November 8, 2021 | Kimberly Randall, Lister Hill Center Program Coordinator
Photo courtesy of Getty Images
Background
In 1975, Alabama Code § 22‐8‐4 went into affect, giving medical autonomy to minors. The law reads:
When minor may give consent generally.
Any minor who is 14 years of age or older, or has graduated from high school, or is married, or having been married is divorced or is pregnant may give effective consent to any legally authorized medical, dental, health or mental health services for himself or herself, and the consent of no other person shall be necessary.
Alabama is one of only a few states to have such a law on file allowing for minors to make their own healthcare decisions. However, the Alabama Department of Public Health announced a challenge to this law in late June, stating that parental consent would be necessary for any child under the age of 19 to receive the Pfizer-Biotech COVID-19 vaccine at a state-run clinic. Earlier this fall, Representative Chip Brown (R-105) proposed legislation (HB19) during a special session to require parental permission for any vaccine, however it was not passed.
Proposed Legislation
Presented to the Senate by Representative Arthur Orr and others, SB15 reads:
Notwithstanding Section 22-8-4, Code of Alabama 1975, no minor may receive a vaccination without the written consent of the minor’s parent or, if applicable, legal guardian. Institutions of education may not inquire into the vaccination status of a minor student without the written consent of the minor’s parents or, if applicable, the legal guardian. The Attorney General may commence a civil action to enjoin a threatened or continuing violation of this section.
Impact
Even with declining COVID cases, public health officials have continually stated the need for vaccinations. Dr. Nola Ernest, Legislative Chair for the Alabama Chapter of the American Academy of Pediatrics, told WPMI there is no medical reason vaccinations should require parental consent and the regulations are causing delays in the process. For example, teenagers who can legally drive may not have a parent present when they wish to get the vaccine, or a college freshman may not be able to return home for an appointment.
Research has also encouraged giving enhanced medical autonomy in teenagers. Morgan, Schwartz, and Sisti (2021) report that “children and adolescents have the capacity to understand and reason about low-risk and high-benefit health care interventions. State laws should therefore authorize minors to consent to COVID-19 vaccination without parental permission.” The Society for Adolescent Health and Medicine (2013) states that “a requirement to obtain parental consent for vaccination can present a significant barrier to improving adolescent vaccine uptake across all health care settings in which adolescents access care. The ability of minors to consent to vaccination can influence whether adolescents receive indicated vaccines during adolescent health care visits when parents are absent and when adolescents are seen for confidential services.”
Next Steps
Alabama Governor Kay Ivey signed SB 15, along with SB9, into law on Friday, November 5. If you want to make your voice heard on this or future legislation, click here to identify your elected officials.
Stay Informed
Want to learn more about Alabama healthcare? Check out these organizations.
October 28, 2021 | Anushree Gade, LHC Student Assistant
Mindful describes mindfulness as the “ability to be fully present, aware of where we are and what we’re doing and feeling”. We can practice mindfulness through meditation. However, mindfulness is not just limited to meditation but also various other practices. You can practice mindfulness throughout the course of your entire day. For example, when you wake up, you can sit in your bed, upright, or find a chair to sit in and just think to yourself about your intentions for the day. You can even practice mindful workouts. Being mindful about your day and your emotions helps you become more aware of your thoughts.
Researches Tang, Holzel, and Posner have shown that mindfulness practices contribute significantly towards improving physical and mental health; it also helps us improve our cognitive processes. It has also further shown that meditative practices promote awareness, attention, emotion regulation, and self-awareness. Not only does meditation improve these functions, but it also causes physical changes in the brain. Furthermore, the “Mindfulness-Based Stress Reduction and Change in Health Related Behaviors” study found the impact of mindfulness on health behaviors has shown that mindfulness enhances dietary choices, physical activity, and sleep quality. Not only does mindfulness promote mental health, but it also positively influences healthy behaviors. This makes it more important for us to discuss mindfulness and its significance in terms of our physical and mental well-being.
Close up of a mother and son doing yoga at home
Having said this, how are we promoting mindful practices in the state of Alabama? Earlier this year, in May, Governor Kay Ivey signed a bill that lifted the ban on yoga in public schools. This ban was initiated back in 1993 due to its implication of Hindu and Buddhist cultures on the elementary, middle, and high school children in Alabama. The Centers for Disease Control and Prevention has posited that the meditation involved in yoga helps those who practice yoga to de-stress and focus their attention better than those who do not. Though public schools across Alabama are allowed to teach yoga now, this bill comes with caveats. The bill still prohibits meditation alongside other things such as saying “Namaste” or even using chanting, mudras, or mantras. Yoga can significantly help children with de-stressing and focusing. Furthermore, in accordance with the research we discussed earlier, yoga can also help children be more self-aware and regulate their emotions at an early age. In the long-run, these children will be able to cope better with stressors and maintain good physical/mental health.
Located in Homewood, Ala., the Magic City Acceptance Academy is a local charter school that is working to promote mindfulness and better mental health in their students. Originally, the institution was founded to create an affirming LGBTQ environment, however, they have affirmed their commitment to increasing access to mental health resources by:
Assuring the presence of a social worker in the academy
Providing access to therapy groups
Including trained mental health professionals in the academy’s staff
Ensuring the existence of a functional crisis team/crisis response team
The social workers, mental health professionals, and teachers support the students through various areas of stress and hardship. Furthermore, they also utilize journaling and mindfulness in their everyday routines. Overall, this academy operates as a local example of how to integrate mindfulness practices and mental health resources in a school environment.
October 19, 2021 | Kimberly Randall, LHC Program Coordinator
Photo Courtesy of Getty Images
Written in 2013, Administration Regulation Number (ARN) 703 dictates the current co-pay system that allows inmates in the Alabama Department of Correction (ADoC) facilities to seek medical care. Constitutionally, inmates have a right to medical care while incarcerated as the Supreme Court referenced the Eighth Amendment’s prohibition against cruel and unusual punishment as a precedent for providing healthcare access to inmates. ARN 703 states that “all inmates have access to healthcare regardless of their ability to pay. No inmate shall be denied care because of a record of non-payment or current inability to pay for health services.” However, the prison co-pay system establishes that ADoC is not responsible for providing care free of charge when an inmate has the means to pay the designated amount for health services.
ARN 703 and similar legislations state that utilizing a co-pay method for healthcare prevents inmates from misusing healthcare services as well as “instilling inmate responsibility by having them make resource allocation decisions.” Forty-two states, along with the Federal Bureau of Prisons, utilize a copay system. Some states operate on a method more closely associated with a deductible, such as the state of Texas which charges $100 per calendar year for unlimited visits with a medical provider.
Recent research completed by the John Howard Association, an independent prison monitoring association advocating for prison reform and improving conditions for incarcerated persons, found that prison co-pays were the top source of stress for inmates, and over half of all inmates stating that they avoid healthcare due to the cost of the co-pay. According to Fisher and Hatton (2012), “co-payments contributed to delays in treatment, avoidance of health care professionals, unnecessary suffering, and poor health outcomes. … [and] place an unfair burden on prisoners who are poor, limit access to health care, and contribute to needless suffering and potentially to preventable deaths.”
While legislation dictates that co-pays should be waived in cases of chronic illness or mandated care, a qualitative research study found that oftentimes those exceptions aren’t equally granted or sometimes ignored entirely. Even in specific scenarios where a medical condition is covered without a copay, such as MRSA, the Center for Disease Control and Prevention identified the perceived costs as one of the leading factors in infectious disease outbreaks within prison systems. According to the Marshall Project, “with prisoners living in close quarters, any policy that deters people from going to the doctor also increases the risk of contagion.”
Healthcare for inmates takes up approximately 20% of prison spending, a key point when arguing for co-pays in the Alabama prison system. However, research conducted in other states such as Illinois shows that the funds collected from the co-pay system in inmates don’t even cover the administrative costs associated with operating it. Additionally, since the state is required to cover the costs associated with chronic conditions, some health researchers state that it may be cost-defective to charge co-pays as minor, treatable conditions can blossom into extensive hospital stays when medical treatment is delayed.
The cost of medical care is an increasingly heavy burden on the financial resources of the facility, state, or county. The cost needs to be controlled legally without affecting needed care.
Sick call can be and is abused by some inmates. This abuse of sick call places a strain on available resources, making it more difficult to provide adequate care for inmates who really need the attention.
Inmates who can spend money on a candy bar or a bottle of shampoo should be able to pay for medical care with the same funds—it is a matter of priorities.
It will do away with frivolous requests for medical attention.
It cuts down on security problems in transporting inmates to and from sick call by reducing utilization.
It instills a sense of fiscal responsibility and forces the inmate to make mature choices on how to spend money.
Arguments against charging inmates a fee for health care services include the following:
Access is impeded. A fee-for-service program ignores the significance of full and unimpeded access to sick call and the importance of preventive care.
Inmates are almost always in an “indigent” mode. They seldom have outside resources and most have no source of income while incarcerated. They most often rely on a spouse, mother, or other family member to provide funds they can use for toiletries, over-the-counter medications like analgesics and antacids, telephone calls, writing paper and pens, sanitary napkins, candy, etc. These “extras” become extremely important to one who is locked up 24 hours per day. The inmate may well choose to forgo treatment of a medical problem in order to be able to buy the shampoo or toothpaste.
The program sets up two tiers of inmates: those who have funds to get medical care and commissary privileges, and those who have to choose between the two.
Avoiding medical care for “minor” situations can lead to serious consequences for the inmate or inmate population, since the minor situation can deteriorate to serious status or lead to the infection of others.
Crowded conditions increase the risk of spreading infections, and effective measures need to be taken to reduce this risk. Daily sick call should be encouraged rather than discouraged. Co-pay has been identified as a contributing factor for outbreaks of methicillin-resistant Staph aureus (Centers for Disease Control and Prevention, 2003).
A properly administered sick-call program keeps costs down through a good triage system, which has a lower level of qualified staff see the complaining inmate first, with referral to higher levels of staff only as medically indicated.
Charging health service fees as a management tool does not recoup costs; rather, when looking at the increased administrative work involved or the long-term effect of the program, charging health service fees can cost more to implement than what is recovered.
Inmates frequently have low health literacy and may not understand the difference between medically significant and medically insignificant symptoms nor when it is important to seek medical services. Thus, it may be ineffective to expect inmates to determine when to pay for medical services.
Several organizations, including the NCCHC, advocate for the removal of a co-pay system. During the pandemic, many states eliminated co-pays for inmates to reduce the impact of the virus on the prison system. Additionally, states like California have voted to eliminate co-pays entirely. Alabama recently passed two pieces of legislation related to prison reform – a bill allocating nearly $800 billion to construct two new prison facilities in the state and an amendment to a previous bill that mandates supervised probation for non-violent offenders. Should the prison co-pay system be examined or overturned as well?
October 11, 2021 | Kimberly Randall, LHC Program Coordinator
Background
Alabama’s Department of Corrections operates the prison system for one of the highest rates of incarceration per capita in the United States, with 938 per 100,000 residents residing in jails, prisons, or other correctional facilities. Additionally, the United States, and subsequently Alabama, use the prison system as a default response to criminal activity with upwards of 70% of convictions resulting in incarceration, many of which are for non-violent offenses.
The massive number of incarcerated persons has led to overcrowded and underequipped facilities. Last month, the Alabama Legislature passed HB4, HB5, and HB6 which would allocate funds for the construction of new, state-of-the-art prison systems in the state. However, it fails to address the root of the problem of overpopulation – over sentencing.
In 2015, Alabama signed Code 15-22-26.2 into law, which mandated supervised probation for non-violent offenders:
(1) If the defendant is sentenced to a period of five years or less, he or she shall be released to supervision by the Board of Pardons and Paroles no less than three months and no more than five months prior to the defendant’s release date;
(2) If the defendant is sentenced to a period of more than five years but less than 10 years, he or she shall be released to supervision by the Board of Pardons and Paroles no less than six months and no more than nine months prior to the defendant’s release date; or
(3) If the defendant is sentenced to a period of 10 years or more, he or she shall be released to supervision by the Board of Pardons and Paroles no less than 12 months and no more than 24 months prior to the defendant’s release date.
However, this legislation only applied to individuals who are sentenced after the law went into effect.
Proposed Legislation
Proposed by Rep. Jim Hill, R-Moody, HB2 retroactively applies the mandated probationary period to individuals who were sentenced before 2015. It maintained the same probationary structure and restrictions, such as not being applicable to child sex offenders. The bill was one of two proposed pieces of legislation from Governor Kay Ivey focusing on prison sentencing reform.
Impact
While this legislation is intended to impact the overcrowding and limited resources of the Alabama prison system, it will have long-term health impacts for inmates, prison staff, and the community. According to researchers at Brown University, prisoner health is a volatile public health issue as correctional facilities often lack the resources to provide adequate healthcare. The majority of inmates will eventually return to their communities, bringing their health conditions with them.
The longer an inmate spends incarcerated, the greater their chances of disease, mental health issues, and chronic illness. The National Institute of Health lists having poor ventilation, limited opportunities for exercise, high levels of stress, poor sanitation, infestations with bugs and vermin, poor nutrition, tension, noise, lack of privacy, and lack of family support as contributing factors in poor inmate health.
Additionally, while HB2 works to get inmates out of prison facilities faster, increasing the number of prisoners granted mandated probationary periods decreases recidivism by as much as 30% when compared to end-of-sentence release, or fulfilling the entirety of their sentence in a correctional facility. According to the Equal Justice Initiative, “thoughtful and expanded parole remains the most effective mechanism for reducing the prison population without undermining public safety.”
In addition to the retroactive sentencing guidelines, the bill also ensures that inmates will be given a state-issued photo identification card, social security card, and birth certificate upon their release, a key hurdle in obtaining employment for many inmates, along with appropriate clothing and public transportation.
Many organizations have advocated for prison reforms, including the EJI, over the last decade; however, the bill has received criticism within the state, particularly from Alabama Attorney General Steve Marshall, who stated that law will only affect a few hundred inmates and doesn’t work to address the overall issue of overcrowding.
Next Steps
Governor Kay Ivey has already signed the legislation into law. It will go into effect on January 31, 2023. If you want to make your voice heard on this or future legislation, click here to identify your elected officials.
Stay Informed
Want to learn more about Alabama prison reform? We recommend following these organizations:
October 4, 2021 | Kimberly Randall, LHC Program Coordinator
Background
The state of Alabama operates the most crowded prison system in the United States, with some facilities operating at 272% capacity. The state also ranks last nationally in the amount of funding allocated per prisoner and has the fifth-highest incarceration rate nationally per capita. The combination of these facts has resulted in several civil, humanitarian, and health crises and subsequent lawsuits against the state, including a class-action lawsuit alleging abuse and inhumane conditions toward female inmates at the Julia Tutwiler Prison for Women, which was later settled by the state.
To read the investigation report from the Department of Justice, click here.
In the last few years, the U.S. Department of Justice launched an investigation under the Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997. The report determined Alabama prisons to “routinely violate the constitutional rights of prisoners” and failed to provide “adequate, humane conditions of confinement.” Additionally, a federal court ruled that the Alabama Department of Corrections failed to provide adequate mental health resources, suicide prevention, psychotherapy, programming, and out-of-cell time, resulting in a significantly higher rate of suicide and violence.
Former governor Robert Bentley proposed legislation in 2016 and 2017 to build new prison facilities; however, no bills were ultimately passed before Bentley left office.
Proposed Legislation
Alabama House Bill 4, proposed by Rep. Steve Clouse, allows the Alabama Corrections Institution Finance Authority to issue bonds up to $785 million to “implement a prison modernization plan” that will construct two 4,000-bed men’s facilities and a 1,000-bed women’s facility while closing several smaller correctional facilities in the process. It also provides funding for the renovation and/or improvement of several remaining facilities across the state. Alabama House Bill 5, also proposed by Rep. Steve Clouse, authorizes the use of $400 million from the American Rescue Act (intended to be used for emergency assistance related to the COVID-19 pandemic) to assist in constructing these prisons. Lastly, Alabama House Bill 6 appropriates an additional $135 million from the State General Fund to assist prison construction projects.
Impact
The construction of new prison facilities is expected to have significantly improved medical, mental health, and rehabilitation services. According to Fraser (2009), overcrowding in prisons results in lowered access to health care services, increased gang activity within prisons due to territorial disputes, an increase in individual mental health issues, an increase in violence and racism, higher spread of disease, and greater risk and stress to prison facility staff.
The rise of the coronavirus pandemic brought about new issues related to overcrowding as COVID infections spread in prisons over three times the rate of the general population. As of October 1, 427,326 inmates across the nation had tested positive for the virus resulting in 2,603 inmate deaths, while 114,275 prison facility staff had tested positive, resulting in 218 staff deaths. While the state of Alabama prioritized inmates and prison staff during the vaccination rollout, only 43% of prisoners have received the vaccine, ranking last in the nation. Diseases like COVID-19 spread rapidly in congregate settings, and prison overcrowding is a serious risk to public health in incarcerated populations.
The words “help we matter 2” are seen written in a window at the Cook County Department of Corrections (CCDOC), housing one of the nation’s largest jails, is seen in Chicago, Illinois, on April 9, 2020. – The jail has seen a rise in coronavirus cases after two inmates tested positive on March 23. The Cook County Sheriff’s Office reported that as of 5pm on April 9, 2020, 276 inmates and 172 Sheriff’s Office staff had tested positive for the virus. (Photo by KAMIL KRZACZYNSKI / AFP) (Photo by KAMIL KRZACZYNSKI/AFP via Getty Images)
The main point of contention regarding HB4, HB5, and HB6 came from the allocation of funding provided by the American Rescue Act. Representative Terri Sewell (D-AL) released a statement through her office criticizing the allocation of COVID-19 resources.
“I am deeply disturbed to learn that the State of Alabama is considering a plan to use $400 million of COVID-19 aid from the American Rescue Plan to build prisons, especially as COVID-19 rages on in our state! Alabama currently has the highest COVID-19 death rate in the country. To be clear, the current state of the Alabama prison system is abhorrent, but the use of COVID-19 relief funds to pay for decades of our state’s neglect is simply unacceptable.
“COVID-19 relief money should be used for COVID-19 relief. Period.”
It is unclear how or if the appropriation of ARP funds for prisons will impact the state’s response to COVID in the future.
Next Steps
While the Alabama House of Representatives and Senate have passed the bill, it will now go to Governor Kay Ivey to be signed into law. Ivey has been a strong supporter of the bill and is expected to sign with no objections. If you want to make your voice heard on this or future legislation, click here to identify your elected officials.
Stay Informed
Want to learn more about Alabama prison reform? We recommend following these organizations:
October 12, 2021 | Anushree Gade, LHC Student Assistant
Mental health is often defined as “emotional, psychological, and social well-being” (U.S. Department of Health and Human Services, 2020). It was not until recent times that there was more awareness of mental health. Furthermore, there is also a stigma associated with the discussion and acceptance of mental health which may vary with culture.
In certain Asian cultures, the stigma surrounding mental health is colossal. Discussing mental health is considered taboo in these cultures. These aspects of culture that impact mental health cause people of that culture to undermine their mental health and well-being. As a result of this, many avoid seeking medical care to address it and avoid talking about it (Nishi, 2012). This stigma can also be seen in African American culture. In one study, 63% of African Americans responded that mental illnesses are seen as signs of weakness (National Alliance on Mental Illness [NAMI], n.d.). In Hispanic culture, it is common to keep private challenges to one’s self. This lack of discussion on such topics inhibits the acknowledgement of mental health and also creates a gap in knowledge in mental health issues and symptoms. Furthermore, this can contribute to strengthening the stigma surrounding mental health in this culture (NAMI, n.d.). As we can see through these examples, culture influences the level of stigma that surrounds the topic of mental health; it can positively reinforce that stigma if there is a lack of awareness around it.
Development of Mental Health at UAB
The mental health of college students has been of growing concern in the past couple of years. A survey conducted by Dr. Sarah Ketchen Lipson in 2020 revealed that half of the students that were surveyed presented symptoms of depression or anxiety and at least 83% said that their mental health was negatively impacting their academic success (McAlpine, 2021). With increases in mental health issues in students across college campuses, it is necessary for university administrations to implement policies, programs, and services which address this.
UAB has implemented several initiatives and services that aimed to address the issue of mental health on campus. One such initiative was the UAB CARES Suicide Prevention Initiative. CARES stands for “communicate, assess, refer, educate.” The goal of the UAB CARES initiative is to help connect students experiencing mental health concerns to resources that are on campus and off in order to help them. This initiative was started in the Fall of 2018 and was unanimously approved by the University’s President and senior cabinet (University of Alabama at Birmingham [UAB], n.d.).
Through the development of the UAB CARES initiative, several recommendations were made after reviewing the existing policies at the time (and were unanimously approved). These recommendations are categorized into three main groups: Prevention and Awareness; Education; and Policies, Procedures, and Services. The full listing of recommendations can be found here. As a result of this initiative, UAB has established that students and faculty should all be able to have continuity in care to support their mental health. Furthermore, the initiative prompted campus wide education efforts on the various crisis response teams available to UAB faculty, students, and staff. Crisis Text Lines specific to UAB were established and the University also began to offer training through the Kognito At-Risk program. Below is a list of resources that UAB provides for students’ mental health!
Crisis Text Line
Do you need someone to talk to, but don’t feel like calling in? Well, you can utilize text to get access to the same service! The Crisis Text Line is a nationwide initiative that provides 24/7 text-based mental health support to those who need it. Text “UAB” to 741741. This partnership resulted from the Suicide Prevention Task Force's Recommendation 1.2
Training on how to approach individuals struggling with mental health issues and how to talk to them about their mental health in a supportive and well-intended manner. This partnership resulted from the Suicide Prevention Task Force's Recommendation 2.1
Crisis and Emergency Clarification
Student Counseling Services is not an emergency facility. Recommendation 3.4 from the Suicide Prevention Task Force called for clarification of the role of various crisis response services. https://www.uab.edu/students/counseling/crisis-emergency
Collegiate Recovery Community
Do you need support as you try and recover from alcohol, drug, or process addictions? The Collegiate Recovery Community brings together others that are also going through the recovery process. Those in the community empower and support each other as they go through the process of recovering. The Collegiate Recovery Community has weekly recovery meetings, organizes social events, and more.
Are you a student that lives on campus and is looking for mental health support or counseling after hours? Connect with your Counselor in Residence. The Counselor in Residence will be available via zoom from 6:30-7:30 PM on Mondays-Thursdays and from 1:00 PM to 2:00 PM on Fridays. The Counselor in Residence provides counseling, consultation, outreach, and emergency intervention/crisis care services.
Are you worried about the well-being of a close friend or an acquaintance? Submit a Student in Distress Referral Form to notify UAB’s Student Assistance and Support teams about a student’s concerning behaviors. This is a step that you can take to ensure the safety and well-being of whoever you may be concerned about.
Want to learn more about mental health, skills related to it, and ways you can sel-promote your mental health? Sign up for the Therapy Assistance Online program. This program offers a variety of educational videos to help you learn more about mental health, self-care, and mindfulness.
Are you interested in promoting mental health on the UAB Campus to your peers? The Mental Health Ambassadors program is for you! As a mental health ambassador, you can help develop educational programs to educate your peers about mental health, self-care, and more. You can also work to improve skills associated with addressing mental health concerns.
Are you looking for a LGBTQA community and resources? There are several resources at your disposal including safezone, The Gender and Sexuality Union at UAB, BorderTrans, and more. There are also a medical student group called MedPride: Gay/Straight Alliance and a graduate organization called GRADient.
Finding it hard to find a community? Togetherall is a platform that allows for peer-to-peer counseling and interaction, along with mental health training and resources to provide a toolkit for dealing with college-related stresses.
Are you a graduate student that is experiencing a crisis or need someone to talk to? Don’t hesitate and call the National Graduate Student Crisis Line at 1-877-472-3475. Individuals operating this crisis line are experienced and are able to cater to your needs as a graduate student.
B-Well App
The B-Well app focuses on individual’s wellness with features that help users monitor their wellness with features such as wellness journals and habit trackers; furthermore, the app provides users with links to other services offered by UAB
Emotional Support Help Line
Are you experiencing anxiety or stress because of COVID-19? Call in at 1-866-342-6892 to have free access to trained specialists who are experienced in providing support to individuals experiencing stress or anxiety. You can call this number any time of the day and any day of the week!
The field of public health aims to enhance and protect the health of individuals and the communities that those individuals are a part of (American Public Health Association [APHA], n.d.). The three core functions of Public Health include assessment, policy development, and assurance (Centers for Disease Control and Prevention [CDC], 2021). These core functions are broad categories that encompass the ten essential functions of public health. In recent times, policy surveillance has become a popular tool to assess and monitor policies and programs created by various levels of government and their effects on public health. Policy surveillance is defined as the “systematic, scientific collection and analysis of laws of public health significance” (Temple University Center for Public Health Law Research, n.d.).
Ongoing research, collection, and evaluation of laws relative to public health serve to identify trends and gaps in laws and how they impact the health of individuals and populations. Policy surveillance further promotes accurate evaluations of public health programs and enables accurate judgments on the viability of prevention measures that can be implemented. Policy surveillance also aligns itself with the three core functions of public health as it aids with assessment, policy development, and assurance. This literature review examines the implementation, outcomes, and impacts of various public health policy surveillance initiatives. Additionally, this literature review further discusses the magnitude of scholarship available regarding public health policy surveillance and its results.
Methods
The amount of literature available on each of the policy surveillance programs identified varied. The Public Health Law Research (PHLR) program has numerous papers published regarding the initiative itself and its contribution to policy surveillance. Similarly, the CDC’s Public Health Law Program (PHLP) has a significant amount of literature discussing their program available. The most comprehensive papers regarding both of these programs were published by Temple University’s Beasley School of Law due to its involvement with the PHLR program. Furthermore, both PHLR and PHLP were extensively used for various research purposes. Though their databases were not as frequently used as the ones mentioned previously, the Alcohol Policy Information System (APIS), State Tobacco Activities Tracking and Evaluation (STATE) system, and the Classification of Laws Associated with School Students (CLASS) databases were also employed to aid with advances in research.
Upon reviewing literature regarding policy surveillance initiatives, there seems to be a lack of literature surrounding the various initiatives covered in this literature review. Publications out of Temple University on PHLR and PHLP served as the primary sources of information. The author utilized Google Scholar to identify literature around these initiatives; initially, databases such as PubMed, Embase, and others failed to find literature related to policy surveillance initiatives. Various keywords were utilized to search through the databases, including “policy surveillance initiatives,” “policy surveillance programs,” “policy surveillance,” “LawAtlas,” “MonQcle,” “Temple University Beasley School of Law Public Health Law Research Program,” “Public Health Law Research Program,” “Public Health Law Program,” “APIS,” “STATE.” The databases did not yield any results to these keywords. Google Scholar, a search engine, efficiently identified scholarly articles related to the keywords used.
Overview of Policy Surveillance Initiatives
The Public Health Law Research Program (PHLR)
Founded by the Robert Wood Johnson Foundation (RWJF) and Temple University’s Beasley School of Law in 2009, the Public Health Law Research Program (PHLR) strives to establish policy surveillance as a scientific method for evaluating the impacts of laws on public health. Temple University provides technical and directional assistance to the PHLR program (Presley et al., 2015). Though it was not the first policy surveillance initiative, PHLR was the first to establish policy surveillance as a scientific study on the health impacts of laws. (Burris et al., 2016). The PHLR initiative identified which types of policies should be investigated concerning the topic of interest.
Did you know?
Health policy goes far beyond pharmecuticals or procedures. Health policy research has influenced recent legislature on evictions, paid time off for employees, and even taxes!
Furthermore, they established specific inclusion and exclusion criteria, described the laws and who they targeted, and established a search methodology (Burris et al., 2016). Due to a large amount of policy surveillance being conducted on various public health topics, PHLR developed LawAtlas, a software system designated to help with the dissemination of public health law research. LawAtlas provides the public with access to “Interactive Law Maps” as well as databases, codebooks, and protocols. Legal researchers at the Temple University Beasley School of Law manage LawAtlas and have developed similar software, MonQcle (Temple University Center for Public Health Law Research, 2012). MonQcle differs from LawAtlas in that it was created for more precise tracking of laws at various levels (local, state, national) on an international scale.
Furthermore, MonQcle allows researchers to edit, update, and share their research through the software system (Temple University Center for Public Health Law Research, n.d.). A significant amount of public health research has been conducted using LawAtlas and MonQcle; these software systems contain databases of various topics that greatly assist researchers. Using LawAtlas, two researchers identified differences in state laws regarding access, safety, and dispensing of medical marijuana. The study concluded that the effectiveness of the federal ban on marijuana is unknown (Klieger et al., 2017). The two software systems were additionally utilized to research Type 2 Diabetes, drugs and alcohol, youth sports concussion, distracted driving, and more.
CDC’s Public Health Law Program (PHLP)
The Center for Disease Control and Prevention’s (CDC) Public Health Law Program (PHLP), launched in 2000, is one of the first policy surveillance initiatives. One of PHLP’s goals is to stimulate extensive legal research on the impacts of laws on public health; additionally, it strives to disseminate public health law research to various professional communities. PHLP essentially focuses on taking a law-based approach to address multiple public health outcomes (Goodman et al., 2006). As the PHLP got involved in other projects, it magnanimously contributed to further establishing policy surveillance as a scientific approach to studying the impacts of laws on public health (Presley et al., 2015). The CDC PHLP has been conducting legal research on “electronic health information, prescription drug abuse, and state coroner/medical examiner systems” (Burris et al., 2016). Additionally, the CDC has also contributed to determining criteria, competencies, and methods for policy surveillance.
Other Policy Surveillance Initiatives: STATE, APIS, and CLASS
The CDC launched the State Tobacco Activities Tracking and Evaluation (STATE) system. Its purpose is to initiate research on state tobacco policies while also promoting awareness of tobacco policies. The STATE system, an application created by the CDC, contained a database with information similar to what was written in the CDC’s State Tobacco Control Highlights (1996). When it was initially launched, it lacked depth; however, a 2004 update and redesign of the STATE system included more detail on state laws regarding tobacco. The system became more interactive for users after the redesign (Burris et al., 2016). Data from the STATE system was further used to study state laws directed towards selling tobacco to minors and using electronic nicotine delivery systems (i.e. vape, hookah, e-cigarettes, etc.) indoors (Marynak et al., 2014).
The National Institute of Alcohol Abuse and Alcoholism (NIAAA) launched the Alcohol Policy Information System (APIS). This initiative aims to measure the impact of public policies on alcohol-related behaviors and develop a resource that promotes additional scientific endeavors regarding the effects of alcohol-related policies (Bloss, 2011). APIS launched its first public website in 2003 (Burris et al., 2016). Furthermore, the National Cancer Institute’s Classification of Laws Associated with School Students (CLASS) is an example of another policy surveillance initiative; it exclusively focuses on examining how state laws regarding school physical education and nutrition impact student health. They evaluate the impacts of these laws by observing student’s body mass index (BMI), their activity levels, and food choices (“About CLASS,” n.d.).
Commonalities and Differences Between the Policy Surveillance Initiatives
Each of the policy surveillance initiatives discussed possess databases that are downloadable for users. The Robert Wood Johnson Foundation’s Public Health Law Research (PHLR) program has databases on policies encompassing various topics. The PHLR is unique because they utilize two software systems, LawAtlas and MonQcle, to publicize the databases and provide an interactive experience for users. Other policy surveillance initiatives have downloadable databases; however, unlike PHLR, they did not develop their software systems. Furthermore, APIS, STATE, and CLASS focus primarily on state-level policies. By monitoring relevant policies at the state level, these programs more effectively determine the impacts of policies on target areas. The PHLR program encompasses laws at local, state, and federal levels. This allows for comparisons of policies between different countries.
Moreover, each policy surveillance initiative differs in terms of its methods for policy surveillance and their purposes. Each of them has different topics that they focus on. For example, APIS focuses on alcohol-related laws, STATE focuses on tobacco-related laws, and CLASS looks at nutrition and physical education laws for schools. PHLR and PHLP are broader in terms of what they focus on compared to APIS, STATE, and CLASS.
Heads Up! The Lister Hill Center for Health Policy teamed up with the Office of Public Health Practice to implement a policy surveillance project of our own. We’ve been tracking municipal-level policies, programs, and initiatives since October 2019 and will publish our database soon! If you’re interested in getting involved, email us at lhc@uab.edu
Conclusion/Discussion
Policy surveillance is becoming an increasingly important practice in public health as professionals have come to realize the magnitude of impact laws have on the lives of individuals and communities. It is critical for public health professionals to understand the details of that magnitude. Furthermore, laws can also be implemented to prevent and address health issues. Understanding and monitoring policies at the local, state, and federal levels will allow professionals to identify which laws would be essential to promoting public health.
Though policy surveillance is becoming increasingly common in the recent decades through various initiatives, there is limited information on the specifics of these initiatives (i.e., methods, database organization, contributions to policy creation). There is a lack of recognition of the gift of policy surveillance to policy development; this is most likely attributable to the fact that policy surveillance is only a recently emerging practice. However, policy surveillance continues to be used as a tool to identify and fill gaps in policies that can further contribute to enhancing public health outcomes and initiatives.
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As a part of a weeklong course for Health Equity Scholars in April 2021, students in the UAB School of Medicine researched current health issues around the world. The Lister Hill Center for Health Policy will be share these evaluations from different students over the next few weeks to shed light on various situations. This post was written by Jasper Kennedy before the end of Alabama’s 2021 Legislative Session. SB 10 passed the state senate this year but its counterpart in the state house of representatives (HB1) never came up for a vote. A similar bill may or may not be proposed next year.
I have lived in Alabama all my life. I was born, raised, and educated here, including my ongoing training as a medical student at the University of Alabama at Birmingham. I am also a transgender person surviving in this state, and I’m worried about what SB10, which would criminalize providing healthcare to trans youth, would mean for my trans community as well as my colleagues.
Transgender youth are an incredibly vulnerable population that is at a greater risk than their peers for violence from others as well as suicide1. We know that the risk of suicide for trans youth drops dramatically when their gender identity is affirmed by the people around them2,3. SB10 would do more than prevent trans youth from accessing affirming healthcare; it would also enlist teachers and school counselors in outing trans students to their parents. In a population that already experiences increased discrimination, harassment, and outright violence at school1, this removes any possibility of finding supportive adults in an educational environment. Trans young people can have healthy, happy lives when they are supported by their families and schools. This bill would disrupt the tenuous balance many trans youth in our state have found. Make no mistake, this legislation will cause suffering and harm to young Alabamians.
SB10 would not only endanger trans youth but also interfere with the provider-patient relationship and medical decision making. It would make it a felony to provide any kind of transition care, including puberty blocking medications. These therapies have been used safely for years in the treatment of a variety of conditions from early puberty in youth to prostate cancer in adults. Puberty blocking therapies allow time for trans youth to think about what they want for their future without the urgency of impending changes to their bodies. Even more compelling is the evidence on the mental health benefits of these medications– puberty blockers are associated with decreased lifetime suicidality in trans people who want access to them4. Under SB10, a physician who provides a patient with this lifesaving therapy would face up to a decade in prison.
Alabama has long struggled to keep enough primary care providers in its borders to provide for our population. At UAB and other medical schools across the state, students are familiar with entreaties to stay and practice in Alabama, particularly in our underserved rural communities. Like many of my classmates, I am excited to be part of the next generation of primary care physicians, but we have to weigh our desire to stay and help the community we love against the opportunity to get the medical training we need to be competent physicians. As someone who cares deeply about the wellbeing of all youth and particularly vulnerable populations like trans kids, I would not be able to learn about the full breadth of comprehensive pediatric care in Alabama if SB10 were made law. In a state with a shortage of primary care providers, it seems a particularly risky gamble to reduce the pool of thoughtful and compassionate trainees even further.
Within the trans community, we talk often about how our narratives are boiled down to trauma and fear without any room for nuance or joy. To be trans in this state is simultaneously a story of beauty, resilience, and sadness. It’s more than just trauma, but the risk of trauma looms large with the possibility of this legislation passing. SB10 represents a scramble by a select few in our state to deny the inevitable– trans children will continue to be trans regardless of what we do. The only thing we can influence is how many of them make it into adulthood.
1. Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. Morbidity and Mortality Weekly Report. 2019; 68: 67–71. DOI: http://dx.doi.org/10.15585/mmwr.mm6803a3.
2. Russel ST, Pollitt AM, Li G, Grossman AH. Chosen Name Use is Linked to Reduced Depressive Symptoms, Suicidal Ideation and Behavior among Transgender Youth. Journal of Adolescent Health. 2018 Oct; 63(4): 503–505. DOI: https://doi.org/10.1016/j.jadohealth.2018.02.003.
4. Turban JL, King D, Carswell JM, et al. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics. 2020; 145(2): e20191725. DOI: https://doi.org/10.1542/peds.2019-1725.
August 13, 2021 | Kimberly Tsoukalas, LHC Program Coordinator
Following the 2020 census, the national and state legislatures are set to redefine the boundaries for congressional elections and representative districts. These districts determine the geographical areas for state and national elected officials including Representatives, State Senators, and Board of Education members. Due to the coronavirus pandemic, the process is running behind schedule but government officials are still working diligently to redraw new district lines in time for the 2022 election cycle. Below, we’ve broken down where the state of Alabama is in the redistricting process, what citizens can expect during the process, and how it can impact healthcare policy in our communities.
April 26, 2021 The United States Census released the apportionment counts to the public showcasing the general state population changes in the country. Some states gained seats in the House of Representatives while others lost seats. Alabama’s population increased to just over 5 million and will retain the same number of representatives (7) for the next redistricting cycle.
August 12, 2021 The US Census released the P.L. 94-171 Redistricting Data Summary Files, which includes information about housing occupancy status, population counts by race and ethnicity for the total population and voting-age population, and by group quarters type for the group quarters population. This information will be released on the Census Bureau’s FTP website using the same file format provided to state governments and requires additional software to extract the data. This information distribution is intended for experienced data users and will be re-released to the general public at a later date in a more digestible format.
Proposed – September 30, 2021
The Census Bureau will release the same data from August 12th in an easier format that allows the public to search for and understand local redistricting data, accessible at https://data.census/gov. Additionally, it will be delivered to the Reapportionment Committee in an interactive toolkit on a flash drive for further publication and reference.
Did you know? The term “gerrymandering” was first used in 1810 after the redistricting of Massachusetts. Elbridge Gerry, a prominent political figure of the time, drew district lines to facilitate political gain in a shape that was thought to look like a salamander. Hence, (Elbridge)Gerry(sala)mander. Today, the term is used to describe disproportionate district lines that give an unfair advantage for a political party or group. See below for a quick graphic on how this looks in a population of 60% blue squares and 40% yellow squares.
Proposed – January 28, 2022
While not an official Census deadline, January 28th is the official filing date for House of Representatives candidates. Redistricting borders are presumed to have been drawn by this point, though there may be delays this year due to the pandemic. Official verification comes by legislative vote which should occur later in the spring.
Proposed – May 2022 Based on previous years, we can expect the Alabama House of Representatives and Senate to approve the newly redrawn districts in May. However, prior to 2020 Census data was available in March, rather than August, allowing for a longer deliberation period. It is unclear how this approval will be affected by the pandemic. Once the lines are approved by the House and Senate, they are passed on to the Governor who has the ability to veto the districts, sending it back to the Alabama Permanent Legislative Committee on Reapportionment (APLCR) for redrawing.
Proposed – October 2022 The final stage in the redistricting process is called preclearance, a term you probably haven’t heard since your AP Government class in high school. The Voting Rights Act of 1965 provided additional protections against discrimination in the elections processes. Section 5 of the Act requires that the United States Department of Justice or a three-judge panel of the United States District Court for the District of Columbia approve any attempt to change any voting practices, including redistricting.
What happens next?
The data released on August 12 will allow the APLCR to begin redrawing districts. However, the committee must abide by certain rules and regulations to ensure the proposed districts are fair.
In addition to keeping each district relatively proportional to each other in terms of population, there are four main criteria for redistricting: Contiguity, Compactness, Community Interest and Political Boundaries. Contiguity simply means that all portions of the district must be geographically adjacent. Similarly, all portions of the district should live as near to one another as is practical to represent the collective interests of a portion of the state. Lastly, political boundaries references the geographical borders of county lines and city limits, allowing for proper representation for those citizens.
Did you know? Any citizen or group can submit a proposed redistricting map during public input meetings occurring through the month of September. Click here to try your hand at drawing your own redistricting lines. Full list of times and locations for public meetings is available here, along with Zoom links for individuals choosing to attend virtually.
The Reapportionment Committee will need to balance these needs when redrawing state lines to account for the population changes within the state. Additionally, they will need to abide by the guidelines enacted by the Voting Rights Act of 1965 to ensure that the districts are not disproportionate to certain populations based on race or other demographic factors.
What does this mean for health policy?
The process of redistricting will impact healthcare more than you might realize. In addition to national issues like universal healthcare or insurance reform which elected representatives could sponsor or support legislation for, redistricting and census data have local implications as well. Hospitals, health care clinics, and health care programs such as Medicaid and Medicare are among the many public health services included in annual budget proposals to be approved by Congress. Additionally, state and federally-funded community health centers are heavily impacted by the annual budget, which can determine where to build new hospitals and clinics or expand existing ones.
Access to rural healthcare continues to decline. The healthcare analytics firm Chartis Group recently released a reportthat 12 of Alabama’s 45 rural hospitals are considered “most vulnerable” to closing partly because the state has not expanded Medicaid. As quoted in an article by AL.com, Danne Howard, chief policy officer for the Alabama Hospital Association, stated “when a rural hospital has to cut services or close, residents have to travel and overload the urban facilities. It’s a domino effect when a rural hospital closes. It becomes an urban hospital issue. It becomes a health access issue.”
Redistricting is a critical part of our electoral process, paving the way for representation at the state and national level. Redistricting, as we’ve seen in the past, can potentially determine the outcome of major legislation. If we consider health as a human right and strive to improve population health through the enactment and enforcement of evidence-based public policy, it is imperative that we nominate leaders who prioritize healthcare access and affordability.
I think I speak for all of us when I say that we had all hoped to be on the path to freedom from COVID-19 by now. Surely, Americans everywhere would like to move on in whatever ways they can – family gatherings, community events, concerts, travel, and so many other things that we’ve been missing for well over a year now seemed within reach just a few weeks ago. Unfortunately, it seems that what progress we had made in overcoming the pandemic is at risk, and we may have to wait a bit longer before we can truly be free from the virus.
Beginning in early June, there were indications in Missouri that we hadn’t quite made it out yet. The delta variant of SARS-CoV-2, the virus that causes COVID-19, began to circulate and cases spiked quite rapidly. As a localized outbreak, the outlook for the rest of the country wasn’t too bleak. However, it wasn’t long until the variant spread down to Florida and the Gulf Coast. Here in Alabama, we are now seeing exactly what it means to have a surge in cases from the delta variant. The figure below uses statistical modeling to predict how many cases we may observe from this new surge.
Figure 1. Actual Epidemic Curves Observed in Alabama and 3 Predicted Curves for the Third Surge. The Alabama rate assumes cases will continue to grow at exactly the same rate as what is currently being observed in Southern Alabama. The India curve assumes the cases will grow in a manner similar to India from April to July 2021 and the United Kingdom (UK) curve assumes cases will accrue at the same rate as the UK observed this summer in a 70% vaccinated population. Updated August 10
What do these data mean for hospitalizations?
One piece of data that has become clear is that the vaccine helps to keep people out of the hospital, even if they develop mild symptoms from exposure to a person who has COVID. UAB Hospital has recent recently reported that over 95% of the people hospitalized with COVID-19 had not yet received the COVID-19 vaccine. Since Alabama only has about a 40% vaccination rate right now, this leaves many people at risk of being hospitalized.
Figure 2. Estimated Hospitalizations Assuming the Middle Path (India Model). COVID19 Epidemic Curve in Alabama – Estimated Cases Based on Epidemic Curve from India Apr-June 2021 and Corresponding Hospitalizations in Alabama.
What about missing work, school or other activities?
The Southern Alabama curve allows us to estimate the number of people who would be infected, quarantined, or in the hospital at the peak of the surge. If the entire state begins to surge at the rate Southern Alabama is currently surging, there would be about 20% of the population out due to either illness or quarantine for 3 weeks centered around August 26. This assumes that each sick person would come into contact with about 5 other people who would have to quarantine. It also assumes isolation and quarantine to be 14 days. It is really challenging to estimate the number of contacts a person may have or the potential impact of a whole sports team, classroom, or congregation in quarantine. It is possible that 30-50% could be out at one time depending on how people were exposed to an infected individual.
Table 1. Outcomes of Various Transmission Rates, Updated August 12
What can be done?
Absenteeism could be reduced by 37% if masking were required in schools while COVID is circulating at high levels. Masking would reduce absenteeism to between 6% and 14% in the setting where 5 close contacts have to quarantine. In the case where large groups (classrooms, teams, choirs) have to quarantine, masking could reduce absenteeism from 50% to 37%.
Higher levels of vaccination will have lower levels of absenteeism, since vaccinated people with no symptoms do not have to quarantine and the biggest driver of absenteeism will be quarantine (accounts for 80% of the absenteeism). This has a direct impact on the faculty and students over age 12. It could keep faculty from having to quarantine due to an exposure in their classroom, which will reduce faculty absenteeism.
A school with 90% of the faculty vaccinated would have an absenteeism rate among the faculty of 1% at the peak of this surge compared to 19% in a school with only 10% vaccination rate. The same is true for classrooms where children are 12 and older.
How will we know which of the 3 curves Alabama is on?
The curves above are only predictions. There is uncertainty in the models so it is important to regularly check the data to see how the models are performing. Actual case data can be used to examine how well the model is predicting hospitalizations in Alabama. The figure below shows how well the models are tracking with the number of hospitalizations reported each day. Currently we are much closer to the Southern Alabama path than the India or UK paths but masking, reducing social activities, and increasing vaccinations will all help to bend the curve down so that we do not stay on this path.
Figure 3. Number of Hospitalizations Estimated by Each of the Three Models vs Actual Cases through August 9. Updated August 10
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