In 1946, Tom Brock spent part of his summer dumping mustard gas bombs off a barge into the Atlantic Ocean. Brock was a civilian employed by the United States Army Transport Service in Charleston, South Carolina. His job was to dispose of surplus bombs and drums filled with mustard gas. Sulphur mustard, commonly called “mustard gas,” can take several forms: a liquid, a solid, or a vapour. Mustard gas, named for its mustard-like color and smell, is a vesicant that is toxic to humans and causes blistering and burns, affecting the lungs, eyes, and skin. Brock recalled that he and the soldiers enjoyed watching the occasional bomb explode as it sunk into the water. “We thought it was fun,” explained Brock. “I was 18 or 19 years old. We weren’t scared. We didn’t fear any explosive. We thought we were immortal.” Later that summer he was required to guard a barge of bombs that were leaking mustard gas, which looked to him like hot molasses. Due to the known health risks, Brock was told to wear a protective suit and gas mask. However, it was a hot day so he loosened the straps around his legs. As a result, enormous blisters developed, swelling out like a balloon from his toes to his knees. His summer job was no longer fun as he experienced firsthand the health hazards of exposure to mustard gas.

The concept of Health in All Policies aims to improve the health outcomes associated with policies in an attempt to mitigate health disparities and provide optimal environments for healthier living. This multidisciplinary framework seeks to improve health through effective assessment and reformation of policy for organizations of any level and stature. The importance of integrating health in policy assessment and decision making is a key concept in the growing field of Health Impact Assessment.

The World Health Organization defines Health Impact Assessment (HIA) as “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.” HIA provides a mechanism for collaboration between various sectors and disciplines bridging the gap between research, policymaking, and implementation of policies, programs, and projects affecting health outcomes. In the United States, while some HIA efforts have focused on proposed public policies, HIA has been used primarily to analyze the health effects of proposed development projects and plans related to community design and transportation.

The most prominent — and certainly the most controversial — feature of the Patient Protection and Affordable Care Act (the ACA, or the Act) is the so-called “individual mandate,” which attempts to address the problem of 50 million uninsured by requiring nearly all Americans, beginning in 2014, to obtain health insurance. While expanded access to health insurance has been both the cornerstone and the lightening rod of the ACA, the Act also contains significant public health provisions focusing on, among other things, promoting the availability of prevention and wellness services. Although these public health provisions have been greeted with mixed reviews, there has been very little discussion of what may be the ACA’s most significant public health feature: the preventive services mandate. In a bold stroke, the ACA changes the way evidence-based preventive services will be provided and paid for by private health insurance plans, Medicare, and Medicaid. By requiring these health plans to provide evidence-based preventive services with no out-of-pocket costs, the ACA transforms the U.S.’s public and private health care financing systems into vehicles for promoting public health.

The Institute of Medicine (IOM) reporting on the quality of health care in America recommends six aims for achieving the health care system we could have. Together with the Institute for Healthcare Improvement (IHI) Triple Aim initiative, a framework has emerged to challenge providers, educators, and policymakers to remake the health care system according to specific objectives: to provide care that is safe, effective, patient-centered, timely, efficient, and equitable to more people at a price we can afford. Complicating this mission of better prevention and better care at a lower cost is a daunting demographic: January of 2011 marked the month and year that the first of the baby boomers turned 65. The U.S. Census Bureau in May 2010 projected the number of Americans of this age and over to reach 88 million by 2050, more than double the current figure of 40.2 million. Parekh and Barton forecast in stark detail what it will be like to address these burgeoning numbers of older Americans with comorbidities, including the fact that over 20% of the population currently experiences at least two chronic medical conditions.

In recent years, the research participant’s family’s need, if not right, to know their disease risk has comprised a great deal of the genetic testing discourse. This most often arises in the context of clinical genetic tests for hereditary cancers, especially colorectal and breast cancer, and other genetic disorders where the presence of a genetic mutation greatly increases the likelihood of the disease’s manifestation (such as Huntington’s Disease). However, this discussion has not led to comprehensive or cohesive guidance for health care professionals or patients. Indeed, various governmental and professional bodies run the gamut of possibilities, from no disclosure to family without the consent of the patient, to recognition that genetic risk information is important enough to the family to allow exception to traditional notions of confidentiality.

The passage of the Servicemen’s Readjustment Act of 1944 — or GI Bill — opened up a dialogue about men’s physical and mental health, for it addressed very directly what ordinary men would need to recover from extraordinary violence. Political leaders identified veterans’ “welfare,” by which they meant general well-being, as a top priority of World War II’s recovery, and the GI Bill was the centerpiece of their agenda. The bill’s passage was an impressive legislative triumph, the collective product of massive medical, legal, and social science research, bipartisan politicking, and veterans’ activism. It provided education, housing, and small business assistance, along with mental and physical rehabilitation in government-funded hospitals. All of these programs, whether they served mind, body, or wallet, amounted to welfare — a set of government-sponsored policies and services designed to aid a soldier’s transition from enlisted man to healthy, productive citizen. Thus we have to think about the broad reach of the GI Bill’s welfare provision as one of the health legacies of World War II.

Current methods of obtaining an informed consent leave much to be desired. Patients rarely read consent forms or understand all of the risks, benefits, or alternatives associated with their treatment. Evaluating the advantages and disadvantages of treatment options often presents a more significant challenge for patients with lower levels of health literacy. This article reviews the evidence of shortcomings in our informed consent system and then explores the potential for a new approach to engage patients at all levels of health literacy in their treatment decisions. Specifically, the article will examine the potential of shared decision-making (SDM) to bridge gaps in knowledge, increase patient adherence to treatment, and improve health outcomes in low health literacy patient populations. Leveling barriers to treatment information for disadvantaged populations should be a public health imperative, especially if it can be shown to improve health outcomes and reduce health disparities.

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA), a major piece of health care reform legislation. This comprehensive legislation includes provisions that focus on prevention, wellness, and public health. Some, including authors in this symposium, question whether Congress considered public health, prevention, and wellness issues as mere afterthoughts in the creation of PPACA. As this article amply demonstrates, they did not.

This article documents the extent of congressional consideration on public health issues based on personal experience working on the framework for health care reform — specifically, my experience as a Fellow for a member of the Health Subcommittee of the Senate Finance Committee from 2008-2009. I also include a review of congressional activity in the United States House of Representatives. Analysis of the congressional meetings and hearings reveals that Congress had a deep understanding about the critical need to reform the U.S. public health and prevention system.

In 2009, Time magazine named “biobanks” as one of the 10 ideas changing the world. These organized collections of human biological material and associated data have been identified as “vital research tools in the drive to uncover the consequences of human health and disease.” Since their inception, however, biobanks have faced ethical and legal challenges. Whether these pertain to informed consent, access by researchers, commercialization, confidentiality, or governance, biobanks must continue to address jurisdictional matters, operational difficulties, and normative frameworks that strive to stay abreast of current scientific innovation. Yet, with some biobanks now having completed their recruitment objectives and with research currently being performed on their data and samples, one topic has become the focus of ongoing debates: the return of research results to participants.

What does it mean to be a “just” and “caring” society in meeting the health care needs of the terminally ill when we have only limited resources to meet virtually unlimited health care needs? This is the question that will be the focus of this essay. Another way of asking our question would be the following: Relative to all the other health care needs in our society, especially the need for lifesaving or life-prolonging health care, how high a priority ought the health care needs of persons who are terminally ill have? Should any of the health care needs of the terminally ill be assigned very low priority? Or should all their health care needs be assigned the highest priority? If we reflect a bit, we will find ourselves greatly internally conflicted. On the one hand, the “caring” side of our moral self might see terminally ill individuals as being among the “medically least well off,” and therefore, deserving virtually any medical resources that will yield any degree of good for them.

The obesity epidemic is not only impairing the health of millions of Americans but also giving rise to billions of added dollars in health care spending. Climbing rates of obesity over the past decades are one of the predominant determinants behind the surging progression of health care expenses in the United States. Moreover, the less fit and less productive U.S. workforce has gradually eroded the nation’s industrial competitiveness. Since the early 1970s, adult obesity rates have doubled and childhood obesity rates have more than tripled, while health expenditures have risen two percentage points faster than the Gross Domestic Product (GDP), burgeoning from 8.8 percent in 1980 to a projected 17.9 percent in 2011. Studies analyze that greater than a quarter of America’s health care expenses are attributed to obesity. The stunning growth in obesity has been imputed for 20 to 30 percent of the increase in health care costs since the late 1970s. If the proportion of obese population had stayed unchanged, then health care expenditures in America would be approximately 10 percent less on a per capita average than they are today.

Until the mid-20th century, biomedical research centered on the study of specific diseases, concerned with short periods of time and small groups of living research participants. However, the growth of longitudinal population studies and long-term biobanking now forces the research community to examine the possibility of the death of their research participants.

The death of a research participant raises numerous ethical and legal issues, including the return of deceased individuals’ research results to related family members. As with the return of individual research results for living research participants, the question of the obligation to return a deceased person’s research results to family members has yet to be settled. This question is particularly acute in the context of genetic research since the research results from one individual may have health implications for all biological relatives.

Most people dread being the subject of interest for doctors, scientists, regulators, and lawyers. While we may joke about the arrogance of the medical profession and the aggressiveness of the legal field, both lie at the core of environmental public health (EPH). They are inseparable, sometimes complementary and other times in tension. The role of medicine and science in EPH is clear, but their relationship with law is often opaque. Yet in no other area of public health, from infectious and chronic disease prevention to providing health care in underserved communities, is law so central as an instrument and partner. In this article we explore the relationship of law and science in the broader context of EPH, beginning with an overview of potential goals and challenges. We then offer three organizing principles that inform and guide the integration of law, science and policy in EPH.

On September 23, 1949, President Harry Truman announced that the Soviet Union had successfully detonated an atomic bomb. The news that the Soviet Union had done this came as little surprise to a number of American scientists and to some members of the intelligence community who had predicted that the Soviets would quickly acquire this advanced weapons technology. But for many Americans this news was disturbing. Truman’s announcement was taken up by, among others, a young Baptist evangelist named Billy Graham. Opening a tent revival in Los Angeles just two days after the President’s report, Graham preached how the news of the Soviet bomb test had “startled the world” and launched an “arms race unprecedented in the history of the world.” President Truman, he informed his listeners, said that we “must be prepared for any eventuality at any hour….” Perhaps even more ominously he asked the crowd, “Do you know the area that is marked out for the enemy’s first atomic bomb? New York! Secondly, Chicago; and thirdly, the city of Los Angeles!” It was not only evangelical preachers who foresaw catastrophic implications from a growing arsenal of atomic weapons.

In 1989, Helga Wanglie, 86 years old, broke her hip. This began a medical downhill course that a year later caused her health care providers to conclude that she would not benefit from continued medical treatment. It would be futile, and therefore, should not be provided. Her husband (the surrogate decision maker) disagreed, and the conflict eventually led to a lawsuit. The Wanglie case touched off an extended debate in the medical and bioethical literature about medical futility: what it means and how useful the concept is in making ethical decisions about starting or stopping treatment.

It is no secret that one of the biggest public health challenges facing this nation is the obesity epidemic. Two-thirds of adults and one-third of children and teens are either obese or overweight. For adults, the number of obese has doubled since 1980, and for children age 6-11 the number of obese has quadrupled. The epidemic has changed what we thought we knew about medicine. For example, until fairly recently, type 2 diabetes was known as “adult-onset” diabetes. But doctors have dropped this moniker as youth account for almost half of new type 2 diabetes in certain communities. Further, there has always been an assumption that life spans and health would improve with advancements in medicine and technology. However, obesity is related to over 20 major chronic diseases, and therefore obese children are more than twice as likely to die before the age of 55 compared to healthy-weight children. In other words, if trends are not reversed, America’s current generation of children are likely to have shorter life spans than their parents.

United States Air Force planes fly across mountains of green forest; behind them, fine white streams of chemical spray fill the sky. The planes fly alone or in formation covering wide swaths of the entire landscape. These images of the herbicide spraying during the United States-Vietnam War are ubiquitous in media material about Agent Orange, the most heavily used of the fifteen herbicides sprayed during the war. This representation of the war does not include guns, grenades, tanks, bombs, or dead bodies. Instead, contemporary documentary filmmakers offer images of airplanes and chemical barrels to provide evidence of another weapon of war, pan dead and leafless forests in an otherwise lush landscape of green, and zero in on children’s deformed bodies to show the lasting environmental and health effects of Agent Orange. In this essay I share preliminary thoughts from my new project on Agent Orange and film in the United States and Vietnam. The bulk of social science writing on Agent Orange has focused on American veterans and their fight to secure benefits, while film scholars have analyzed the Vietnam War in Hollywood movies and television. I investigate documentary film, the transnational activism that generates these films, and the representations of gender, disabilities, bodies, history and culture within them. Here I offer a close reading of two turn-of-the-twenty-first-century documentaries about Agent Orange in Vietnam.

The cost of health care at the end of life accounts for a high proportion of total health care costs in the United States. The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006. This indicates how little progress has been made in containing these costs, though doing so will be important to promote a financially sustainable health care system. These expenditures also highlight the prospect that efforts to reduce health care costs overall are likely to disproportionately affect the care patients receive at the end of life.

Where research was once strictly confined to one laboratory or office, investigators now widely share and compare their plans, analyses, and results. With the advent of genomic knowledge, researchers are seeking to understand the genetics and genomics of complex human disease. They are combining their efforts into international consortia in order to take on problems that face individuals around the world, such as cancer and malaria — problems that are too large to solve by one country alone. These consortia bring together diverse research groups from different parts of the world to focus on a common goal. Their projects may all focus on one disease or condition, but examine it from different perspectives (i.e., disease subset or methods of transmission) and share the newly gained information with each other and the wider scientific community.

The governance structures of state public health systems vary as much as the states themselves, including the existence and role of state boards of health. Understanding these differences is essential to a complete understanding of the governmental public health enterprise. State boards of health are obvious vehicles for public health policy development in some states, where they work closely with or oversee state health agencies. In other states they do not exist or serve only in a non-binding advisory capacity.

In this article, we distinguish and identify state boards of health and state public health advisory boards, examine state boards of health in practice, and discuss their role in advocacy and policy development in the context of state politics. We used a set of mixed qualitative methods, including a literature review, online research of state statutes establishing state board of health authorities, and key informant interviews. Informants were five current and former state board of health members, four current and former state health officers, and nine state health agency senior policy staff, spanning 13 states.