay the impact of scuttling the law for almost four years, denying Planned Parenthood roughly $400 million in Medicaid funds would take effect immediately.

“We’ve already shown what we believe with respect to funding of Planned Parenthood,” House Speaker Paul Ryan, R-Wis., told reporters last month. “Our position has not changed.”

Legislation to both repeal the law and cut Planned Parenthood funds for services to low-income women moved through Congress along party lines last year. Obama vetoed it; Trump’s win removes any obstacle.

Cutting off Planned Parenthood from taxpayer money is a long-sought dream of social conservatives, but it’s a loser in the minds of some GOP strategists.

Planned Parenthood is loathed by anti-abortion activists who are the backbone of the GOP coalition. Polls, however, show that the group is favorably viewed by a sizable majority of Americans — 59 percent in a Gallup survey last year, including more than one-third of Republicans.

“Defunding Planned Parenthood as one of their first acts in the New Year would be devastating for millions of families and a huge mistake by Republicans,” said incoming Senate Minority Leader Charles Schumer, D-N.Y.

Democrats pledge to defend the group and they point to the issue of birth control and women’s health as helping them win Senate races in New Hampshire and Nevada this year. They argue that Trump would be leading off with a political loser.

But if he were to have second thoughts and if the Planned Parenthood provision were to be dropped from the health law repeal, then social conservatives probably would erupt.

“They may well be able to succeed, but the women of America are going to know what that means,” said Rep. Diana DeGette, D-Colo., citing reduced access to services Planned Parenthood clinics provide. “And we’re going to call Republicans on the carpet for that.”

At least one Republican senator, Susan Collins of Maine, may oppose the effort.

Collins has defended Planned Parenthood, saying it “provides important family planning, cancer screening, and basic preventive health care services to millions of women across the country.” She voted against the health overhaul repeal last year as a result.

Continued opposition from Collins, which appears likely, would put the repeal measure on a knife’s edge in the Senate, where Republicans will have a 52-48 majority next year.

Senate GOP leaders could afford to lose just one other Republican.

Anti-abortion conservatives have long tried to cut Planned Parenthood funds, arguing that reimbursements for nonabortion services such as gynecological exams help subsidize abortions. Though Planned Parenthood says it performed 324,000 abortions in 2014, the most recent year tallied, the vast majority of women seek out contraception, testing and treatment of sexually transmitted diseases, and other services including cancer screenings.

The defunding measure would take away roughly $400 million in Medicaid money from the group in the year after enactment, according to the nonpartisan Congressional Budget Office, and would result in roughly 400,000 women losing access to care.

One factor is that being enrolled in Medicaid doesn’t guarantee access to a doctor, so women denied Medicaid services from Planned Parenthood may not be able to find replacement care.

Planned Parenthood says private contributions are way up since the election, but that they are not a permanent replacement for federal reimbursements. “We’re going to fight like hell to make sure our doors stay open,” said Planned Parenthood spokeswoman Erica Sackin.

Menasha officials reject replacement plan for lead pipes

Menasha aldermen have rejected a proposal requiring homeowners to replace lead service lines on their properties at their own expense, saying it’s unacceptable.

Property owners could’ve paid between $800 and $2,500 to replace the lines, even though the city has received a $300,000 state grant to help reimburse property owners for some of the costs, The Post-Crescent reported.

Water utility manager Tim Gosz said the utility plans to pursue more grant funding for 2018.

Menasha Utilities officials estimate there are 1,200 to 1,500 lead service lines on private properties.

Lead service lines have been in the spotlight since scientists found Flint, Michigan, residents were exposed to elevated lead levels when the toxic metal leached into water from lead pipes.

Lead can be dangerous for children and expectant mothers, causing things like brain and kidney damage, increased blood pressure, deficits in attention span and hearing, and learning disabilities.

“I’d be concerned that this body only feels abatement is only important when grant dollars are involved,” said Alderman Marshall Spencer, who voted in favor of the plan. “I called it a good step forward but not a total solution before. The science is not debatable, it’s real.

“Anybody who doesn’t understand that, just spend a little time on Google and you’ll see a whole lot.”

The American Water Works Association said there are an estimated 6.1 million lead service lines across the nation.

 

Surgeon general report: ‘Addiction is not a character flaw’

In what may be his last significant act as President Barack Obama’s surgeon general, Dr. Vivek Murthy released a report calling for a major cultural shift in the way Americans view drug and alcohol addiction.

The report, “Facing Addiction in America,” details the toll addiction takes on the nation — 78 people die each day from an opioid overdose; 20 million have a substance use disorder — and explains how brain science offers hope for recovery. While its findings have been reported elsewhere, including by other federal agencies, the report seeks to inspire action and sway public opinion in the style of the 1964 surgeon general’s landmark report on smoking.

With President-elect Donald Trump taking office, it’s uncertain whether access to addiction treatment will improve or deteriorate. Trump and the Republican-led Congress are pledging to repeal and replace the 2010 Affordable Care Act, which made addiction treatment an essential health benefit.

In an interview this week, Murthy said he hasn’t spoken to Trump but looks forward to working with his administration to save lives with expanded access to treatment.

“We have made progress,” Murthy said. “How do we keep that progress going? A key part is making sure people have insurance coverage.”

The Associated Press reviewed the report ahead of its official release. Here’s a look at what’s in it and some early reaction:

 

MEDICATION MYTHS

The surgeon general’s report refutes abstinence-only philosophies as unscientific and supports medications such as buprenorphine and methadone that are used to treat opioid addition. That may annoy supporters of traditional 12-step programs who see medications as substituting one addiction for another.

Medication-assisted treatment for opioid addiction can take time. “One study suggested that individuals who receive MAT for fewer than 3 years are more likely to relapse than those who are in treatment for 3 or more years,” the report states.

 

TV-STYLE INTERVENTIONS

Staged interventions, like those depicted on TV, may backfire. Planned surprise confrontations “have not been demonstrated to be an effective way to engage people in treatment,” the report says. The trouble with the approach? According to the surgeon general’s report, it can heighten resistance and attack the self-worth of the addict.

 

ALCOHOLICS ANONYMOUS

Alcoholics Anonymous was founded in 1935 because mainstream medicine wasn’t treating alcohol disorders. That started a legacy of separating addiction treatment from the rest of medicine.

The report makes room for AA and other recovery support services, noting they don’t require health insurance and are free, but it also says they “are not the same as treatment and have only recently been included as part of the health care system.”

AA gets praise for adaptability. American Indians, for instance, have incorporated Native spirituality and allowed families to attend meetings. Research shows AA to be “an effective recovery resource,” the report concludes.

 

HIGHER ALCOHOL TAXES

Alcohol tax policies get a nod in a section on evidence-based prevention: “Higher alcohol taxes have also been shown to reduce alcohol consumption.” Other policies suggested by research include limiting the density of stores selling alcohol, banning Sunday sales and holding bars liable for serving minors.

 

WHAT ABOUT MARIJUANA?

The report suggests learning from alcohol and tobacco policies to find out what works to minimize harm as marijuana becomes legal.

Voters in eight states have approved adult use of recreational marijuana and more than two dozen states have medical marijuana laws. The report cites “a growing body of research” suggesting marijuana’s chemicals can help with “pain, nausea, epilepsy, obesity, wasting disease, addiction, autoimmune disorders, and other conditions.”

Murthy supports easing existing barriers to marijuana studies, but said that he’s worried the legalization movement is moving faster than research. “Marijuana is in fact addictive,” he said.

 

NOT A MORAL FAILING

Addiction is a chronic illness, not a character flaw or a moral failing, the report says. Stigma and shame have kept people from seeking help and weakened public investment.

Murthy issues a call to action in the preface: “How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss?”

 

RED STATE-BLUE STATE ISSUE

Ohio Republican Sen. Rob Portman, co-sponsor of bipartisan legislation passed this year that creates grants to expand treatment programs, said he hopes the report raises awareness.

“We have to change the way we talk about addiction and break the stigma to help more Americans suffering from this disease get the treatment and recovery they need,” Portman said.

Addiction should be a bipartisan issue, said Democratic former U.S. Rep. Patrick J. Kennedy, an addiction treatment advocate.

“This affects all of America, but it really affects the Trump voter,” Kennedy said. Red states such as West Virginia, Ohio and Kentucky have the highest overdose rates, Kennedy said. Enforcing laws that require insurers to cover addiction treatment will be a test of Trump’s “promise to put average Americans ahead of corporate interests,” said Kennedy.

Wisconsin’s lead poisoning rate among kids close to Flint’s

A new analysis shows the lead poisoning level for children in Wisconsin is lower than in recent years, but is nearly as high as Flint, Michigan, where lead contamination caused a drinking water crisis.

Wisconsin Public Radio reports that the analysis released this week by the Wisconsin Council on Children and Families includes data from the Wisconsin Department of Health Services that shows 4.6 percent of children under the age of 6 who were tested in 2015 had lead poisoning. The rate in Flint was 4.9 percent.

Analysis author Leland Pan said the state’s rate of lead poisoning among children is a serious issue because it can negatively affect a child’s development.

“Lead poisoning is correlated with increased rates of learning disabilities, intellectual disabilities, it hampers with brain development, it’s correlated with increased aggression and juvenile incarceration,” Pan said.

The report suggests that many children are exposed to lead-based paints in older homes. The state also has at least 176,000 lead service lines that carry drinking water to homes and businesses.

A disproportionate number of African-American children living in Wisconsin were also diagnosed with lead poisoning. The analysis referenced 2014 data from the Wisconsin DHS that showed 10 percent of the 16,221 black children under 6 who were tested had lead poisoning. Out of the 27,984 white children who were tested, only 2.9 percent had high blood lead levels.

The analysis provides recommendations for prevention, such as increased state supporting for public health departments and providing funding to restore accountability initiatives to increase the number of children tested for lead.

Pop consumption falls beyond expectations after soda tax

As voters consider soda taxes in four cities, a new study finds that some Berkeley neighborhoods slashed sugar-sweetened beverage consumption by more than one-fifth after the Northern California city enacted the nation’s first soda tax.

Berkeley voters in 2014 levied a penny-per-ounce tax on soda and other sugary drinks to try to curb consumption and stem the rising tide of diabetes and obesity.

After the tax took effect in March 2015, residents of at least two neighborhoods reported drinking 21 percent less of all sugar-sweetened beverages and 26 percent less soda than they had the year before, according to the report in the October American Journal of Public Health.

“From a public health perspective, that is a huge impact. That is an intervention that’s more powerful than anything I’ve ever seen aimed at changing someone’s dietary behavior,” senior author Dr. Kristine Madsen said in a telephone interview.

Madsen, a professor of public health at the University of California at Berkeley, said the drop in sugary drink consumption surpassed her expectations, though it was consistent with consumption declines in low-income neighborhoods in Mexico after it imposed a nationwide tax on sugar-sweetened beverages.

The Berkeley results also pleasantly surprised Marion Nestle, a professor of nutrition, food studies and public health at New York University.

“I hadn’t expected the effects to be so dramatic,” she said in an email. “This is substantial evidence that soda taxes work.”

The soda industry has spent millions of dollars defeating taxes on sugary drinks in dozens of U.S. cities. But the tax passed easily — with 76 percent of the vote — in Berkeley. In addition to soda, the measure covers sweetened fruit-flavored drinks, energy drinks like Red Bull and caffeinated drinks like Frappuccino iced coffee. Diet beverages are exempt.

In June, the Philadelphia City Council enacted its own tax on sugar-sweetened beverages. The 1.5-cent-per-ounce tax is set to take effect in January, although soda trade groups have sued to try to block the measure.

Meanwhile, voters in Boulder, Colorado and the Bay Area cities of San Francisco, Oakland and Albany will vote on whether to tax their sugary beverages on Nov. 8.

San Francisco voters also considered a soda tax in 2014, but it failed to garner a two-thirds majority needed for approval.

Public health officials and politicians point to the Berkeley study as proof of the power of an excise tax to wean people off sweetened drinks.

“The study is another tool highlighting how effective a tax on sugary beverages will be on changing the consumption rate,” San Francisco Supervisor Malia Cohen told Reuters Health.

“Just like tobacco, these are commodities we can live without that are killing us,” she said. Cohen wrote the San Francisco ballot measure.

Researchers surveyed 873 adults in Berkeley and 1,806 adults in nearby San Francisco and Oakland before and a few months after imposition of the soda tax.

Sweetened beverage consumption increased slightly in San Francisco and Oakland at the same time it dropped in Berkeley, the study showed. In Berkeley, water consumption spiked 63 percent, compared to 19 percent in San Francisco and Oakland, after the tax took effect.

The researchers attributed the surge in water consumption to a heat wave. But the American Beverage Association saw it as example of the study’s flaws.

In a statement, Brad Williams, an economist working for the trade group, criticized the research for using “unreliable and imprecise methodology” and producing “implausible” results.

The association’s criticism may hold grains of truth, Nestle said. But she largely dismissed it. “Obviously, the ABA is going to attack the results. That’s rule number one in the playbook: cast doubt on the science,” she said.

Public health experts believe soda helped drive American obesity rates to among the highest in the world. The U.S. spent an estimated $190 billion treating obesity-related conditions in 2012.

Diabetes rates have almost tripled over the past three decades, while sugary beverage consumption doubled.

2 UW-Madison students hospitalized with meningococcal disease

Two University of Wisconsin-Madison students were hospitalized with meningococcal disease this week, with one case being identified as serogroup B. Both students are currently recovering.

Additional details are not being disclosed out of respect for the medical privacy of the students and their families.

University Health Services is coordinating with officials from the state and Public Health Madison & Dane County and will continue to monitor the situation.

UHS has reached out to individuals who have been in close contact with the patients.

“We are still investigating whether these cases are related. Depending on that determination, a vaccine recommendation from UHS may be forthcoming,” said Dr. William Kinsey, director of medical services at UHS. “We are taking this situation seriously and responding based on guidance from public health officials. We will share more information as it is made available.”

Meningococcal disease most often causes meningitis, an inflammation of the lining surrounding the brain and spinal cord. It’s very rare, often comes on suddenly, and can progress rapidly.

Symptoms include high fever (greater than 101 degrees F), accompanied by severe headache, neck stiffness and confusion.

Vomiting or rashes may also occur.

Anyone with these symptoms should contact a health care provider or go to an emergency room immediately.

Meningococcal disease is typically treated with antibiotics.

Most students are immunized against serogroup ACYW but not against serogroup B. Serogroup B vaccine has only recently become available.

Meningococcal bacteria are spread through close contact with an infected person’s oral or nasal secretions, such as by sharing cups.

The UHS website has additional information about meningococcal disease. Additional updates will be shared as they are available next week.

Questions from the campus community can be directed to .

Students who are concerned or have questions about their health or are in need of counseling or support are encouraged to contact UHS at 608-265-5600. For students experiencing symptoms over the weekend, the UHS nurse line is available at 608-265-5600, option 1.

The Wisconsin Immunization Registry contains records for children and adults who were vaccinated in the state.

Fighting HIV, one dirty needle at a time

The doctor on a mission met the homeless heroin addict who lived under a tree last year at Jackson Health System’s special immunology clinic when both men were struggling to overcome the odds. Jose De Lemos, infected with HIV and hepatitis C from a shared needle, had gone without treatment for almost a year.

He’d dropped 80 pounds, suffered from night sweats and a rash on his leg and chest. Even walking hurt.

He was in no mood for conversation with a well-meaning doc.

But Hansel Tookes, a University of Miami doctor with a degree in public health and a calling to public service, isn’t the kind of doctor who is easily put off. He talked to De Lemos anyway. Sent him to dermatology, started him on meds for HIV and hepatitis C, worked to find him a bed in rehab, and talked — about his own uphill battle to create a syringe exchange program in South Florida, the kind of program that might have prevented De Lemos’ infection.

A public health advocate in Miami, where new HIV infection rates consistently top the state and national charts, Tookes had been struggling for years to get a bill passed in the Florida Legislature to create a program in Miami-Dade County to help end that terrible distinction.

In that time, he had gone from medical student to doctor. Testified before legislative committees over and over. And learned just how hard he would have to fight to get what he considered a very modest proposal to save lives and improve public health through a conservative, Republican-dominated Legislature.

For De Lemos, his doctor’s commitment to the cause — an unpopular one, at that — was a revelation: “I’m hard-headed. And he’s persistent. He’s like, ‘If you get clean, you can talk about this. You’ll be great . You can help me.’ I admire him because he went through a lot but he kept going.”

Tookes recalled a different moment with his patient: “He started crying because he said he didn’t know people cared.”

For the next eight months, as De Lemos kicked heroin, endured a skin condition that caused blisters across his entire torso and finally saw his sky-high viral count drop, Tookes started seeing hope, too. His proposal, which had been stalled for years, started gaining traction. The nationwide heroin epidemic had changed the dialogue about blood-borne diseases. De Lemos’ appointments with Tookes now usually included an update on the needle exchange bill in Tallahassee. Sometimes, when there was a big vote, Tookes played video recordings of the committee meetings on his phone for De Lemos to see.

“The reception in the ER isn’t great. I had to prop the door open,” Tookes said, with a laugh. “But we watched.”

In March, a full five years after Tookes published a study in a medical journal when he was still a student that documented the harsh reality of illicit needle use in Miami, Gov. Rick Scott signed the Miami-Dade Infectious Disease Elimination Act, making Miami-Dade’s program the first legal needle exchange in the American South.

The victory didn’t mean his fight was over. Legislators weren’t unanimous when they approved the bill, and the IDEA act reflects that: It creates a five-year test program, only in Miami-Dade and without any public financing. Tookes and UM, which will run the program, must raise all the money for the program privately, through grants and donations. Tookes — doctor, public health advocate and needle exchange crusader — must now also become a fundraiser.

He’s undaunted. His determination has carried him this far, and he is already envisioning the rest.

“When I flew back to Miami after the bill had passed, I looked at the city as we were landing at MIA and I thought, what we just did is going to change the health of tens of thousands of people,” Tookes said. “And that was an amazing feeling. And that’s an amazing truth. And that’s where we are.”

 

Advanced HIV cases

Tookes, a 35-year-old internist, took on the against-the-odds fight for a needle exchange because he felt he had to. Too many people were coming through the doors of Miami-Dade’s public health system like De Lemos, with advanced cases of HIV in an era when the virus that causes AIDS is generally treated as a disease you live with, not one that kills you. Injection drug overdoses were rising, too.

The doctor knew getting people into treatment earlier could make a huge difference in their lives and reduce infections of others. (“I’m trained to look for public health solutions,” he said.) A needle exchange was a step toward that goal. Florida had never allowed a needle exchange program before. But why couldn’t that change?

His grandmother, Gracie Wyche, had set the bar high in his family. She was a pioneering black nurse in Miami who started out in the then-segregated wards of Jackson Memorial and eventually became a head nurse, concentrating on a mysterious illness in the 1980s that later became known as AIDS. Tookes became even more interested in public service during his undergraduate work at Yale University and a stint as an investigator for Project Aware, an HIV testing/counseling clinical trial at UM. He got a public health degree at UM, and then his medical degree.

Now a third-year resident who does his research through UM’s division of infectious diseases at the Miller School of Medicine, Tookes said his grandmother’s work set him on this path. “She inspired me,” he said. “There’s just a long history of service on both sides of the family.”

The HIV numbers drove him, too. In 2014, the Miami-Fort Lauderdale region ranked No. 1 in the nation by the U.S. Centers for Disease Control and Prevention for the rate of new HIV infections in areas with more than 1 million people. That year, Miami-Dade County had 1,324 new HIV cases, the CDC said, while Broward had 836 cases. Statewide, in 2014, the Florida Department of Health said 110,000 people were diagnosed and living with HIV. People are still dying of the virus: In the United States, 6,955 people died from HIV and AIDS in 2013, according to the CDC.

Tookes saw the toll up close, in the examining room. A man in his 40s who had sex with men, no body fat and pneumocystis pneumonia, a disease often associated with AIDS _ who didn’t know he’d probably had HIV for years. An impoverished woman from Liberty City with a debilitating bacterial infection from a severely compromised immune system, who had never before been tested for HIV. Or a young man diagnosed with HIV a few months ago who revealed to Tookes during a clinic visit that he uses intravenous methamphetamine.

“Everything with this issue _ all of the advocacy that we did for this policy _ was to fix an issue that we were seeing in everyday clinical practice . I think as physicians, we had a duty to intervene,” Tookes said. “We knew there was something we could do for these people to help them from getting so sick, and so we decided to fight for it.”

He faced deep suspicion about the idea going back to the just-say-no 1980s. Although needle exchange programs have become increasingly common even in GOP-controlled states _ Indiana’s governor and now Republican vice presidential candidate Mike Pence changed his position last year after an outbreak of HIV and hepatitis C _ Florida remained a holdout. Some lawmakers continued to believe that giving addicts clean needles amounted to government-endorsed drug use.

Starting in 2012, Tookes — backed by a coalition including the Florida Medical Association, the Florida Hospital Association and the Miami-Dade State Attorney’s Office — tried to make headway with lawmakers. When he hit the wall of opposition, he didn’t give up. He didn’t get disillusioned or cynical. He tried again. And again. In the legislative sessions of 2013, ‘14, ‘15.

Then 2016 came along. The heroin epidemic created a whole new conversation around the issue of injection-drug use.

State Sen. Oscar Braynon, a Miami Gardens Democrat, sponsored the syringe exchange bill — over and over — because of the high rates of HIV and hepatitis C in his district. He said he saw opposition flag after Florida shut down its “pill mills” starting in 2011, sending opioid users to the needle.

“The first thing people hear is that you’re trying to empower drug users to use drugs,” Braynon said. “But the narrative changed over time … What started to happen is that drug use picked up. First it was people in the ‘hood. But now it’s some of the wealthier people.”

And so the Legislature’s attitude changed. Injection drug use — and the blood-borne diseases that can go with it — were no longer just “a Miami problem,” Tookes said.

“In the context of a nationwide heroin epidemic and in the context of what I believe were many more constituents across the state going to see their senators and representatives and telling them that this was something that was ravaging their communities, we had a lot more of a sympathetic ear from the Legislature this year,” he said.

A needle exchange program won’t fix Miami-Dade’s problem with HIV and hepatitis C. But Tookes says it will help. And though a small percentage of HIV infections can be traced directly to needle use and the biggest risk factor is still sex, reducing the number of shared needles reduces the community’s risk overall. People who share needles don’t always tell their sexual partners that they are at risk.

A needle exchange also brings the hard-core, drug-injecting population into the public health system to be tested and treated. That reduces the risk to everyone else and cuts costs of treating their illnesses.

This is not just theory. In Washington, D.C., the number of new HIV infections dropped from an average of 19 a month to six a month after a needle exchange program was introduced in 2008, according to a study released last year by George Washington University’s public health school. The reduction in cases saved taxpayers an estimated $45.6 million, using CDC estimates that the average lifetime of care for AIDS patients costs about $380,000.

Miami-Dade stands to save money, too, if addicts stop reusing needles. A study co-authored last year by Tookes showed that the cost of treating patients who had bacterial infections as a result of dirty needles ran about $11.4 million a year at taxpayer-funded Jackson Memorial Hospital.

For Tookes, all of these public health arguments start with what he learned on the streets of Miami interviewing intravenous drug users when he was still a medical student at UM. The study he published in 2011 showed that drug users in Miami were 34 times more likely to dispose of their needles in public than drug users in San Francisco, which has had a needle exchange program since 1988.

Tookes still sees the bits and pieces of drug equipment in bushes and along streets, even in upscale places like Brickell Avenue, lined with highrise condos and financial companies from all over the world.

“I still have syringe radar,” he said. “I spot them everywhere.”

 

Street needles

A few miles away from the Jackson clinics where Tookes works, in the shadow of the Metrorail station in Miami’s Overtown neighborhood, Carlos Franco is handing out his precious stash of clean needles to addicts once again.

Franco, 67, says he began his underground one-man operation more than two decades ago after he was horrified to see his girlfriend share needles with other drug users. He buys the sterile syringes, 100 to a box, at his own expense when he has the money, from the North American Syringe Exchange Network.

Franco is instantly recognizable to many in the neighborhood, where orange caps from syringes are sprinkled in vacant, overgrown lots and along sidewalks and under bushes.

“φOye!” yells one man, hailing Franco from a block away.

The operation is quick, Franco reaching into his backpack and handing over several packs of needles. The man, identified only as Flaco _ “Skinny,” in Spanish _ nods his thanks, looks both ways and disappears behind a metal gate next to a house across the street.

Around the corner, near the Interstate 95 overpass, Franco points out the improvised “cookers” that litter the shrubbery, bottoms of soda cans fashioned to heat up drugs. As he’s talking, a blond, thin guy in a T-shirt and jeans walks up poking a toe into the shrubbery.

Franco pulls the box from his backpack. “You need this?”

The man nods, his face now eager. Franco hands him a packet of syringes. Sean says he is 41, from New Jersey, a construction worker when he can find work. He is a heroin addict.

Sean has hepatitis C, something he shrugs off. “If you’re on the streets, it’s sort of required,” he says, with a short laugh that reveals a few missing teeth.

He walks away. A moment later, only half-hidden by a metal fence, he hunches over his arm.

“What really bothers me,” Franco says, “is when the numbers on the side of the syringe are worn off because it’s been used so much. That, and when they use a needle so dull it looks like a nail going into the skin _ it can’t get through.”

Franco knows his needle distribution is both illegal and dangerous, but he’s not sure if he’ll give it up when the official needle exchange program is running. He supports the idea of a legal program but worries about the people who might be too afraid to try it.

“I’ll wait and see,” he says. “A lot of people on the streets know me. I’m not sure if they will go to an official program. The cops might harass the program.”

‘People are still dying’

No one knows exactly why Miami-Dade’s HIV infection rate remains higher than other metropolitan areas, even as medicines are better than ever, statewide rates have declined and mother-to-child transmissions _ AIDS babies _ are rare.

Public health officials rattle off a variety of contributing factors: Thirty-five years into this epidemic, younger people think of HIV as a treatable, chronic disease. Drugs like Truvada, which can prevent HIV infection if taken as a precaution, have added to that perception. HIV is largely an urban disease. Immigration brings people to Florida from places without much access to healthcare or health education. Miami is an international party town, and the highest risk for HIV is unprotected sex, especially for men having sex with men. Testing and medication in South Florida can be difficult to find.

Also, HIV has fallen out of the headlines for the most part, added AIDS Healthcare Foundation’s advocacy and legislative affairs manager Jason King.

“People are still dying. But you don’t get the press coverage … So it’s not at the forefront of people’s minds.”

Stigma is part of the problem, too. If you can’t admit you have HIV, your sexual partners are probably at higher risk.

“It’s not a death sentence like before but the stigma still exists,” said King, who is HIV positive. “And then they have to be conscientious about disclosing it to their next partner and they fear rejection.”

That’s definitely true in Miami-Dade, said Dr. Cheryl Holder, a general internist who works at Jessie Trice Community Health Center and is an associate professor at Florida International University.

Holder says stigma, especially in the African-American community, is one of the toughest issues she combats when she sees patients with HIV.

“We’re seeing changes in communities, but it’s still labeled as wrong and there’s something wrong with you … I still have patients who hide their medicine.”

Walking out of the health center at the end of a day not long ago, she saw one of her patients, a young man in a hoodie, waiting for a ride from a family member. “If it weren’t for his diagnosis, I would have waited with him for his family. But as I walked by, he didn’t look at me and I didn’t look at him. And that’s when I know it’s stigma. He couldn’t just pull me over and say, this is my doctor. We need to normalize healthcare so I don’t have to walk past my patient and not meet his mom.”

 

Raising money

In some ways, Tookes’ work starts again now. Though Congress lifted a ban on federal funding for needle exchanges late last year, no federal money can be used on needles themselves. And Florida’s bill specifies that no public money can be used for the program.

That leaves Tookes, working with UM, raising it all — about $500,000 a year. And the pressure is on: Other counties in Florida are watching to see how well the program works.

“This pilot program is going to make a big dent in the infection rate in Miami. All eyes are on us. We have to make this a success.”

He has raised $100,000 from private donors locally — including Joy Fishman, the widow of the inventor of Narcan, the “save shot” for people who are overdosing — and another $100,000 from the MAC AIDS Fund.

Nancy Mahon, global executive director of the fund, said that syringe exchanges are key to fighting HIV/AIDS. “Needle exchange programs like this halt new infections, period. There is still work to do, but providing sterile syringes and supportive services to IV drug users is a solid step in order to begin saving lives.”

Miami-Dade’s health department is joining the effort.

“Definitely, we will be helping in any way we can,” administrator Lillian Rivera said. “We can’t buy the syringes, but we definitely will be providing wrap-around services. As the patients come in, we will be ensuring that they will be tested for HIV and hepatitis … All of the services that we have will be available to the patients that come through the door.”

The IDEA Exchange, which will be run through UM, comes too late to prevent De Lemos’ infections. But it’ll help others as the 35-year war on the epidemic continues _ as many as 2,000 in the first year, Tookes said. A project manager will start work in August, and other staff members are next. The AIDS Healthcare Foundation is donating the HIV and hepatitis C test kits with the agreement that those identified with one of the diseases will be linked with medical care. Tookes is hoping that other groups will follow.

And De Lemos — at 53, homeless no longer — will do his part, inspired by the fight of his doctor to pass the law. His viral load is so low it’s considered undetectable, and he is looking at life with new eyes. Service is part of his personal plan now. “I really want to be a part of this needle exchange program. If he can do that, I can do anything.”

Tookes says he will measure success with each HIV test, each syringe handed out.

“This has been a long journey … It’s a very exciting time for Miami. We’re going to save a lot of lives. We’re going to save a lot of money. We’re going to give people a lot of clean needles. We’re going to provide HIV tests. We’re going to get people into treatment … We’re going to change the world.”

 

Published via the AP member exchange.

Pop or fizzle: Are soda taxes gaining steam?

A sip of soda will become more expensive next year in Philadelphia, which recently became the second city in the United States to pass a tax on sugary beverages — after Berkeley voters passed one in 2014.

The Philadelphia measure, approved by the City Council in June, could lend momentum to efforts by public health advocates to get similar taxes enacted elsewhere around the nation.

Voters in three Northern California cities — San Francisco, Oakland and Albany — will decide in November whether to approve such taxes. A soda tax initiative in San Francisco in 2014 failed to get the two-thirds vote needed to pass.

Several states also have tried and failed to pass soda taxes. In California, a bill to do so died this spring.

Outside of the United States, Mexico, England and France also tax sugar-laden beverages.

Advocates of taxing these drinks say that they contribute to high rates of obesity and diabetes, and that putting a bigger price tag on them can reduce consumption and improve people’s health. Critics argue the taxes are unpopular and that it is discriminatory to single out one item in the grocery cart.

The American Beverage Association, one of the staunchest opponents of soda taxes, has funded successful opposition campaigns throughout the United States, including in California.

The association has spent $64.6 million since 2009 fighting such initiatives — including more than $9 million just to defeat the proposed San Francisco tax in 2014, according to a report last year by the Center for Science in the Public Interest, a Washington, D.C.-based advocacy group. Coca-Cola and Pepsi have also been big contributors to the opposition.

Lauren Kane, a spokeswoman for the beverage trade group, said there is no evidence that soda taxes make anyone healthier. “Obesity has been rising … while soft drink consumption has been declining,” she said. “It would defy logic to say that soft drink consumption is driving obesity.”

Overall, soda sales dropped 1.2 percent in 2015, according to Beverage Digest, which tracks the industry, continuing a downward trend.

Kane added that taxing any grocery item is a “slippery slope” that makes other groceries vulnerable to taxation.

To hear more about the campaigns for soda taxes, we spoke with Harold Goldstein, executive director of California-based Public Health Advocates, who has played an active role in some of these efforts. A transcript of the conversation below has been edited for clarity and space.

Q: What are the health and medical effects of drinking too many sugar-sweetened beverages?

It is now proven that sugary beverages are a leading contributor to obesity, diabetes and heart disease. When we consume liquid sugar, the body converts much of that sugar to fat in the liver, causing fatty liver disease. We now have an epidemic in this country of fatty liver disease.

There are studies showing, for example, if you drink two sodas a day for just two weeks, that your unhealthy cholesterol, your LDL cholesterol, will go up 20 percent and that your triglycerides will go up 20 percent. If you drink that amount for six months, the amount of fat in your liver will go up 150 percent. This is a dramatic impact in a short period of time because our bodies are not designed to consume liquid sugar.

Q: How big is the problem of obesity and diabetes in the U.S.?

The obesity and diabetes epidemics are among the most fundamental public health problems facing our country today. They impact every demographic group. At the same time, they are a particular problem in low-income communities and communities of color, in large part because it’s in those communities where there is the least access to healthy food and the least access to opportunities to be physically active.

We know that diabetes rates are going to increase by 80 percent in the next five years, costing the state $15 billion more in direct health care costs. With that kind of money on the table … it is imperative that we invest in diabetes prevention. Whether it is through a soda tax, through the state legislature or state general funds, it is time to establish a major statewide diabetes prevention campaign in California.

Q: A recent report by your organization and the UCLA Center for Health Policy Research found that more than half of Californians have either diabetes or prediabetes. Aside from sugar-sweetened beverages, what else is causing this?

We have created a world that is designed for diabetes. We have fast food outlets on every corner. We have staggering portion sizes of sugary beverages and restaurant meals and everything from bagels to burgers. We have gotten rid of [physical education] in schools. We allow unregulated advertising of unhealthy products to children.

Q: Why target sugary beverages and not other junk food?

A: If you eat a candy bar, it takes hours to digest it. The liquid sugar is just floating sugar molecules and we absorb that sugar in as little as 30 minutes. The research is continuing to show that sugar itself is a particular problem, and perhaps the biggest problem. We know that the body turns sugar into fat. [Soda] is the right place to start. It represents half of the sugar in the food supply, it is the largest source of sugar and our body treats it differently.

Q: In Philadelphia, the mayor argued for the new tax based on the revenue it would bring in, rather than the health risks of soda. Do you think that helped get it approved?

I think different communities are going to support soda taxes for different reasons, in large part based on what the funds are going to be used for. In Berkeley, the revenues go into the general fund. City council members wanted that money to be dedicated to obesity and diabetes prevention efforts, as they have done. That was something clearly important to voters in Berkeley. In Philadelphia, the funds are dedicated to a variety of things, especially pre-K [education] in low-income communities and parks and rec programs. It is important that through this democratic process, residents get to decide how they want to use the revenues raised by such a tax.

Q: The effort to pass a soda tax in California died in committee this spring. Can you explain what the bill would have done and what happened to it?

The bill would have established a 2 penny-per-ounce fee on sugary beverages. As a fee, it would have required that all the revenues raised be dedicated to mitigating harm caused by those products. As has happened now five times in the state legislature, the beverage industry put their corporate might behind their lobbying efforts and successfully killed the bill.

Q: How difficult is it to overcome opposition by the soda industry?

What we are learning is that it’s far easier to enact soda taxes at the local level than at the state level in California. The beverage industry has enormous power in the state Legislature. And getting it passed in California requires a two-thirds vote in the legislature, which is a big hurdle. Other states don’t have that hurdle. There are a number of states that are currently working on it in one way or another.

Q: Critics say that soda taxes won’t reduce obesity rates and give government too much control over consumer choice. What do you think about the argument that this might not be the best way to address diabetes and obesity?

Soda taxes are one way to address the diabetes and obesity epidemic. What has been shown in Berkeley and Mexico, where the tax has now been in effect for quite some time, is that those taxes reduce consumption of sugary beverages, which we know are a leading contributor to the epidemic.

At the same time, those taxes provide funds to pay for much needed programs in communities. Soda taxes aren’t the end-all and be-all of obesity and diabetes prevention. There is a lot more that can and needs to be done to address the epidemic.

Q: As public health advocates like yourself work to reduce access to these beverages, what sort of alternatives are you promoting?

The biggest solution is to encourage and support people to drink water instead of sugar. It is the simplest, easiest change that any of us can make to reduce our chance of getting diabetes. Sixteen teaspoons of sugar in every 20-ounce beverage is way more than our body can handle and still be healthy.

Q: Will there be another try to get a statewide tax in California?

I am sure there will be, with Philadelphia passing theirs. One or more of the soda taxes in the Bay Area are likely to pass. I think that in the coming years, states around the country will also establish soda taxes.

Published from Kaiser Health News under a creative commons license. KHN is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.