June 4, 2007

In March of this year, the federal government shocked Connecticut health advocates and legislators by slashing support for Ryan White funds to support people with AIDS, including a 50 percent cut in dollars to Hartford and New Haven.

The Ryan White program, named for a young man with hemophilia, who died of AIDS, addresses the unmet health needs of persons living with HIV and AIDS by funding primary health care and support services.

At a time when President Bush is touting his multi-billion dollar program targeting AIDS in Africa, the action seemed hypocritical. Is politics involved? Is this another story about the callousness of the Bush administration?

Yes and no. And Ryan White dollars may even be affected by the politics of the Democratic presidential primary.

There is no question that Bush's cuts in health care and housing have harmed all vulnerable groups, including people with AIDS.

But the response to AIDS has been controversial from the start. Traditional public health measures to prevent transmission of the disease - whether closing down bathhouses in New York, screening blood donors, encouraging use of condoms, testing mothers to prevent transmitting the disease to their babies, funding needle exchange, reporting of disease, and even promoting circumcision have raised tensions between autonomy and privacy of the individual and the protection of the public.

It is true that under George Bush, emphasis on AIDS prevention is tepid: opposition to both needle exchange and promotion of condoms, but encouraging talking to partners, testing moms to prevent transmission to newborns, and abstinence.

Even so, tensions over prevention measures do not always fall along party lines.

In the past, the formula favored states with the most cases and best reporting, pioneers in AIDS prevention that also tended to be wealthier: New York, California, and Connecticut. Poorer states like Georgia fared less well, but these are also states that adopted prevention measures a decade or two later.

The proposed change shifts dollars from states with large caseloads to those with large number of new - or incident - cases. So in March, New Haven was cut.

Any choices about money are stark. How do we measure need? Can we keep politics out of it?

Should we send dollars to communities with large numbers of new cases, or to communities http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2006supp_vol12no3/pdf/table2.pdf
maintaining large numbers of people with AIDS? If a community has a large number of new cases, are we rewarding states that fail to prevent the disease?

As might be expected, when money is involved, where you stand depends on where you sit. Last year, the National Black Chamber of Commerce and the Gay Men's Health Crisis were in different corners.

Connecticut is a pioneer in AIDS prevention; beginning in the late 1980s, with needle exchange, we adopted aggressive measures to reduce transmitting the virus. Unlike many states with diverse populations, new cases in Connecticut are more evenly distributed by race, although minorities are still over represented.

Further, Connecticut and New York, for example, are relatively wealthy states. Is the cut political? Is it fair?

Last year, Hillary Clinton said no, at first holding up legislation because of cuts to New York. But Henry Alford of the National Black Chamber of Commerce, citing the threat to minorities in the South, questioned Clinton's action, and others speculated that she was appealing not only to New York, but California, a key state in the Democratic presidential primary.

This year, for the time being, the formula will change as proposed, and reaction has been more muted than last year. Recently, Congress replaced some dollars with supplemental funds, but large gaps remain The Connecticut Appropriations budget adds back dollars to avoid layoffs and homelessness, but those line items are still being negotiated in Hartford.

So - would George Bush divert money from New York, California, and Connecticut to Florida, Georgia, and Texas for political reasons? In a New York minute. But Democratic lawmakers in the South would cheer him on because it helps their communities.

For this year, supplemental funds and state dollars buy time, but avoid painful decisions about rationing dollars and building grassroots support for measures to prevent AIDS.

May 30, 2007

The most serious medical conditions for seniors are mystifying, require teams of physician detectives to diagnose, and require major investments in biomedical research in search for a cure. Right?

Wrong. If you are over 70, a better quality of life, and the choice to stay in your own home rather than a nursing home, could be undone in a flash by a throw rug.

If you slip on a throw rug in your home, you may require surgery for a broken hip, take months to recover, and you may never regain full mobility. You may spend months, or even years, in a nursing home.

One of the most expensive, most common, and most preventable health problems for those over 70 is slipping and falling down. Falls are more frequent than strokes and almost as serious in their consequences, such as hip replacement. Falls lead to a loss of function, decline in activities of daily living, and higher likelihood of placement in long term care. Falling is the leading cause of injury-related deaths in seniors, and costs $20 billon annually.

This year the Democratic state budget proposes to do something about it.

For years, advocates have urged legislators to include prevention programs in the state budget. But when a Senator from Manchester, Sen. Mary Ann Handly, suffered a fall on the punishing marble steps of the state Capitol, the issue had a human face, and legislators paid attention.

As it happens, a New Haven researcher, Dr .Mary Tinetti, authored the groundbreaking article in 1994 that demonstrated the consequences of falls. Most importantly, she argued that falls are preventable , and that preventing falls saves money in health costs.

This year's Appropriations budget proposes a pilot program to assess risks to seniors, and interventions to make seniors safer. If the program survives budget talks, it's a safe bet that seniors will be hearing more about throw rugs.

May 28, 2007

On the eve of this Memorial Day weekend, 70 percent of Americans disapproved of President Bush's job helping returning troops. Professionals testifying before Congress faulted the Department of Defense for failure to identify post traumatic stress (PTSD), predicting a future of "loneliness and family breakdown" if the mental health needs of soldiers and their families are not met.

But in Connecticut, 500 National Guard members returning from Afghanistan - and their families - were the first to share in a unique program to intervene quickly at the sign of mental health or substance abuse problems with veterans in the Guard and reserves along with their families. Although younger veterans of Iraq are at higher risk for suicide, stresses between couples and anxiety in children of soldiers is also common.

The Military Family Support Program is a network of trained psychologists, social workers, and substance abuse counselors available statewide for those who call a confidential hotline, (866) 251-2913. Funded by the proceeds of the sale of Fairfield Hills Hospital, which housed the mentally ill, the program is the first contact and the payer of last resort for the behavioral health needs of military and families who may lack health insurance coverage. Since it is state funded, soldiers can call for counseling and referral without fear of hurting their military careers.

Planning for the program began in 2003, when the Iraq invasion relied heavily on National Guard and reservists who lack the benefits, social supports, and even eligibility of career military. In addition, red tape in federal programs can delay treatment for those who are eligible on paper at a critical time of adjustment.

Today the picture is worse than expected at the outset of the invasion. Extended deployments and the stress of urban warfare have resulted in higher levels of PTSD and suicide
than the Vietnam War. It could climb to 35 percent of military, with Iraq veterans at higher risk, and even the Pentagon is taking notice.

Family impact is not known because the Pentagon does not study National Guard or reserve families. In addition to providing timely care for families, learning about the stresses - and gaps in coverage -- of Guard and reserve families through the Connecticut initiative may help in meeting the needs of the uninsured.

You can find GAO reports on veterans here.

May 13, 2007

One public health dispute overshadowed by other health initiatives involves community-based efforts to improve the health of newborns. In the late 1980s, New Haven had the highest infant mortality rate in the country.

At the time the state was paying $1 million to hospitalize babies born early, but there were few prevention efforts. In response, activists and legislators designed and funded a number of programs targeting pregnant women.

One program, FIMR, or Fetal and Infant Mortality Review, based on a national model, brings together providers and community to share information and best practices. New Haven's regional program, which includes 15 towns, has had the most dramatic results.

But FIMR is under siege.This past year, state bureaucrats cut community programs - New Haven was cut 46.3 percent -- and gave the dollars to a researcher at the University of Connecticut. UConn's political power at the capitol is legendary, and it seemed to be winning. This year, the Health Department says it will wipe out remaining local programs.

But a coalition of lawmakers from New Haven, New Britain, Manchester, Hartford, and Willimantic is fighting back, supporting legislation to compel the department to fund community efforts. Many New Haveners, including Maria Damiani of New Haven's Health Department and Dr. Brian Karsif, provided powerful testimony in support of community based health.

Although the dollars are small -- $300,000 in a budget of $16 million -- the stakes are high, especially for African-American babies. Infant mortality is down, but African-American babies are still at risk for low birth weight.

May 9, 2007

This month's rallies for universal health care in Connecticut have been important to create the climate for change in our health system.
At the same time, legislative committees are working to restore or expand the building blocks of our current system.
Legislators were quick to restore a proposed cut of 21 percent in the statewide needle exchange program pioneered in New Haven.
To the Health and Hospitals Subcommittee on Appropriations, cutting $102,000 from a successful program in a $16 billion budget was inexplicable. After all, taking infected needles out of circulation prevents transmission of HIV, and HIV costs both human lives and money in social services and corrections. Without including programs in the Department of Health or Department of Social Services, the cost of medication and hospitalization for HIV-positive inmates in the Department of Corrections alone is $7.75 million. Preventing even one more case would justify the exchange program.
The governor's budget and the Democratic budget are currently $300 million apart, so nothing is totally secure. But so far, the needle exchange has passed the first hurdle.