Public Policy That Can Impact Community Health

1. Public Policy That Can Impact Community Health Tim Monroe, MD, MPH Forsyth County Health Summit 2008

2. What is Public Policy? • Laws • That allow or constrain various activities • Sell, purchase, or holding of property • Criminal justice system • That are ignored by accepted practices • Voting rights during Jim Crow • That guide the garnering and distribution of public resources • Levy and allocate tax and other revenues • Community planning

3. What is Public Policy? • Laws • That create, configure, and sustain services • Public transportation system • Public education system • Commercial/Market practices • Legally condoned or prohibited • Public segregation prior to 1964 • Red-lining and steering in real estate in the past • FHA government backed mortgages

4. The Public Process • The process of government = the process of community • A process of public debate and balloting • Inherently ideological and political • The product is a body of public policy that reflects our collective values and priorities • The ultimate product is a constructed and configured community which, in great part, dictates the life experiences of its residents

5. The Public Process • Collective will of the community • Active and passive • The governmental process • Active and Passive • The truest barometer of collective community values • Actively or passively

6. The Public Process • Competing Interests • Objectivity • Science • Common sense • Secular ideologies • Theologies • Vested interest

7. Comparative Causes of Death in the US

8. Tobacco • In NC in 1996, 201 individuals experienced death (38) or incapacitating injury (163) as a result of alcohol related automobile accidents involving drivers aged 15-20 years (Buescher) • In NC in 2003, 27.3% of high school students were smokers (22.7% in US) – NC Youth Tobacco Survey • Increases in cigarette tax and total restriction in public schools have been demonstrated to reduce smoking, especially by adolescents

9. Tobacco and NC Law • Sale, use, and enforcement • Tobacco sales tax • Pre-emption law by the G.A. • 100% Tobacco Free Schools

10. Tobacco • Strong EtOH laws and vigorous enforcement • Sale and use age 18 to 21 • Restrictions on public properties • Sale-to-minors laws vigorously enforced • Taxation

11. Tobacco Tobacco laws Sale and use age at 18 Allowed on public property Sale-to-minors laws less well enforced Slow to tax School tobacco use policies flexible Local option to fully restrict until 2008

12. Cigarette Tax • $0.05/pack in 2004 – 3rd lowest • To $0.30 in 2005 and $0.35 in 2006 • Still fifth lowest today in nation • National average is $1.11 • Maximum is $2.58 • Every 10 percent increase in the price of cigarettes will reduce youth smoking by about seven percent and overall cigarette consumption by about four percent.

13. Preemption Law • Local Boards of Health rule making activity in the early 1990’s • Restrictions in restaurants & other indoor public places • 1993 - Response of General Assembly • G.S. 143, Article 64 • Curtailed authority of local Boards of Health

14. Public School Policy and Values(Adolescent Sexuality) • Condom Use: An educational and public health initiative to reduce spread of disease and reduce risk of pregnancy • Condoms can be purchased without age restriction in the market • Issue: A public school system providing condoms free to students

15. Public School Policy and Values(Adolescent Sexuality) • 1996 State Law prohibiting distribution of condoms in NC public schools (GS 115c-81(e1)(9)) • School policy to “send the right message” with regard to adolescent sexual behavior • Statutes on sexuality curriculum content • Condom distribution law

16. Public School Policy and Values(Tobacco) • 100% TFS Campaign begun in 2000 • Law enabled total restriction by local option • State law mandated in 2008 • Final count: 87 of 115 systems • Forsyth County not among the 87 • “Sending the right message” has seemed less important in the case adolescent tobacco use

17. Public School Policy and Values(Nutrition) • School nutrition policies changed in the 1980’s • $1.8 billion federal budget cuts drove programs from entitlement-like programs to self-financing • State and local governments forced to transform to profit making business • Marketing of unhealthy foods and beverages to children proved highly profitable • Schools currently depend on revenues from nutrition programs to support operational costs

18. Public School Policy and Values(Nutrition) • WS/FC Schools - Pepsi pouring rights contract • $600,000 signing bonus • $140,000 annual payment • 42% annual sales commission ($188,000 in 2004)

19. Public School Policy and Values(Nutrition) Chartwells, Inc. is the WS/FCS contracted Foodservice Management Company • $5.86M revenues from supplemental sales (29.4% of foodservice budget) • Paid WS/FCS $1.1M 1st year, $300K 2nd year, and $200K 3rd year for contract

20. Public School Policy and Values(Nutrition) • In the face of the obesity epidemic, are we concerned about school policy that “sends the right message” with regard to nutrition? • Are we willing to pay more taxes to finance our schools in order to shield children from marketeering of unnecessary calories in the school setting?

21. The Built Environment(Community Planning) • Sidewalks • Bike lanes • Greenways • Connectivity • Sidewalk Ordinance in Forsyth • Role of vested interests

22. Public Resources to Stimulate Commerce • Dell? • Ball Park? • Revitalizing blighted and neglected neighborhoods? • Grocery stores in East Winston?

23. Health and Diet • African-Americans have higher rates of type II diabetes and cardiovascular disease than the white population • Higher proportionate consumption of healthy fruits and vegetables can prevent morbidity and mortality from heart disease and type II diabetes

24. Diet and Community Resources • Consumption of healthy fruits and vegetables increases substantially with increased residential proximity to full service grocery stores • Full service grocery stores are relatively sparse in racially segregated minority neighborhoods

26. Market Resources and Health • Limited access to full service grocery stores or food markets can be understood as a contributor to preventable morbidity and mortality from type II diabetes and cardiovascular disease • Food retail marketing is unlikely to meet the needs of racially segregated minority neighborhoods as a consequence of market forces

27. Planning, Health, and Justice • Need public policy-based mechanisms to assure that a resource (grocery stores) important to the welfare (health) of all residents is provided equitably • The American Planning Association’s Policy Guide on Public Redevelopment identifies “social equity and environmental justice” as critical guiding principles

28. Planning and Justice • Social equity: “the expansion of opportunities for betterment that are available to those communities most in need, creating more choices for those who have few” • A legitimate application of the community planning process is to redress the consequences of injustice that continue to adversely impact minority neighborhoods and the welfare of their residents.

29. School Attendance Patterns(Policy of “Choice”) • Driven by universal desire for “neighborhood school” and parallel geographical limitations • Neighborhoods are defined by SES status and color • Limited by availability of independent transportation • Availability of transportation defined by SES status and color

31. Access to Health Care • Majority in US believe access to health care to be a right: however, not assured by government • In US, private sector is given first dibs on all profitable aspects of the health care market • Public sector and/or charity are expected to fulfill moral obligation to assure care for all • Public sector will never be given adequate resources to meet the need until we recognize that it is a responsibility of government

32. Downtown Health Plaza Funding(Garnering and Allocating Public Resources) • History of the Reynolds Health Center • Hospital to Clinic • County Management and Funding through 1997 • Transition to and contract with Baptist, 1998-2002 • Gradual divestiture, 2003 – 2005 • Final withdrawal, 2006

33. Minimum Wage • The 1938 Fair Labor Practices Act established a minimum wage as one component of an effort designed to promote the “maintenance of the minimum standard of living necessary for health, efficiency, and general well-being of workers” • The Federal Minimum Wage of $1.60 in 1968 would be worth $8.30 in today’s dollars

34. Poverty and Health • The Federal Minimum Wage increased from $5.15/hr ($10,712/yr) to $5.85/hour ($12,168/yr) in 2007 • The FMW will increase to $6.55/hr ($13,624/yr) in 2008 • The FMW will increase to $7.25/hr ($15,050/yr) in 2009 • The NC MW is $6.15/hour or $12,792/year

35. Poverty and Health • The Federal Poverty Guideline (FPG) was established in 1965 as a budget necessary to prevent starvation in an emergency or temporary situation • The FPG is $9.93/hour (with health benefits, or $12.00 without health benefits) or $20,650/year for a full-time, year round worker supporting a family of four

36. Poverty and Health • Public Policy and Values: • The American work ethic dictates that individuals sustain their families and themselves with gainful employment; i.e., a personal responsibility • Yet we expect individuals to work for half the income necessary on which to do so. • Those living in poverty do not have the same opportunity to be healthy as those with means.

37. Public Policy to Change Values • Leadership of Professionals and Public Officials • Infant car seats in Tennessee (1979) • Bicycle helmets in NC (2001) • Civil Rights Legislation and Case Law

38. References • Healthy Communities through Collaboration: Public Health and Land Use Planning. American Planning Association. : http://www.planning.org/research/healthycommunities.htm • Schulz AJ, et. al. 2002. Racial and Spatial Relations as Fundamental Determinants of Health in Detroit. The Milbank Quarterly 2(4):677-707.