In Footnote’s Ask An Academic series, scholars answer reader questions fielded from social media. In this edition, public health expert Stephanie Morain weighs in on vaccination policy, programs to encourage breastfeeding, and other upcoming challenges for the field of public health.
Are policies that promote breastfeeding, like NYC’s Latch On initiative, tantamount to government policing of women’s bodies?
Policies aimed at promoting breastfeeding can provoke considerable disagreement, as evidenced by the controversy that erupted over Latch On NYC. Critics lambasted the policy for “sucking the choice out of parenting,” and “shaming” women who use formula. To be fair to NYC, many of the criticisms were hyperbolic. Nevertheless, they reveal a broader challenge for government efforts to promote breastfeeding: What are the limits of government authority to promote healthier behaviors? Should breastfeeding be viewed as a public health issue, given the health benefits it confers on breastfed infants and mothers alike, or is it instead a matter best reserved for women (and their families)?
While numerous public health policy decisions require navigating the boundaries individual choice and population health goals, this decision becomes especially complex when dealing with infant feeding practices, because they operate against the backdrop of a broader social debate about gender, social norms, and what it means to be a “good” mother in contemporary American society. For those who are interested in this debate, I’d recommend checking out Joan Wolf’s book Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood. I also have an article on the ethics of breastfeeding promotion campaigns, co-authored with Anne Barnhill, that’s due out in the International Journal of Feminist Approaches to Bioethics later this year.
What will be the most important challenges in public health in the next 15 years?
Only time will tell what the future holds for public health. However, there are several challenges for the field in the years ahead. First, we can likely anticipate further policymaking activity on medical marijuana. Legalization – for medical purposes or more broadly – presents a range of ethical, legal, and administrative challenges for health departments. These include challenges surrounding the development and operation of statewide registry and licensing programs; safety concerns presented by edibles and unintentional consumption by children; and debates over inappropriate prescribing, which are exacerbated by the limited state of clinical research on marijuana’s effectiveness as a therapeutic agent.
Another challenge will be identifying and implementing effective strategies to combat prescription drug overdose. According to the CDC, fatal drug poisonings increased nearly 500% from 1980 to 2008. Unintentional drug overdoses are now responsible for 36,000 deaths each year in the U.S., and the majority of these deaths are attributable to prescription pain killers. Addressing this epidemic will likely require a diverse set of strategies, including changing physician’s prescribing patterns; implementing effective Prescription Drug Monitoring Programs (PDMPs) to reduce abuse; increasing access to naloxone, an effective treatment for opioid overdoses; and reducing the stigma of drug addiction, which may serve as a barrier to accessing effective treatment.
What role should the government play in vaccination policy?
The Disneyland measles outbreak has brought renewed attention to childhood vaccination policies. In the U.S., the authority to require childhood vaccination rests with individual states, generally through legislative mandates that condition school entry upon proof of immunization. All 50 states and the District of Columbia require children to provide documentation that they have met their state or jurisdiction’s respective vaccine requirements before attending school. All states provide exemptions for children with medical contraindications to vaccination, such as those who are severely immunocompromised from HIV/AIDS or another condition or those who have a severe allergy to a vaccine component. Forty-eight states and DC also offer exemptions for non-medical reasons: 48 for religious reasons and 20 for “philosophical” reasons. The two notable exceptions are Mississippi and West Virginia, who permit only medical exemptions. Not surprisingly, they consistently have among the highest vaccination rates in the country.
While medical exemptions are relatively uncontroversial, the issue of exemptions for non-medical reasons has been more contentious. While some support such exemptions as a mechanism to avoid violating religious liberty and a parent’s rights to autonomy in decisions about raising their child, others argue that non-medical exemptions raise issues of social equity, as those who opt-out benefit from herd immunity without assuming the small-but-real risk of adverse events associated with vaccination. The recent measles outbreak and similar outbreaks of vaccine-preventable illnesses among unvaccinated individuals have fostered renewed interest in reducing the number of parents who obtain non-medical exemptions for their child.
Several options exist for states to increase their vaccination rates. Some state legislatures are currently considering revisions to their legislative vaccination mandates, with several proposing new limits on non-medical exemptions. For example, bills have been introduced in both the Vermont and California State Senates to remove the philosophical exemption from their state’s respective vaccine mandates. Other strategies may exist, short of changing the vaccination requirements. Some studies have found that the procedures required to obtain a non-medical exemption can influence the rate of vaccine exemptions. For example, some states only require that parents complete a form at a child’s school or local health department in order to obtain an exemption. Other states require more complex and time-consuming procedures, requiring parents to write a statement describing their specific objection to vaccination and, in some cases, requiring that letter to be notarized. Perhaps not surprisingly, states with simpler procedures for opting out of vaccines have far higher rates of non-medical exemptions.
In your articles on Footnote, you emphasize the importance of public input and transparency in forming health policy. Do you think governments have done a good job of this so far? If not, how can they improve?
The idea that ordinary citizens should have an opportunity to influence government policy is arguably old as democracy itself. However, we’ve recently seen a renewed interest in engaging individuals in various domains of health policy and practice – as consumers, patients, and citizens. In particular, there has been a huge push behind engaging patients in health research, due, in no small part, to a large influx of federal dollars from the Patient Centered Outcomes Research Institute. This effort has the potential to transform the whole lifecycle of research, from the early stages of developing research questions to best meet the needs of patients, through engaging patients in the dissemination of research findings to speed their translation into changes in clinical practice and care delivery.
I would love to see a similar commitment to engaging citizens in health policy, particularly in the development of public health policy. There are some great examples of health departments that have made a real investment in engaging citizens around tough policy decisions. One example is a Maryland-based project that held community forums with citizens and relevant stakeholders to evaluate what ethical principles should be used to allocate scarce life-saving medical resources during a catastrophic event like an influenza pandemic. Similar projects aimed at engaging the public in disaster preparedness have been undertaken in other states and localities. While these engagement exercises are resource intensive, they have demonstrated that lay persons are capable of deliberating about complex policy decisions, and they can serve as a source for information about both the acceptability and feasibility of different policy approaches.
