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Phreshest of 2013!

The Phreshest and most rotten news of 2013

Obamacare, government shutdowns, NFL head injuries—as the last days of 2013 squeak out, we’ve looked back on the best and the worst of the year to deliver Phresh! Top Ten Stories of the year as well as the Top Five Public Health Fails of 2013. Public health is an ever-changing beast and, as we move forward, it’s worth a review of what’s been done and what’s left to be done. So, without further ado, the best and the worst…



It is easy to forget that healthcare reform in the U.S. was for so many decades a pipedream, something that many Americans thought they would never see in their lifetimes. Thinking of it in this light may put some perspective on the constant roller coaster ride that is the Affordable Care Act (ACA). The ACA weathered many storms in 2013 including challenges from Republican governors and a GOP-led shutdown that failed in its attempt to halt the plan, plus a website rollout that was filled with glitches, preventing thousands of people from enrolling. Yet as we move into 2014, over 500,000 individuals have signed up for an ACA exchange, enrollment has surged  in recent weeks, and it appears Obamacare is safe—at least for now. It is still unclear what the composition of the health care exchanges will look like and how they will fare long-term. Much remains up in the air, but despite many glitches, the ACA, in itself, is a huge step forward. All of this will hopefully come into focus in 2014, when health coverage becomes effective.

Several forms of government gridlock, most notably a budget sequester and a 16-day shutdown of the federal government, hampered public health efforts across the United States this year. On March 1, 2013, President Obama signed an order to initiate $85 billion in sequester cuts. As a result, the Centers for Disease Control and Prevention (CDC) had to cut more than $285 million from its fiscal year 2013 budget. Sequestration also harmed a wide range of public health efforts beyond the CDC, notably slashing nearly $600 million in funding of global health programs through cuts to the Department of State and USAID.

Just a few months later, these painful cuts were followed by a 16-day shutdown of the federal government in October. This third-longest government shutdown in American history came with a price tag of $24 billion, according to an estimate from Standard & Poor. Among its many costs, the shutdown placed numerous key public health programs in limbo, from shuttering the annual influenza program to sidelining the FDA’s routine food safety inspections. Both the sequester and the shutdown disrupted essential public health services, which require consistent support to most effectively protect the health and well-being of Americans.

The shift towards progressive marijuana laws hit a milestone this year with marijuana legalization in Washington State and Colorado. The criminalization of marijuana disproportionately affects young people and people of color, imprisoning individuals to an industrial prison complex and adding to taxpayer burden. These resources could be better served for substance abuse prevention and treatment services as well as on shifting law enforcement focus to more violent crimes.

Marijuana is also the biggest cash crop in twelve states, and the in the top five in 39. Billions of tax revenue dollars could be generated, shifting profits from organized crime to public coffers. One unintended consequence that should be considered is the potential public health damage of legalization, from increased adolescent youth to unsolicited targeting of existing medical dispensaries and their patients. An alternative approach would be to shift the focus of marijuana legalization from the societal view of the substance as not a product, but a drug that can be dispensed over-the-counter at pharmacies.

Obesity is one of the greatest health issues of current times, triggering heart disease, diabetes and stroke, among others. From 1997 to 2012, U.S. obesity rates increased about 50 percent. More than thirty percent of American adults are obese and childhood obesity has tripled in the past 30 years. As its prevalence has grown, the word obesity has taken on new meanings. This past year, the American Medical Association adopted a new policy officially labeling obesity as a disease, basing an illness on an often inaccurate measure—body mass index (BMI). Meanwhile, researchers debated the benefits of BMI after a meta-analysis in the Journal of the American Medical Association (JAMA) indicated that being overweight was associated with lower risk of death, going against previous understanding. The events were two substantial contributions to the ongoing perception of obesity in public health and our society.

For the first time since 2001, the American Heart Association (AHA) and the American College of Cardiology (ACC) revised the cholesterol guidelines for which clinicians should recommend their patients to begin statin therapy. While many misunderstood the changes in recommendations and accused the AHA of making a decision that will benefit the pharmaceutical industry more than anyone else, the AHA stood its ground. The expert panel involved in the November decision emphasized that the new guidelines were developed from and based on the best evidence available. Moreover, they were intended to spark a conversation between patients and their physician rather than automatically dictate to physicians when they should prescribe statin therapy.

The new guidelines featured a risk calculator that incorporates patient characteristics to assess one’s likelihood of succumbing to a cardiovascular event so as to inform the level of future care. Given that 1 out of every 3 Americans dies of cardiovascular disease, this decision holds a lot of weight for physicians and patients alike. There is little doubt that lifestyle changes including increased exercise, decreased smoking, and healthier diets are steps in the right direction to lower one’s cholesterol. However, truth of the matter is that for those in the highest risk group, these lifestyle changes cannot reduce risk as quickly as statin therapy, and this may be a life or death decision.

In August 2013, the NFL reached a $765 million settlement with over 4,000 former players who alleged that the league had concealed its knowledge about the risks of concussion associated with the sport. Some observers regarded the settlement as a positive resolution, given that the money will go toward research and help pay for the medical care of retired players. Others argued that the settlement would enable the NFL to continue denying the relationship between head injuries and long-term diseases. These concerns received further attention in October, when FRONTLINE aired a widely viewed documentary entitled League of Denial: The NFL’s Concussion Crisis. The documentary highlighted the influence of the NFL’s behavior on safety attitudes and practices at all levels of play. Football has the highest numbers and rates of concussion among the sports examined by the CDC, and millions of children continue to play the game. The settlement was therefore not only a major development in professional sports, but also a milestone in an ongoing public health conversation about the risks of concussions.

What did a bat, camel and a 60-year old Saudi man have in common this year? A novel respiratory virus. Symptoms include renal failure and severe acute pneumonia, which can often result in death. With 165 laboratory-confirmed cases since September 2012, the Middle Eastern Respiratory Syndrome (MERS) has claimed 71 deaths, making it one of the biggest public health stories of the year. As the SARS-like coronavirus spread from Saudi Arabia to as far as France, concern of a larger epidemic grew. Controversy arose, when Dr. Ali Mohamed Zaki, the Egyptian physician working in Saudi Arabia who isolated the virus, provided it to Ron Fouchier, a virologist at Erasmus Medical Center in Rotterdam to sequence the viral genome and better understand the disease.

In October, during the Islamic pilgrimage to Mecca, or the Hajj, the Saudi Kingdom’s Ministry of Health enacted sweeping public health measures to control any potential spread of the MERS virus. The transparency and prevention approaches appeared to keep the spread under control. However, in November, a Spanish woman who traveled to Saudi Arabia for Hajj had contracted the disease. For now, authorities are trying to keep it under control using annual influenza vaccination and pneumococcal vaccinations given every 5 years, while Novavax and Greffex, Inc. are awaiting clinical trials to develop a vaccine from the spike protein.

In December of 2012, 20 children and seven adults were murdered in a school shooting in Newtown, Conn., and many believed that the year 2013 held new promise for gun control legislation. In 2013, there have been 109 new gun laws passed, but surprisingly, the large majority of them have loosened restrictions on guns. On the national level, the Senate defeated a law that would have expanded background checks and banned some semi-automatic weapons in April. President Obama called it “a pretty shameful day for Washington.”

California, Colorado, Connecticut, Delaware, Illinois, Maryland, and New York passed laws that would make gun restrictions tighter. The laws address assault rifle sales, “gun-show” loop holes, expanded background checks, and bans on gun ownership for the mentally ill among other issues. This year, the Supreme Court stayed out of the debate, declining again to hear an appeal on gun rights.

When it comes to scales, they’ve been tipping for years on account of trans fats. But, not how you would expect. Unbeknownst to many, McDonald’s stopped cooking its French fries in trans fats over ten years ago. In 2007, New York City banned hydrogenated vegetable oils and spreads in restaurants. And, U.S. intake of trans fats have decreased from 4.6 grams per day in 2003 to a gram a day in 2012.

Trans fats—often used in processed foods like desserts, microwave popcorn, pizza, margarine and coffee creamer—are known to raise bad LDL cholesterol and are linked to heart disease. After years of food manufacturers reducing trans fats on their own, the FDA’s move to ban the majority of trans fats is a long-awaited, but bold step for the future of America’s health.

After decades of an international effort to eradicate polio, the world community saw a 99 percent reduction in cases last year. This is a significant change since the 1980’s when at least 1,000 children were paralyzed by polio every day. Now many are watching a global increase in cases due to internal conflict and politics, most closely in Pakistan, where a decree by the Taliban in June 2012, banned polio vaccinations. This was a direct response to reports that the CIA used a sham vaccine campaign to help track down Osama bin Laden in 2011. The ban is rooted in a deep mistrust of the West and some fears that the vaccinations are actually designed to sterilize Muslim children. The public health community has voiced its concern and dismay at the US government’s use of public health campaigns as an intelligence-gaining device.  This violates the humanitarian service that public health campaigns provide and the medical neutrality outlined in the Hippocratic Oath.

In 2013, only three countries (Afghanistan, Nigeria and Pakistan) remain polio-endemic, down from more than 125 in 1988.  The decrease in vaccinations has led to an increase in Pakistani polio cases, up from 58 in 2012 to 77 currently. This is in contrast to trends in Nigeria and Afghanistan, which have seen decreases in the number of cases from 2012 to 2013.

Since the ban, 32 polio-workers have killed. This includes community health volunteers and those hired to protect them. The death threats are broadly targeted, including some of Pakistan’s most famous citizens. Earlier this month, Imran Khan, the country’s best-known cricketer, now a politician, received a death threat from the Taliban for his statement that criticized the attacks on polio workers.  There are some Taliban-affiliated religious scholars that have supported vaccination efforts and have urged parents to vaccinate their children. Many others in the global and Pakistani health communities are hoping that the political rhetoric and distrust will resolve, allowing for vaccination of Pakistan’s most vulnerable community—the one and a half million unvaccinated children.



1. HEALTHCARE.GOV was riddled with problems on day one: October 1, 2013. Both heavy traffic and technology failures lead to an opening day fiasco that resulted in very few enrollments. Later in the month, government officials admitted that they had only tested the site for two weeks prior to the launch, when months of testing would have been advisable. By the end of October, Health and Human Services (HHS) Secretary Kathleen Sebelius apologized for the website failures and told the nation, “Hold me accountable for the debacle.”

President Obama named Jeffrey Zients to run an overhaul of the website, and an improved website was promised by November 1. Performance improved and capacity increased, but about one-third of those enrolled as of the beginning of December have records containing errors that could keep them from having insurance coverage in place by January 1, and there are concerns over how secure applicants’ information is, once entered into the site.

The deadline to have coverage as of Jan. 1 continues to be a moving target. Dec. 23 was already an extended deadline, but when the site received 2 million visitors on that day, the deadline was extended for yet another 24 hours. Currently, lists a phone number for potential applicants who have missed the deadline due to high demand or technical difficulties to call and plead their case saying, “If this happened to you, don’t worry – we still may be able to help you get covered as soon as January 1.”

This year’s rise in pertussis, a bacterial infection of the respiratory tract that can spread easily through droplets in the air when an infected person coughs or sneezes, is a major public health fail. Though 2012 was one of the worst in the past 12 years, pertussis increases have been seen in 17 states and Washington, D.C. in 2013. Pertussis, often called whooping cough due to the high-pitch sound an infected person makes when they cough, can result in coughing fits that become so strong they can lead to vomiting or gagging. All adults and children should be immunized with DTaP and receive a booster later on, especially anyone who spends time around infants. Infants do not have immunity until they receive their three-dose vaccine series.

Unfortunately, two trends have appeared that may be resulting in this rise: 1) a dip in vaccination rates in certain states, like in Oregon, California and Washington, fueled by the anti-vaccine movement and misled stars like Jenny McCarthy; and 2) changes in the virus that seem to be making the vaccine less effective. Despite issue 2, vaccination is still the best way to protect our population from a potentially deadly disease. However, the public health message has failed to drown out the anti-vaccine movement in some areas of the U.S.

November 1st, 2013 marked the end of the expansion of the Supplemental Nutrition Assistance Program (SNAP) better known as food stamps. Cuts to the program, designed to keep low-income Americans out of hunger following the economic recession, have since forced increasing numbers of families to rely on food banks for sustenance. The impact of the SNAP cuts is widespread, as millions of dollars are being siphoned out of the economy at the expense of poor Americans. Those affected are seeing their benefits run out by long before the month’s end, with 90% of benefits redeemed by day 21 of the month.

The cuts arise based on negotiations around the most recent farm bill where the Senate alone cut $3.9 billion from SNAP not to mention the $39 billion to be cut by the House over the next 10 years. This now means that the average family of 4 will have less than $432 a year to spend on food. The 50 million Americans living in hunger would agree that this is one of the biggest public health fails of 2013.

Does the United States own a monopoly on the world’s pain? If consumption of pain medication is any indication, this indeed seems true.

The United States consumes 99 percent of the world’s supply of hydrocodone, and the FDA continues to approve of new formulations oblivious to the rampant abuse of the past. There has been some public health wins this year in regards to prescription opioids, including tighter regulations of current formulations and the development of a risk evaluation mitigation strategy (REMS), though these tighter restrictions only seem to manifest by restricting access to those who need it most. Pain management is a health priority, but without responsible conduct at all levels, including prescribers and regulators, pain prescriptions here in the United States seem to only add to the problem.

Motorcycle deaths rose 9 percent in the last year, making us all bang our heads against the wall in confusion. With the rise, that’s 5,000 total lives lost in 2012. This year’s report from the Governors Highway Safety Association showed that 2012 was the 14th in 15 years that motorcycle fatalities increased. Meanwhile, a parallel trend was taking place—a decrease in states with universal helmet laws. Currently, only 19 states require all riders to wear helmets, down from 26 in 1997. The failure to enact universal helmet laws in more states and the push by some legislatures to repeal these laws is represented in this year’s rise in motorcycle deaths and is one of 2013’s biggest public health fails.

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