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In our ongoing debate about the role of government in public health—and of public health in government—some topics generate a lot of fire

Government Programs

Medicare

The Issue: The biggest challenge we face with Medicare is long-term financing. Underlying this challenge are both rising per capita costs for Medicare beneficiaries, and increasing enrollment as Baby Boomers age into the program—each accounts for approximately half of the program's projected cost growth. The Affordable Care Act addresses this challenge in two ways: first, through a gradual series of reductions in payments to providers to account for increased productivity in health care delivery, and secondly, through new delivery and payment models—such as accountable care organizations and bundled payments—that have the potential to lower costs by transforming how providers deliver care and moving away from traditional fee-for-service payments.

The Debate: Democrats and Republicans agree that the U.S. can no longer afford to spend 18 percent of GDP on health care costs. There is also general agreement that the ACA alone—regardless of one's position on the legislation—is not enough to address the problem. There is a philosophical debate over whether Medicare should continue as a government entitlement program, or whether Medicare-eligible individuals should receive a fixed sum of money to purchase their own health insurance plan. There is also debate over structural issues, such as how to modernize Medicare's benefit structure, and whether the eligibility age should be raised from 65 to 67.

A Way Forward: As part of the ACA, Congress funded the creation of a new Center for Medicare and Medicaid Innovation within the Department of Health and Human Services and empowered this center to implement novel ideas on reform. Additionally, as full implementation of the ACA approaches and is nearly complete by 2014, we should see more creativity around insurance design and delivery in the public and private sectors. The ACA implements a new model for health insurance in the U.S.—one in which the government helps provide both the infrastructure for a health insurance marketplace and funding to help low-income Americans afford insurance—but the purchase and delivery take place in the private sector. These kinds of changes may help policymakers think about health insurance as a continuum across the pre- and post-65 populations, drawing from success in both the public and private sectors to improve Medicare.

—Ruth E. (Brown) Tabak, M.P.H./MPP Student, U-M SPH and Ford School of Public Policy; Staff Member, Committee on Ways and Means, U.S. House of Representatives (2009-2010); Intern, White House National Economic Council, 2012

Medicaid

The Issue: Medicaid, a program to provide health care coverage to low-income Americans, operates as a partnership between the federal government and states. Each state designs its own program within parameters set by federal regulations, and the federal government provides a significant share of the money to run the program. In an effort to provide coverage for nearly half of the nation's 45 million uninsured, the Affordable Care Act calls for states to expand Medicaid coverage, with the federal government picking up the full cost for the first three years of the expansion. The federal share gradually decreases to 90 percent in year six and after.

The Debate: In June 2012, the Supreme Court ruled that individual states have the option to participate in the Medicaid expansion. On the one hand, there's an incredible opportunity for states to provide health care for millions of uninsured individuals who would otherwise rely on the emergency room for their care. On the other hand, it's unclear how states can pay for this expanded coverage once states have to start paying. In general, progressive-leaning states and policymakers support Medicaid expansion. Conservative-leaning states and policymakers prefer to limit Medicaid spending, fearing a scenario where Medicaid programs have unlimited benefits and costs.

A Way Forward: Some states are philosophically opposed to expanding Medicaid programs. But a significant number of states are in the middle—they want to expand coverage and take full advantage of federal funds in the initial years, but they're concerned about the fiscal impact on future state budgets. States could be attracted to participate if given more flexibility on when and how to implement expanded coverage in order to mitigate their financial risk. Whatever the outcome of the 2012 election, the next several years will see enormous changes in our health care system. In addition to insurance exchanges and the expansion of Medicaid programs, there's a new initiative in some states to improve access to care for so-called "dual-eligibles"—people who are eligible for both Medicaid and Medicare.

—Khoa Nguyen, M.P.H. '02, Director, Government Affairs and Business Development, Health Plan of San Mateo, California

Individual vs. Societal Rights

Gun Control

The Issue: In 2009 firearms caused over 30,000 deaths in the U.S. The number of nonfatal injuries was probably four times as high. Based on the numbers alone, this makes prevention of firearm-related injuries a major public health challenge. Surveys indicate that approximately 40 percent of all homes in America contain one or more firearms. Epidemiological research has determined that a gun kept in the home is far more likely to be involved in the fatal or nonfatal injury of a member of the household than to be used to injure or kill an intruder in self-defense.

The Debate: In District of Columbia v. Heller, a landmark 2008 U.S. Supreme Court case, the court held, for the first time, that the Second Amendment to the U.S. Constitution protects an individual's right to possess a firearm, although the court also made it clear that the Second Amendment allows for reasonable firearms regulations. Despite evidence to the contrary, many people fervently believe that keeping a gun for protection is not only a reasonable precaution but essential. The firearms industry reinforces this view with ads that imply that your home is not "safe" unless it is protected by a handgun. Meanwhile, many of the country's leading medical and public health organizations have position statements that recommend safe storage of any guns kept in the home, and many are actively working to reduce the public health impact of gun injuries. Unfortunately, the type of research both the public and policymakers need to inform their decisions has slowed to a trickle because Congress, under pressure from the National Rifle Association, has sharply limited federal funding for firearm injury prevention research at the Centers for Disease Control and Prevention and, more recently, the National Institutes of Health.

A Way Forward: Rather than arguing over whether the U.S. needs more restrictive guns laws, we could make progress by more effectively applying the laws that exist today. For example, adult felons and juvenile offenders are not legally entitled to purchase, much less carry, a firearm, but many do so anyway with little fear of interdiction. Burglary or theft funnels roughly a half-million guns per year to illegal markets. A few scofflaw firearms dealers sell large numbers of guns directly to criminals. Others unwittingly sell to "straw purchasers" who purchase guns and hand them to legally proscribed accomplices, or to purchasers who use false IDs to "lie and buy." Public health and health care professionals can also partner with law enforcement judges, public safety colleagues, crime laboratory technicians, and community advocates to collect the data we need to inform changes in both clinical practice and public policy aimed at saving more lives.

—Arthur Kellermann, M.D., M.P.H., Director, RAND Health; Founding Chair, Department of Emergency Medicine, Emory University

Editor's note: Arthur Kellermann delivered the 2012 U-M SPH commencement address.

Immunizations

The Issue: The National Advisory Committee on Immunization Practices makes immunization recommendations for all U.S. children and adults. Each of America's 50 states decides how to implement the national recommendations, and many states require children to have specific immunizations in order to attend school. Some parents don't want their children to receive immunizations, either for health reasons or for philosophical or religious reasons. States vary in how they handle this situation. Some require a medical contraindication while others, including Michigan, allow parents to sign a waiver stating their philosophical opposition to immunization. From a public health perspective, this creates a dilemma. If herd immunity is to be achieved, a certain percentage of a community's population must be vaccinated (or have had the disease). Unvaccinated children pose a health risk not only to themselves, but to the community at large.

The Debate: Following the publication of a study by Andrew Wakefield in The Lancet in 1998, many parents became convinced that childhood immunizations were the root cause of autism. Wakefield's study has since been discredited, but its impact persists, and herd immunity has been compromised in a number of communities in Great Britain. In the U.S. there is significant controversy about the HPV vaccine, which protects young women against a sexually transmitted virus that can cause cervical cancer. Public health experts recommend that girls as young as 11 receive the vaccination, and this has many parents—and politicians—upset.

A Way Forward: Public health practitioners and health care providers need to continue to educate families about the utility of immunizations. Health care providers need to sit down with families and discuss the issues surrounding immunizations so that parents understand why they're necessary—for their children, them- selves, and for the larger community. Sadly, families who have lost children to vaccine-preventable diseases can also play a critical role by going public with their stories and reminding others of how important it is to immunize their kids. This is equally true for seasonal influenza, which kills upwards of 30,000 Americans every year.

—Laura Bauman, RN, M.P.H. '99, Washtenaw County (MI) Epidemiologist

Motor Vehicles and Personal Technology

The Issue: Despite the risks posed from cell-phone use and texting inside cars and trucks, auto manufacturers have begun installing and marketing the use of touchscreen computers on automobile dashboards. At least 18 percent of all reported injury crashes in the U.S. in 2010 involved distracted driving, so the question now is whether the escalation of personal technologies inside motor vehicles will lead to a corresponding escalation of injuries. If so, what should the federal and/or state governments do to keep the public safe?

The Debate: The federal government has issued regulations on trucks, and legislators in many states have considered laws to restrict the use of cell phones and other personal technologies. But auto manufacturers are not being challenged on their decisions regarding personal computing technologies. Aside from limits on texting and hand-held cell phones in some states, regulators at the federal and state level are not aggressively pursuing restrictions on personal technology use inside cars and trucks.

A Way Forward: We need a much broader discussion about the availability and use of personal computing technologies inside motor vehicles—and about the responsibility of auto manufacturers and the role of state and federal governments. States could consider legislation to ban the use of touchscreen computers on state roads and highways. In addition to supporting such laws, public health professionals should develop the same kind of campaigns they used so successfully to advocate for seatbelt use and designated driving.

Auto insurers can begin offering lower rates to drivers who adopt restrictions on technology use. Both the U.S. Department of Transportation and state DOTs should mount vigorous campaigns to heighten public awareness of the dangers of personal technology use while driving. Auto manufacturers need to think seriously about what they're putting inside motor vehicles and why, and should work to develop new safety features to help offset the risks posed by new technologies.

Peter D. Jacobson, Professor of Health Law and Policy, U-M SPH Department of Health Management and Policy; Director, U-M Center for Law, Ethics, and Health; President, Public Health Law Association

Tobacco Control

The Issue: The tobacco control campaign is one of the most successful public health efforts of all time. Thanks to programs and policies implemented since the 1964 Surgeon General's Report, several million lives have been saved that otherwise would have been lost to tobacco-caused illnesses. But in recent years, the smoking rate has remained relatively stagnant. We've entered a period where we must develop more effective interventions for vulnerable subpopulations, understanding that the tobacco industry will keep fighting to maintain its profits by targeting those very groups and marketing newfangled nicotine-delivery products.

The Debate: A major debate revolves around the concept of harm reduction—whether and in what ways public health advocates and health authorities (particularly the Food and Drug Administration) should condone or even promote the use of alternative nicotine-delivery products that might maintain addiction while reducing illness and death. Wherever one stands, the practical aspects of how to pursue a safe and effective harm-reduction strategy on the population level are not yet well understood and will be the subject of ongoing scientific and policy-level research. The FDA now has the authority to order changes in mass-marketed tobacco- and nicotine-delivery products, but needs both the science and, equally importantly, the political will in order to take significant action.

A Way Forward: The public health and scientific communities have already started to pursue cutting-edge research into such areas as modified-risk tobacco products and how to more effectively intervene with hard-to-reach populations whose addiction to conventional tobacco products continues at a high level. Nearly half of all cigarettes smoked in the U.S. are consumed by people with co-occurring psychiatric or addictive disorders. The tobacco industry has long been interested in this relationship, and has itself conducted and supported psychiatric and basic science research on the mental health implications of smoking. The industry also seeks to impede all meaningful government efforts to combat the smoking epidemic. Public health advocates must do a much better job of defending against these practices, and together with government leaders must strive for more effective regulation while defending the FDA's efforts to protect consumers. We need new frontier interventions. The FDA, for example, could mandate the reduction of nicotine in tobacco products to non-addicting levels.

Clifford Douglas, Director, U-M Tobacco Research Network; Adjunct Lecturer, U-M SPH; Kenneth E. Warner, Avedis Dona- bedian Distinguished University Professor of Public Health, U-M SPH

Leading-Edge Science

Nanotechnologies

The Issue: Nanotechnologies have been with us for at least 30 years and are now widely employed across numerous sectors. Engineered nanoparticles—commonly defined as a particle with at least one dimension between one and 100 nanometers—turn up in a wide range of everyday products, from paint to washing machine filters. But we don't yet fully understand their long-term impact on human health and the environment. In the U.S., products with nanoparticles, such as sunscreens, are currently regulated by existing regulatory instruments and agencies that were designed and enacted for conventional, non–nano-based products. The question scientists and policymakers must ask is whether these existing regulatory frameworks are sufficient to protect both consumers and the environment, or are nano-specific requirements needed?

The Debate: Globally, key stakeholders—including environmental and consumer groups—have expressed concern about the long-term impact of nanotechnologies on health and safety. Recently, the European Union passed legislation requiring that all cosmetic products containing nanoparticles be labeled as such. In the U.S., regulatory agencies like the Food and Drug Administration and Environmental Protection Agency recognize that as scientists learn more about the impact of nanoparticles on the environment and human health, amendments to existing regulations or guidelines may be needed. To date, these agencies have resisted the idea of requiring labeling for nanoparticles. Many of the big players in industry have taken a proactive stance by developing voluntary systems for monitoring this new technology and by engaging in discussion with academic and community leaders.

A Way Forward: Scientists are working hard to understand how nanoparticles affect the environment and human health, but it's likely that it will take another five to ten years before we have enough knowledge to accurately inform public policy. The good news is that countries and industry are working together to generate data as quickly as possible.

Diana Bowman, Assistant Professor, U-M Risk Science Center and U-M SPH Department of Health Management and Policy; International Visiting Professor, Department of Governance and Regulation, University of Twente, The Netherlands

Genetically Modified Foods

The Issue: Global disparities in access to healthy, nutritious, and plentiful food are worsening. If major crises are to be averted in the coming decades, we need new solutions to ensure that everyone has access to the food they need to guarantee their health and well-being. Political, social, and economic solutions are essential to this process. Technology is also key. By genetically engineering plants that have higher yields, are pest- and disease-resistant, and have higher nutritional quality, scientists can design crops to better meet society's needs. But the rapid introduction of new genetic material into plants has raised fears that there may be unanticipated health and environmental impacts—including the transfer of potentially disruptive genetic material between plants and other organisms, the unintended production and release of toxic substances, and allergic reactions to genetically modified food products.

The Debate: Large companies like Monsanto and Syngenta have promoted genetically modified (GM) crops as a critical technology for future food security and sustainability. Many food scientists and governments support the technology. A number of NGOs and consumer advocacy groups have actively and successfully opposed the development and introduction of GM crops on the grounds of inadequate risk assessment and management. European consumers remain reticent over the widespread use of GM crops. In the U.S., consumers have been more ambivalent, and GM foods are now ubiquitous in the North American diet. Nevertheless, the introduction of new GM products remains contentious on the basis of concerns over potential and perceived risks, possible unintended consequences, who controls the technology, and how such an innovative technology is regulated effectively.

A Way Forward: As the technologies become increasingly sophisticated, the tension between what we can do as a society, what we need to do, and what we should—or maybe should not—do will only increase. In order to move forward, we need serious dialogue among stakeholders; partnerships among developers, users, and consumers; transparency on development and deployment; more research on safety; and more effective regulation, communication among stakeholders, and partnerships on sustainable development.

Andrew Maynard, Interim Chair and Professor, U-M SPH Department of Environmental Health Sciences; Director, U-M Risk Science Center; Charles and Rita Gelman Risk Science Professor

Privacy

Health Information Sharing

The Issue: As digital information increasingly becomes available as a natural byproduct of health care, we've got the potential to set in motion all kinds of analytic activities to generate what many call "health system learning." This information can be used for a range of public health purposes, including early detection and tracking of disease outbreaks and improvement of health care quality. But there are concerns, one of which is the extent to which individuals should control their health information and should have the right either to grant or refuse permission for its use in analytic activities not mandated by law. Another concern is corporate re-use of personal data. Blue Cross Blue Shield in Chicago, for example, has a new spin-off called Blue Health Intelligence, which plans to sell individual health data to other entities for a range of uses. Yet another concern is whether health data about individuals can be so completely stripped that the identity of the individual cannot be determined (the answer is: probably not). Lastly, scientists and the public alike need to consider just how valuable for analytic purposes these data are, given that they are not collected for research purposes but rather exist as a byproduct of routine health care.

The Debate: Most of the public is unaware of this issue, but a small and occasionally vocal group of people is opposed to the use of an individual's health information for research absent explicit "opt-in" consent by each individual. While the majority position is that "opt-out" consent is sufficient, the debate continues.

A Way Forward: The nation needs an open, public, and ongoing dialogue that will lead to a deeper public understanding of the true risks and benefits of health information sharing and analytics. The public must understand that there are risks (and what they are) and there are benefits (and what they are), and that it is impossible to fully realize the benefits without taking some risk. Through sharing and open dialogue, a comfortable balance point—one that will make almost all individuals comfortable—can be attained. And, of course, anyone who wishes to opt out must have that option.

Charles Friedman, Director, U-M Program in Health Informatics

Young Adult Rights

The Issue: Under the 2010 health care overhaul, millions of young adults in the U.S. can access health care on a parent's health insurance policy. That's a good thing, because it means they are more likely to get preventive care—yet a glitch in the system means that young adults might forgo treatment for conditions they don't want their parents to know about. These young people are afraid, and rightly so, that an insurance company will send an explanation of benefits (EOB) home to the parent who holds the health insurance policy. Research suggests that many young adults will skip a visit to the doctor if they're worried about privacy. In the worst-case scenario, that translates to no treatment at all or delayed care for sexually transmitted diseases, mental health problems, substance abuse, domestic violence, unplanned pregnancies, and many other serious and potentially costly conditions.

The Debate: EOBs document receipt of health care services and are required by law in most states, because they notify the patient about services received and encourage them to report errors or fraudulent billing to the insurer. In this way, they save money for our health care system. Some states have eliminated EOB requirements when a dependent requests a sensitive service, such as testing for an STD. Many insurance companies eliminate the EOB when the holder of the policy, in this case a parent, has no financial obligation. But patchwork solutions will not give young adults throughout the country the privacy they deserve.

A Way Forward: We clearly need a national solution to this problem. The Centers for Disease Control and Prevention recently funded a study (PDF) of state confidentiality laws with regard to insurance dependents and privacy, which showed that at least eight states have statutes or regulations that could provide a starting point for national or state-by-state legislation to give dependents the confidentiality protection they need to stay healthy.

— Denise Chrysler, Director, Network for Public Health Law, Mid-States Region, U-M SPH; Robyn Rontal, Network Collaborator for Health Information Data Sharing, Network for Public Health Law, Mid-States Region, U-M SPH

Genetic Data Sharing

The Issue: From a clinical perspective, we have begun to collect massive amounts of genetic information on people—information that has the potential to help researchers understand the genetic basis of human diseases and to help clinicians make diagnoses. It seems clear that DNA sequencing will soon become standard clinical practice, likely at or soon after birth. So we face the question of how to maintain privacy and protect individuals from information disclosure. From a research perspective, we need to determine the extent to which we should restrict the use of genetic information collected during studies. The current default is that data will be narrowly used, but many scientists would like to see the default be a broad usage of data, with exceptions as needed.

The Debate: The specter of episodes such as the infamous Tuskegee study—in which the U.S. Public Health Service withheld treatment from poor African-American men in order to study the natural progression of untreated syphilis—looms large over any discussion of the usage of personal data. Many people fear a loss of privacy, or worse, if information from their DNA is shared. Researchers clearly need to protect both individual and group rights and privacy.

A Way Forward: As long as the research community proceeds with transparency and insists that information be used appropriately and carefully, and as long as individuals and groups are given the chance to opt out of sharing their data, we should see broad public support for data-sharing.

Researchers need to engage with communities and seek to implement standards globally. The Genetic Information Nondiscrimination Act, which Congress passed in 2008, protects in key ways against genetic discrimination by employers, educational institutions, and other entities.

Michael Boehnke, Richard G. Cornell Distinguished University Professor of Biostatistics, U-M SPH; Director, U-M Center for Statistical Genetics; Director, U-M Genome Science Training Program

Health Behaviors

Wellness

The Issue: The Affordable Care Act will trigger a systemic change in the way we provide chronic-disease care to people in the U.S. This means moving away from a hospital/medical model and toward a population-health model that emphasizes prevention, with coordinated care administered at the community level by physician-sponsored patient-centered medical homes, Federally Qualified Health Centers, and community-based wellness centers. Ideally, these entities will use data in collaboration with one another to identify and address "health hot spots"—areas of particular need and disparity—by establishing community-based wellness centers and movements.

The Debate: The U.S. health care system currently funds a fee-for-service model based on acute in-patient care, but there's very little funding for community wellness initiatives. We need to create incentives that will prompt people and providers to invest in good health. As we begin to manage population health more effectively, we'll need fewer hospital beds, more physicians and primary care professionals, and a greater emphasis on prevention and chronic disease management. How do we change the funding formula to achieve this?

A Way Forward: Private industry needs to align with the hospital industry and local providers to reallocate resources to improve population health. Here's an example of how that might work: Mrs. Jones, a diabetic in her mid-forties, visited the hospital emergency room five times last year. On her fixed income, she needs to pay for housing, utilities, food, transportation, kids' clothes, and her diabetes medications. Often she ends up not buying her medications. But what if Mrs. Jones were told that a wellness center had opened two blocks from her home, and that it offered a program on managing diabetes, and that if she showed up three times in the next two weeks, she'd receive a $100 credit toward her next utility bill? We'd have Mrs. Jones's attention. This is just one way corporations can be directly involved in promoting community health and wellness. We also need to do a better job of working together to assess and address the social determinants of population health.

—Chris Allen, M.H.S.A. '80, Executive Director and CEO, Detroit Wayne County Health Authority

Obesity

Prevention

The Issue: In an effort to combat the rising epidemic of obesity in the United States, especially among children, many public health and other officials are calling for government intervention, such as a tax on soft drinks and restrictions on the contents of vending machines in school cafeterias.

The Debate: The big debate is between those who think obesity is a matter of personal responsibility and those who believe it's driven primarily by the environment. Those who subscribe to the first view feel there's no need for government action. As a pediatrician, I know people are better able to change their behavior if the environment is conducive to it—and the environment in the U.S. is hardly conducive to healthy eating. In the past 50 years, we've learned how to grow vast quantities of food cheaply and efficiently, so now there's an excess of food in the U.S., and portion sizes are immense. To increase profit margins, the food industry continually comes up with new products—many of them high-salt, high-fat, and high-sugar. Because the federal government subsidizes foods like cheese, restaurants and grocery stores push those products. In the face of such challenges, it takes enormous energy to eat healthily—and to get kids to eat healthily.

A Way Forward: The public health campaign against smoking can serve as a model for obesity prevention. The first step towards a reduction in smoking rates was the public beginning to view smoking as socially unacceptable. We're seeing a similar shift in attitude when it comes to eating "junk foods" and going to fast-food restaurants. The second phase of the anti-smoking campaign was a grass-roots effort to reduce tobacco use, and again, we're seeing that with obesity. Schools are increasingly saying no to treats on kids' birthdays, and parents across the income spectrum are calling for healthier school lunches. The next phase will be to implement real policy change aimed at preventing obesity, much as we saw with anti-smoking regulations.

Julie Lumeng, Associate Professor, Pediatrics, U-M Medical School; Associate Professor, Environmental Health Sciences, U-M SPH

Medical Marijuana

The Issue: There's clear evidence that Tetrahydrocannabinol (THC), the principal psychoactive ingredient in marijuana, has significant potential to relieve pain without the side effects of more conventional opiate pain relievers, such as morphine and oxycodone. At present, however, the most effective delivery system for THC is smoked or aerosolized marijuana. Despite the existence of federal laws controlling marijuana, 13 states and the District of Columbia have now passed laws legalizing marijuana for medical use. These state laws are in conflict with anti-smoking laws.

The Debate: A faction of the U.S. population feels very strongly that there should be zero tolerance for any marijuana use. They believe marijuana can lead to greater substance abuse, based on the so-called "gateway theory." In fact, while it's true that most people who use other drugs have previously used marijuana, most people who smoke marijuana do not go on to use other drugs. Proponents of medical marijuana point to hundreds of years of anecdotal evidence that marijuana can relieve pain. But we lack the science to substantiate this claim, in part because of the difficulties of studying the effects of numerous compounds in varying doses in the different varieties of marijuana plants. In addition, there are chilling effects from the politics surrounding the issue that have hampered more robust research efforts. Furthermore, the National Institutes of Health is organized to focus on specific diseases instead of broad issues like pain, which affects multiple diseases and requires collaboration across several institutes.

A Way Forward: The public health, medical, and policymaking communities need to unite around a research agenda that clearly and credibly examines the potential therapeutics of aerosolized cannabinoids for pain relief (the united response to AIDS provides a good example). NIH could make pain an interdisciplinary research priority. Scientists also need to continue their efforts to develop an alternative delivery system for THC.

—Don Vereen, Director, U-M Substance Abuse Research Center; Director, Community-Academic Engagement, Prevention Research Center of Michigan; previously Special Assistant to the Director, National Institute on Drug Abuse; Deputy Director, White House Office of National Drug Control Policy

The Environment

Climate Change

The Issue: Despite scientific consensus that the world is warming more rapidly than at any previous time in its history, and that human activities are a cause of this climate change, some people dispute the evidence and argue against measures aimed at addressing climate change. In its efforts to achieve "balanced coverage," the news media often obscures the overwhelming agreement on the science. Evidence suggests that we are now seeing the impacts of climate change, and that there are known ways to prevent or diminish those impacts, particularly with regard to human health.

The Debate: From a public health perspective, we know that heat waves kill people; that flooding affects both mental and physical health; that the increasing incidence of hurricanes, tornadoes, wildfires, and drought is a consequence of climate change and indisputably affects people's health, lives, and livelihoods. We also know that the people who are most affected by climate change are those who have done the least to contribute to it. These people are often more vulnerable because of age, socioeconomic status, illness, and geographic location. So there is a moral dimension to our response to climate change. Indeed, many traditionally conservative churches and faith-based organizations have called for more responsible stewardship of our planet in terms of curbing energy use and addressing climate change.

A Way Forward: We know that greenhouse emissions currently in the atmosphere have put us on an irreversible course toward a warming planet and more variable weather. We can't stop climate change—but we can slow its future pace through such actions as reducing emissions, increasing energy efficiency, and planting trees. Individuals can contribute in important ways by adjusting thermostats, using public transport, reducing consumption, recycling and reusing, and supporting policies for more sustainable energy sources.

Marie O'Neill, Associate Professor, Environmental Health Sciences, Epidemiology, U-M SPH; Member, Advisory Committee, National Climate Assessment (a Congressionally mandated effort to characterize how climate change affects the nation in various sectors, from economics to energy to health)

Chemicals Management

The Issue: Chemistry is essential to solving some of the world's biggest public health challenges, among them adequate food and drinking water for a global population that will reach nine billion by 2050. Ninety-five percent of the products we use today—from plastics to pharmaceuticals to electronics—depend on chemistry. So we need to ask, first, is a given chemical product safe to use? If it is, then what is its environmental fate once it reaches the end of its life, and are we managing that responsibly?

The Debate: Many proponents of environmental safety advocate a hazards-only approach to the issue of chemicals management, meaning that when a chemical is identified as hazardous, it should be banned from all manufacturing uses. The chemical industry believes that once a chemical is identified as having hazardous properties, experts should determine whether it can be used safely in certain contexts. If so, its usage should be governed by the Responsible Care Initiative and the Global Product Strategy, two global initiatives aimed at improving product safety and stewardship worldwide. The large multinational chemical companies all subscribe to these initiatives and commonly have standards that go well beyond government regulation, and through the International Council of Chemical Associations (ICCA), they are working with both governments and small and medium-sized companies to implement these standards around the world, particularly in developing nations.

A Way Forward: The best chemicals management is a combination of strong regulation that's science- and risk-based and is equitably enforced, and a voluntary industry effort that goes above and beyond legally imposed safety requirements. In partnership with the United Nations Environment Programme, ICCA, and environmental advocacy groups working in the public interest, large multinationals such as Dow, Dupont, BASF, and Bayer should continue working with developing nations and with smaller- and medium-sized chemical companies to develop and implement a high level of chemical safety standards worldwide.

—Gregory Bond, Ph.D. '85, M.P.H. '79, Loaned Executive to U-M, working on Sustainability Education, Research, and Service; Corporate Director, Product Responsibility, Dow Chemical Company (1997–2012)

Fracking

The Issue: For several decades, the energy industry has been using hydraulic fracturing, or "fracking"—the process of injecting water, with or without additives or sand and chemicals, underground—to release deep deposits of natural gas from the earth. What's changed is the addition of horizontal drilling and new and sometimes undisclosed chemicals. From a public health perspective, there's concern about the potential for both underground water contamination and above-ground spills from stored water supplies and wastewater. From an environmental perspective, there are concerns about the vast quantities of water the process requires and the disruption of habitat.

The Debate: Proponents of fracking contend that it's a safe and secure domestic energy source that can help re-industrialize the U.S. Opponents argue that it's a shaky bridge to a cleaner energy future. Because of the diesel required for the process and the potential for methane leaks from extraction through distribution, it's not clear that fracked gas is any cleaner than coal, and there are legitimate questions about the potential danger to both human health and the environment from underground water contamination and above-ground spills. Organizations such as the Sierra Club believe fracking should be banned outright. At the Graham Sustainability Institute, we take the position that it's difficult to condemn a process that's been around for so long, especially given the positive regulatory track record in Michigan. However, we should certainly examine the technology and scale of what's happening today.

A Way Forward: In Michigan, the Graham Sustainability Institute is committed to examining multiple facets of the issue—from public health and the environment to economics and geology—in collaboration with other U-M institutes (the Michigan Energy Institute, the Risk Science Center, and the Erb Institute); U-M faculty; environmental and industry groups; and state regulatory officials. We acknowledge that fracking is happening and will probably expand—we want to make sure it happens in the best way possible, and we hope by early next year to develop recommendations for that. Ideally, this kind of "engaged problem-solving" could set an example for other states to follow.

—John Callewaert, Integrated Assessment Program Director, U-M Graham Environmental Sustainability Institute

2 Reader Comments

Dec 07, 2012 at 12:11 PM Posted By Diane Lehman Wilson

I would love to volunteer and work with someone on studying and proposing ways that high quality familial care could be supported to reduce the need for high cost institutional care, especially after hospitalizations of the elderly. Having learned how other countries support families who serve as foster parents for relatives and having seen how my father recovered much faster back in his independent apartment (with a small amount of private duty nursing care and a large amount of unsubsidized familial TLC), I believe that Medicare & Medicaid could save millions and achieve better results by investing a little more in supporting familial care. My own degrees (MPP, JD, MA) are not in Public Health, but my Certificate of Gerontology years of working with seniors in volunteer and paid settings, and some personal and video connections may help support such an endeavor.

Dec 06, 2012 at 01:29 PM Posted By Carolyn Poissant

Human-created toxic substances (emissions, pesticide residues,extraction by-products etc). which are so pervasive in our environment have been shown time and again to be a significant cause of serious biological, human health, and genetic impacts, including cancer, birth defects, Parkinson's and other neurological diseases, etc. Yet legislators and regulators alike refuse to properly address these issues in ways that will PREVENT DEBILITATING HEALTH IMPACTS instead of having to TREAT DISEASE AFTER THE FACT. This is a no-brainer. What we need is a PRO-ACTIVE APPROACH to prevent the introduction of hazardous substances in our enviroonment in the first place.

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