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The Health Benefits of Zoning: Observations from Prince Goerge’s County’s Zoning Rewrite

Introduction

For the first time in about a half century, Prince George’s County (Maryland) is close to completing a multi-year process to rewrite its Zoning Ordinance, the set of regulations that determines land use, where buildings are located (or not, such as in wildlife preserves), and how the built environment (buildings, sidewalks, roads, parks) impacts daily life. The County’s Zoning Rewrite[1] began a few years ago, and is now nearing completion.

In a county where 2 out of 3 adult residents are obese, there are 1,837 residents for every primary care physician (PCP), compared to 1,153:1 in the state of Maryland.  As well, Emergency Department visits for asthma were approximately 4.9 times higher among Black residents compared to White residents[2].

In HPRC’s response to the County’s call for public comment, HPRC observed that the Rewrite draft could be strengthened by incorporating mechanisms that could improve health.  Below we summarize the potential for improved health outcomes, and the health equity opportunity declined by the current version of the Rewrite.

Potential for Positive Impact on Health Outcomes

An Emphasis on Creating Mixed-use Spaces

Mixed-use developments foster a more equitable use of space that leads to an increase in physical activity,[3] reductions in obesity,[4] and less time spent in cars, given that these changes make residents more likely to walk for both transport and recreation.[5] Walking to and from public transit is linked to an increase in daily exercise, particularly among low-income and minority subgroups[6]. This has long been a focus of discussion in the County.

Improved Access to Fresh Fruits and Vegetables

Zoning can be an important tool for increasing access to fresh fruits and vegetables.  Efforts to improve access are crucial for Prince George’s County, as nearly 16 percent of residents are food insecure[7] (unpredictable access to affordable, nutritious meals). Within some census tracts, more than 25 percent are food insecure[8]).  Community gardens, and access to farmers’ markets, have been linked to an increase in fruit and vegetable consumption. [9],[10

Pedestrian and Bicycle Friendly Developments

Multiple studies have shown that when built environments are walking- and biking-friendly residents are more likely to be active.[11], [12], [13] Additionally, research highlights that neighborhood walkability can lead to a decrease in BMI[14] regardless of income,[15] and can be even more important for reducing BMI than simply living in a mixed-use area.[16] Studies have also shown that some traffic calming measures lead to increased traffic safety, as well as an increase in physical activity.[17]

Open Space Set-Aside Standards

The prioritization of natural landscape and parks in particular should have a positive effect as green spaces have been linked to improved mental health,[18], [19] and parks have been linked to increased levels of walking and bicycling.[20]  The literature regarding green spaces has also demonstrated positive environmental impacts, as they are associated with better air quality,[21] decreased temperatures during the summer,[22] and natural storm-water management.[23]

Green Building Standards

The establishment of a green building standards points system, and incentives to motivate builders to add additional green features, should also have a positive impact on the health of County residents.  Living in green buildings has been associated with improved air quality,[24] and a reduction in asthma symptoms among children.[25] Studies show that working in such buildings has been linked to reduced absenteeism from work attributed to asthma, respiratory allergies, depression, and stress, as well as self-reported improvements in productivity[26].

Community Involvement

Improvements to community notification and public comment requirement for new developments could foster increased community participation during the approval process. The notification requirements are however overly reliant on mail, posted signs on development properties, and newspapers.  These activities could be strengthened by using newer technologies, such as social media, a website, or email. Additionally, we would encourage the County to consider notification requirements that consider basic literacy levels, the needs of non-English speakers, and the use of translators or other instruments that would facilitate participation during community meetings.

Health Equity Opportunities Not Taken - Limitations of the County’s Rewrite Effort

Lack of attention to established neighborhoods

One significant limitation of the proposed zoning rewrite is that it predominantly affects new developments. Residents living in established neighborhoods may not benefit from the same health advantages as those who move to newly developed areas.  

Health Equity in all Policies Safeguard Mechanism

A Health Equity in all Policies (HEIAP) Safeguard Mechanism is a policy device designed to ensure that human health always trumps the competing priority whenever a conflict arises between a development and public health.  The city of College Park, Maryland has established such a safeguard, which could serve as a model for the Prince George’s County.[27]

Improving Access to Healthy Food

Nearly three quarters of Prince George’s County restaurants are considered fast food establishments. This is a public health concern as high density of fast food outlets has been linked to an increased risk for obesity.[28] The County’s long-range growth plan, Plan Prince George’s 2035 (PPGC 2035), specifically mentions the use of zoning to restrict the number of fast food restaurants and the location of fast food outlets in the County,[29] but this is not included in the proposed rewrite.

Community Involvement

Some residents reported that it is difficult to participate in the existing process[30], [31]. The following recommendations could create a more inclusive process: 1) a clear schedule of community notifications for hearings regarding each type of development; 2) a requirement that the technical staff application report include a summary of citizen comments; 3) a requirement that civic organizations be given the opportunity to register and receive notification when an application is submitted or a hearing is scheduled for a development in their geographic area of influence; and 4) pre-application meetings which could create communication between developers and the community before construction begins.

Future Directions

Most importantly, HPRC encouraged Prince George’s to include a section in the County code that requires a health assessment of the zoning ordinance every 10 years, or some other periodic interval determined by the County.  This should allow for policy makers to examine data and gain needed insight for evaluating health impact.

We look forward to an even more robust community participation, by any and all available means, as the rewrite heads into the County Council’s approval stage.

Endnotes

[1] Prince George’s Zoning Rewrite. Creating a 21st Century Zoning Ordinance. Prince George’s County Planning Department. Retrieved from the internet. December 2017. https://pgplanning.civicomment.org/

[2] Prince George’s County Health Department. PGC health zone. Available from: http://www.pgchealthzone.org/index.php?moduledashboard&alias=alldata&localeId=1260

[3] Frank LD, Schmid TL, Sallis JK, Chapman J, Saelens BE. Linking objectively measured physical activity with objectively measured urban form: findings from SMARTRAQ. American Journal of Preventative Medicine. 2005; 28(2):117-25.

[4] Mumford KG, Contant CK, Weissman J, Wolf J, Glanz K. Changes in physical activity and travel behaviors in residents of a mixed-use development. American Journal of Preventative Medicine. 2011;41(5):504-7.

[5] Frank LD, Andresen MA, Schmid TL., Obesity relationships with community design, physical activity, and time spent in cars. American Journal of Preventative Medicine. 2004;27(2):87-96.

[6] Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. American Journal of Preventative Medicine 2005;29(4):273-80.

[7] The Capital Area Food Bank.  The Capital Area Food Bank in Prince George’s County. http://www.capitalareafoodbank.org/wp-content/uploads/2011/01/PG-Fact-Sheet.pdf. Accessed December 12, 2017.

[8] Capital Area Food Bank. CAFB Hunger Heat Map. http://cafb.maps.arcgis.com/apps/MapJournal/index.html?appid=b4906ac11bf74cd781c5567124be9364. Accessed December 12, 2017.  

[9] Alaimo K, et. al, Fruit and vegetable intake among urban community gardeners. Journal of Nutrition Education and Behavior 2008 Mar-Apr;40(2):94-101. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18314085

[10] Pitts, Jilcot, Q, Wu, et. al. Associations between access to farmers' markets and supermarkets, shopping patterns, fruit and vegetable consumption and health indicators among women of reproductive age in eastern North Carolina, U.S.A. Public Health Nutrition. 2013 Nov;16(11):1944-52. https://www.ncbi.nlm.nih.gov/pubmed/23701901

[11] Berke E, Koepsell T, Moudon A, Hoskins R, Larson E. Association of the built environment with physical activity and obesity in older persons. American Journal of Preventative Medicine. 2007; 97(3): 486-492.

[12] Noyes P, Fung L, Lee KK, Grimshaw VE, Karpati A, DiGrande L. Cycling in the city: an in-depth examination of bicycle lane use in a low-income urban neighborhood. Journal of Physical Activity and Health. 2014;11(1):1-9.

[13] Freeman L, Neckerman K, Schwartz-Soicher O, Quinn J, Richards C, Bader M et al. Neighborhood walkability and active travel (walking and cycling) in New York City. Journal of Urban Health. 2013; 90(4): 575–585.

[14] Smith KR, Brown BB, Yamada I, Kowaleski-Jones L, Zick CD, Fan JX. Walkability and body mass index density, design, and new diversity measures. American Journal of Preventative Medicine. 2008;35(3):237-44.

[15] Sallis J, Saelens B, Frank L, Conway T, Slymen D, Cain K et al. Neighborhood built environment and income: examining multiple health outcomes. Social Science and Medicine. 2009; 68(7): 1285–1293.

[16] Brown BB, Yamada I, Smith KR, Zick CD, Kowaleski-Jones L, Fan JX. Mixed land use and walkability: variations in land use measures and relationships with BMI, overweight, and obesity. Health and Place. 2009;15(4):1130-41.

[17] Morrison DS, Thomson H, Petticrew M. Evaluation of the health effects of a neighbourhood traffic calming scheme. Journal of Epidemiology & Community Health 2004;58:837-840.

[18] Sturm R, Cohen D. Proximity to urban parks and mental health. The Journal of Mental Health Policy and Economics. 2014; 17(1): 19–24.  

[19] Zhang Y, Van Dijk T, Tang J, Van Den Berg AE. Green space attachment and health: a comparative study in two urban neighborhoods. International Journal of Environmental Research and Public Health. 2015; 12(11): 14342-63.  

[20] Zlot Al, Schmid TL. Relationships among community characteristics and walking and bicycling for transportation or recreation. American Journal of Health Promotion. 2005;19(4):314-7.

[21] Selmi W, Weber C, Rivière E, Blond N, Mehdi L, Nowak D. Air pollution removal by trees in public green spaces in Strasbourg city, France.  Urban Forestry & Urban Greening. 2016; 17: 192–201.

[22] Reduce Urban Heat Island Effect. United States Environmental Protection Agency. Available from: https://www.epa.gov/green-infrastructure/reduce-urban-heat-island-effect

[23] Green Scaping: The Easy Way to a Greener, Healthier Yard. United States Environmental Protection Agency. Available from:  https://www.epa.gov/sites/production/files/2014-04/documents/greenscaping_-_the_easy_way_to_a_greener_healthier_yard.pdf

[24] Coombs KC, Chew GL, Schaffer C, Ryan PH, Brokamp C, Grinshpun SA et al. Indoor air quality in green-renovated vs. non-green low-income homes of children living in a temperate region of US (Ohio). Science of the Total Environment. 2016;554-555:178-85.

[25] Colton MD, Laurent JG, MacNaughton P, Kane J, Bennett-Fripp M, Spengler J et al, Health benefits of green public housing: associations with asthma morbidity and building-related symptoms. American Journal of Public Health. 2015;105(12):2482-9.

[26] Singh A, Syal M, Grady SC, Korkmaz S.  Effects of green buildings on employee health and productivity. American Journal of Public Health. 2010;100(9):1665-8.

[27] College Park, Maryland, Municipal Code § 87-21

[28] Li F, Harmer P, Cardinal BJ, Bosworth M, Johnson- Shelton D. Obesity and the built environment: does the density of neighborhood fast-food outlets matter? American Journal of Health Promotion. 2009;23(3):203-9.

[29] Plan Prince George's 2035 Approved General Plan. The Maryland-National Capital Park and Planning Commission, May 6, 2014. Available from: http://www.pgplanning.org/Resources/Publications/Plan_Prince_George_s_2035.htm

[30] Maryland-National Capital Park and Planning Commission, Evaluation and Recommendations Report: Countywide Listening Sessions. January, 28-29, and February 10, 2015. Available from: http://zoningpgc.pgplanning.com/wp-content/uploads/2014/11/PGC-Listening-Session-Notes-FINAL-2-26-15.pdf

[31] Prince George’s County Zoning Rewrite: Listening Session Notes. Mitchellville, MD.  June 3, 2014. Available from: http://zoningpgc.pgplanning.com/wp-content/uploads/2014/11/June_3-PG_Zoning_Listening_Session_Summary.pdf

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Diabetes Awareness

World Diabetes Day was celebrated on 14 November, an opportunity to raise awareness about a deadly disease that affects all ages, including the 1 in 7 childbirths globally that are affected by gestational diabetes, according to the International Diabetes Federation (IDF). IDF also notes that 2 out of 5 women with diabetes are of reproductive age. This is a massive policy challenge here in the United States, and a growing menace around the world.

Quick distinction - usually when people say diabetes they are referring to diabetes mellitus, which is distinct from diabetes insipidus, a rare disease caused by damage to either the hypothalamus or the pituitary gland. 

Diabetes mellitus is caused by the body’s inability to transport glucose (sugar) from the bloodstream into the cells where they are needed for energy. This inability is either because the body makes no insulin (the hormone responsible for transporting the glucose into the cells), or the body does not make or use insulin well. The body requires sugar at optimal levels to keep working properly, and if levels are too low or too high diabetes can, over time, damage vital organs, including the kidneys and the heart.

Risk factors include family history, prediabetes, overweight, age, or race/ethnicity. Click here for pointers from the National Institute of Diabetes and Digestive Kidney Diseases (NIDDK) regarding how to prevent diabetes-related health problems.

Diabetes is a massive policy challenge. The Centers for Disease Control and Prevention (CDC) estimated that there were about 30 million adults in the United States living with diabetes in 2015, of whom about 7 million were undiagnosed. In context - imagine every adult in California affected by diabetes, or imagine every adult in Virginia having diabetes but not knowing it.

The burden rests disproportionately heavier on people of color. CDC’s National Diabetes Statistics Report 2017 paints a grim picture: 

American Indians/Alaska Natives, non-Hispanic Blacks, and people of Hispanic ethnicity had a higher prevalence than non Hispanic Whites - 15.1%, 12.7%, 12.1%, and 7.4% prevalence, respectively.

The first policy challenge is the sheer size and scope of the problem, and its implications for direct and indirect medical costs, the economic burden of diabetes patients who have to take so much time off work and school to manage their condition, and the societal costs of care givers and family members who have to supervise their care, and most importantly the suffering of the patients themselves, many of whom are disabled by diabetes-related symptoms ranging from diabetic nerve pain to vision loss and sometimes amputations. 

Here’s the second policy challenge - how many of the communities most affected understand the nature of the disease, how to prevent or diagnose it, and why it is necessary to treat it in a timely and regular manner? This raises not just health literacy questions for individuals and communities, but cultural and linguistic competency questions for providers and policymakers.  

Then there’s another policy dilemma that requires research (clinical, public health, public policy, social science, economic), societal awareness, patient engagement, and strategic policy-making to address - namely the challenge of dealing with the social determinants that likely contribute to the ethnic and racial disparities, and the resources necessary to enable health equity and improved health outcomes. 

Some policy solutions are by now well-established and understood: 

patient awareness and education that enables prevention and timely diagnoses and treatment;

robust and strategic policy-making that enables access to affordable care for all Americans, especially those at highest risk for chronic diseases such as diabetes;

strategic allocation of public and private sector resources to support the clinical and basic science research that may one day lead to a cure;

a healthcare workforce scientifically and culturally equipped to provide health care of the highest quality;

an ongoing societal discussion about the social determinants of health and the need for health in all policies, whether in housing, public education, transportation, or health care access and delivery.

This is not an exhaustive list, but it is representative. Ultimately, the more we know the better equipped we are to prevent and treat diabetes in all its forms.

For more details about the diabetes burden in the Mid Atlantic region, click:

here for Maryland; 

here for the District of Columbia;

here for Delaware;

here for Pennsylvania;

here for Virginia;

and here for West Virginia. 

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Open Enrollment 2017 - Overcoming Barriers to Full Coverage

Open Enrollment (abbreviated OE5, because it is the 5th open enrollment since 2013) for qualified health plans under the Affordable Care Act (ACA) begins November 1st 2017, for the 2018 plan year. If you plan to shop on Healthcare.gov, the health insurance marketplace run by the federal government, you have until December 15th to select a plan. This is a narrower enrollment window than previous periods, so you should get started with your plan comparisons if you’re looking to renew. 

OE5 may last longer if you live in a state like Maryland or the District of Columbia that runs their own exchange. For more details about deadlines for your state, click here. 

The dramatic contraction of the open enrollment period and the near-elimination of the outreach and advertising budget has likely caused some confusion about what consumers can expect for OE5. This merely compounded the yearlong battle over whether to completely repeal the ACA. 

Potential and returning customers still need to make decisions for this plan year however, the difficulties notwithstanding. Below are some key considerations:

keep track of the deadlines, but don’t procrastinate;

shop around - a GOLD plan may be cheaper where you are than a SILVER plan;

don’t ‘passively’ auto-renew - you may get a better deal this year than last year (see previous point);

financial assistance is still available for those who qualify - some states have made provisions for those who don’t;

yes, the Individual Mandate will be enforced this year, i.e. Uncle Sam will charge you a penalty at tax time if you don’t buy health insurance or your employer does not cover you.

The uninsured rate among the non-elderly population in the United States has been nearly halved since the ACA became law in 2010, dropping from 18.2% in 2010, to 10.4% in 2016, according to 2016 data. This is a dramatic improvement, but 1 in 10 non elderly adults without coverage is still a big number. 

These decreases in the number of uninsured varies by race and ethnicity, income, and geography. 11% fewer Hispanics are uninsured, compared to 7.5% for Asian and Pacific Islanders and 7.2% for Blacks. Racial and ethnic minorities are more likely to be uninsured than Whites. There was a 7.1% decrease in the number of uninsured in states that expanded Medicaid compared to 3.7% that did not. Those Americans who earn between 100 and 199% of the federal poverty level (FPL) saw an 11.7% decrease in the number of uninsured, and those who earn less than 100% of FPL saw an 8.6% decrease in the number of uninsured. 

Although 3 out of every 4 uninsured Americans work full time, and about an additional 1 in 10 work part time, the main reason most remain uninsured is cost -related. Typically, their employer does not offer or they are not eligible for their employer’s health coverage, or they are unable to afford coverage in the ACA marketplaces, even with financial assistance. Some live in states that did not expand Medicaid, and fall into the gap between where regular Medicaid ends and where the ACA subsidies begin. 

As a public policy matter, covering the remaining uninsured requires understanding and solving the following key policy problems:

affordability - making sure the uninsured can afford coverage by keeping costs down and making subsidies available;

stabilizing markets - creating enough certainty in insurance markets so that insurers are willing to compete in the non-group and small group space;

continuing the re-orientation of the health care system toward prevention and primary care;

continuing to improve the quality of care delivered in order to improve efficiency and thus improve outcomes;

maintaining a focus on innovation, so that we continue to do necessary things better;

maintaining a focus on health equity, so that there are many more Americans, especially those from disadvantaged and vulnerable groups, who have all the tools they need to live their healthiest lives;

maintaining a focus on ‘health in all policies’ by convincing policy makers that healthy living begins long before a patient sets foot in a doctor’s exam room.

HPRC’s work intersects these issues. For our work on health equity, click here (click Health Care Policy). For our podcasts - which cover a variety of related health policy topics - click here. 

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Tobacco Use Among America’s Youth

According to data from the Centers for Disease Control and Prevention (CDC), nine out of ten American youth first try smoking before they turn eighteen years of age, and 99% have first tried smoking by the time they are 26. 

Smoking exacts a heavy burden on society. According to the Campaign for Tobacco Free Kids, smoking kills more people than alcohol, AIDS, car crashes, illegal drugs, murders and suicides, combined. In Virginia alone, they estimate the annual health care costs directly caused by smoking at $3.11 billion, and the Medicaid costs at $485.7 million. 

As a public policy matter the challenges are immense - direct and indirect medical costs, lost economic productivity when those who use tobacco cannot work, the hazard of secondhand smoke, and the pain, suffering, and preventable death (smoking is still the number one cause of preventable death) that tobacco use imposes on our society. 

One key outcome of tobacco use prevention is to lower the risk of developing a potentially deadly disease such as lung cancer by reducing the number of Americans who smoke. One way to achieve this goal is to never smoke at all. Another is to reduce the number of years a person smokes. Prevention efforts among the nation’s adolescents therefore focuses on education and awareness, so that Americans understand the risks of smoking at exactly the ages when they are most likely to be exposed to these products for the first time.

Current cigarette smoking declined nationwide among middle and high school students between 2011 and 2016, but current use of electronic cigarettes increased in that population within that same period. Unfortunately, the use of multiple tobacco products is prevalent among America’s youth, and this increases the risk of nicotine dependence. As well, youth who use multiple tobacco products might be more likely to continue the habit into adulthood. 

Males are more likely to use tobacco products than females, and among high school students electronic cigarettes were favored over all other tobacco products in 2016. According to the National Institute on Drug Abuse (NIDA), their “easy availability, alluring advertisements, various e-liquid flavors, and the belief that they’re safer than cigarettes” all contribute to the popularity of electronic cigarettes within this population. 

Maryland measures progress in reducing tobacco use among the state’s youth via the biennial Youth Tobacco Survey and the Youth Tobacco and Risk Behavior Survey, both of which are reported to the state legislature every two years, as required by state law. The most recent legislative report can be found here.

CDC has compiled a ‘best practices’ document for comprehensive tobacco control programs. For details, click here. The Campaign for Tobacco Free Kids has estimated the toll of tobacco use on the United States, by state. For more details, click here. For related HPRC policy work, click here and here. 

There are other aspects of the tobacco control and prevention conversation which we hope to explore in a future blog, including, as we argue in a peer reviewed paper, the notion that policy effectiveness requires intentionality. A link to the HPRC paper, which appeared in the Journal of Racial and Ethnic Health Disparities, can be found here.

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Oral Health

October is National Dental Hygiene Month, an excellent opportunity to highlight the importance of oral health as a key component of overall health.

The Centers for Disease Control and Prevention (CDC) notes that about $113B is spent nationwide every year on oral health. About $6B of lost productivity every year in the United States can be attributed to people missing work in order to go to the dentist. For many Americans, however, the cost of dental care causes many to skip going to the dentist altogether, which leads to significant clinical and policy challenges.

First, a dentist can be the first to spot any number of symptoms that indicate the presence of diseases that run the gamut from nutritional deficiencies to drug abuse to cancer.  Researchers have also uncovered linkages between oral health and other serious diseases, such as HIV.

Second - proper oral hygiene and regular dental checkups can not only prevent cavities, but can in turn help prevent bacterial infection and gum disease. Unfortunately too many Americans cannot afford this routine care, a public policy problem that has long been a subject for discussion.

Third, some populations carry a disproportionate burden of poor oral health status.  For example - among American adults aged 35-44 years of age Blacks, non-Hispanics, and Mexican Americans, suffer from untreated tooth decay at nearly twice the rate of white non-Hispanic Americans, according to the Centers for Disease Control and Prevention (CDC). The policy challenges are not confined merely to disparate access. There are also quality of care issues as well, such as cultural competency in care delivery and the diversity of the dental care workforce.

Pediatric oral health was included as an essential health benefit (EHB) under the Affordable Care Act (ACA), but the benefits appear to have accrued more on the Medicaid expansion side than on the private insurance side, according to an opinion blog published by Health Affairs. Repealing the ACA would have predictably adverse impact on the amount of Americans who would be able to access affordable dental care, and by extension their health outcomes. As previously mentioned - this would have a worse effect on some than others. 

To add insult to injury - the Children’s Health Insurance Program’s appropriation for the current fiscal year is now three weeks overdue, which jeopardizes gains in pediatric oral care made possible under this vital program that covers 9 million American children.   As previously mentioned - this would have a worse effect on some than others. 

As is often the case with public policy - it is very helpful to personalize policy challenges in order to help policymakers and stakeholders connect the dots. Free dental clinics, such as the one in which HPRC volunteered during a recent weekend, are one way to help illustrate the demand for oral care among the most vulnerable, and provide needed relief to those who would otherwise suffer, sometimes for months or years on end. The tragic story of Deamonte Driver has been a notable example for us here at HPRC, given its local and national import as the poster child for what can go wrong when public policy fails.

For more information on oral health in the Mid Atlantic, please visit the following:

for Maryland click here; 

for the District of Columbia here; 

for Virginia here; 

for Delaware here; 

for Pennsylvania here; and 

for West Virginia here.

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Healthy Aging

Scientific research into the biological and chemical processes associated with aging used to compare older people with younger people. This approach has some value. The Baltimore Longitudinal Study of Aging took a different approach. Since 1958, the BLSA has observed the aging process over time in the same group of dedicated volunteers. The implications for understanding the science of aging have been profound. The public policy implications may be just as important, a discussion of which is the focus of today’s post.

By some estimates Baby Boomers (those Americans born in the 2 decades just after World War II) are turning 65 at the rate of about ten thousand every day, on average. Medicare eligibility is 65 years of age, and roughly 77 million Baby Boomers will qualify for the program at some point this decade or next. This is an enormous policy challenge for obvious and not so obvious reasons, a few of which are listed below.

First - people need more health care services as they age, so the cost of keeping them healthy increases as they age. (A growing number of Americans are living into their nineties). 

Second - the health care workforce needs to keep up with the demand. Some (including the hospitals that train the nation’s doctors) argue this is not happening. This is a problem.

Third - fiscal and budgetary realities (declining tax revenues in some states, high debt burdens in others)  at the state and federal levels intersect with the urge to reform entitlements to keep them agile and sustainable. This can often be more complex than meets the eye.

Fourth - some seniors are more vulnerable than others, given that some age into Medicare already sicker than the rest of the population, have lower incomes, or are at greater risk for developing chronic diseases for a variety of reasons. 

Fifth - Alzheimer’s Disease and other dementias are a particular challenge in this age group. Current understanding of this challenge have not yielded effective therapies (or prevention strategies). The policy challenges in this category alone could bankrupt Medicare by mid century absent scientific advances to stem the tide.

 BLSA has led investigators to two important conclusions in its first half century. First, the changes that occur as people age do not necessarily or inevitably result in diseases commonly associated with older people, such as dementia. Second, there’s “no single chronological timetable” of human aging. The study has also led to thousands of scientific papers on aging, of which public policy has been an important beneficiary. 

Those summary conclusions are vital for effective policy-making. Notably, people age differently, with multiple factors playing a role. It is crucial that policy makers understand the interplay of all these factors. BLSA has generated plenty of literature. Optimally, the evidence generated by this important study should become actionable public policy, in order to help society meet the growing challenge of keeping an aging population healthy.

The study issues a periodic newsletter. For the latest issue, click here.

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In the Zone

Prince Georges County, Maryland is in the process of revising their zoning ordinance and subdivision regulations, and are inviting County residents to provide input on the draft document before it is finalized by the County Council next summer. Details about that process can be found here.

Zoning has important public policy implications, including its potential impact on the health of everyone who lives, works, or travels through the county. Zoning ordinances determine land use, that is who is allowed to build what, and where, and how close to each other, and how high. It also determines which sections of a particular jurisdiction will be residential, or commercial, or industrial. And how close the industrial will be to the residential, and what recourse citizens will have if the built environment impacts their living standards.

Consider the potential health impact - neighborhoods can be built on the wrong side of a busy highway, so that walking or biking can become an unsafe activity. 

Noxious fumes from an industrial waste site or a highway exit can adversely impact the air quality of the neighborhoods located in closest proximity. Such a situation arose in Prince George’s in the recent past. Details here. 

Schools, parks, grocery stores, or hospitals can be located so far away from neighborhoods as to require motorized transport to reach them. 

Walkable neighborhoods, on the other hand, can be designed and built to increase the likelihood of walking for exercise, as well as to improve air quality. 

There is a growing body of research about the effect of zoning on health, and a few jurisdictions have revised their zoning laws and ordinances in the recent past to reflect current thinking. Health Impact Assessments, for example, have been lauded by some as a mechanism for gauging health impact before the zoning process is complete. Results have been mixed.

Healthy Homes and Healthier People, an HPRC publication, highlighted some of the issues related to zoning and health, such as: crime prevention; the interaction (or lack thereof) between urban planners and public health professionals; and the disproportionate burden of environmental injustice borne by low income and racial and ethnic populations.

Zoning can contribute to individual and community access (notably prices) to fresh foods and safe recreational spaces, which in turn could potentially impact the prevalence of obesity (the evidence remains less than compelling). Obesity remains a key public health challenge for Prince George’s. As with the obesity challenge in the county, African American and low-income residents also suffer from asthma that is associated with previously noted environmental factors. 

The County has invited public input into their zoning rewrite process. It is the first time they’ve done such a revision in about 50 years. The larger objective for the county is to ensure growth and development that are consistent with their long term goals (Plan 2035). Our views on the early stages of the process can be found here. For more about listening sessions and where to submit written comments, click here. For the draft document, click here and here. 

Important dates: 

October 24th: Listening Session - Fort Washington

October 25th: Focus Group - Upper Marlboro

October 25th: Listening Session - Laurel

October 26th: Listening Session - Landover.

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Budget Deadlines

The Children’s Health Insurance Program (CHIP) was enacted in 1997 to cover children whose parents’ incomes were too high to qualify for Medicaid, but not enough to buy insurance on their own (or did not receive insurance coverage on the job). As a policy matter CHIP has become wildly successful. A total of 8.9 million children were enrolled in FY 2016, according to data from the Centers for Medicare and Medicaid Services (CMS), up from 8.4 million the previous year. Rates of uninsurance among the nation’s children has dropped from 14.9% in 1997 to 4.8% in 2015.

The law needs to be re-authorized periodically. In addition current funding (a joint venture between the states and the federal government) runs out in short order. At least thirty states around the country will have to deal with this crisis by March 2018 at the latest, according to the Medicaid and CHIP Payment and Access Commission (MACPAC). Here in the Mid Atlantic funding for the District of Columbia’s CHIP program is estimated to run out during the first quarter of FY 2018. Similarly, funding runs out in the second quarter for Delaware (DE), Pennsylvania (PA), and Virginia (VA), and in the third quarter for Maryland (MD) and West Virginia (WV). In summary - all CHIP programs will have to depend on leftover money if the funding is not renewed by September 30, 2017.

The main policy challenges to meeting these budgetary deadlines (thus alleviating the pressure the states feel as the dollars run out) are these: the current debate about overhauling the nation’s health insurance marketplace has drowned out the CHIP conversation; cash-strapped states would be hard-pressed to replace (or supplement) federal funds; legislative calendars in the states are not necessarily in sync with the federal calendar. 

CMS attempted to address some of these issues in the recent past, by proposing contingency plans that included Medicaid expansion options and other insurance affordability programs. 

And then there are statutory and regulatory restraints with which the states must contend. For instance - the National Academy for State Health Policy (NASHP) has indicated that some states require that their CHIP administrators officially notify the public about any changes (such as funding adjustments) to the program, and these notices should be posted within specified time-frames. This gets tricky if the state is waiting to see what the US Congress will do, or if they’re worried about the undue stress on CHIP parents if any of these delays eventually impact enrollment and delivery of care. 

The alarm in the states is growing as we approach the start of the new fiscal year on 1 October 2017. Unfortunately, funding delays are likely to have a disproportionately adverse impact on children from racial/ethnic minority communities, because that population is disproportionately represented among uninsured children. For more information that disparity, click here. For more detail about enrollment, click here. 

We will continue to watch this space. Tick, tock...

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Public Understanding of Public Policy: Pedagogy in the Public Square

The battle over health insurance coverage in the United States has returned to the public square with a fury, and the most consequential public policy challenges have been articulated this week by a voice not normally associated with the intricacies of health care delivery.

As is usually the case the public policy conversation begins with the articulation of a problem. This week’s proposal, if enacted, will: ‘repeal and replace’ the ACA by ending the Medicaid expansion, stop the subsidies that enable middle-income Americans afford coverage on the insurance exchanges; fund Medicaid with ‘block grants’; and ultimately reduce the federal expenditure on Medicaid within a decade to such a level as to generate panic among Medicaid’s proponents that the program’s very existence would be an open question after 2026. 

A public policy conversation that was animated in health care circles took a more dramatic turn in short order as an unexpected voice framed the debate in a way that compelled the attention of lawmakers and the general public alike. Some derided the apparent sensation of the moment, but it opened an interesting window into the public understanding of how public policy affects the life of a population.  As Crammond and Carey noted in their recent paper, “effectively understanding policy and its relevance for public health requires an awareness of the full range of places and contexts in which policy work happens and policy documents are produced.”

To borrow a literary analogy - we could consider it a play in four acts: awareness; understanding; motivation; mobilization.

First, the proposal unveiled this week had been whispered and hinted at while a parallel conversation was going on about how the nation should create a “single payer” system, endorsed by former and future candidates for President. So an awareness of the distinction between the single payer proposal and this week’s proposal was necessary to engage health care consumers. 

Turns out awareness quickly turned into understanding for many consumers, because once they grasped the essential elements of what was on the table they were in a better position to take the next logical step.  We note that policy negotiations, of necessity, require a certain ‘give and take’, which is in turn driven by how well each side understands opposing viewpoints.

This predictably led to motivation, given that one side has a self-imposed deadline of September 30th to enact their proposal. The sponsors of the bill face another non-trivial challenge, namely that key members of the health care delivery community (doctors, nursing homes, hospitals, insurers) and a constellation of patient groups are also arrayed on the other side of the argument. 

Motivation has quickly inspired mobilization of respective constituencies, in order to ensure that the final policy product achieves their desired goals. Congressional leaders are promising a vote next week (before a comprehensive fiscal and budgetary analysis is available), and consumers are promising robust social action between now and then. 

For an overview of the potential impact of this week’s proposal, by state, click here.

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Suicide Prevention

September is Suicide Prevention Month, a vital observance given that suicides happen about once every 12 minutes in the United States, for a total of 44,193 in 2015, according to data from the Centers for Disease Control and Prevention (CDC).

This is a major public health and public policy challenge. CDC data indicates it is a problem throughout the lifespan, and overall suicide rates increased 28% between 2000 and 2015. Non-Hispanic American Indian/Alaska Native and non-Hispanic Whites experience the highest rates among racial/ethnic groups. The rates among veterans and other military personnel nearly doubled between 2003 and 2008. High school students who are lesbian, gay, or bisexual are another high risk group. A recent survey indicated that 29.4% of these young people had attempted suicide, compared to 6.4% of their heterosexual counterparts.  Men are about four times more likely to die from suicide than women, and those who attempt suicide with firearms are more likely to succeed than those who attempt via other means. 

Many Americans who attempt suicide survive, which results in an estimated $10.4 billion in combined medical and lost productivity costs. The risk factors that contribute to suicide are complex, and for prevention and intervention to succeed those factors have to be taken into account. Risk factors include previous suicide attempt(s), family history of suicide or violence, feeling alone, history of depression or mental illness, and physical illness. 

Preventing suicides is fraught with challenges, not least identifying those at risk and intervening in a timely fashion. As a matter of public policy the CDC publishes and disseminates information related to who’s at risk and best practices regarding viable strategies for intervention, from the individual and relationship level all the way up to the societal level. These include: strengthening economic supports, improving access to mental health services and suicide care, increasing relational opportunity for connectedness and engagement with others, teaching coping and problem-solving skills, and lessening harms and preventing future risk. 

There is a national suicide hotline, available 24/7, at 1 800 273 8255. It is connected to dozens of local crisis centers.  For suicide prevention in the Mid-Atlantic please visit the following:

for Maryland click here; 

for Virginia here; 

for the District of Columbia, here; 

for Delaware here; 

for Pennsylvania here, and 

for West Virginia here. 

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Disaster Preparedness

Disasters can be natural or man-made, with varying implications for public policy. Depending on the nature and scope of the disaster, the public health aspect of the response could take any number of forms. 

Some natural disasters, like hurricanes, are associated with a certain time of year, so preparedness follows a set framework. Not so earthquakes, which show up unannounced, and are therefore less straightforward from a public policy standpoint.

As a matter of public policy preparing for hurricanes requires data collection and analyses, in order to project the estimated time of arrival of the storm, wind speed, and storm intensity. The public health aspect requires predicting storm surge and potential for flooding, because while drowning and electrocutions would worry public health authorities at the outset, waterborne diseases are the bigger threat in the storm’s aftermath. 

Waterborne diseases in this context would imply not just the spread of infectious diseases (from overwhelmed sewers or disabled water pumping stations, for example), but the potential for spreading chemical and environmental toxins, such as if industrial facilities are flooded. Such toxins can also be spread in the air, such as if there were fires or explosions at such facilities. There would also be the risk of injury from submerged or airborne debris (tetanus), or animal bites (snakes, alligators). 

Taking a proactive (rather than reactive) approach to preparing for these events necessitates consideration of the following: 

budgets - how much would such an event cost to prepare for - and clean up after the fact - and who should pay?

personnel - how many people are needed to prepare at the local, state and federal level? Who will lead the preparation effort and who will lead the disaster response?

public education - how much should the public know about the hazards, and what should communication look like before, during, and after?

impact - is there differential or disparate impact on people and populations? If so, how should public health authorities prepare?

health system preparation and response - should health care facilities prepare in advance for evacuations, or should health care authorities and governments prepare for the safeguarding and portability of health records? What happens to pharmacies and access to medications?

table top drills and other simulations - akin to fire drills these exercises can be simulated at actual locations that are potentially in harm’s way, or on computers or table tops. They are crucial to the readiness of first responders.

first responder readiness - making sure fire, rescue, EMS, and National Guard have all they need to respond to disaster

emergency supplies - emergency supplies of food, water, first aid, fuel, and electricity in case hospitals and shelters are impacted by the disaster.

There are other policy approaches authorities can consider for the purpose of long-term planning, such as land use, zoning, building standards and codes, drainage systems and other solutions for the built environment, to ensure that the impact of disasters such as hurricanes and floods are mitigated ahead of time.

The 2017 Atlantic hurricane season has several more weeks to go. For more details on disaster preparedness in the Mid Atlantic, click: here for Maryland; here for the District of Columbia; here for Virginia; here for Delaware; here for Pennsylvania; here for West Virginia.

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Healthcare for the Homeless

The unfolding catastrophe in southeast Texas is raising profound public policy questions, from infrastructure and the built environment to disaster preparedness and the public health response. About the latter - all that water generated by Hurricane Harvey affected homeless Houstonians before everybody else in the city, and is therefore worth careful attention. This is true not just in Texas (or wherever Harvey goes next), and not just in the middle of an unfolding disaster, but it matters all across the country, year round.

 We know that housing can compromise a person’s health, for any number of reasons, but homelessness carries its own set of risks. Not only can homelessness make you sick, it can make an illness worse. Sadly, being sick can also make you homeless (if you’re too sick to go to work and therefore can’t afford your rent or mortgage). Research has also shown that a complex web of social factors can contribute or lead to homelessness, which underscores the need for comprehensive public policy solutions.

Providing care for the homeless often falls on the shoulders of community health centers (CHC), America’s best kept secret in primary care. Individuals experiencing homelessness receive high quality affordable care at CHCs across the country, and the care goes beyond health care delivery, to include, in many cases, connection to sustainable housing solutions and other services.

Persons experiencing homelessness face several barriers to personal hygiene and self-care, compounded by other obstacles that stand in the way of good health. They include - income challenges, regular access to soap and water due to restricted access to restroom and laundry facilities, no regular address from which to apply for work or receive safety net benefits, mental health challenges, chronic diseases that make it hard or impossible to find work, and restricted access to transportation, often for a combination of the aforementioned reasons. 

Providing health care to people who experience homelessness on a short or long term basis is fraught with difficulty. First, they have no address or mail box to which an insurance or prescription card can be sent. Next, there’s no income or employer to pay for care, including for prescriptions and dialysis for example. Emergency rooms (ER) and safety net clinics such as CHCs therefore become the default option, the latter being the preferred option given that it is primary care (more proactive, likely more effective, and definitely less costly).  

The public policy problems to be solved in order to improve health outcomes among populations dealing with homelessness include the following: reaching them where they are, such as at the local shelter or soup kitchen; doing the outreach necessary to schedule the clinical encounter; doing the necessary follow-up to ensure they keep coming; appropriating the necessary funding at the state or federal level to pay for the care and train the personnel who deliver the care; keeping accurate electronic medical records, especially because these populations are - by definition - transient; implementing local solutions that are customized for local populations.

Homeless populations vary, by community. Unfortunately (and unsurprisingly) racial and ethnic minorities are over-represented among the nation’s homeless. According to the National Coalition for the Homeless, 40% of the nation’s homeless (2012 data) are African American, even though they comprised only about 11% of the total US population. By comparison - during that same time period 41% of the nation’s homeless were Caucasian, even though they comprise 76% of the nation’s population. 

The situation seems to have improved somewhat in the last few years. According to the National Alliance to End Homelessness (NAEH), the nation’s overall homeless rate (including among veterans) decreased to 17.7 per 10,000 persons in 2015 from 18.3 in 2014. Page 14 of NAEH’s 2016 report indicates the following trends in the Mid Atlantic region - homelessness increased in Maryland (MD), Delaware (DE), and Pennsylvania (PA) by 6.8%, 5.8%, and 0.6% respectively. Homelessness decreased by 5.8%, 0.3%, and 8.8% in the District of Columbia (DC), Virginia (VA), and West Virginia (WV), respectively. 

 For more information about health care delivery to individuals experiencing homelessness in the Mid Atlantic region, please click the following links: for MD, click here (p 42); for DC, here; for VA, here; for DE, here; for PA here; and for WV, here.   

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Health In All Policies

Earlier this year Maryland passed a ‘health in all policies’ law that would require that the Center for Health Equity (CHE) at the University of Maryland’s School of Public Health submit recommendations regarding health equity. Specifically, CHE would work with the Maryland Department of Health and Mental Hygiene to propose policies - across various sectors - that would, if implemented, improve the health of all Marylanders. 

‘Health in all policies’ (HIAP) is the idea that all public policy should serve the purpose of improving the health of all the people affected by the policy. This, necessarily, would apply to transportation policy, housing policy, and education policy, to name a few social determinants of health. 

Our work has underscored the fact that HIAP, like other public policy, requires a level of timeliness and intentionality in order to be effective. But public policy is only as effective as the mechanisms for implementation. Maryland’s new HIAP law will require that all major sectors of state government are involved in a workgroup that recommends policies to improve health, potentially re-orienting the state’s long term approach to improving health equity.

Given Maryland’s pioneering role in this aspect of public policy and practice it is hard to compare outcomes with the rest of the Mid Atlantic region. But the region is likely to benefit from all the data and insight that result from the implementation of this law. As a CHE partner on other projects we are eager to learn from the process, especially regarding the input and engagement of the communities that will be affected by the work. There are lessons learned already, regarding the process of turning academic research into legislation that an elected executive sign into law. 

The text of an academic journal can turn into a story that triggers a conversation that leads to policy proposals that can solve problems for real people. At the end of the day that is the whole point of public policy, and if the implementation of public policy improves health outcomes, eliminates disparities, and enhances health equity, then entire communities can live healthier, more productive lives. 

For a framework for implementing HIAP in every state, click here.

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Health Spending By State

Health spending varies by region and by state, according to a study recently published in Health Affairs. As always, this is a fundamental health policy challenge, made especially urgent whenever state budgets are under strain and federal lawmakers start worrying about deficits and the federal debt.  

In Delaware, per capita health spending grew from $8405 in 2009 to $10,254 in 2014. The numbers in the District of Columbia were higher - from $10,439 in 2009 to $11,944. The size and populations of both jurisdiction are not significantly different but the differences in per capita spending may be largely due to a more generous Medicaid package in DC. 

In Maryland, where the state has deployed an “all payer” system, per capita spending rose from $7,507 in 2009 to $8,602 in 2014 Although Pennsylvania has a larger and in some places older population, the Keystone State’s per capita spending was very similar to Maryland’s, at $7,701 in 2009 and increasing to $$9,258 in 2014. West Virginia has very similar numbers, at $7,772 per capita in 2009, but increasing to $9,462 in 2014. Virginia’s per capita spending is the lowest in the Mid-Atlantic region, rising from $6,452 in 2009 to $7,556 in 2014.

Increased insurance coverage as a consequence of the Affordable Care Act (ACA) accounted for most of the increase in health spending during this period. Although some states refused to expand Medicaid (e.g. Virginia), citizens in all states were able to access private insurance coverage via marketplaces, whether state run or federal.

Increases in health spending can also be attributed to aging populations and the cost of providing the care. We should note, however, that the growth of health care inflation has slowed in recent years, relative to the decades that preceded the enactment of the ACA. Although Medicare spending was less affected by the ACA than other programs, regional variations in spending were observed during the same period. 

The quest for a more efficient health care system that delivers higher quality and improves outcomes for less money continues unabated. Many policymakers are considering models in other advanced countries where per capita spending is much less than here in the United States. Health outcomes, such as life expectancy, are much better in these nations - a goal to which the United States should aspire.

We will continue to watch this space. 

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Traumatic Brain Injury

Traumatic brain injury (TBI) has been in the news a lot lately, largely due to increased public awareness as wounded warriors return home from war, and as the sporting world confronts the long-term impact of chronic traumatic encephalopathy (CTE) on deceased professional football players. 

The high-profile exposure of professional athletes may in fact be obscuring a larger scale problem, namely all the student athletes and other adolescents who play amateur sports and suffer TBI, especially concussions, every single week in America. 

The public policy challenge is considerable. First, there’s the need for ongoing (and accelerated) medical research about the disease process. We need to understand the science about how brain injury occurs, how it affects speech, cognition, coordination between brain activity and moving the body, and how it affects mortality. These injuries often manifest in conditions such as Alzheimer’s, Parkinson’s and Lou Gehrig’s Disease, and the medical, social, and economic costs are vast, and growing. 

Unfortunately, some populations are at increased risk and are therefore more vulnerable. Racial and ethnic disparities have been documented in the treatment and outcomes associated with TBI, including the brain injury and severity reported in this study about adolescents.

TBI is caused by trauma to the head - falls, blows from objects, collisions, or the casualties of war, and the causes vary by age group and occupations/activity. CTE has been associated with boxing and football, and symptoms include memory loss, personality changes, speech and gait abnormalities. 

According to the Centers for Disease Control and Prevention (CDC), there were 2.8 million emergency room visits, 282,000 hospitalizations, and 50,000 deaths attributable to TBI in the USA in 2013. Unfortunately, the number of ER visits have risen sharply in the last decade and a half. More data about violence and injury prevention at the state level are available here.

The core public policy challenges remain, but there are a number of useful policy solutions. First, there is the injury prevention aspect, at the state and federal level. This works best in scenarios where public awareness and education are most robust. Second, there is the societal commitment to providing emergency care of the highest quality and effectiveness, and reducing or eliminating disparities where they exist. Third, policymakers must be continually encouraged to optimize the funding, training, and recruitment resources necessary for basic science and clinical medicine research.

We are farther along in understanding the disease process than we were in previous generations. The prognosis for developing the treatments and therapies that help return patients to wholeness now seems slightly more hopeful.

We will continue to watch this space.

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Hepatitis C Awareness

The Hepatitis C Virus (HCV) is spread primarily via contact with the blood of an infected person, and can result in a lifelong chronic disease that can ultimately damage the liver. According to the Centers for Disease Control and Prevention (CDC) an estimated 2.7-3.9 million people in the United States have chronic Hepatitis C.

The CDC goes on to say that before 1992 HCV was often transmitted via blood transfusions and organ transplants, but today it is more commonly transferred between people who share needles for injecting illegal drugs. The latter mode of transmission is of particular resonance given the ongoing opioid epidemic. 

The key policy challenges for dealing with HCV are these: 

HCV is contagious;

many people who have the virus have never been tested, so they don’t know they’re carrying it; 

Baby Boomers are five times more likely to contract HCV than the general population, meaning that the oldest among them are starting to age into Medicare eligibility; 

HCV is the leading cause of liver transplants; 

HCV causes liver cancer, and African Americans between the ages of 50-64 had higher rates of liver cancer than the general population, according to 2008-2012 data;

HCV drugs are expensive, to the tune of $1,000 per pill or $84,000 for a 12-week regimen.

Policy makers are hard at work confronting these problems. First, increased awareness can increase the number of people who get tested for HCV, which should lead to more patients getting treatment. Unfortunately this also means confronting the prohibitive cost of HCV therapies. 

The cost places a particular burden on the Medicare program, given the age of many adults who live with HCV. For those who sustain liver damage there is another challenge - finding donors if they need a transplant, and the cost and follow-up care associated with transplant surgery. Cost sharing arrangements mean that patients foot some of the bill for treatment, while the health plan (Medicare or employer-sponsored) and drug rebates take care of the rest.

The long term prognosis for HCV is good if treated in a timely fashion, and some people clear the infection from their bodies without treatment. It remains an ongoing challenge for federal, state and local policymakers, however, for all the aforementioned reasons.

For more about HCV prevention and treatment in the Mid-Atlantic region, please click on the links below:

 Maryland; 

Distict of Columbia;

Virginia;

Delaware;

Pennsylvania; 

West Virginia.

We will continue to watch this space. 

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Bugs and Bites

Summer is a great time to spend valuable time outdoors - sunshine, nature, lazy days...

Warmer weather brings potential health hazards however, not the least of which are vector-borne diseases (illnesses carried around by insects) such as Lyme Disease, West Nile virus and Zika. These pose policy challenges, that are, thankfully, well documented and understood. But they are challenges nonetheless. 

Some of these diseases are borne by mites and ticks, others by mosquitoes and flies. Their geographic distribution also varies, given that variations in weather and climate conditions determine whether one area gets it more or less than another. 

The main policy challenges are these: are people aware of these hazards; do they know how to prevent exposure to the vector; is there a robust stockpile of vaccine for the illness, if indicated; and are there factors related to climate change that policymakers should consider? Parents should be extra careful in helping their children navigate these potential threats, from helping them select appropriate clothing to applying insect repellent when necessary. 

Most importantly - people spending time outdoors should be made aware of the hazards, including the risk of exposure, signs and symptoms, and what to do if you think you’ve been exposed. Secondly, populations should also be aware of potential prevention or treatment, such as vaccines (page 42), and where to get these vaccines and if there are potential side effects. Third, policymakers should consider the effects of climate change, such as prolonged droughts or more severe storms or changes in the jet stream, which may each impact what areas of the country are affected by which disease. Zika, for example, was more traditionally more likely in Africa or Asia, but the number of reported cases in the United States (and the rest of the Americas) have increased in recent years. Experts suspect climate change may be a factor.  

Policymakers must also be aware of the need to fund public health laboratories and public health departments. 

The Centers for Disease Control and Prevention (CDC) as well as state and local health departments are increasingly vigilant about surveillance, public health education and public awareness, and prevention and treatment of these diseases. Unfortunately, these occurrences sometimes turn into outbreaks, and sometimes resource allocation struggles to keep up with demand. Hence the need for citizen engagement and awareness.

For more information about dealing with these diseases in the Mid Atlantic, please contact your state or local health officials. For Maryland, click here, for Virginia, here; for the District of Columbia, here; for Delaware, here; for Pennsylvania, here; for West Virginia, here. 

We will continue to watch this space.