This symposium issue of the Journal of Law, Medicine & Ethics is devoted to the convening of the national public health law conference, Practical Approaches to Critical Challenges, on October 10-12, 2012, in Atlanta, Georgia. The conference was co-sponsored by the Network for Public Health Law and the American Society of Law, Medicine & Ethics (ASLME) with generous support provided by the Robert Wood Johnson Foundation, de Beaumont Foundation, California Endowment, and Healthcare Georgia Foundation.

With the support of those organizations and the dedicated efforts of the individuals mentioned below, the conference focused on building effective interactions between attorneys and public health practitioners in order to:

• • examine practical legal approaches to address priority public health issues;

• • learn about helpful public health law resources and evidence-based research;

• • discuss public health legal questions and answers; and

• • build partnerships to accomplish public health objectives and foster innovation.

Weight of the Nation (WON) is a national forum for obesity prevention leaders who are “game changers” — those who are leading the field of innovative obesity prevention practice — to provide opportunities to expand and advance evidence-based and emerging solutions to the epidemic and brainstorm on collaborative efforts to apply these solutions in settings that reach individuals across the lifespan. WON is hosted by the U.S. Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Division of Nutrition, Physical Activity, and Obesity (DNPAO). WON is unique for its conference style which focuses participants on population-level approaches that can be implemented in select settings and sectors and in its use of social media and long-distance training to increase participation and information dissemination.

The Early Care and Education (ECE) track presentations from CDC’s Weight of the Nation (WON) 2012 conference showcased innovative national, state, and community obesity prevention efforts. The track was organized around CDC’s “Spectrum of Opportunities” for obesity prevention in ECE (the Spectrum; Table 1), which outlines a common set of opportunities that can enhance the ECE environment with respect to nutrition, breastfeeding support, physical activity, and screen time — all important areas for obesity prevention targeting young children. Participants discussed the opportunities on the spectrum that had been pursued, the obesity prevention standards and best practices that had been the emphasis of their efforts, and common steps for developing, implementing, and evaluating initiatives. This paper provides background information on why ECE is an important component of any jurisdiction’s obesity prevention efforts, references for the primary national reports offering standards and best practice recommendations, an introduction to the Spectrum, and brief summaries of the WON ECE track presentations.

BPA Production and Associated Health Risks Bisphenol A (BPA) is a chemical agent found in many everyday products, including canned goods and plastic food containers. BPA exposure is linked to a variety of adverse health effects, such as obesity and diabetes. To protect the public's health — especially the health of vulnerable fetuses, infants, children, and pregnant women — BPA regulations should encompass products intended specifically for these populations. Even with tremendous public outcry against the use of BPA, current federal restrictions do not reach far enough. The U.S. Food and Drug Administration (FDA) recently banned the use of BPA in children's sippy cups and baby bottles, but failed to address its inclusion in canned infant formula or plastic tableware.

BPA production began in the 1950s to make epoxy resins and was later employed to create polycarbonate plastic products.

The widespread view — proclaimed by proponents of disability studies, some disability federations, and many disabled people — that there is a human right to inclusive education, was eventually substantiated by international law with the UN Disability Convention (CRPD) in 2006. One of the most discussed issues in disability studies concerns the CRPD; the contributions are legion. Surprisingly, there are hardly any substantial contributions that pay particular attention to the important question of whether inclusive education is a moral human right, and, if so, how this particular human right could be morally justified. A related topic that is frequently discussed concerns the question of whether inclusive education is compatible with the International Bill of Human Rights. Other scholars, such as Theresia Degener, wholeheartedly support the idea that inclusive education is a substantial legal and moral human right.

To someone holding a hammer, the cliché goes, everything looks like a nail. A similar myopia often afflicts legal minds as they approach deep-seated problems in global health, as every crisis is approached by first asking how it might be litigated away. In recent years, there has been a growing recognition of the limits of litigation as a tool for advancing equitable access to health — indeed of its potential, under some circumstances, to have a positively regressive impact. This very timely symposium offers us a chance to reflect more deeply on the matter.

The federal Common Rule, which governs the conduct of research with human subjects, specifies the criteria and procedures by which Institutional Review Boards (IRBs) should review such research. Although there is wide agreement that IRBs, or Research Ethics Committees as they are called in most of the world, are essential to assuring that human subjects research meets common standards of ethics, IRBs have always come under considerable criticism. Some have critiqued IRBs for using important resources inefficiently, including the large amount of time researchers put into submitting applications, modifications, and reports and delaying the start of data collection within the limited time that grants and contracts provide. Others have critiqued the inconsistency of review of multi-site projects.

In 1995, Dennis Thompson, the founding director of Harvard’s program in Ethics and the Professions, authored a book entitled Ethics in Congress. That subject, in and of itself, seemingly was not new. And it undoubtedly inspired a few irreverent snickers. Consider that a Goggle search of “Ethics in Congress oxymoron” recently produced 5.79 million results in just over a tenth of a second.

But it was the subtitle of the book — From Individual to Institutional Corruption — that revealed how Thompson’s tome signaled an abrupt departure from the standard paradigms for measuring political corruption.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) aims at empowering people with disabilities by granting them a number of civil and political, but also economic, social, and cultural rights. This is a groundbreaking agreement for all persons with disabilities, especially because it is the first human rights agreement for disabled people, and it is legally binding. For those states who signed it, it also brings various governmental obligations. Implementing the CRPD will clearly be politically challenging and also very expensive for all states, but even more so for poor ones.

The foregoing, both appearing in early 2012, represent very different understandings about the significance of being substantially overweight and possible responses. The first focuses on being fat as the problem. 3 The solution is weight loss or, better still, prevention of weight gain. Of particular note is the plight of obese children and their physical ailments and psychological stress because of bullying by other children and embarrassment in wider society. The second underscores the enormous difficulty of losing weight and, even more so, of maintaining any such reduction. Being fat may give rise to problems. But the greatest difficulty may be in not accepting that most people who become fat will remain fat. That denial stymies efforts to foster the healthiest state possible for the obese and to create effective prevention programs, especially for children.

It has now been 10 years since the framework for public health legal preparedness was put forth as a model to meet new public health challenges in the 21st century. Public health legal preparedness is defined as the “attainment by a public health system of specified legal of standards essential to the preparedness of the public health system.” The framework has continued to develop over time and four core elements have emerged to make up the basis for public health legal preparedness. The four core elements are: (1) laws and legal authorities; (2) competency in using laws effectively and wisely; (3) coordination of legally based interventions across jurisdictions and sectors; and (4) information on public health laws and best practices.

Imagine a study in which HIV-infected pregnant women are given antiretroviral treatment (ART) to determine how effectively it will prevent HIV transmission during childbirth. Each mother’s involvement in this study ends with the birth of her child, at which time her access to antiretrovirals provided by the study also ceases. At the outset of the study, the investigator and sponsor agree that after the child’s birth, they will refer mothers who require treatment for their HIV to a national program that provides antiretroviral treatment and care. Assuming the Institutional Review Board (IRB) raises no objections to this plan, should the research team consider their ethical obligations to participants fulfilled? If the investigator and sponsor were to consult the Common Rule, they would find little to suggest that there are any further ethical issues to address.

Engaging the health care setting at the systems level to support healthy eating and active living and prevent obesity can help address the problem of obesity. A number of key attributes of the clinical realm impacts population-level obesity prevention. Health care facilities serve large groups of people, including patients seen at the medical facility, the family and friends who accompany them for visits, as well as the large number of employees who provide care and service the facilities. Thus, system-level improvements to the health care setting have great potential for large reach and impact. In 2011 there were more than 5,700 hospitals registered with the American Hospital Association, with more than 36 million inpatient admissions in the U.S. Even more medical facilities are included in the reach of clinics and other places providing care. These facilities also have the potential to influence the health of the surrounding community by serving as promoters and models of healthy eating and active living, which may influence good health practices. A health care facility services communities by integrative work in both the primary care and public health domains.

The Affordable Care Act (ACA) and other federal initiatives are fostering the emergence of a coherent vision for chronic disease prevention that has never before existed in the United States. This investment in population health and prevention comes not a moment too soon. Health care costs are proving very difficult to control and are rising at an unsustainable rate, driven in part by sky-rocketing chronic disease rates.

This article looks at how a health system can engage in prevention activities beyond the clinical setting and makes a strong case that these interventions will result in documented cost savings. We first examine an individually targeted strategy that helps patients obtain health insurance coverage. This strategy furthers a hospital's goal of receiving reimbursement for care while also having the social benefit of increasing patients’ economic stability.

Health care insurance schemes, whether private or public, are notoriously unaccommodating to individuals with disabilities. While most nonelderly nondisabled persons in the U.S. are insured through private sources, coverage sources for nonelderly persons with disabilities have traditionally been a mix of private and public coverage. For all age groups, the employment-to-population ratio is much lower for persons with a disability than for those with no disability. Moreover, employed persons with a disability were more likely to be self-employed than those with no disability. As a group, therefore, nonelderly people with disabilities have not been as well positioned as others to obtain private health care insurance because in the U.S., acquiring such coverage usually is employer based.