EDITORIALS Promoting Public Health in Health Care Facilities
The health care system in the United States is undergoing profound changes. Unprecedented demographic, technological, political, and economic shifts have led to new organizational structures, reimbursement systems, and professional relationships in health care delivery. The most commonly used criteria for determining success of a health care system are access, quality, and cost. These measures are important, but they are not the only elements worthy of consideration at this time of systemic change in health care. In the past, health promotion and disease prevention too often were considered separately from the provision of acute care. Although health promotion now has a more prominent role in national health strategy,1 it has not yet been incorporated widely into all health care settings. Besides the health policy imperative of greater emphasis on health promotion, the obligation of health care providers and institutions to devote the effort and resources to health promotion stems from the ethical obligations of health professionals2 and the societal obligations of institutions receiving public licensure, funding, and trust.3 Health care providers and institutions should develop a more holistic vision of their role in public health. In particular, they have an important responsibility to their patients and employees, as well as to the public, to serve as public health role models, health promotion advocates, and infection control agents. By integrating these activities into the operations of their facilities, health care
June 2014, Vol 104, No. 6 | American Journal of Public Health
providers and institutions can satisfy their professional duties and take advantage of their unique opportunities to effect change in health behavior. The following three examples indicate actions to promote public health in health care facilities.
HEALTHY FOOD AND DRINK The widespread problem of obesity has significant consequences for morbidity and mortality from diabetes, hypertension, hypercholesterolemia, and cardiovascular and other diseases. According to the Centers for Disease Control and Prevention (CDC), in the United States, 69.2% of adults (aged 20 years and older) are overweight, including 35.9% who are obese; 18.0% of children aged 6 to 11 years and 18.4% of adolescents aged 12 to 19 years are obese.4 Diet is a leading factor in obesity5; it is important for overweight children and adults to break bad eating habits and to develop sound new ones. Health care providers and institutions can play both a direct and a symbolic role in improving diet by urging patients to adopt improved nutrition and by showcasing healthy food and drink at their institution. Unfortunately, rather than demonstrating better dietary options, some hospitals, including children’s hospitals, actually have fast-food restaurants in their facilities. For example, numerous hospitals have an onsite McDonald’s restaurant,6 and some hospitals have four or five fast-food restaurants.7 The main
patrons of these restaurants are employees and guests. More nutritious and palatable food for inpatients and healthier cafeteria food also are needed. The symbolism of fast-food restaurants in hospitals is unmistakable and disconcerting. In the face of a major obesity problem, it is indefensible for a hospital to give tacit endorsement to eating at fast-food restaurants that often epitomize unhealthy food choices. Even without a complete fast-food menu, it is still possible to realize the “comfort value” of some fast food. For instance, after Children’s Hospital of Philadelphia closed its McDonald’s, it reopened a milkshake service for its pediatric patients.8 Healthy food options may be more expensive than fast food, and it might require a hospital not only to forego additional income, but to subsidize healthy food purchases by low-income employees and hospital visitors. Maximizing revenue, however, is no more a justification for a hospital having a fast-food restaurant than it would be for installing cigarette machines in the lobby. Health care institutions took a leadership position in banning smoking on their campuses. Now is the time for them to take a similar leadership position in controlling the types of food and drink publically available in their facilities.
PHYSICAL ACTIVITY Another factor contributing to obesity, especially in children, is the lack of physical activity.9 Most hospitals and other health care
Editorials | 965
EDITORIALS
facilities are occupied by hundreds of patients, employees, and visitors each day. For visiting children, play areas should include some level of exercise instead of merely featuring televisions and video games. For adult visitors and employees, there should be opportunities for moderate exercise, including walking and climbing stairs. At many institutions, the only way to reach a different floor is by taking an elevator. On some multibuilding campuses it is difficult to walk between buildings because of a lack of sidewalks, inadequate lighting, or structural barriers. As employers of numerous workers in diverse occupations, health care institutions should commit to offer high-quality, noncoercive wellness programs providing smoking cessation, weight management, and other services. Health care institutions also should make exercise facilities and equipment widely available. For those health care facilities with a lack of space, especially older institutions, arrangements should be made to permit convenient, cost-free or low-cost access to exercise facilities off-site.
INFLUENZA VACCINATION Each year, seasonal influenza causes approximately 200 000 hospitalizations and between 3000 and 49 000 deaths in the United States.10 Children and the elderly are especially vulnerable. Extremely safe and reasonably effective influenza vaccines are widely available, usually at little or no cost to individuals. Regrettably, vaccination rates for health care workers in many hospitals and residential care facilities are unacceptably low, with some studies indicating less than 50% vaccination rates.11 In a CDC
966 | Editorials
Internet survey during the 2012--2013 influenza season, of health care workers who participated in the survey, only 72% selfreported being vaccinated.12 It is disappointing to have such inadequate compliance with a basic public health measure that could prevent potentially fatal outbreaks of hospital-acquired infection. Appropriate vaccination mandates, with narrow exceptions,13 should apply to the following: (1) all health care workers employed by hospitals and other health care facilities regardless of their degree of direct patient contact, (2) independent contractor physicians with privileges at health care facilities, (3) employees of enterprises performing patient-related services at health care facilities, (4) students, and (5) volunteers. Regular visitors to residential care facilities also should be strongly encouraged to be vaccinated. It is incongruous for health care providers to urge patients to be vaccinated against seasonal influenza when they or many of their colleagues have not been vaccinated. To prevent health care facilities from being the source of infectious diseases and to fulfill their obligations as public health role models, health care facilities should require seasonal influenza vaccination.
MOVING FORWARD The three examples used in this article, healthy food and drink, physical exercise, and influenza vaccination, strongly suggest that health professionals and health care institutions should reassess their responsibilities in health promotion and disease prevention. In particular, they should embrace their obligations as public health role models, health
promotion advocates, and infection control agents. Two main approaches should be pursued to achieve the health promotion and disease prevention objectives outlined above. First, health care providers and institutions should be encouraged to adopt a suite of generally accepted health promotion activities.7 For example, in response to public health advocates, several hospitals have removed McDonald’s food and advertising from their facilities, including Lurie Children’s Hospital in Chicago, Illinois; Parkland Health and Hospital System in Dallas, Texas; Truman Medical Centers in Kansas City, Missouri; and Vanderbilt Medical Center in Nashville, Tennessee.14 Once a critical mass of institutions has committed to health promotion it will be easier for other institutions to undertake similar, voluntary efforts. Second, appropriate standardssetting actions should be undertaken by public and private entities with regulatory authority over health care facilities. In addition, recommendations supporting health promotion in health care facilities should be adopted by professional associations. Thus, using the example of mandatory vaccination of health care workers: (1) accrediting bodies (e.g., Joint Commission, Accreditation Council for Graduate Medical Education) should incorporate facility-wide vaccination measures into their accreditation standards, (2) public and private payers (e.g., Medicare, Medicaid) should make mandatory vaccination policies a precondition for receiving reimbursement, and (3) professional organizations (e.g., American Medical Association, American Nurses Association) should promulgate health policy statements advocating vaccination of their
members against seasonal influenza. Similar action should be undertaken for both healthy food and drink and physical activity in health care facilities. Health care providers and health care institutions have an obligation to safeguard and support the health of all who come through their doors and, through their example, promote the health of the public. j Mark A. Rothstein, JD
About the Author Mark A. Rothstein is with the Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine, Louisville, KY. He is also a Department Editor for the American Journal of Public Health. Correspondence should be sent to Professor Mark A. Rothstein, University of Louisville School of Medicine, 501 East Broadway #310, Louisville, KY 40202 (e-mail mark.rothstein@louisville. edu). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted January 12, 2014. doi:10.2105/AJPH.2014.301885
Acknowledgments The author is indebted to Kyle B. Brothers, MD, for his help in conceptualizing this editorial and in reviewing an earlier draft.
References 1. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363(14): 1296---1299. 2. American Medical Association. Health promotion and disease prevention, H-425.993. Available at: http://www. ama-assn.org/resources/doc/PolicyFinder/ policyfiles/HnE/H-425.993.HTM. Accessed March 4, 2014. 3. De George RT. The moral responsibility of the hospital. J Med Philos. 1982; 7(1):87---100. 4. Centers for Disease Control and Prevention. Obesity and overweight. Available at: http://www.cdc.gov/nchs/ fastats/overwt.htm. Accessed March 4, 2014. 5. Weinsier RL, Hunter GR, Heini AF, et al. The etiology of obesity: relative contribution of metabolic factors, diet, and physical activity. Am J Med. 1998; 105(2):145---150.
American Journal of Public Health | June 2014, Vol 104, No. 6
EDITORIALS
7. Physicians Committee for Responsible Medicine. The five worst hospital food environments. 2011. Available at: http:// www.pcrm.org/health/reports/the-fiveworst-hospital=food-environments. Accessed March 4, 2014.
Sexual Orientation Data Collection Policy in the United States: Public Health Malpractice
8. Castillo M. Advocacy group petitions hospitals to get rid of McDonald’s. 2013. Available at: www.cbsnews.com/news/ advocacy-group-petitions-hospitals-to-getrid-of-mcdonalds. Accessed March 4, 2014. ˆ
6. Doctors: no more McDonald’s in hospitals. Bus News. April 15, 2012. Available at: http://www.upi.com/ Business_News/2012/04/15/DoctorsNo-more-Mcdonalds-in-hospitals/UPI38111334515389. Accessed March 4, 2014.
9. Parízková J, Roville-Sausse F, Molnar D. Interdisciplinary aspects of childhood obesity and physical fitness. J Obes. 2013;2013:828463.
http://www.cdc.gov/flu/about/qa/ disease.htm. Accessed March 4, 2014. 11. Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis. 2010;50 (4):459---464.
13. Antomarria AH. An ethical analysis of mandatory influenza vaccination of health care personnel: implementing fairly and balancing benefits and burdens. Am J Bioeth. 2013;13 (9):30---37.
10. Centers for Disease Control and Prevention. Seasonal influenza (flu). 2013. Available at:
12. Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel: 2012-13 influenza season---United States. MMWR Morb Mort Wkly Rep. 2013;62 (38):781---786.
14. Lappe A. Kicking McDonald’s out: the hospitals getting serious about food. 2013. Available at: http:// www.theguardian.com/sustainablebusiness/blog/kicking-mcdonaldsout-hospital-food. Accessed March 4, 2014.
The greatest threat to the health of lesbian, gay, and bisexual (LGB) Americans is the lack of scientific information about their health. Researchers studying LGB health recognized the importance of having data to understand the health of sexual minorities over a century ago using the motto “Justice through Science.”1 Researchers in the United States, many of them lesbian, gay, or bisexual themselves, beginning in the late 1980s and through the 2000s, started to argue for the collection of sexual orientation data in publicly funded data sets and, in particular, surveillance systems at the Centers for Disease Control and Prevention (CDC). Surveys targeted included the National Health Interview Survey (NHIS) and the National Health and Nutrition Examination Survey (NHANES), and surveillance systems including The Behavioral Risk Factor Surveillance System (BRFSS) and the Youth Risk Behavior Surveillance System (YRBSS). Arguments for sexual orientation data collection largely centered on the need for data concerning the spread of HIV/ AIDS, but arguments also recognized other sexual minority health concerns including drug, alcohol, and tobacco use; mental health; cancer; aging; and violence.2 Some researchers even argued for sexual orientation data collection in all data collection activities
directly or indirectly supported by the US Department of Health and Human Services (HHS) including all research funded through the National Institutes of Health (NIH).3 The arguments and actions on the part of researchers sometimes focused on individual variables that could be added to specific surveys, but they also sometimes argued for recognizing sexual orientation as a demographic variable like race, ethnicity or age, and providing guidance for standardized sexual orientation data collection in all HHS activities in the same way the Office of Management and Budget’s Directive 15 provided instructions for the collection of race and ethnicity data.4 Outside of some extremely modest steps to collect sexual orientation data in relationship to understanding the spread of HIV, HHS largely ignored these calls for greater data collection. In fact, we would argue that the handful of data sets and surveillance systems that have added sexual orientation variables have done so despite leadership at HHS through numerous political administrations beginning in the 1980s, including those of Ronald Reagan, George H. W. Bush, Bill Clinton, George W. Bush, and Barack Obama. Individual managers of surveys have sometimes on their own made the decision to add sexual orientation variables to the survey they manage because
they recognized the importance of this data in the context of their specific survey. For example, three variables that can be used to measure sexual orientation were added to The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) in the early 2000s after the director of the survey held public hearings in which researchers made the case for sexual orientation data collection. Having well-documented requests from outside experts shielded the survey to some degree from potential criticisms. But the managers of many data sets actually feared collecting sexual orientation data based on their understanding of what happened with The National Health and Social Life Survey, which lost funding before its completion because of its collection of data on sexuality, including sexual orientation.5 Many other studies that directly or indirectly studied LGB people and received funding from the US government were called into question by antigay organizations that monitored NIH funding. Studies of LGB people were often consequently hidden within other studies, and the studies used terms such as “diverse” populations instead of the terms “lesbian,” “gay,” or “bisexual” to remain invisible to those opposing such research. This tactic served to keep researchers studying sexual minorities as well as the resultant research in a scientific closet. This
June 2014, Vol 104, No. 6 | American Journal of Public Health
Editorials | 967
The health care system in the United States is undergoing profound changes. Unprecedented demographic, technological, political, and economic shifts have led to new organizational structures, reimbursement systems, and professional relationships in health care delivery. The most commonly used criteria for determining success of a health care system are access, quality, and cost. These measures are important, but they are not the only elements worthy of consideration at this time of systemic change in health care. In the past, health promotion and disease prevention too often were considered separately from the provision of acute care. Although health promotion now has a more prominent role in national health strategy,1 it has not yet been incorporated widely into all health care settings. Besides the health policy imperative of greater emphasis on health promotion, the obligation of health care providers and institutions to devote the effort and resources to health promotion stems from the ethical obligations of health professionals2 and the societal obligations of institutions receiving public licensure, funding, and trust.3 Health care providers and institutions should develop a more holistic vision of their role in public health. In particular, they have an important responsibility to their patients and employees, as well as to the public, to serve as public health role models, health promotion advocates, and infection control agents. By integrating these activities into the operations of their facilities, health care
June 2014, Vol 104, No. 6 | American Journal of Public Health
providers and institutions can satisfy their professional duties and take advantage of their unique opportunities to effect change in health behavior. The following three examples indicate actions to promote public health in health care facilities.
HEALTHY FOOD AND DRINK The widespread problem of obesity has significant consequences for morbidity and mortality from diabetes, hypertension, hypercholesterolemia, and cardiovascular and other diseases. According to the Centers for Disease Control and Prevention (CDC), in the United States, 69.2% of adults (aged 20 years and older) are overweight, including 35.9% who are obese; 18.0% of children aged 6 to 11 years and 18.4% of adolescents aged 12 to 19 years are obese.4 Diet is a leading factor in obesity5; it is important for overweight children and adults to break bad eating habits and to develop sound new ones. Health care providers and institutions can play both a direct and a symbolic role in improving diet by urging patients to adopt improved nutrition and by showcasing healthy food and drink at their institution. Unfortunately, rather than demonstrating better dietary options, some hospitals, including children’s hospitals, actually have fast-food restaurants in their facilities. For example, numerous hospitals have an onsite McDonald’s restaurant,6 and some hospitals have four or five fast-food restaurants.7 The main
patrons of these restaurants are employees and guests. More nutritious and palatable food for inpatients and healthier cafeteria food also are needed. The symbolism of fast-food restaurants in hospitals is unmistakable and disconcerting. In the face of a major obesity problem, it is indefensible for a hospital to give tacit endorsement to eating at fast-food restaurants that often epitomize unhealthy food choices. Even without a complete fast-food menu, it is still possible to realize the “comfort value” of some fast food. For instance, after Children’s Hospital of Philadelphia closed its McDonald’s, it reopened a milkshake service for its pediatric patients.8 Healthy food options may be more expensive than fast food, and it might require a hospital not only to forego additional income, but to subsidize healthy food purchases by low-income employees and hospital visitors. Maximizing revenue, however, is no more a justification for a hospital having a fast-food restaurant than it would be for installing cigarette machines in the lobby. Health care institutions took a leadership position in banning smoking on their campuses. Now is the time for them to take a similar leadership position in controlling the types of food and drink publically available in their facilities.
PHYSICAL ACTIVITY Another factor contributing to obesity, especially in children, is the lack of physical activity.9 Most hospitals and other health care
Editorials | 965
EDITORIALS
facilities are occupied by hundreds of patients, employees, and visitors each day. For visiting children, play areas should include some level of exercise instead of merely featuring televisions and video games. For adult visitors and employees, there should be opportunities for moderate exercise, including walking and climbing stairs. At many institutions, the only way to reach a different floor is by taking an elevator. On some multibuilding campuses it is difficult to walk between buildings because of a lack of sidewalks, inadequate lighting, or structural barriers. As employers of numerous workers in diverse occupations, health care institutions should commit to offer high-quality, noncoercive wellness programs providing smoking cessation, weight management, and other services. Health care institutions also should make exercise facilities and equipment widely available. For those health care facilities with a lack of space, especially older institutions, arrangements should be made to permit convenient, cost-free or low-cost access to exercise facilities off-site.
INFLUENZA VACCINATION Each year, seasonal influenza causes approximately 200 000 hospitalizations and between 3000 and 49 000 deaths in the United States.10 Children and the elderly are especially vulnerable. Extremely safe and reasonably effective influenza vaccines are widely available, usually at little or no cost to individuals. Regrettably, vaccination rates for health care workers in many hospitals and residential care facilities are unacceptably low, with some studies indicating less than 50% vaccination rates.11 In a CDC
966 | Editorials
Internet survey during the 2012--2013 influenza season, of health care workers who participated in the survey, only 72% selfreported being vaccinated.12 It is disappointing to have such inadequate compliance with a basic public health measure that could prevent potentially fatal outbreaks of hospital-acquired infection. Appropriate vaccination mandates, with narrow exceptions,13 should apply to the following: (1) all health care workers employed by hospitals and other health care facilities regardless of their degree of direct patient contact, (2) independent contractor physicians with privileges at health care facilities, (3) employees of enterprises performing patient-related services at health care facilities, (4) students, and (5) volunteers. Regular visitors to residential care facilities also should be strongly encouraged to be vaccinated. It is incongruous for health care providers to urge patients to be vaccinated against seasonal influenza when they or many of their colleagues have not been vaccinated. To prevent health care facilities from being the source of infectious diseases and to fulfill their obligations as public health role models, health care facilities should require seasonal influenza vaccination.
MOVING FORWARD The three examples used in this article, healthy food and drink, physical exercise, and influenza vaccination, strongly suggest that health professionals and health care institutions should reassess their responsibilities in health promotion and disease prevention. In particular, they should embrace their obligations as public health role models, health
promotion advocates, and infection control agents. Two main approaches should be pursued to achieve the health promotion and disease prevention objectives outlined above. First, health care providers and institutions should be encouraged to adopt a suite of generally accepted health promotion activities.7 For example, in response to public health advocates, several hospitals have removed McDonald’s food and advertising from their facilities, including Lurie Children’s Hospital in Chicago, Illinois; Parkland Health and Hospital System in Dallas, Texas; Truman Medical Centers in Kansas City, Missouri; and Vanderbilt Medical Center in Nashville, Tennessee.14 Once a critical mass of institutions has committed to health promotion it will be easier for other institutions to undertake similar, voluntary efforts. Second, appropriate standardssetting actions should be undertaken by public and private entities with regulatory authority over health care facilities. In addition, recommendations supporting health promotion in health care facilities should be adopted by professional associations. Thus, using the example of mandatory vaccination of health care workers: (1) accrediting bodies (e.g., Joint Commission, Accreditation Council for Graduate Medical Education) should incorporate facility-wide vaccination measures into their accreditation standards, (2) public and private payers (e.g., Medicare, Medicaid) should make mandatory vaccination policies a precondition for receiving reimbursement, and (3) professional organizations (e.g., American Medical Association, American Nurses Association) should promulgate health policy statements advocating vaccination of their
members against seasonal influenza. Similar action should be undertaken for both healthy food and drink and physical activity in health care facilities. Health care providers and health care institutions have an obligation to safeguard and support the health of all who come through their doors and, through their example, promote the health of the public. j Mark A. Rothstein, JD
About the Author Mark A. Rothstein is with the Institute for Bioethics, Health Policy and Law, University of Louisville School of Medicine, Louisville, KY. He is also a Department Editor for the American Journal of Public Health. Correspondence should be sent to Professor Mark A. Rothstein, University of Louisville School of Medicine, 501 East Broadway #310, Louisville, KY 40202 (e-mail mark.rothstein@louisville. edu). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted January 12, 2014. doi:10.2105/AJPH.2014.301885
Acknowledgments The author is indebted to Kyle B. Brothers, MD, for his help in conceptualizing this editorial and in reviewing an earlier draft.
References 1. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363(14): 1296---1299. 2. American Medical Association. Health promotion and disease prevention, H-425.993. Available at: http://www. ama-assn.org/resources/doc/PolicyFinder/ policyfiles/HnE/H-425.993.HTM. Accessed March 4, 2014. 3. De George RT. The moral responsibility of the hospital. J Med Philos. 1982; 7(1):87---100. 4. Centers for Disease Control and Prevention. Obesity and overweight. Available at: http://www.cdc.gov/nchs/ fastats/overwt.htm. Accessed March 4, 2014. 5. Weinsier RL, Hunter GR, Heini AF, et al. The etiology of obesity: relative contribution of metabolic factors, diet, and physical activity. Am J Med. 1998; 105(2):145---150.
American Journal of Public Health | June 2014, Vol 104, No. 6
EDITORIALS
7. Physicians Committee for Responsible Medicine. The five worst hospital food environments. 2011. Available at: http:// www.pcrm.org/health/reports/the-fiveworst-hospital=food-environments. Accessed March 4, 2014.
Sexual Orientation Data Collection Policy in the United States: Public Health Malpractice
8. Castillo M. Advocacy group petitions hospitals to get rid of McDonald’s. 2013. Available at: www.cbsnews.com/news/ advocacy-group-petitions-hospitals-to-getrid-of-mcdonalds. Accessed March 4, 2014. ˆ
6. Doctors: no more McDonald’s in hospitals. Bus News. April 15, 2012. Available at: http://www.upi.com/ Business_News/2012/04/15/DoctorsNo-more-Mcdonalds-in-hospitals/UPI38111334515389. Accessed March 4, 2014.
9. Parízková J, Roville-Sausse F, Molnar D. Interdisciplinary aspects of childhood obesity and physical fitness. J Obes. 2013;2013:828463.
http://www.cdc.gov/flu/about/qa/ disease.htm. Accessed March 4, 2014. 11. Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis. 2010;50 (4):459---464.
13. Antomarria AH. An ethical analysis of mandatory influenza vaccination of health care personnel: implementing fairly and balancing benefits and burdens. Am J Bioeth. 2013;13 (9):30---37.
10. Centers for Disease Control and Prevention. Seasonal influenza (flu). 2013. Available at:
12. Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel: 2012-13 influenza season---United States. MMWR Morb Mort Wkly Rep. 2013;62 (38):781---786.
14. Lappe A. Kicking McDonald’s out: the hospitals getting serious about food. 2013. Available at: http:// www.theguardian.com/sustainablebusiness/blog/kicking-mcdonaldsout-hospital-food. Accessed March 4, 2014.
The greatest threat to the health of lesbian, gay, and bisexual (LGB) Americans is the lack of scientific information about their health. Researchers studying LGB health recognized the importance of having data to understand the health of sexual minorities over a century ago using the motto “Justice through Science.”1 Researchers in the United States, many of them lesbian, gay, or bisexual themselves, beginning in the late 1980s and through the 2000s, started to argue for the collection of sexual orientation data in publicly funded data sets and, in particular, surveillance systems at the Centers for Disease Control and Prevention (CDC). Surveys targeted included the National Health Interview Survey (NHIS) and the National Health and Nutrition Examination Survey (NHANES), and surveillance systems including The Behavioral Risk Factor Surveillance System (BRFSS) and the Youth Risk Behavior Surveillance System (YRBSS). Arguments for sexual orientation data collection largely centered on the need for data concerning the spread of HIV/ AIDS, but arguments also recognized other sexual minority health concerns including drug, alcohol, and tobacco use; mental health; cancer; aging; and violence.2 Some researchers even argued for sexual orientation data collection in all data collection activities
directly or indirectly supported by the US Department of Health and Human Services (HHS) including all research funded through the National Institutes of Health (NIH).3 The arguments and actions on the part of researchers sometimes focused on individual variables that could be added to specific surveys, but they also sometimes argued for recognizing sexual orientation as a demographic variable like race, ethnicity or age, and providing guidance for standardized sexual orientation data collection in all HHS activities in the same way the Office of Management and Budget’s Directive 15 provided instructions for the collection of race and ethnicity data.4 Outside of some extremely modest steps to collect sexual orientation data in relationship to understanding the spread of HIV, HHS largely ignored these calls for greater data collection. In fact, we would argue that the handful of data sets and surveillance systems that have added sexual orientation variables have done so despite leadership at HHS through numerous political administrations beginning in the 1980s, including those of Ronald Reagan, George H. W. Bush, Bill Clinton, George W. Bush, and Barack Obama. Individual managers of surveys have sometimes on their own made the decision to add sexual orientation variables to the survey they manage because
they recognized the importance of this data in the context of their specific survey. For example, three variables that can be used to measure sexual orientation were added to The National Epidemiological Survey on Alcohol and Related Conditions (NESARC) in the early 2000s after the director of the survey held public hearings in which researchers made the case for sexual orientation data collection. Having well-documented requests from outside experts shielded the survey to some degree from potential criticisms. But the managers of many data sets actually feared collecting sexual orientation data based on their understanding of what happened with The National Health and Social Life Survey, which lost funding before its completion because of its collection of data on sexuality, including sexual orientation.5 Many other studies that directly or indirectly studied LGB people and received funding from the US government were called into question by antigay organizations that monitored NIH funding. Studies of LGB people were often consequently hidden within other studies, and the studies used terms such as “diverse” populations instead of the terms “lesbian,” “gay,” or “bisexual” to remain invisible to those opposing such research. This tactic served to keep researchers studying sexual minorities as well as the resultant research in a scientific closet. This
June 2014, Vol 104, No. 6 | American Journal of Public Health
Editorials | 967
