Existing data sources have tremendous potential to inform public health activities. However, a patchwork of data protection laws impede data sharing efforts. Nevertheless, a data-sharing initiative in Peoria, IL was able to overcome challenges to set up a cross-sectoral data system to coordinate mental health, law enforcement, and healthcare services.
A major factor explaining government actors’ failure to mitigate or avert the Flint, Michigan, water crisis is the sheer complexity of the laws regulating how governmental agencies maintain and monitor safe drinking water. Coordination across agencies is essential in dealing with multiple legal arrangements. Public health legal authority and intervention mechanisms are not self‐executing. Legal preparedness is essential to efficiently navigating complex legal frameworks to address public health threats. The Flint water crisis demonstrates the importance of democracy for protecting the public's health. Laws responding to municipal fiscal distress must be consistent with expected norms of democracy and require consideration of public health in decision making. ContextThe Flint, Michigan, water crisis resulted from a state‐appointed emergency financial manager's cost‐driven decision to switch Flint's water source to the Flint River. Ostensibly designed to address Flint's long‐standing financial crisis, the switch instead created a public health emergency. A major factor explaining why the crisis unfolded as it did is the complex array of laws regulating how governmental agencies maintain and monitor safe drinking water. MethodsWe analyzed these legal arrangements to identify what legal authority state, local, and federal public health and environmental agencies could have used to avert or mitigate the crisis and recommend changes to relevant laws and their implementation. First, we mapped the legal authority and roles of federal, state, and local agencies responsible for safe drinking water and the public's health—that is, the existing legal environment. Then we examined how Michigan's emergency manager law altered the existing legal arrangements, leading to decisions that ignored the community's long‐term health. Juxtaposed on those factors, we considered how federalism and the relationship between state and local governments influenced public officials during the crisis. FindingsThe complex legal arrangements governing public health and safe drinking water, combined with a lack of legal preparedness (the capacity to use law effectively) among governmental officials, impeded timely and effective actions to mitigate or avert the crisis. The emergency manager's virtually unfettered legal authority in Flint exacerbated the existing complexity and deprived residents of a democratically accountable local government. ConclusionsOur analysis reveals flaws in both the legal structure and how the laws were implemented that simultaneously failed to stop and substantially exacerbated the crisis. Policymakers need to examine the legal framework in their jurisdictions and take appropriate steps to avoid similar disasters. Addressing the implementation failures, including legal preparedness, should likewise be a priority for preventing future similar crises.
Ms. R" is a 32-year-old woman of normal intelligence with over 50 psychiatric hospitalizations in the past 8 years, most for cutting behavior deemed dangerous to self because of the quantity and severity of the wounds. She had a diagnosis of recurrent major depressive disorder superimposed on borderline personality disorder, with micro-psychotic episodes and poor impulse control. The patient had failed to benefit from multiple adequate trials with various combinations of antidepressants, atypical antipsychotics, conventional antipsychotics, mood stabilizers, benzodiazepines, alpha^ antagonists, intensive case management, and elements of dialectical behavioral therapy. We discussed with the patient the risks and the potential benefits of a trial of naltrexone to reduce her urges to cut. Liver function test results were mildly elevated from fatty liver secondary to metabolic syndrome. Other psychotropic medications were not changed. The patient was treated with naltrexone, 25 mg/day, titrated up to 50 mg after 1 month. Her medications were given by her home health nurses or her grandmother, and she was compliant with taking them.Ms. R noted decreased urges to cut after 1 week of treatment, with a reduced frequency of cutting behavior after her dosage was increased to 50 mg/day. The patient stated that she used to think about cutting "constantly" and would cut one to three times per day, but now will go "days" without thinking about it and only cut one to two times per week at most. After 5 months of continuous treatment, she had a 6-month period with only one superficial cutting episode. Liver function tests improved from baseline, with the exception of a 16-point increase in aspartate aminotransferase, which was stable over the course of several months.This case highlights the potential efficacy of naltrexone in self-injurious behavior resistant to multiple psychopharmacological and behavioral interventions. Utilization of this treatment may allow for tapering or discontinuation of atypical antipsychotics and mood stabilizers that have significant metabolic side effects, including weight gain and diabetes. Although previous reports have described similar effects, the magnitude of the response, the medical comorbidities, and the resistance to treatment in this patient demonstrate a need to consider naltrexone sooner in treatment algorithms. Our group has also used naltrexone to treat an autistic man with sexually violent behavior and an elderly man with dementia and sexually inappropriate behavior, with resolution of symptoms and no adverse events. Large-scale randomized placebo-controlled trials are necessary to provide further evidence for the use of naltrexone in refractory cases of impulse control disorders. References 1. Modesto-Lowe V, Van Kirk J: Clinical uses of naltrexone: a review of the evidence. Exp Clin Psychopharmacol 2002; 10:213-227 2. Sandman CA, Touchette PE, Marion SD, Chicz-DeMet A: The role of proopiomelanocortin (POMC) in sequentially dependent self-injurious behavior. Dev Psychobiol 2008; 50:...
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