Ecological countermeasures to prevent pathogen spillover and subsequent pandemics.

Substantial global attention is focused on how to reduce the risk of future pandemics. Reducing this risk requires investment in prevention, preparedness, and response. Although preparedness and response have received significant focus, prevention, especially the prevention of zoonotic spillover, remains largely absent from global conversations. This oversight is due in part to the lack of a clear definition of prevention and lack of guidance on how to achieve it. To address this gap, we elucidate the mechanisms linking environmental change and zoonotic spillover using spillover of viruses from bats as a case study. We identify ecological interventions that can disrupt these spillover mechanisms and propose policy frameworks for their implementation. Recognizing that pandemics originate in ecological systems, we advocate for integrating ecological approaches alongside biomedical approaches in a comprehensive and balanced pandemic prevention strategy.

Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA.

CONTEXT: Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness. METHODS: Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007-2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories. FINDINGS: Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period. CONCLUSIONS: While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

Pivot: partisan policy responses to COVID-19 health disparities.

How did partisanship influence rhetoric about, public opinion of, and policies that prioritize racial and ethnic health disparities of COVID-19 during the first wave of the pandemic between March and July 2020? In this retrospective, mixed-methods analysis using national administrative and survey data, we found that the rhetoric and policy of shared sacrifice diminished and partisan differences in pandemic policy increased once it became clear to political elites that there were major racial disparities in COVID-19 cases and deaths. We trace how first disparities emerged in data and then were reported in elite, national media, discussed in Congress, and reflected in public opinion. Once racial disparities were apparent, partisan divides opened in media, public opinion, and legislative activity, with Democrats foregrounding inequality and Republicans increasingly downplaying the pandemic. This temporal dimension, focusing on how the diffusion of awareness of inequalities among elites shaped policy in the crucial months of early 2020, is the principal novel finding of our analysis. Overall, there is a clear, partisan policy response to addressing COVID-19 racial disparities across media, public opinion, subnational legislative activity, and congressional deliberations.

How do you solve a problem like Maria? The politics of disaster response in Puerto Rico, Florida and Texas.

COVID-19 is not the first, nor the last, public health challenge the US political system has faced. Understanding drivers of governmental responses to public health emergencies is important for policy decision-making, planning, health and social outcomes, and advocacy. We use federal political disaster-aid debates to examine political factors related to variations in outcomes for Puerto Rico, Texas, and Florida after the 2017 hurricane season. Despite the comparable need and unprecedented mortality, Puerto Rico received delayed and substantially less aid. We find bipartisan participation in floor debates over aid to Texas and Florida, but primarily Democrat participation for Puerto Rican aid. Yet, deliberation and participation in the debates were strongly influenced by whether a state or district was at risk of natural disasters. Nearly one-third of all states did not participate in any aid debate. States' local disaster risk levels and political parties' attachments to different racial and ethnic groups may help explain Congressional public health disaster response failures. These lessons are of increasing importance in the face of growing collective action problems around the climate crisis and subsequent emergent threats from natural disasters.

Resources or trust: What matters more in the vaccination strategies of high-income liberal democracies?

Objectives: This paper presents an overview of the vaccination policy responses to the COVID-19 pandemic in Denmark, Canada, and the United States until September 1, 2021. The article seeks to understand the reasons for vaccination differences among high-income, liberal democracies. Methods: The country cases were selected based on tiers of population-level vaccination uptake within six months after vaccines became broadly available (for high-income countries). We conducted a rapid review of primary data for each country case. Through a graphical and descriptive analysis, we evaluated common patterns as well as significant divergences in the vaccination rollout across countries and its relationship with COVID-19 health outcomes, government policy responses, resource constraints, and socio-political factors. This inductive analysis provides a sense of how resource constraints compare with current political contexts in each country case that may influence the public's response to a national vaccination strategy. Results: Resources, socio-economic factors, and health outcomes related to COVID-19 do not ensure vaccination policy success as the case of the United States makes clear. Instead, trust in government and health systems appear to promise a higher vaccination uptake and maintained support for measures during a pandemic. Trust in government can be defined as the confidence citizens have that governmental actions will do what is right and perceived as fair. Conclusion: Denmark, the United States, and Canada are high-income liberal democracies with very different vaccine strategies and subsequently different vaccination outcomes across their populations. What appears to be critical to successful vaccination outcomes is high trust in government or health officials, along with the depoliticization of the COVID-19 pandemic among the country's political parties.

Healthcare lobbying on upstream social determinants of health in the US.

Healthcare stakeholders are increasingly investing to address social determinants of health (SDOH) as they seek to improve health outcomes and reduce total healthcare costs in their communities. Policy heavily shapes SDOH, and healthcare lobbying on SDOH issues may offer large impacts through positive policy change. Federal lobbying disclosures from the ten highest spending health insurance and healthcare provider organizations and related associations between 2015 and 2019 were reviewed to identify lobbying reported on the salient SDOH issues, defined based on the Accountable Health Communities Model health-related social needs screening tool. Five of the organizations reported lobbying on some SDOH issues, including financial strain, employment, food insecurity, and interpersonal safety, but none reported lobbying on other issues, such as non-healthcare-related employment, housing instability, transportation, or education. Lobbying has been a missed opportunity for addressing SDOH. Healthcare organizations have the opportunity to expand their lobbying on upstream SDOH policy issues to increase the impact of their SDOH strategy and further improve population health.

Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness.

CONTEXT: Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems. METHODS: We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana, which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation. FINDINGS: Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid. CONCLUSIONS: Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges.

Double-edged sword of federalism: variation in essential health benefits for mental health and substance use disorder coverage in states.

The Affordable Care Act requires all insurance plans sold on health insurance marketplaces and individual and small-group plans to cover 10 Essential Health Benefits (EHB), including behavioral health services. Instead of applying a uniform EHB plan design, the Department of Health and Human Services let states define their own EHB plan. This approach was seen as the best balance between flexibility and comprehensiveness, and assumed there would be little state-to-state variation. Limited federal oversight runs the risk of variation in EHB coverage definitions and requirements, as well as potential divergence from standardized medical guidelines. We analyzed 112 EHB documents from all states for behavioral health coverage in effect from 2012 to 2017. We find wide variation among states in their EHB plan required-coverage, and divergence between medical-practice guidelines and EHB plans. These results emphasize consideration of federated regulation over health insurance coverage standards. Federal flexibility in states benefit design nods to state-specific policymaking-processes and population needs. However, flexibility becomes problematic if it leads to inadequate coverage that reduces access to critical health care services. The EHBs demonstrate an incomplete effort to establish appropriate minimum standards of coverage for behavioral health services.

Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978-2017.

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in-person, semi-structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology's professional autonomy was correlatively diminished. Decision-making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.

Addressing Major Health Disparities Related to Coronavirus for People With Behavioral Health Conditions Requires Strength-Based Capacity Building and Intentional Community Partnership.

Far from being an equalizer, as some have claimed, the COVID-19 pandemic has exposed just how vulnerable many of our social, health, and political systems are in the face of major public health shocks. Rapid responses by health systems to meet increased demand for hospital beds while continuing to provide health services, largely via a shift to telehealth services, are critical adaptations. However, these actions are not sufficient to mitigate the impact of coronavirus for people from marginalized communities, particularly those with behavioral health conditions, who are experiencing disproportional health, economic, and social impacts from the evolving pandemic. Helping these communities weather this storm requires partnering with existing community-based organizations and local governments to rapidly and flexibly meet the needs of vulnerable populations.

Infectious disease, public health, and politics: United States response to Ebola and Zika.

Politics, rather than disease characteristics, complicated the United States response to Ebola virus disease and Zika virus. We analyze how media and political elites shaped public opinion of the two outbreaks. We conducted a retrospective analysis of media coverage, Congressional floor speech, and public opinion polls to explain elite cueing and public perceptions of Ebola and Zika. We find evidence of elite cueing by Congress and the media on public opinion. Public opinion of both disease outbreaks initially followed partisan patterns. However, while Ebola public opinion remained partisan, ultimately, opinion emerged of a bipartisan nature for Zika, mirroring elite framing. Public health officials should be aware of how elite cueing shapes policy and prioritizes partisan strategies. Politics and public opinion can focus attention on or away from infectious disease; it can also undermine public health responses by biasing the public's view of a diseases' relative risk.

Normalizing inconvenience to promote childhood vaccination: a qualitative implementation evaluation of a novel Michigan program.

BACKGROUND: In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability. METHODS: We conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring). RESULTS: There was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring). CONCLUSIONS: The immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.

Quantifying inequities in US federal response to hurricane disaster in Texas and Florida compared with Puerto Rico.

If disaster responses vary in their effectiveness across communities, health equity is affected. This paper aims to evaluate and describe variation in the federal disaster responses to 2017 Hurricanes Harvey, Irma and Maria, compared with the need and severity of storm damage through a retrospective analysis. Our analysis spans from landfall to 6 months after landfall for each hurricane. To examine differences in disaster responses across the hurricanes, we focus on measures of federal spending, federal resources distributed and direct and indirect storm-mortality counts. Federal spending estimates come from congressional appropriations and Federal Emergency Management Agency (FEMA) records. Resource estimates come from FEMA documents and news releases. Mortality counts come from National Oceanic and Atmospheric Administration (NOAA) reports, respective vital statistics offices and news articles. Damage estimates came from NOAA reports. In each case, we compare the responses and the severity at critical time points after the storm based on FEMA time logs. Our results show that the federal government responded on a larger scale and much more quickly across measures of federal money and staffing to Hurricanes Harvey and Irma in Texas and Florida, compared with Hurricane Maria in Puerto Rico. The variation in the responses was not commensurate with storm severity and need after landfall in the case of Puerto Rico compared with Texas and Florida. Assuming that disaster responses should be at least commensurate to the degree of storm severity and need of the population, the insufficient response received by Puerto Rico raises concern for growth in health disparities and increases in adverse health outcomes.

Shelter from the Storm: Roles, responsibilities, and challenges in United States housing policy governance.

Housing is a critical social determinant of health. Housing policy not only affects health by improving housing quality, affordability, and insecurity; housing policy affects health upstream through the politics that shape housing policy design, implementation, and management. These politics, or governance strategies, determine the successes or failures of housing policy programs. This paper is an overview of challenges in housing policy governance in the United States. I examine the important relationship between housing and health, and emphasize why studying housing policy governance matters. I then present three cases of housing governance challenges in the United States, from each pathway by which housing affects health - housing quality, affordability, and insecurity. Each case corresponds to an arm of the TAPIC framework for evaluating governance (Krieger and Higgins) [1], to assess mechanisms of housing governance in each case. While housing governance has come a long way over the past century, political decentralization and the expansion of the submerged state have increased the number of political actors and policy conflict in many areas. This creates inherent challenges for improving accountability, transparency, and policy capacity. In many instances, too, reduced government accountability and transparency increases the risk of harm to the public and lessens governmental integrity.