Faculty Bibliography

Since its inception in September 2010, the Network for Public Health Law has responded to hundreds of public health legal technical assistance claims from around the country. Based on a review of these data, a series of major trends in public health practice and the law are analyzed, including issues concerning: the Affordable Care Act, tobacco control, emergency legal preparedness, health information privacy, food policy, vaccination, drug overdose prevention, sports injury law, public health accreditation, and maternal breastfeeding. These and other emerging themes in public health law demonstrate the essential role of law and practice in advancing the public's health.

INTRODUCTION/BACKGROUND:Improving access to sterile injection equipment is a key component in community-based infectious disease prevention. Implementation of syringe access programs has sometimes been complicated by community opposition and police interference. CASE DESCRIPTION/METHODS:In 2006, the Delaware legislature authorized a pilot syringe exchange program (SEP). A program designed to prevent, monitor, and respond to possible policing and community barriers before they had a chance to effect program implementation and operation. A program designed to prevent, monitor, and respond to these barriers was planned and implemented by a multidisciplinary team of legal practitioners and public health professionals. DISCUSSION/CONCLUSIONS:We report on an integrated intervention to address structural barriers to syringe exchange program utilization. This intervention employs community, police and client education combined with systematic surveillance of and rapid response to police interference to preempt the kinds of structural barriers to implementation observed elsewhere. The intervention addresses community concerns and stresses the benefits of syringe exchange programs to officer occupational safety. CONCLUSIONS:A cohesive effort combining collaboration with and educational outreach to police and community members based on the needs and concerns of these groups as well as SEP clients and potential clients helped establish a supportive street environment for the SEP. Police-driven structural barriers to implementation of public health programs targeting populations engaged in drug use and other illicit behavior can be addressed by up-stream planning, prevention, monitoring and intervention strategies. More research is needed to inform the tailoring of interventions to address police-driven barriers to HIV prevention services, especially among marginalized populations.

Assessing social risks has proven difficult for IRBs. We undertook a novel effort to empirically investigate social risks before an HIV prevention trial among drug users in Thailand and China. The assessment investigated whether law, policies and enforcement strategies would place research subjects at significantly elevated risk of arrest, incarceration, physical harm, breach of confidentiality, or loss of access to health care relative to drug users not participating in the research. The study validated the investigator's concern that drug users were subject to serious social risks in the site localities, but also suggested that participation in research posed little or no marginal increase in risk and might even have a protective effect. Our experience shows that it is feasible to inform IRB deliberations with actual data on social risks, but also raises the question of whether and when such research is an appropriate use of scare research resources.

INTRODUCTION/BACKGROUND:In light of overwhelming evidence that access to sterile injection equipment reduces incidence of injection-attributable bloodborne disease without encouraging drug use, many localities have authorized sterile syringe access programs (SAPs), including syringe exchange and pharmacy-based initiatives. Even where such interventions are clearly legal, many law enforcement officers are unaware of the public health benefits and legal status of these programs and may continue to treat the possession of injection equipment as illegal and program participation as a marker of illegal behavior. Law enforcement practice can impede SAP utilization and may increase the risk of needlestick injury (NSI) among law enforcement personnel. Many SAPs conduct little or no outreach to law enforcement, in part because they perceive law enforcement actors as unreceptive to health-promotion programs targeting drug users. CASE DESCRIPTION/METHODS:We report on a brief training intervention for law enforcement personnel designed to increase officer knowledge of and positive attitudes towards SAPs by bundling content that addresses officer concerns about infectious disease and occupational safety with information about the legality and public health benefits of these programs. Pilot trainings using this bundled curriculum were conducted with approximately 600 officers in three US cities. DISCUSSION AND EVALUATION/RESULTS:Law enforcement officers were generally receptive to receiving information about SAPs through the bundled curriculum. The trainings led to better communication and collaboration between SAP and law enforcement personnel, providing a valuable platform for better harmonization of law enforcement and public health activities targeting injection drug users. CONCLUSION/CONCLUSIONS:The experience in these three cities suggests that a harm reduction training curriculum that bundles strategies for increasing officer occupational safety with information about the legality and public health benefits of SAPs can be well received by law enforcement personnel and can lead to better communication and collaboration between law enforcement and harm reduction actors. Further study is indicated to assess whether such a bundled curriculum is effective in changing officer attitudes and beliefs and reducing health risks to officers and injection drug users, as well as broader benefits to the community at large.

Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States. Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided not to interfere. Given legal uncertainty, and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.

Repeated measurements and mixed-effects models were used to analyze the effects of an intensive long-term street-level police intervention on syringe exchange program use. Utilization data for 9 months before and after the beginning of the intervention were analyzed. Use fell across all categories and time periods studied, with significant declines in use among total participants, male participants, and Black participants. Declines in use among Black and male participants were much more pronounced than decreases among White and female participants.