A Q&A with Robert Greenwald on ‘Getting to Zero’ And the Success of PEPFAR, 15 Years Later

“Getting to zero”—what Harvard Professors Ingrid Katz and Ashish Jha describe as “end[ing] transmission of [HIV] and control[ing] the epidemic in the United States within the next 10 years”­—will take a suite of tools to achieve, according Robert Greenwald, a clinical professor at Harvard Law School and the faculty director of the Law School’s Center for Health Law and Policy Innovation (CHLPI). Greenwald has been a leader in the field of health law for more than 25 years and is currently serving as co-chair of the Federal Chronic Illness & Disability Partnership and the HIV Health Care Access Working Group.

On October 7, the Harvard Global Health Institute, the Harvard University Center for AIDS Research, the Center for Health Law Policy and Innovation at Harvard Law School, and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School hosted “15 Years of PEPFAR,” a full-day conference looking back on the uncertain early days of the epidemic, the successes of President George W. Bush’s President’s Emergency Fund for Aids Relief, and opportunities for the future.

Kaitlyn Dowling, communications associate at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, sat down with Greenwald to discuss PEPFAR’s impact at home in the United States, policy barriers to “getting to zero,” and ways to address the epidemic head-on. The following interview has been edited for length and clarity.


Kaitlyn Dowling: Your work focuses on domestic HIV care and prevention efforts. How do you see your work relating to what’s happening globally with such efforts?

Robert Greenwald: The U.S. and global efforts to end the HIV epidemic face many of the same challenges. To start, I think we all recognize the critical role that biomedical treatments play in any getting to zero plan. Successfully engaging all people living with HIV in antiretroviral therapy is a significant first step, as treatment leads to viral suppression which promotes individual health and eliminates the risk of transmitting HIV. We also recognize the critical role that Pre Exposure Prophylaxis (or PrEP) plays in preventing HIV transmission.

Yet, biomedical interventions alone will not get us to zero. A successful ending the epidemic plan must also address the political, economic and social conditions that often drive the HIV pandemic. While both the U.S. and PEPFAR countries are confronting similar issues, the specific challenges often vary by country and region.

Dowling: Since the beginning of the epidemic in the early eighties, many norms have shifted within American government, in particular the problem of partisan gridlock in Congress. How has that impacted your work and the work of other activists, policy makers, and public health officials?

Greenwald: Partisan gridlock certainly has an impact on the role that Congress plays in ending the epidemic. Thankfully, our current Congress appears, to some extent, to continue bipartisan support for both domestic and global HIV funding. On the other hand, the expectation that Congress will pass any meaningful, substantive legislation is low.

Domestically, gridlock is good news for people living with HIV, at least as compared to before the 2018 mid-term elections in the U.S. Then, Republicans controlled both the legislative and the executive branches of government, and their health law and policy agenda was largely focused on repealing the Affordable Care (ACA) and restructuring our health and public health systems.

If this agenda had succeeded, over 20 million people would have lost their health insurance coverage and we would have returned to a time when many people living with HIV were excluded from public and private health insurance systems.

Thankfully that didn’t happen, and as a result of the ACA’s Medicaid expansion and other reforms, the rates of uninsured people living with HIV has declined by over 50% in most of the states that expanded Medicaid. That’s a tremendous gain in health care coverage, and as a result we’ve seen the U.S. go from about 25% of people living with HIV virally suppressed to about 54% in 2019. So, I’ll take gridlock over the prior political landscape.

Dowling: What are your thoughts on President Trump’s Ending the Epidemic program?

Greenwald: I agree with the Trump Administration that an important focus of the plan must be on improving access to biomedical interventions. I also agree that Phase One of the plan should focus on geographic hotspots, the 48 counties with the highest number of new diagnoses. Additionally, it is important that the Administration recognizes the rural epidemic in the Southeast, U.S., where health inequities are greatest and outcomes are far below the national average, by including seven states in the Southeast as geographic hotspots.

With that said, I have concerns that there is insufficient funding for the plan to succeed, that the plan is substantively too limited, and that there are serious disconnects between the Administration’s ending the HIV epidemic plan and its broader health policy agenda.

The Administration is promoting new regulations that would undermine our public and private health insurance systems and reverse the gains we have made in recent years, by supporting the sale of Association Health Plans and other forms of “junk insurance” that were largely prohibited under the ACA. These plans operate outside of mandates that prohibit insurers from denying health insurance based upon pre-existing conditions, or from ignoring the coverage of essential health benefits and consumer protections. In addition, the Administration’s attacks on immigrant communities, transgender and gender non-binary people, and women seeking sexual and reproductive health care services have been relentless.

These policies, and many others proposed by the Administration, clearly undermine access to effective HIV care and prevention services. Despite biomedical advances, we will not end the HIV epidemic in the US, and elsewhere, until we end policies that threaten the health and well-being of all people living with HIV.

Dowling: You’ve describe several of the challenges that the U.S. faces in getting to zero. Have there been any successful efforts to address these challenges?

Greenwald: There are many examples of successful efforts to address the challenges we face in current health and public health law and policy. I will focus on some of the litigation successes, but it is important to note that community mobilization and advocacy have also been successful in protecting and promoting sound health and public health.

As to litigation, a federal district court judge has struck down the Trump Administration’s approval of Medicaid work requirements in the first three cases to challenge them in our courts, finding that the Administration’s approval of such requirements reflected an arbitrary and capricious disregard for the primary purpose of the Medicaid program, which is to provide medical assistance to state residents.

Earlier this year, a federal district court judge invalidated the Trump Administration rule that encouraged insurers to offer Association Health Plans, a major form of “junk insurance” that I had mentioned earlier, saying the rule relied on a tortured reading of what the ACA allowed.

Most recently, at the intersection of the opioid, HIV and HCV epidemics, a federal district court judge in Pennsylvania ruled that safe injection sites do not violate the Controlled Substances Act, allowing for the development of public health programs that can dramatically reduce opioid related deaths and the transmission of infectious diseases.

These are just a few examples of how litigation has worked to defend against efforts that undermine ending the HIV epidemic goals.

Dowling: We’ve talked a lot about challenges to “getting to zero” in the United States, but where do you see hope for the future? Where do you think we’ll see successes?

Greenwald: I think we are at a crossroad in deciding the future direction of this country. I’m not sure what will happen in upcoming elections, but I believe that they will determine whether we have federal officials who support strong national standards in sound health and public health law and policy. In this past decade, we have made some great progress. We’ve seen this country make strides in moving away from disability-based health care financing and delivery systems toward systems that are focused on prevention, early intervention and value. I would like to think that we will move forward in a positive way and build on these successes, so that we have systems in place that truly respect the health, well-being and dignity of all people living in the United States.

World Food Day: The Fight Against Food Waste

Originally published October 16, 2019 by Al Jazeera News. Written by Usaid Siddiqui.

From fairs promoting healthy diets to lectures teaching students how to reduce food waste, a wide range of public events is planned for Wednesday in some 150 countries to raise awareness about tackling world hunger and highlight the challenges facing the global food supply. The initiatives are part of World Food Day, which is marked annually on October 16, the day the Food and Agriculture Organization (FAO), a United Nationsagency, was founded in 1945.

While on a downward trend between 2005 and 2015, world hunger has slowly but steadily increased in recent years. In 2018, approximately 820 million people worldwide were undernourished – up from 785 million people four years ago. At the same time, an estimated 1.3 billion tonnes of food are wasted or lost annually, according to the FAO, which defines food waste as “the discarding or alternative (non-food) use of food that is safe and nutritious for human consumption”.

“We waste about one-third of the food produced for human consumption, at a cost of $990bn per year,” Inger Andersen, executive director of the United Nations Environment Programme, told Al Jazeera. “You would be hard pressed to find such inefficiencies in other industries,” she said.

The threat of food waste

In recent years, there has been a renewed attempt to drastically reduce food waste as part of efforts to eliminate hunger. One of UN’s 17 Sustainable Development Goals (SDGs) set the target of halving food waste by 2030 “at the retail and consumer levels and reduce food losses along the production and supply chains, including post-harvest losses”.

World Food Day 2019 infographic 01
 

A key area affected by food waste is the climate. According to Andersen, food waste was currently generating eight percent of greenhouse gas emissions and hence food loss and waste was a “critical tool” for nations in the fight against climate change. She also warned about the dangers posed to biodiversity: “Food wastage exacerbates the negative externalities that mono-cropping and agricultural expansion into wild areas create on biodiversity loss.”

“In addition to deforestation to grow foods that will never be consumed, agricultural runoff and fish farming wastes are creating dead zones in aquatic ecosystems, and food waste in landfills (waste disposal sites) is disrupting food webs, as certain predators shift towards a diet of human trash.”

Gulnihal Ozbay, a professor at Delaware State University, told Jazeera that in the United States – one of the biggest producers of food waste in the world – the “majority of material in landfill comes from food waste”. Ozbay said creating landfills means finding more land to clear – “more trees that need to be cut” – an exercise that can severely affect the world’s efforts to tackle climate change.

According to the United States Environmental Protection Agency (EPA), municipal solid waste landfills are the “third-largest source” of human-related methane emissions – a major contributor to global warming. In the US, they were responsible for approximately 14.1 percent of these emissions in 2017, as documented by the EPA.

Changing consumer habits

Andersen said that “making a huge shift in household behaviour” was a major challenge in combatting the efforts to reduce food waste.

Ozbay agreed, saying many people “take our food supply for granted”, especially in places such as the US. “Thinking that there is an endless supply of food, people are unlikely to use it efficiently.”

The FAO says that in middle and higher-income countries, food is wasted at later stages in the supply chain – mainly at the retail level and due to consumer behaviour. The agency estimates that consumers in rich countries waste approximately as much food – 222 million tonnes – as the entire net food production of sub-Saharan Africa – 230 million tonnes.

World Food Day 2019 infographic 02

Harvard professor and food law expert Emily Broad Leib told Al Jazeera it was important to encourage and teach people to how to prepare food and repurpose it, if needed. “People may buy something for one purpose … like tomatoes for their salad … and if the tomato gets mushy, they are like, ‘I don’t want to eat this tomato raw,'” she said. Leib noted classrooms were a key place where authorities can direct their focus in educating youth on how to repurpose food and combat its wasting. “It is hard to reach consumers once they’re grown up and in their homes. However, we have seen a lot of social change take place at the school level such as the campaign against littering, against smoking or to recycle,” she said.

2030 goal

Looking ahead, Andersen said reaching a 50 percent reduction in the next decade globally “will necessitate a nuanced understanding of the root causes of food waste in different cultures and family structures around the world”. Rethinking and understanding of the way “we shop, cook, store, reuse, and value food”, especially within the “time constraints of working families”, was necessary, she added.

For her part, Leib cast doubt whether the target was achievable by 2030, identifying the lack of benchmarks as one of the challenges. “It would be helpful if countries set goals for 2020 and 2025 to have benchmarks so they can show they are making progress towards the overall goal,” Leib said.

Another major hurdle was a shortage of date, according to Andersen, who pointed to the limited availability of first-hand figures on household food waste in Africa, Asia and Latin America. “Collectively, we know that food waste is a problem, but individually, we think we waste very little”, she said. “Baseline data at country level makes a clear economic case for action – and enables countries to track their progress,” Andersen said. 

Ozbay urged governments to support local businesses and markets to avoid a reliance on packaged food items from mega-corporations when it comes to covering food needs around the world.

The nonprofit organization ReFED estimates that food waste generated by grocery retailers is eight million tonnes a year – while the EPA believes 23 percent of landfill waste comes directly from containers and packaging.

Andersen said that while there were extremely dedicated individuals working in this area to bring change, there also needed to be more efforts by countries in setting targets and measuring baselines in order to “make the profound changes the target requires”. “What we put on our plate, or don’t, matters tremendously for the planet,” she added.

Food is Medicine Approach Behind New Pilot Bill

Originally published October 23, 2019 by State House News. Written by Colin A. Young.

Lawmakers are expected to announce legislation Wednesday night to create a pilot program to determine the effectiveness of medically-tailored meals and their health benefits for chronically-ill MassHealth enrollees.

Sen. Julian Cyr and Rep. Denise Garlick recently filed a bill (SD 2605) that would create the “Food and Health Pilot Program,” which supporters said is the first program of its kind in the country. The bill is expected to be detailed Wednesday night at the annual Food is Medicine Symposium at Harvard Law School.

The Food is Medicine State Plan, released in June by the Center for Health Law and Policy Innovation of Harvard Law School and service provider Community Servings, focused on nutrition’s link to chronic diseases like diabetes or cardiovascular disease, and the notion that food can act as medicine when meals are tailored to meet the specific needs of people living with or at risk for certain serious health conditions.

The report said there are 736 food pantries, meal programs, food rescue organizations and produce voucher programs in Massachusetts, but only 63 of them work with health care providers or tailor meals to meet specific medical needs.

Access to food as medicine programs remains limited in the state and across the country, the report found. But as consumers think more about the food they eat and as Massachusetts shifts its Medicaid program into an accountable care organization model, the report said the time is now to integrate food and medicine. – Colin A. Young/SHNS | 

 

New Bill Would Make Massachusetts the First State in the Nation to Comprehensively Test “Food As Medicine”

On Monday, October 21, Senator Julian Cyr and Representative Denise Garlick moved to make Massachusetts the first state in the country to comprehensively test the impact of nutrition interventions in health care. The new legislation would establish a Food and Health Pilot Program that connects Medicaid-eligible individuals with diet-related health conditions to one of three nutrition resources, with the expectation that health outcomes will improve and cost of care will decrease.[1] The Pilot is a response to rising rates of diet-related chronic disease and health care costs in Massachusetts, where nearly $1.9 billion in avoidable health care costs is attributable to food insecurity per year.

While the interventions to be tested – medically-tailored meals, medically-tailored grocery bags, and vouchers or prescriptions for nutritious food like fruits and vegetables – have demonstrated significant positive impact on health and cost in research studies conducted across the country, the Massachusetts Food and Health Pilot will be the first in the nation to use a multi-intervention approach to connect individuals to the food they need. Thus, someone with a very complex illness might receive a medically-tailored meal while someone else with a different health profile would be given a prescription for fruits and veggies.

In addition to filling a critical gap in research on nutrition and health, the Food and Health Pilot will simultaneously expand access to sorely-needed services in areas of the state where they don’t exist. “From speaking to researchers across the country, we know that a multi-tiered study is the next frontier when it comes to testing the use of food as medicine,” said Robert Greenwald, a Clinical Professor of Law and the Faculty Director of the Center for Health Law and Policy Innovation of Harvard Law School. “This pilot will help us see what it means to respond to the entire spectrum of need for nutrition services, from prevention to treatment. And,” he added, “if the research that we’ve seen so far bears out, the state should save money doing it.”

Researchers from Greenwald’s team at Harvard recently identified 26 cities and towns across the state where the need for medically-tailored nutrition services is particularly high, but access is limited. In partnership with the Boston-based nonprofit Community Servings, which delivers medically-tailored meals in Massachusetts, they developed a Massachusetts Food is Medicine State Plan to address the gaps in access. A multi-tiered research pilot is a key component of the State Plan, which has been hailed by Senator Cyr as a “blueprint to equip our health care system to identify and respond to food insecurity.”

For Senator Cyr and Representative Garlick, establishing the Food and Health Pilot program is a natural expression of the experiences, subject matter expertise, and values they bring to the legislature. Both are outspoken on the subject of comprehensive health care coverage. As Representative Garlick states, “Nutrition is a core component of health. Thus, nutrition should be a core component of health care.”

[1] (HD.4549 / SD.2605)

FDA Gearing Up For ‘New Era Of Smarter Food Safety’

Originally published by Forbes on October 15, 2019. Written by Tommy Tobin.

Following the enactment of the Food Safety and Modernization Act (“FSMA”) in 2011, the Food and Drug Administration (“FDA”) embarked on a series of regulatory efforts to increase the safety of America’s food supply. Later this month, the agency will host a public meeting to discuss its plans for “A New Era of Smarter Food Safety.”

In its upcoming public meeting, the FDA plans to discuss food traceability, digital technologies and evolving food business models. According to the agency, “No matter how consumers get their food, whether they are ordering online or at their favorite restaurant, they deserve to have confidence in the safety of the food supply.” The FDA’s initiative aims to harness technological improvements to better prevent, mitigate, and investigate food safety issues.

In a statement, the agency noted, “There will be significant innovation in the agriculture, food production, and food distribution systems in the next 10 years, which will continue to provide an even greater variety of food sources, food ingredients, and delivery conveniences for American consumers. With this ever-changing landscape, FDA must continue preparing to take advantage of new opportunities and address potential risks.”

 

One of the architects of the FDA’s new initiative, Frank Yiannas, explained that the agency’s approach will incorporate “new technologies that are being used in society and business sectors all around us. These include blockchain, sensor technology, the Internet of Things, and Artificial Intelligence to create a more digital, traceable, and safer food system.”

The FDA has already adopted new data tools to address food safety. Just days ago, the agency launched a Food Safety Dashboard, which highlighted metrics for food safety outcomes and measurements for initial data on FSMA-related regulations and associated compliance. The FDA hopes that the Dashboard and its data “will ultimately help the agency identify trends in food safety, continue to improve [its] risk-based food safety framework, and modernize the agency’s food safety approaches in a way that will help prepare us for a New Era of Smarter Food Safety.”

The FDA’s public meeting regarding its “New Era of Smarter Food Safety” is scheduled for October 21, 2019 in Maryland. While the in-person registration is at capacity, electronic webcast registration is available. Members of the public can submit written or electronic comments regarding the public meeting at Regulations.gov until November 20.

Our Diets are Killing Us and Doctors aren’t Trained to Help

Originally published by The Hill on October 18, 2019. Written by Emily M. Broad Leib; Stephen Devries, M.D.; and Walter Willet, M.D., Ph.D.

What if your doctor failed to talk to you about the most important threat to your health? Wouldn’t you worry about the quality of your health care? Poor quality diet is a leading cause of death in the United States, but it is unlikely that your doctor has the knowledge to even begin a meaningful conversation about your nutrition or to make an appropriate dietary referral.  

Most doctors lack the knowledge necessary to offer nutrition advice to patients; indeed, fewer than 14 percent of physicians report feeling equipped to advise on diet or the connection between food and health. This is unsurprising given that, for example, 90 percent of cardiologists in a recent survey reported receiving minimal or no instruction on nutrition during medical training. 

Yet it is also concerning. Obesity, type-2 diabetes, heart disease, cancer, and stroke, which are leading causes of death in the United States, all are closely linked to diet and nutrition. Nearly 40 percent of adults and 18 percent of children are obese, and these numbers are increasing; almost 10 percent of Americans suffer from diabetes, compared with less than 1 percent just 50 years ago. Even more concerning, more than one-third of Americans have pre-diabetes. 

A focus on treatment rather than prevention has led to medical education that ignores the central role that food plays in health. The average U.S. medical school devotes less than 1 percent of total lecture hours to nutrition. Accreditation requirements for medical residencies and fellowships do not include nutrition. 

The standardized exams that medical students must pass to become board certified lack questions that test the ability to advise patients on diet. And to date, no state requires continuing medical education in nutrition or diet-related disease as part of the ongoing education for physicians to maintain licensure. 

This dangerous gap in their education means that doctors do not learn the basic guidance in the U.S. Dietary Guidelines for Americans, or stay apprised of the latest nutrition science. Accordingly, they fail to recognize, and are unable to convey to patients, the importance of diet to health. This means fewer referrals to nutritionists, even when diet plays a vital role in their patient’s health.

The lack of nutrition education during medical training is also a costly mistake. Health-care spending has skyrocketed — Medicare benefit payments exceeded $730 billion in 2018 and account for nearly 15 percent of all federal spending. 

At its current rate, Medicare spending will exceed $1 trillion in the next 10 years. Diet-related diseases account for 5 of the 8 most common conditions among Medicare beneficiaries, so it’s clear that as the prevalence of diet-related diseases increase, health-care spending increases.  

Fortunately, we can change this troubling status quo. Opportunities exist for policymakers at the state and federal level, as well as the bodies responsible for testing and accreditation, to make systemic changes to medical training. For example, state legislatures and Congress can offer grants to medical schools to develop curricular content; the American Council of Graduate Medical Education can amend residency requirements to require competency in diet and nutrition; and testing organizations like the National Board of Medical Examiners and the American Board of Medical Specialties can incorporate nutrition-focused content on step and board examinations, respectively. 

Perhaps the most logical and effective solution is to ask Congress to spend our health-care dollars more wisely. Medicare is the single largest source of federal funding for graduate medical education, providing more than $10 billion to eligible programs in fiscal year 2015. This funding comes with “no strings attached,” i.e. no curricular requirements or performance benchmarks, and certainly no expectation that residents or fellows receive education in nutrition. 

Rather than spend a whole lot more on Medicare to treat diet-related diseases down the road, Congress should leverage this funding to require nutrition education for residents and fellows. These policies and others are explored in a recent report from the Harvard Law School Food Law and Policy Clinic

The education of doctors is a critical issue with universal implications for our national health. When it comes to the care we receive at each doctor’s visit, we reap what we sow. By not insisting that physicians receive at least foundational education in nutrition, we produce a medical system that is focused almost exclusively on drugs and devices, and in which the most costly diseases continue to grow. 

Alternatively, by helping physicians understand the connection between food and health, we can produce better individual patient outcomes, improve population health, and change our nation’s health-care landscape for the better.

Emily M. Broad Leib, J.D., is an assistant clinical professor of law at Harvard Law School and the director of the Harvard Law School Food Law and Policy Clinic. Stephen Devries, M.D., is a preventive cardiologist and executive director of the nonprofit Gaples Institute for Integrative Cardiology. Walter Willet, M.D., Ph.D., is a professor of epidemiology and nutrition at Harvard T.H. Chan School of Public Health and a professor of medicine at Harvard Medical School.

One by One, They’re Making a Difference

Originally published by Harvard Gazette on October 18, 2019. Written by Alvin Powell.

Sarah Lockridge-Steckel left Harvard College in 2009 and headed to Memphis, Tenn., where she co-founded The Collective, a nonprofit that works with schools, businesses, and community groups to remove barriers to success for disadvantaged youth.

Anne Sung returned home after Commencement in 2000, trading in classes in Harvard Yard to teach in one of Texas’ poorest regions, the Rio Grande Valley on the Mexican border. The lessons from her days with Teach for America resonate today in her role as a trustee of the Houston Independent School District, overseeing the public schools she’d graduated from decades earlier.

Fresh from Harvard Law School, Emily Broad Leib went to the rural Mississippi Delta to use her background to improve the lives of residents. Her work there was varied and included one unlikely task early on: Writing a grant for a wood chipper to get rid of fallen tree limbs that were drawing snakes. Now an HLS assistant professor, her experience prompted her to start the Law School’s Mississippi Delta project, which provides public policy and legal help on issues important to the community.

The trio are just a sampling of the legions of dedicated, caring, and talented individuals who over the years have brought the skills developed and passions nurtured at Harvard to communities around the country, embracing former Harvard President Charles William Eliot’s admonition, “Depart to Serve Better Thy Country and Thy Kind.” That call to public service, inscribed on Dexter Gate at the edge of the Yard, amounts to a kind of final lesson upon leaving campus.

Today the Harvard Gazette is launching a digital project titled “To Serve Better,” featuring dozens of tales of Harvard affiliates like Broad Leib, Sung, and Lockridge-Steckel who returned home — or set up shop in a new home — and worked tirelessly toward the greater good, teaching, inspiring, organizing, legislating, and persevering through setbacks.

The series website contains stories, photos, maps, links, and video chronicling the work of these individuals across the U.S. and its territories. It launches this week with the first wave of 14 from California, Georgia, Iowa, Kansas, Kentucky, Mississippi, Nevada, North Carolina, Tennessee, Texas, South Carolina, South Dakota, Washington, and Washington, D.C.

The theme for this first batch is “empower,” and the accounts highlight people who work with small groups or grass-roots organizations to strengthen their communities.

The project will eventually include sagas from all 50 states, plus additional ones from U.S. territories and the District of Columbia. They will be posted in waves with the themes of “Create,” focusing on inventors, makers, designers, and artists; “Respond,” dedicated to those who heal, fix, and provide service or aid to others; and “Improve,” spotlighting those who seek to fight injustice, solve problems, and advocate for communities at an institutional level.

While working on this project, one thing became clear. While the range of their experiences was wide and varied, all of those profiled shared a similar goal. Take Theresa Reno-Weber, a 2008 Harvard Kennedy School graduate, former U.S. Coast Guard lieutenant, and president and CEO of Metro United Way in Louisville, Ky. This is how she explained what drives her to the work she does: “At my core is a desire to leave any place better than I found it, including the organization in which I work or the community in which I live.”

Hep C Drug Access Still Problematic

Excerpt from POLITICO’s Prescription Pulse, published October 15, 2019. Written by Sarah Karlin-Smith.

The National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation of Harvard Law School sent a letter to CMS complaining that more than half of all state Medicaid programs still deny treatments to Hepatitis C patients. The letter comes on the heels of the groups’ third annual report grading states on the accessibility of the treatments. More than half of Medicaid programs received a “D” or “F” grade in the group’s first report, in 2017. Now, only eight did — and 19 states got an “A.”

States are not allowed to restrict access to drugs in Medicaid due to cost. But given the price tag of Hepatitis C drugs and the large population eligible for treatment, many groups have speculated that states have unfairly withheld the medicine.

If Food is Medicine, Why Isn’t It Taught At Medical Schools?

Originally published by New Food Economy on October 14, 2019. Written by Jessica Fu.

Earlier this year, Mount Sinai, the biggest hospital network in New York City, invested in a meal delivery service. Though it seemed like an unusual move at the time, the network’s decision makes sense if you consider the intrinsic relationship between food and health—a connection underscored by countless other recent examples of healthcare initiatives that harness diet as a tool to improve well-being.

At a California rehabilitation facility, for instance, doctors use the rituals of eating to help people recover from trauma. And over the past decade, cities across the country have launched “food prescription” programs that incentivize participants in the Supplemental Nutrition Assistance Program (SNAP) to buy fresh fruits and vegetables at farmers’ markets. A number of nonprofit organizations have launched medically-tailored meal services for people suffering from diet-related diseases.

Culturally and politically, we’re increasingly acknowledging that what we eat plays a major role in our health. Which is why it’s especially strange that healthcare providers know so little about it. Medical curriculums have been developed historically, foregrounding disciplines like biology, behavior, and disease to the detriment of food and nutrition.

In a new report published by the Harvard Food Law and Policy Clinic, researchers write that, on average, students in medical schools across the country spend less than 1 percent of lecture time learning about diet, falling short of the National Research Council’s recommendation for baseline nutrition curriculum. Neither the federal government, which provides a significant chunk of funding to medical schools, nor accreditation groups—which validate them—enforce any minimum level of diet instruction.

And it shows: While you and I might show up for our annual physicals expecting feedback on our what and how much we should be eating, just 14 percent of doctors feel qualified to offer that nutrition advice.

How did the gap get this wide? Much of it can be explained by the way medical curriculums have been developed historically, foregrounding disciplines like biology, behavior, and disease to the detriment of food and nutrition. Today, the legacy of this framework makes it hard for medical schools to retroactively integrate nutrition into their curriculums.

“Because [nutrition] wasn’t prioritized for so long, there aren’t a lot of faculty and medical schools that have any knowledge about nutrition and diet,” says Emily Broad Leib, the report’s lead author. “To build it into schools now requires real investment in hiring and training.”

The report recommends a wide range of policy changes that could function as carrots and sticks in getting nutrition onto course outlines. They range from making federal funding contingent on nutrition training to performance-based incentives that encourage schools to include diet-related subjects in curriculums.

“Why are we spending so much government money to educate physicians and residents, and yet we’re not getting any impact in terms of these this large set of [diet-related] diseases?” Broad Leib asks.

The recommendations also implicate other players in the world of medicine, like accreditation organizations and licensing boards, for not requiring a baseline level of dietary expertise from schools and doctors, respectively. Part of the reason that may be is the prevailing attitude society has toward food as a soft science.

“People believe that nutrition is easy, when in reality, nutrition is most of medicine—and then a lot more,” says Martin Kohlmeier, a professor of nutrition at the University of North Carolina-Chapel Hill. “You have cultural, food production, and food safety issues. It is a challenge for physicians to learn enough.”

Kohlmeier leads the Nutrition in Medicine Project, a free, online nutrition curriculum tailored to medical students and doctors. Kohlmeier estimates that 150,000 students have participated in some aspect of the program since its launch in 1995. Nevertheless, he stresses, voluntary education is only a temporary fix for a systemic problem.

“A lot of institutions have electives, all kinds of nice things that maybe 1 to 5 percent of their students use. And I’m always saying: ‘You are going to be treated by the physician who skipped those classes.’”

But why teach doctors nutrition and diet when there already exists a specialty in those fields? Nutritionists and dieticians are experts in the way our individual biologies are affected by what we eat. What role will they play if our general practitioners develop that same expertise? 

Shoring up what doctors know about food won’t render nutritionists moot, says Carol DeNysschen, a registered dietician and chair of the health, nutrition, and dietetics program at the State University of New York-Buffalo. 

“The more that [doctors] know, the more they realize what they don’t know, and the more they realize how complicated it can be to develop an individualized nutrition plan for people and to get them the support they need to monitor or manage [issues like] their weight, their diabetes,” DeNysschen says.

DeNysschen characterizes the relationship between doctors and nutritionists as a symbiotic one. Doctors with expertise in nutrition are more likely to spot diet-related issues earlier in a patient’s prognosis, and that could mean more referrals to diet experts. “The more nutrition knowledge they have, the more they’re aware of looking for those areas where a nutritionist or dietitian could interject,” she says.

Beyond the healthcare implications, the Harvard report also makes an economic case for teaching doctors about food. Taxpayer dollars fund most physician residencies in the United States through Medicare. (Medical school graduates train to become doctors via residency in  a hospital.) Simultaneously, Medicare serves as the national insurance program for aging Americans, and thus, incurs the costs of diet-related diseases during that stage of our lives. Therefore, the report argues, requiring nutrition education in medical residencies is another way for Congress to trim its own bills.

That’s one element of the case that Broad Leib will likely make next week at a Congressional hearing. Though the report largely focuses on federal policy changes, some local lawmakers are introducing legislation that would require nutrition education among doctors within their jurisdictions. In New York, for example, state legislators recently proposed a bill that would require practicing physicians to receive six hours of nutrition coursework or training every two years. In Washington, D.C., municipal lawmakers introduced a bill that would require continuing education for doctors to be expanded to include nutrition coursework.

Poor diet continues to be one of the biggest contributors to chronic disease and mortality in the U.S., killing one in five Americans. That’s a higher rate than three other risk factors—pollution, lack of exercise, alcohol and drug use—combined. As the tide continues to rise in favor of ideas and policies that combine food and healthcare, medical schools may be next to center nutrition in their work. Someone’s just got to prescribe it.

New Job Opportunity: Mississippi Delta Fellow, 2020

The Mississippi Delta Fellowship connects recent law school graduates to on-the-ground, community-centered work in the Mississippi Delta. Based in the heart of the South and home of the Blues, the Fellowship provides a unique opportunity to inform and catalyze community change through the creation, development, and management of interdisciplinary projects. In turn, the Fellowship provides opportunities for professional development, especially in the areas of project management, engagement with social and public health scientists, policy analysis and implementation, community coalition-building, teaching and mentoring, public speaking, research, and writing. Previous Fellows have gone on to careers in policymaking, teaching, writing (academic and non-academic), research, film-making, and professional legal practice in community development. The Fellowship is a one-year commitment with opportunity for renewal at the end of the first year to two years; however, due to the Delta Fellow’s central role in the Mississippi Delta community, applicants able to commit to a two-year fellowship are preferred. The Fellow receives a competitive salary and benefits, detailed further below, commensurate with or above that of most fellowships for recent law graduates, particularly in light of relative cost of living.

The Fellow works in collaboration with the Delta Directions Consortium (DDC), an interdisciplinary group of academic institutions, community-based organizations, and foundations focused on pursuing improvements in health, food systems, and economic development in the Mississippi Delta Region. The Delta Fellow is hosted by the Center for Population Studies (CPS) at University of Mississippi, which is the backbone organization of DDC. While reporting to the Director of the CPS, the Fellow also works closely with the Harvard Law School Center for Health Law and Policy Innovation and Harvard Law School Mississippi Delta Project, as well as the Delta Directions Consortium Advisory Committee.

By working closely with the DDC and its partners, the Fellow will become a part of a diverse network creating transformational change in the Mississippi Delta. Through their work, Fellows become familiar with community needs, assets, challenges, and opportunities. Fellows have the chance to pair academic resources of University of Mississippi, Mississippi State University, Harvard Law School, and Harvard School of Public Health with community-based organizations in the Delta, to translate academic resources into projects that address community interests. The Fellow will build on existing projects, launch new projects in partnership with DDC members, and have the opportunity to design one new signature project for completion during their tenure, subject to review and input by the Director of the CPS and members of the DDC Advisory Committee. The Fellowship is supported by the Winokur Family Foundation and the Community Foundation of Northwest Mississippi.

Previous and current project themes of the Delta Directions Consortium include:

  • Food Policy: Delta Fellows’ work has included establishing and supporting the Mississippi Food Policy Council, a diverse group of stakeholders aiming to educate Mississippians about food and farm policies that build healthy communities and strengthen local food systems; supporting farm to school programs by helping launch pilot programs, publishing legal guides, and assisting in the creation of an annual statewide Farm to Cafeteria Conference; supporting small farmers by publishing guides and conducting trainings on topics such as the impacts of inheritance laws on farms; and working to increase food access, by launching farmers markets and making recommendations to eliminate the ban on drug felons utilizing SNAP.
  • Public Health, Health Care Access, and Social Determinants of Health: Delta Fellows’ projects have included supporting better mental health practices via research on policies needed to keep those utilizing mental health services in the least restrictive settings; supporting breastfeeding through conducting a multi-tiered outreach and education strategy, working with local hospitals to establish breastfeeding-friendly practices, and promoting systemic change through passage of local and state breastfeeding policies; engaging in research and recommendations on improving maternal and infant health; and conducting research on policy opportunities to support better lead testing in small rural water systems.
  • Economic Development: Delta Fellows’ work has included partnering with University of Mississippi to create a small business incubator and launch a transactional legal clinic; publishing guides to support small businesses, including a small business legal guide and a guide for farmers to sell products to local Mississippi institutions; and publishing reports about economic development topics, such as recommendations for Mississippi to enact paid family leave and recommendations for Arkansas to develop microfinance lending.

Principal responsibilities of the Delta Fellow include:

  • Managing existing and developing new projects, based on local needs, research, evidence-based results, interdisciplinary opportunities, and interest from Delta Directions partners;
  • Researching, drafting, and editing policy and research reports, and educating community partners and policymakers on the research;
  • Working with faculty and staff to develop clinical and pro bono projects for Harvard Law students in the Mississippi Delta Project, the Center for Health Law and Policy Innovation, and other Harvard Law clinics;
  • Identifying opportunities for, mentoring, and teaching college students from local universities with interest in creating change in the Delta;
  • Helping to plan and host the annual Delta Regional Forum;
  • Coordinating with partners for the Delta Scholars program concerned with student leadership development;
  • Reporting twice annually to Delta Directions Advisory Committee and preparing a public annual report; and
  • Supporting coordination, growth, and development of the Delta Directions Consortium.

For more information, please visit http://www.deltadirections.com (for information about Delta Directions) and http://www.chlpi.org (for information about the HLS Center for Health Law and Policy Innovation).  For questions please contact flpc@law.harvard.edu

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APPLICATION MATERIALS

Experience & Qualifications:

  • Law degree;
  • Strong writing, research, organizational and communication skills;
  • Interest in learning and developing skills for conducting and connecting social and public health research and legal/policy research and working in interdisciplinary teams to inform stakeholders;
  • Ability to work both independently and in diverse teams, and in demanding and periodically high stress circumstances;
  • Strong sense of self-motivation and entrepreneurial mindset;
  • Demonstrated leadership experience, experience bringing together diverse stakeholders, and/or experience with direct public action or community development preferred;
  • Relevant academic or professional experience, including interest in or experience with economic development or public health, especially in rural areas, preferred but not required; and
  • Interest in or knowledge of the Delta or the American South preferred.

Salary: $55,000 plus benefits in year one (subject to salary increase if fellowship is renewed beyond year one), along with a relocation stipend, health benefits, and generous retirement benefits; also includes $15,000 in the program budget to cover travel, event planning, hiring, and other expenses related to the position.

Application Materials & Deadline:

  • Curriculum vitae, including relevant coursework, work experience, and extracurricular activities;
  • Personal statement (500 words maximum) about the applicant’s relevant experience, interest, and suitability for theDelta Fellow position, as well as future career aspirations;
  • Two recommendation letters, at least one from an academic reference; and
  • Academic transcript.

Application Instructions:

Applications must be submitted through CARAT. To access the submittal screen you may either search for “Mississippi Delta Fellowship” once logged into CARAT or click on this direct link to the fellowship opportunity.

Please submit the application materials by midnight (11:59pm) on January 31, 2020.

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