Vermiculite

This series of articles should provide ample background to the story of vermiculite. It has served as a valuable commercial product over time, and continues to be mined, processed, and utilized around the world. For many years, vermiculite has been appreciated for its physical and chemical properties. Its physical properties, which allow expansion to a light density particle, make it suitable for light aggregate in concrete and other building materials and low heat transfer effective for insulation. The chemical properties which include an active cation exchange surface are ideal for agricultural products. Its natural formation is a micaceous mineral, composed of flat crystal plates arranged in a multi-laminate stack. Of great misfortune is the association of some vermiculite deposits with asbestiform amphibole formations. A remote Montana vermiculite deposit cohabitated with a large formation of these asbestiform minerals. Further complicating the situation is that this vermiculite deposit near Libby, Montana, produced a large majority of the world supply during the sixty-seven years of operation resulting in wide distribution of contaminated vermiculite. The epicenter of mining and processing was an isolated town where ongoing occupational and environmental exposures spanned throughout the years of mining operations. Morbidity and mortality studies recognize the pervasive adverse effects from amphibole exposure, not just in Libby, Montana, but also at export sites processing the vermiculite ore. Being the first population exposed to the unstudied asbestiform amphiboles winchite and richterite, there has been significant advancement in understanding their induced health effects. Studies in the toxicology of fibrous amphiboles and human health studies where a different pattern of asbestos-induced disease has been observed with Libby amphibole asbestos exposure have been completed. The observations have broadened our understanding of Libby amphiboles and enlightened us to the hazards of environmental exposure, and the long-term public health risk from existing contaminated vermiculite.

Pediatric Environmental Health

Pediatric environmental health is the academic discipline that studies how environmental exposures in early life — biological, chemical, nutritional, physical, and social—influence health and development in childhood and across the lifespan. This discipline emerged in the mid-1980s after the discovery that secondhand smoke exposure was linked to increased rates of lower respiratory illness in children. Before that, most people did not realize that smoking cigarettes harmed anyone but the smoker. When the harmful effects of secondhand exposure to tobacco smoke were uncovered, researchers began asking questions about other pollutants—could it be that other biological, chemical, physical, and social agents to which children are routinely exposed also harm their health? Children have environmental exposures that are different from and often larger than those of adults. Children also have enormous susceptibilities in early development—unique “windows of vulnerability”—to toxic exposures that have no counterpart in adult life. It is well understood that timing of exposure is critically important in early human development. The tissues and organs of embryos, fetuses, infants, and children are rapidly growing and developing. Adolescence also is a period of rapid growth. These complex and delicate developmental processes are uniquely sensitive to disruption by environmental influences. Exposures sustained during windows of early vulnerability, even to extremely low levels of toxic materials, can cause lasting damage.

Work-Related Asthma

Work-related asthma encompasses both new-onset asthma and aggravation of pre-existing asthma from work exposures/conditions. New-onset asthma can be caused by exposure to an irritant or a substance that causes sensitization. Approximately 350 substances have been identified by which exposure at work can lead to sensitization and asthma. When the term occupational asthma is used, it generally does not include work-aggravated asthma. Some authors limit the use of occupational asthma to new-onset asthma from sensitization to a substance at work, while others also include new-onset asthma from exposure to an irritant at work under this category. New-onset asthma from an acute single exposure is called reactive airways dysfunction Syndrome (RADS) (note this is not the same as reactive airways disease). New-onset asthma from repeated chronic exposure to an irritant at work as a cause of asthma has also been described, but it is not as well accepted as an entity as RADS. Aggravation of pre-existing asthma by work can occur from any exposure as well as stress, physical activity, and temperature/humidity. Unlike the work-related lung diseases such as the pneumoconioses, which cause irreversible fibrosis, work-related asthma is potentially completely reversible if diagnosed soon after onset of symptoms and the patient’s exposure to the etiologic agent ceases. Beginning in the early 1900s, asthma from exposure at work to plant material and metals first began to be reported in the medical literature. In the 1970s, Dr. Jack Pepys from England markedly advanced the identification of etiological agents by developing a practical way to perform specific inhalation challenge testing. The field has continued to advance with the recognition of an increased number of etiological agents, an understanding of the pathophysiology, an understanding of the prognosis and factors associated with a better prognosis, and the initiation of work on the interaction with genetic variability. At least in more developed countries, such as in European countries and the United States, which have implemented controls or banned the use of the mineral dusts (i.e., asbestos, silica) that have caused the most common pneumoconioses, work-related asthma has become a more important cause of new-onset work-related lung disease than the more traditional pneumoconioses.

UK Public Health Systems

Within the UK there are four public health systems covering each of four countries making up the UK: England is the largest country, followed by Scotland, Wales, and Northern Ireland. There are many commonalities between the systems in terms of their functions and workforce terms and conditions as well as the challenges each faces. But in keeping with the devolved systems of government enjoyed by each country, the public health systems are organized differently and their structures and priorities reflect the differing contexts in which they are located. Drawing on the three domains outlined by Griffiths, Jewell, and Donnelly in their seminal 2005 paper and comprising health protection, health improvement, and health service delivery and quality, UK public health systems exist to protect and promote health improvement and well-being in the population and do so through devising policies and strategies and providing services as well as contributing to the evidence base in regard to what works to improve health. The definition of a public health system is clearly contingent on the definition and scope of public health. The UK public health systems have adopted the definition of public health advanced by the UK Faculty of Public Health and other bodies and first produced by a former Chief Medical Officer for England, Sir Donald Acheson, in 1998: “Public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society.” A slightly extended version appeared in a review of public health carried out for the UK government by its appointed independent adviser, Sir Derek Wanless, in 2004: “Public health is the science and art of preventing disease, prolonging life, and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.” These definitions share important characteristics including: public health is both a science and an art, essentially and always a combination of knowledge and action; the core purposes of public health are to prevent disease, prolong life, and promote health; public health is an organized societal function. Several aspects of these definitions can be highlighted as being especially pertinent to public health systems. Notable among these is the desire for closer links across health and the environmental sector; addressing social and political determinants of health as an essential and legitimate public health action; and the importance of health systems for public health improvement. Given these definitions with their whole-of-society focus, a public health system is wider and more inclusive than a health system. An effective public health system can be judged by the extent to which relevant groups, organizations, and sectors work effectively together on specific issues.

The Health Systems of Low- and Middle-Income Countries

“Health system” is a term generally considered to be relatively recent. It is defined as all organizations, institutions, and resources that produce actions whose primary purpose is to improve health, whether these be targeted at individuals (such as health-care delivery) or populations (such as public health measures). Health-care and public health institutions have a long history, but the notion of an organized “health system” is a relatively recent development (dating from the mid-20th century). In low- and middle-income countries (LMICs), Western medicine was often introduced by former colonial authorities through the construction of public hospitals, health centers, and training schools, with church authorities also making a major contribution. As in high-income countries, there was a gradual process over the latter half 20th century to construct an organized and coordinated national health system. However, health systems became a key focus of international attention only in the late 1990s, when it became apparent that achieving the health-related Millennium Development Goals (e.g., reduction of child and maternal mortality; control of HIV, TB, and malaria) was threatened less by the availability of technical solutions and more by the ability of health systems to put them into practice. More recently, the Ebola epidemic in West Africa highlighted the critical importance of health systems in ensuring health security. In response to the increased awareness of the role of health systems, significant attention has been paid to defining the health system and its goals, categorizing its elements, assessing problems and testing solutions, and seeking to identify the relationship between different health system configurations and overall performance. Over time, specific issues within the general area of health systems have received special attention, including achieving universal health coverage (where the whole population of a country has access to health care and protection against its costs), the role of primary health care, the relative merits of different ways of financing a health system, the relative roles of public and private health sectors, and the appropriate mix of different types of health worker. Many disciplines can contribute to improved understanding of health systems, including economics, sociology, anthropology, history, political science, and management science. Until recently, the discipline of economics has tended to dominate the study of health systems. However, with the emergence of health policy and systems research as an important area of study, other disciplines have been making growing contributions, especially political science and the behavioral sciences concerned with the behavior of both individuals and organizations.

Socioeconomic Inequalities in Adolescent Health

Among adults, there is solid evidence of socioeconomic inequalities in health, with regard to both objective measures (such as mortality and morbidity) and subjective measures (such as self-rated health, health complaints, well-being, and health behaviors). Socioeconomic inequalities denote a range of differences in socioeconomic status (SES) linked with a person’s work experience and economic and social position in relation to others, based on income, education, wealth, and occupation. During adolescence, socioeconomic inequalities in health may be less profound, partly because adolescents (in the Western world) generally are in good health. Moreover, adolescents are in a transit position between the SES of their family of origin and the SES they obtain as adults, and upward or downward social mobility may mask inequalities in this specific period. Nevertheless, adolescence is regarded as a pivotal life phase in the development of health inequalities. Such inequalities probably reflect a way of life that is caused both by life choices and by life opportunities. Life opportunities refer to social position and access to resources in the environment, which may differ widely among adolescents and thus limit or enable their potential for healthy development. Adolescence is a crucial period for making important life choices in terms of education and occupation, as well as choices of lifestyle (including health habits such as food consumption, physical activity, or drug use). The combination of vulnerable life circumstances and unwise life choices is likely to yield negative consequences for adolescent health, and, during the life course, these accumulate to produce poorer adult health, compared to a combination of growing up in a prosperous environment and making choices that are conducive to good health. Globalization and economic and political development lead to changes in “modern” values, including an increasing emphasis on quality of life, self-expression, and freedom of choice. While such development may infer increased opportunities for adolescents to achieve good health and well-being, it can also marginalize those who do not have the capability to “make it” on their own, rendering significant segments of the populations at risk and creating a new type of health inequality.

IANPHI and National Public Health Institutes

More than one hundred countries around the world have established national public health institutes (NPHIs) to coordinate and lead their public health systems. Some NPHIs, such as the US Centers for Disease Control and Prevention (CDC), South African National Institute for Communicable Diseases (NICD), Brazilian Oswaldo Cruz Foundation (FIOCRUZ), and Chinese Center for Disease Control and Prevention, have developed over time. Others, such as the Public Health Agency of Canada (PHAC), emanated in response to more recent global public health threats like severe acute respiratory syndrome (SARS). NPHI functionalities range from combatting primarily infectious diseases to comprehensive mandates to lead national efforts for prevention and control of both infectious and noncommunicable disease threats. The International Association of National Public Health Institutes (IANPHI), envisioned in 2001 and chartered in 2006, serves to link and catalyze the capacity of NPHIs around the world through a robust international professional and scientific network. IANPHI works closely with the World Health Organization (WHO) through a formal partnership agreement. The Bill & Melinda Gates Foundation, the Rockefeller Foundation, member dues and peer assistance, bilateral cooperative agreements, and private-sector partnerships support its activities. IANPHI’s members encompass more than five billion people across six continents. IANPHI is the only organization whose mission is to strengthen national public health institutes. To do this, IANPHI’s work focuses on (a) supporting a robust scientific community of NPHI directors through an annual meeting, a listserv, and collaborative activities; (b) developing and distributing guidelines and tools that strengthen NPHIs’ abilities to conduct and evaluate public health programs and efforts, including the IANPHI NPHI development framework, the Staged Development Tool, NPHI-to-NPHI evaluation guidance, and a best practices series; and (c) investing in projects designed to create NPHIs and strengthen public health systems in low-resource countries. IANPHI helps NPHIs by advocating for strong and well-supported NPHIs and providing timely information and insights for public health programs and actions.

Healthy Public Policy

Healthy public policy (HPP) became an important idea in the 1980s. The concept can be traced primarily to Nancy Milio, who produced a now hard-to-find book, Promoting Health through Public Policy (Philadelphia: Davis, 1981), and was subsequently cemented in the WHO’s Ottawa Charter for Health Promotion as a strategy to use in promoting, protecting, and maintaining the health of populations. HPP is not, however, a modern phenomenon. Historically HPP was embedded in the 16th-century Poor Laws and passed through to 19th- and early-20th-century public health activity and legislation. Across this history is the recognition that improving public health requires addressing the social and economic (and environmental) conditions created by public policy. It follows, as explained by many, that public health practice is inherently political. This bibliography introduces the large literature that falls under the broad pantheon of HPP. Definitions, as this bibliography will show, do matter. Central is the often underrealized truth that “healthy public policy” fundamentally concerns how public policy influences the health of populations. This, in turn, necessitates that HPP practice is interdisciplinary. For knowledge, this means much of the theory and evidence underpinning HPP is to be found in other disciplines that have public policy at their core, political science being the most obvious (public administration another). It is through HPP that societies in general and public health researchers and practitioners in particular seek to create social and economic and environmental conditions for whole populations. Attention thus moves “upstream” to policies and institutions rather than “downstream” to behaviors or health services. Not all healthy public policy is generated with the intention to influence population health directly. Nor are all public policies that impact on the health of populations generated by the health sector, although many are. A core goal of HPP is reducing inequities in health. These inequities are what the 2008 WHO Commission on the Social Determinants of Health named as a “toxic mix of poor social policies, unfair economic arrangements and bad politics.” Just as policy actors are responsible for policies that have created inequalities, so too are they responsible for developing and implementing policies in that overcome the unfair and unjust distribution of the resources necessary for good health and well-being. Public policies are formed through “contests for power” between the various actors involved in policy-making in part because they are value-laden. The choices actors make are influenced by powerful structures and ideas that are not always explicit. HPP, therefore, can never be “atheoretical” just as it cannot be divorced from a normative position (what is believed “should” happen) concerned with changing political conditions for the betterment of the health of the population in general and disadvantaged in particular. In recent years there has been some confusion (see Oxford Bibliographies article Health in All Policies) whether HiAP replaces HPP as a concept and method. This article errs on the side of history by suggesting HiAP, with intersectoral action, is one recent strategy to achieve HPP.

Immunization in Pregnancy

Routine childhood immunization has had a substantial impact on pediatric morbidity and mortality globally. However, owing to suboptimal immune responses to vaccines in very young infants, immunization schedules do not begin until infants are at least two months of age (six weeks of age in countries following the World Health Organization’s (WHO) Expanded Program on Immunization [EPI] schedule). Thus, the youngest infants are unable to benefit from the protective effects of routine vaccines. These infants are also the most vulnerable to complications and death due to many vaccine-preventable diseases. Immunization in pregnancy, often referred to as maternal immunization, has emerged as a promising strategy to address this gap. This immunization strategy takes advantage of the normal transplacental transfer of antibodies from mother to fetus during pregnancy (as well as to the infant through breast milk in the postpartum period) to confer passive immunity to young infants through maternally derived vaccine-induced antibodies. In addition, because pregnant women are at higher risk of complications due to certain infectious diseases that are or may be vaccine-preventable, maternal immunization is increasingly recognized as an essential component of routine antenatal care. Widespread programmatic use of immunization in pregnancy began with the inclusion of maternal tetanus toxoid vaccination in the WHO’s Expanded Program on Immunization in the 1970s. Since then, immunization of pregnant women against influenza and pertussis has now also become routine in many countries, and vaccines against other important pathogens in infancy (e.g., respiratory syncytial virus and group B Streptococcus) that may be prioritized for use in pregnancy are in development. Indeed, with increased recognition of the substantial burden of potentially vaccine-preventable diseases in pregnant women and infants, the potential public health benefits of maternal immunization could be enormous. Maternal immunization has thus grown into a field at the leading edge of vaccinology. This article highlights research that has examined a broad range of questions pertaining to immunization in pregnancy, including the immunology of pregnancy; the epidemiology of vaccine-preventable diseases in pregnant women and young infants; the clinical efficacy and safety of vaccines currently used in pregnancy; issues related to vaccine acceptance, policy, and implementation; and maternal vaccines on the horizon.

Sustainable Development Goals

The adoption of the 2030 Agenda for Sustainable Development marked a defining moment in the history of the United Nations and the creation of an unprecedented development paradigm bringing together the social, environmental, and economic development strands into one comprehensive, ambitious, and balanced framework. With seventeen interdependent Sustainable Development Goals (SDGs) and 169 targets, the Agenda replaces the narrower and more limited Millennium Development Goals, and has two important features: universality (applicable to all countries and populations); and a commitment to “leaving no one behind”—irrespective of population characteristics or place on the development-humanitarian continuum. SDG 3 (the “health goal”) is supported by nine substantive targets across a broad spectrum of health issues, and four means of implementation targets covering issues such as financing, human resources, and research and development. Given that the social determinants of health (e.g., education, employment, gender-equality) are the focus of other SDGs and the Agenda’s architects conceptualize the goals and targets as interdependent with cross-cutting approaches as well as intersectoral collaboration, in practice at least eleven goals and many more targets are health-related (see World Health Organization 2017, cited under Health-Related Goals, Targets, and Indicators in Agenda 2030). Accountability is key, and many countries have reoriented their national development strategies around the SDGs and have been enthusiastic in presenting Voluntary National Reviews to the annual UN High-Level Political Forum on Sustainable Development. Nonetheless, the SDGs have been critiqued for their omissions (from social mobilization to global health security) as well as their perceived failure to disrupt deep economic and structural injustices which are harmful to people and planet. In our review of the English language literature, we identified over fifty papers addressing some aspect of the SDGs and health. We are reluctant to conceptualize these as a single literature on the broad, diverse, and complex nature of sustainable development as it relates to human health, particularly since a significant proportion are commentaries rather than primary studies or new theoretical/conceptual ideas. We have grouped the papers into six areas: the genesis and significance of Agenda 2030 and its relationship to health; goals, targets, and indicators; projections of progress and financing implications; goal interdependence and intersectoral collaboration; human rights, participation, and the principle of leaving no one behind; critiques and criticisms. If any topic dominates, it is on universal health coverage, one of the thirteen targets in SDG3; conversely the literature tends to lack a detailed prescriptive guidance on how to move from analysis to action. Given the Agenda was only agreed upon in the past few years we are hopeful that policy- and practice-relevant literature on how to implement action and activities to reach the Goals will be forthcoming in the near future. The views contained herein do not necessarily reflect those of UNAIDS.