Please send items of interest for the E-News -- and any other feedback -- to E-News editor Dave Cundiff, MD, MPH. Thanks!
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CONTENTS:
1) AAPHP Opposes FDA-Tobacco Bill, S.625/H.R.1108
2) Dr. Goldstein shares NBPHE plans for PH "certification"
3) Call for AMA Resolutions
4) Save the Date! AAPHP Annual Meeting, Chicago, 2007-06-23
5) 2007 Dues Announcement
6) John Snow, cholera, sewage, and making big cities livable
7) Philip Morris - Friend of Children?
8) Member News
9) Corrections and Acknowledgements
1) AAPHP Opposes FDA-Tobacco Bill, S.625/H.R.1108:
In our 2007-02-20 E-News, we reported on the newly introduced "Family Smoking Prevention and Tobacco Control Act", S.625/H.R.1108. A copy of this 155-page bill is at http://www.aaphp.org/WebLinks/Introduced%20Bill%20Language%20FDA-Tobacco021607.pdf. (The URL is long, like many of those in this issue; remember that long URL's may require cut-and-paste in your browser.)
This is similar to a previous bill analyzed by public health physician MICHAEL SIEGEL, MD, MPH at AAPHP's November 2004 membership meeting (http://www.aaphp.org/minutes/nov704.pdf, agenda item #23). At the time, Dr. Siegel noted the implicit "stamp of approval" that FDA regulation would convey. He noted that a new Federal initiative, whether effective or not, would deprive other Federal, state, and local anti-smoking initiatives of "political capital". He cautioned that compliance with federal rules (no matter how weak), would shield the tobacco industry from future litigation about industry behavior. Finally, he warned us that industry support for this litigation would be touted as evidence that the industry has "changed its ways", creating undeserved goodwill for the tobacco industry. Dr. Siegel then went on to describe several regulatory weaknesses of the bill itself.
Reviewing the 2007 FDA/Tobacco bill, AAPHP Tobacco Control Task Force Chair JOEL L. NITZKIN, MD, MPH, DPA came to essentially the same conclusions -- plus a few more. (http://www.aaphp.org/WebLinks/022207JLNAnalysis_FDA_%20Tobc.pdf) Dr. Nitzkin noted that this bill, while denouncing all tobacco products and setting high standards for "reduced risk" products, does nothing meaningful to discourage use of currently formulated cigarettes. Under this bill, the FDA is specifically prohibited from reducing nicotine yields to zero, and from institutionalizing most currently proven tobacco control methods. While prohibited from child-oriented advertising -- such as "Hey, kids, smoke this!" -- tobacco companies can still use far more effective "forbidden fruit" messages, such as "Smoking is an adult decision. Kids shouldn't smoke. We don't want kids to smoke."
We reviewed the positive pictures of the bill presented by the Campaign for Tobacco Free Kids (CTFK) at http://www.tobaccofreekids.org/reports/fda/summary.shtml. CTFK doesn't mention that this bill was drafted in secret negotiations with Philip Morris. For that information, Roll Call subscribers can see a full article, Mullins B: "How Philip Morris, Tobacco Foes Tied the Knot". Roll Call, October 5, 2004. http://www.rollcall.com/issues/50_39/news/7035-1.html. Others can see excerpts at http://no-smoking.org/oct04/10-06-04-1.html, http://www.notobaccodeal.net/news.htm, or http://www.tobacco.org/articles/org/ctfk/?top_only=1&starting_at=45.
CTFK doesn't mention that some of the bill's proposed advertising restrictions are already in the 1998 "Master Settlement Agreement", thus basically superfluous. CTFK doesn't acknowledge that many of the bill's proposed advertising restrictions will not pass the Supreme Court's First Amendment tests, laid out in Lorillard v. Reilly, 2001. In-store displays (which favor dominant manufacturers) are the most likely to be preserved on First Amendment grounds, but other ads may also persist. (http://www.law.umkc.edu/faculty/projects/ftrials/conlaw/lorrilard.html)
Because this bill is most likely to cause a net harm to the public's health, AAPHP opposes S.625/H.R.1108. Our written statement to the Senate Health, Education, Labor, and Pensions (HELP) Committee is at http://www.aaphp.org/WebLinks/022607FDATobcEnzi%20_2_.pdf. We urged "that the 'fast track' for this legislation be temporarily derailed to allow in-depth consideration" of the bill's actual language and effects. We said, "Our reading of this bill, in its current form, leads us to believe that it offers no possibility of any public health or other community benefit."
A summary of the entire HELP Committee hearing is at a link at http://www.aaphp.org/WebLinks/SBupdatefeb28.html. Video of the 2007-02-27 hearing is available at http://help.senate.gov/Hearings/2007_02_27/2007_02_27.html. The only witness allowed to testify personally against the bill was family physician and longtime activist ALAN BLUM, MD, founder of the "Doctors Ought to Care" organization. Dr. Blum's testimony is at http://www.aaphp.org/WebLinks/BlumTestimony07-02-27.pdf. Since the hearing, AAPHP has worked with Dr. Blum to develop additional educational and advocacy materials.
Many individual and organizational opponents of the bill have registered their opposition on AAPHP's "Stakeholders" list at http://www.aaphp.org/WebLinks/stakeholders.html. Most of the bill's supporters have chosen to register their support in other forums. AAPHP officers have provided assistance where possible. Additional registrations of individuals' and groups' positions are welcome.
The next move is likely to be the consideration of proposed amendments by the Senate HELP Committee in late April. The bill's proponents support this bill exactly as introduced, and say that it cannot be improved by any amendment. Opponents say this stance is further evidence that the secret negotiations with Philip Morris have skewed bill supporters' judgment.
AAPHP welcomes communication from all Public Health physicians and from other health advocates. We'll present a selection of cogent arguments at http://www.aaphp.org/Feb07tobaccbill.html.
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2) Dr. Goldstein shares NBPHE plans for PH "certification":
In the 2007-02-20 E-News, we reported on "Board Certification in Public Health for non-physicians", noting a new effort to "certify" qualifications of Public Health graduate-degree holders who pass a qualifying exam from the "National Board of Public Health Examiners" (NBPHE). We apparently got the NBPHE's funding source wrong -- see below under "Corrections and Acknowledgements" -- but the rest of the story appears to have been accurate.
In response to this article and subsequent telephone conversations, public health physician BERNARD D. GOLDSTEIN, MD volunteered to speak with the AAPHP Board about the NBPHE's plans.
Discussions with Dr. Goldstein at the 2007-03-19 AAPHP Board audioconference were courteous and collegial. Nearly all participants had strong beliefs and feelings about the issues addressed by NBPHE's proposal.
A record of Dr. Goldstein's presentation, and of AAPHP Board members' responses, is in the draft minutes of the AAPHP Board's 2007-03-19 meeting at http://www.aaphp.org/minutes/2007/minutes_winter07.html. During his presentation, Dr. Goldstein referred to a slide presentation "NBPHE MARCH-07", which is posted at http://www.aaphp.org/minutes/2007/NBPHE_MARCH-07.pdf.
Dr. Goldstein will convey the AAPHP Board's concerns to the NBPHE. We hope for a positive and constructive response.
Further information about the National Board of Public Health Examiners is available at their Web site, http://www.nbphe.org.
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3) Call for AMA Resolutions:
AAPHP's AMA Delegate ARVIND K. GOYAL, MD, MPH and Alternate Delegate JOSEPH L. MURPHY, MD request that proposed AAPHP Resolutions for the AMA be sent to AAPHP by Monday, April 30, 2007. This will allow time for internal consideration of the resolution's expected public health impact, and for any necessary editing.
Please send proposed resolutions to the Secretary "cundiff@reachone.com" and ask that they be forwarded to AAPHP's AMA delegation. Drs. Goyal and Murphy are also available for consultation, if you want to discuss your ideas or if you aren't sure how to write them up most effectively for consideration within AAPHP and at the AMA.
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4) Save the Date! AAPHP Annual Meeting, Chicago, 2007-06-23:
At its 2007-03-19 teleconference, the AAPHP Board approved SATURDAY, JUNE 23, 2007 for AAPHP's 2007 General Membership Meeting. The meeting will be held at the Hilton Chicago, 720 South Michigan Avenue, Chicago IL, beginning just after the adjournment of the AMA House of Delegates (about 3 pm CDT) and extending, with breaks, to 7 pm CDT.
We expect business sessions, talks and discussions with AMA leaders (including AMA President-Elect RONALD M. DAVIS, MD, MS, if his schedule allows), and educational sessions. Any AMA member in Chicago may attend meetings of the Reference Committees of the AMA House of Delegates, with other associated sessions and exhibits.
The Annual Meeting is open to all AAPHP members and guests. There is no fee or registration requirement. It's nice to know if you're coming, though, so we can plan for the right number of people. We hope to see you there!
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5) 2007 Dues Announcement:
AAPHP remains a vibrant organization because of YOUR involvement. If you haven't done so already, please download AAPHP's 2007 Membership Form at http://www.aaphp.org/Membership/2007MembForm.pdf and send it to us by fax or postal mail.
AAPHP dues can be paid by credit card -- either by faxing the membership form to (847) 255-0559 or by calling the AAPHP Secretary's secure mobile/voicemail at (360) 870-2483.
Please download and print the "2007 Membership Brochure" at http://www.aaphp.org/Membership/AAPHPBrochure20061105.pdf for your colleagues. Resident and medical student membership is still FREE for 2007. All other dues categories are modest and may be tax-deductible as a business expense.
For purposes of AAPHP membership, a Public Health Physician is "a physician dedicated to helping guide a community, agency, health organization, medical office or program in pursuit of group or community health goals." (http://www.aaphp.org/bylaws/Bylaws_2005_revdec05.htm, Article I). If you've read this far, that definition probably includes YOU! Please join, or renew your AAPHP membership, today.
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6) John Snow, cholera, sewage, and making big cities livable:
Steven Johnson, author of Everything Bad is Good for You, published a new book in late 2006 about epidemiology and citizen-based public health. The Ghost Map, about London's cholera outbreak in summer 1854, turns public health history -- apparently with a great deal of scholarly research -- into a fascinating story!
The prologue, familiar to most public health physicians: Nineteenth-century London was built with informal, small-scale waste disposal systems -- including household-level disposal systems for urban sewage. Flush toilets, popular and widely installed by mid-century, increased the volume of sewage -- decades before the city built modern sewage collection systems -- and often routed sewage into rivers. Disposal of the dead, and of solid waste, was often chaotic.
Bad odors flourished, and so did disease. Obviously, bad odors CAUSED disease. Medical and public health authorities controlled disease primarily by suppressing odor sources, and by educating people to avoid malodorous places. Authorities were aware of "germ theories", but rejected them because of the overwhelming evidence favoring "miasma".
An August 1854 cholera outbreak in the Soho neighborhood seemed initially to fit the "miasma" pattern. It was a densely populated, smelly neighborhood. But a local clergyman, who knew the neighborhood and the neighbors, realized that the disease didn't favor the most crowded houses, nor the smelliest houses, nor the "immoral" houses. An experimental anesthesiologist, convinced since 1849 of cholera's waterborne transmission, viewed the 1854 outbreak as a "natural experiment" to prove or disprove his theory.
The anesthesiologist, John Snow, convinced city statisticians to collect data on water source. He found that cholera patients inside and outside the hardest-hit area generally had a demonstrable connection to water from the "Broad Street pump". After initially solving the outbreak, he convinced parish authorities -- somewhat reluctantly -- to shut down that pump. If the outbreak wasn't already over, it ended when the Broad Street pump was disabled.
The clergyman, Henry Whitehead, didn't believe the waterborne hypothesis. Believing his interviews would disprove Snow's theory, Whitehead gathered risk-factor information on hundreds of neighborhood residents. Ultimately, Whitehead's efforts to disprove Snow's theory led to stronger and stronger evidence for its validity. The two became friends and collaborators, mutually providing evidence to the parish's Vestry Committee for its final report on the outbreak.
Snow explained to Whitehead, "the time will arrive when great outbreaks of cholera will be things of the past, and it is the knowledge of the way in which the disease is propagated which will cause them to disappear." (p. 181) It took twelve more years for Snow's theories to attain "consensus" status in medical circles. (p. 209-213) By then, John Snow was dead at age 45 from a stroke.
Steven Johnson frequently connects his epidemiologic narrative to another narrative about the nature of modern cities, and about the many problems that must be continually solved in order for large cities to thrive. Did the importation of tea from India help London grow? Is beer a prerequisite for a city without refrigeration? How do wage rates determine a city's primary recycling methods?
Johnson notes that cities facilitate epidemiologic investigation: "The Broad Street pump was a kind of urban antenna, sending out a signal … that allowed humans to 'see' V. cholerae without the aid of microscopes. But without those thousand bodies crowded around the pump, the signal would have been lost, like a sound wave dissipating into silence in the vacuum of space." (p. 171)
Within months of the outbreak, Snow produced a new kind of map -- based on proximity to various water sources, but measured by walking distance rather than "as the crow flies". Initially dismissed as an oddity, this map supplied persuasive evidence for the waterborne theory of cholera transmission. But it couldn't have been produced without close knowledge of the area. Johnson points out that epidemiologic investigations are often most productive when local residents are closely involved with the work. (p. 202)
In his Epilogue, "Broad Street Revisited", Johnson speculates on the vulnerability of modern cities to disease and terrorism. A Brooklyn resident, he notes the specialization, diversity, and scholarship that large cities can support. Johnson speculates on ways in which epidemiology, risk analysis, and information technology can help us maintain the safety and livability of large cities around the globe. (p. 231-256)
To keep the narrative readable and compelling, Johnson appends extensive notes and bibliography at the end. He pays homage to several John Snow scholars, in a way that suggests careful research and documentation.
The Ghost Map is available at medical and general bookstores, including the bookstore where I bought it, and online. Additional resources on John Snow are available at the UCLA John Snow web site, http://www.ph.ucla.edu/epi/snow.html, recommended by AAPHP Webmaster Kim Buttery, MBBS, MPH.
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7) Philip Morris - Friend of Children?
Tobacco giant Philip Morris has been on an image makeover in recent years. They renamed their holding company "Altria". They have advocated for FDA regulation of tobacco -- as long as it's on their terms. They have managed some great publicity -- particularly Joe Nocera's 2006 article "If It's Good for Philip Morris, Can it Also Be Good for Public Health?", in the New York Times Magazine, June 18, 2006 (http://www.nytimes.com/2006/06/18/magazine/18tobacco.html?pagewanted=1&ei=5090&en=6f161cfc2cb0a4b7&ex=1308283200&partner=rssuserland&emc=rss).
Has Philip Morris really changed? Has it earned the privilege of co-writing the nation's tobacco regulations?
Oregon's Governor Kulongoski has proposed a cigarette tax increase to fund children's health care. The introduced version of this measure is at http://www.leg.state.or.us/07reg/measpdf/hb2200.dir/hb2201.a.pdf.
Your editor recently found a pad of consumer messages in an Oregon convenience store. With capitalizations intact, this speaks for itself:
SPEAK OUT & SAY NO TO CIGARETTE TAX INCREASES
Governor Kulongoski has proposed an increase in the Oregon state cigarette excise tax from $1.18 per pack to $2.025 per pack. This tax increase means that adult smokers in Oregon could pay over $20.00 per carton in state excise taxes alone, equal to that of Washington and the third highest cigarette state excise tax rate in the country. Enough is Enough!
Make your voice heard
TAKE ACTION TODAY!
CALL (800) 332-2313 (outside Salem)
(503) 986-1187 (in Salem)
You may want to tell your legislator:
- Stop targeting adult smokers with increased taxes and start finding stable revenue solutions to support new programs!
- Taxes should be reasonable and shared by everyone not just smokers.
- An issue as important as healthcare shouldn't be funded by an unstable and declining source of revenue such as cigarette taxes.
VOTE NO on HB2201!
TAKE ACTION TODAY
CONTACT YOUR ELECTED OFFICIALS
AT (800) 332-2313 & 503-986-1187 (in Salem)
Paid for by Philip Morris USA
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8) Member News:
AAPHP Life Member DONALD S. KWALICK, MD, MPH received AAPHP's Ben Freedman, MD, MPH award for lifetime achievement, on Saturday, March 10, 2007, in Las Vegas. Dr. Kwalick has been a staunch supporter of our specialty and of AAPHP, and a mentor to many other public health physicians, and a public health leader nationwide and in Nevada.
AAPHP Member MARK B. JOHNSON, MD, MPH was recently elected as President-Elect of the American College of Preventive Medicine (ACPM). Dr. Johnson is scheduled to serve as ACPM's President from winter 2009 to winter 2011.
Thanks and congratulations to Drs. Kwalick and Johnson!
Also thanks to AAPHP's new and renewing 2007 members, including Satya Ahuja, MD; Charles E. Alexander, MD, DrPH; Mary Alice Anderson, MS, MD, MPH, MA; Richard W. Biek, MD, MPH; David D. Blaney, MD, MPH; Lynn R. Blavin, MD; Wendy E. Braund, MD, MSEd; Kathy K. Byrd, MD; Karen A. Chapman, MD, MPH; Curtis E. Cummings, MD, MPH; Dave Cundiff, MD, MPH; Virginia Dato, MD, MPH; Mario P. DeMarco, BS; Nila Desai, MD, MPH; Herman M. Ellis, MD, MPH; James D. Felsen, MD, MPH; Dominique Fradin-Read, MD, MPH; Madison W. Gay, MD; Philip Gioia, MD, MPH; Carolyn H. Grosvenor, MD; Shauna Guthrie; Steven Hale, MD; Raam Hirlekar, MD; Arthur C. Hollister, MD, MPH; Supriya Janakiraman, MD; Claude L. Jones, DO, MPH, MBA; C. William Keck, MD, MPH; Susan B. Kern, MD; Katayoun Khosravani, MD, MS; Curi Kim, MD, MPH; Clifford A. Kolba, DO, MPH, EdD; Tony Kuo, MD, MSHS; Henry M. Kurban, MD, MBA; Kim Kuri, MD, MPH; Lucius M. Lampton, MD; Anne P. Lanier, MD; Bruce Leistikow, MD, MS; Iraj Lou, MD; Sara E. Luckhaupt, MD, MPH; Douglas A. Mack, MD, MPH; Jean Malecki, MD, MPH; Charles C. Mashek, MD, MBA; Kelli K. Maw, MD, MPH; Wayne Z. McBride, DO, MPH; Venita Morell, MD; Joseph L. Murphy, MD; Jolene Nakao; Marietta Nelson, MD; Van M. Nguyen, MD; Erika G. Olson, MD; David G. Ostrow, MD, PhD; Doruk Ozgediz, MD, MPH; Jay D. Parkinson, MD; Thomas Prince, MD; Padmini D. Ranasinghe, MD; Alfio Rausa, MD, MPH; Stan Reedy, MD, MPH; Linette Scott, MD, MPH; Arlene G. Seid, MD, MPH; Kevin M. Sherin, MD, MPH; David Shih, MD, MS; Dexter W. Shurney, MD, MPH, MBA; Olapeju Simoyan, MD, BDS, MPH; Suzanne G. Smith, DO, RN; Richard Solero, MD; Tung M. Tran, MD; Patrick Tranmer, MD, MPH; Peter T. Troell, MD; Chris Ugwu, MD, MPH; Christina Weng; Rachel K. Wierzba, MD, MPH; Leah Z. Ziskin, MD, MS; and AAPHP's Life Members.
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9) Corrections and Acknowledgements:
Your editor had almost forgotten how to spell "erratum" -- let alone when to use "errata" -- until the 2007-02-20 issue. It's good to hear about your errors from your friends, and I sure did!
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In our 2007-02-20 story, we reported that the National Board of Public Health Examiners (NBPHE) had been funded by the Robert Wood Johnson Foundation. Since publication, public health physicians BERNARD D. GOLDSTEIN, MD and HARRISON SPENCER, MD each told me that the Robert Wood Johnson Foundation has not funded NBPHE.
At the 2007-03-19 AAPHP Board meeting, Dr. Goldstein clarified that NBPHE's startup funding has come from "various foundations" and from "loan guarantees". (When asked later to be more specific, he declined -- saying that if he gives us a partial list, someone omitted from the list might be displeased with the omission.) AAPHP regrets the error.
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Due to a transcription error, the referenced URL was incorrect on the 2007-02-20 story "Masks may work pretty well to prevent disease". Dr. Toner's full article is found at
http://www.upmc-cbn.org/report_archive/2007/02_February_2007/cbnreport_02152007.html. Thanks to AAPHP Member ADRIENNE LEBAILLY, MD, MPH for pointing this out!
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Also in the 2007-02-20 issue, we reported that Larry Sands, DO, MPH would become Chief Health Officer of Southern Nevada Health District "upon Dr. Sands' retirement". Thanks to Shelli Clark, from Southern Nevada Health District, for noting that we should have said "upon Dr. KWALICK'S retirement"!
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In addition to those listed above, thanks to WILLIAM T. GODSHALL, MPH, Executive Director of Smokefree Pennsylvania, for background information about tobacco issues; and to SYRINDA SHARPE, General Books representative at University Health Sciences Bookstore (877) 335-READ, for recommending The Ghost Map to your editor soon after it came out.
Thanks also to all of you for your support of AAPHP!
Dave Cundiff, MD, MPH (cundiff@reachone.com)
AAPHP Secretary and E-News Editor************ About AAPHP E-News ************
This message is an electronic update from the American Association of Public Health Physicians (AAPHP) to public health physicians.
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