Making Gender Justice, Birth Control,
And Abortion Access Health Priorities

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Women’s health and life are under fire in the United States and around the world. Here are  issues that health policymakers need to incorporate into health quality. It’s time to stop marginalizing them.

Last week, women’s groups coordinated by the Women’s Media Center and Everyday Sexism, successfully organized a campaign against Facebook rape #fbrape to get advertisers to pull ads off the site unless it pledged to monitor and remove content condoning violence against women. It was successful: the campaign led to an editorial in the New York Times,  and papers and social media nationally and internationally. The campaign’s success suggests organizing other campaigns around gender justice and reproductive rights may pick up steam and make the world friendlier to women.

Delaying “Beatriz” Access to Abortion Unconscionable

Broad international outrage over the forced continuation of one woman’s pregnancy with an anencephalic fetus, i.e. a fetus missing most higher brain structures, in El Salvador, led to an international court ruling that a woman’s pregnancy must be terminated.

Another issue in this case concerns detection of an anencephalic fetus. A routine fetal ultrasound will clearly show a fetus lacking parts of the brain. Because anencephalic fetuses have never lived more than a few hours after they are born, women who learn that their fetus lacks higher brain structures, choose to have an abortion as soon as it is detected. This option was not open to “Beatriz” because abortion for any reason is illegal in El Salvador. In states that block women from speedy abortion access, women will also have to prolong a useless pregnancy like this.

“Beatriz” also had her own health risks, namely lupus and kidney failure, which made her continued pregnancy hazardous. But that carried no weight in El Salvador, nor does it carry much weight with far too many legislators in the United States and elsewhere. That’s worrisome.

“Beatriz” had a cesarean section under general anesthesia at 26 weeks of gestation. The fetus died shortly after the procedure. Broad consensus exists in the ob/gyn and public health community that cesarean section abortions (hysterotomies) are hazardous and that an induced abortion would have been far safer. In fact, in the United States, these procedures are rarely done.

Frances Kissling, President of the Center for Health, Ethics and Social Policy, and past-president of Catholics for a Free Choice, had this to say: “ I totally agree that an early abortion should have been performed and the case is an example of extremist anti-abortion medicine…We have every right to condemn the delay, the decision to incur greater risk by performing a hysterotomy rather than use the best technique for abortion in her case. We also should reject the noting of trying to save both woman and fetus, especially when the fetus has no chance of more than minutes of survival. This way of constructing cause and effect is hooey, which results in women’s death and/or suffering.”

The Vast Scope of Reproductive Control Practices

El Salvador and several other countries in Central and Latin America have some of the most regressive policies internationally on abortion. A Foreign Policy post this week points this out. As shown repeatedly, in countries that block access to abortion and contraception, maternal and child health outcomes suffer.

You don’t have to look very far to see that access to birth control and abortion are getting blocked. Legislation on the books and proposed, puts discriminatory hurdles up to women getting contraceptives and abortion. Sadly, federal programs and religious organizations are controlling access. Unscientific, biased regulations, including waiting periods, mandatory fetal ultrasounds that pregnant women must view, and onerous abortion facility construction requirements are just some of the barriers. Efforts to pressure women to continue unplanned pregnancies must be stopped.

The so-called “pro-life” fanatics will stop at nothing to state their case. Just like edited ACORN tapes by James O’Keefe and Hannah Giles on Andrew Breitbart’s website that went viral at first uncritically,  Live Action anti-abortion fanatics have gone to abortion clinics using secret microphones and cameras, photoshopping and editing alarmist videos for their cause. As Carol Joffee, MD, notes in this article: “I fear that a possible consequence of these Live Action videos may be a chilling effect on the free and open conversation between clinic staff and patients that is such an important part of abortion care.”

Honoring and Organizing for Quality Women’s Health

In the past week, we remembered the four-year assassination anniversary of George Tiller, abortion provider who was murdered by anti-abortion fanatics, as well as the death of Henry Morgentaler, Canadian doctor who helped spearhead legalized abortion. Conscientious providers who provide quality reproductive care merit thanks from us too.

We must continue to organize to protect access to contraception and reproductive care. As Robin Marty and Jessica Mason Pieklo note in their new book, Crow After Roe: How Separate But Equal Has Become the New Standard in Women’s Health and How We Can Change That, a separate, discriminatory standard of health care for pregnant women is expanding rapidly across the United States. Our elected officials must be held accountable.

Mental Health for the 99% Following Hurricane Sandy

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Two weeks after Hurricane Sandy and a Nor’Easter that left thousands of New Yorkers without light, heat, and power for weeks, many New Yorkers were understandably shaken. Some had endured 911 and the disruption, though of an entirely different cause, elicited an anniversary stress reaction. Deaths, drownings, and unacceptable losses happened here and in many other areas.

In New York, I tried assisting a friend get psychiatric help who was traumatized after 911. She feared that she’d sink into the morass that she did following 911.
Here’s the picture that emerged:

>Many psychiatrists in New York City take no insurance. For many people, this means 100% out of pocket, or possibly a small reimbursement.
>Trauma and post-traumatic stress disorder are not something primary care physicians (PCPs) want to deal with, nor is it appropriate for them. Let’s hope health plans don’t think it is within their purview.
>Many PCPs in New York City have no psychiatric referrals to offer patients that are in network.
>Many major academic medical centers in the 5 boroughs have no participating psychiatrists at all in the largest health plans in the area. How can that be?
>Listings of participating psychiatrists in health plan networks are enormously inaccurate: psychiatrists tell you that they have not been on these plans for years.
>One friend in need got two off-network psychiatrists to consult with: the first offered a first visit for two hours at $695, followed by repeat visits of $350.
>She reached that one after ten calls to psychiatrists off list.

I know that this is not unique to New York, nor is it unique to mental health. What do you think should be done to change this? Are there more equitable ways to be sure mental health services serve people most in need?

Immigration and Healthcare: No Talking Points This Election

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Immigrants on a steamship heading around the Statue of Liberty. Credit: Library of Congress

This week, I will be attending a two-day meeting on immigration and healthcare.  It’s not an area that I know a lot about and I am interested in your thoughts on the topic. Presidential candidates are not discussing the issues.

One worry that I have concerns privatizing of many public healthcare programs that have served immigrants well for centuries. America seems keen on privatizing right now, but the benefits and harms are not clearly known.

These issues are on my mind:

  1. Will immigrants who were able to get care in the public sector still have the same access once health care is privatized?
  2. Will preventive care, chronic care be available?
  3. Will more care be provided in the emergency room?
  4. Will shrinkage of the public sector mean that they will be sicker?
  5. What will happen to elderly immigrants? Will the healthcare system accommodate immigrants when they decline?
  6. What can be done in health policy and planning to bolster equity and fairness?

What are your thoughts on this issue?

 

My $5,000 Tooth and the Institute of Medicine Dental Report

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What a coincidence! The Institute of Medicine released a report today titled Improving Access to Oral Health Care for Vulnerable and Underserved Populations and I am one step further in my saga of trying to save a tooth! It is looking good in the save-the-tooth department, but this dental care is breaking my wallet. I lost a bit of time this week blogging and working because of pain. I don’t have the money to pay for this.

I am sad to say that no matter what I do, in New York City, this was bound to cost me thousands of dollars. I have no dental insurance. Not mentioned in the report are the extraordinary numbers of Americans out of work. Affordability is mentioned, of course, but the report doesn’t get into fixing that very much. Dental care is a luxury for people unemployed or under-employed and I put myself in that camp. I have been in a tizzy about what to do most of this week.

The Limits of Shared Decision Making

The shared decision making (SDM) people would have thought the world of my dentist, who kept trying to explain various treatment options, as if I was sizing up whether to buy a sofa, or a loveseat and a chair, or two chairs. Missing from the script was any discussion of dollars, as if it was a variable that was beyond the scope of the decision-making. I think that is a big mistake. I was buoyed this week, when an SDM proponent told me that the community is debating just how to bring $$ into treatment discussions.

I investigated the $$ situation on my own. I quickly learned that the cheapest course of care would have been pulling the tooth and getting a flipper (a tooth that you remove at night).  This is the course of action that the poor and the vulnerable get. But the other options—#2 – a root canal plus a post, core, and crown, can put you out a few thousand dollars. That is what I opted for. Option 3 is a tooth pull, combined with an implant,  a crown, and depending on the tooth, possibly a sinus flap, that can put you out thousands of dollars. It’s not uncommon to see payment plan brochures at dental offices, meaning that in the end, the dentist gets these fees, plus you shell out interest, bringing your out of pocket costs way up.

In high school, I had an after-school job with a dentist, who ended up removing teeth in an emergency for a lot of first-generation immigrants. Aside from preparing his instruments, my job was to hold the hands of these people; many came to the office in agony. Some had tried unsuccessfully to pull their own teeth. For the most part, we didn’t see these people again for a bridge. Some lived with a half a set of teeth. It was one of the first jobs where I felt that I was helping people feel better. I cannot say it is reassuring to see that, years later, I am in the same predicament as new immigrants in seeking dental care. I have worked hard all my life, but I cannot afford quality dental care.

Well, I am glad that Congress got the IOM panel to look at dental care for the poor and underserved, but I know that the Health Resources and Service Administration and the California Healthcare Foundation did not quite have me in mind when they solicited this report. It addresses vulnerable and underserved children, Medicaid, and Medicare patients, showing that in 2006, 4.6 million children missed dental check-ups, only 38 percent of retirees had dental coverage,  Medicaid providers are poorly reimbursed. I agree that these are  high-priority populations for basic dental coverage.

The report recommends expansion of the use of dental hygienists and assistants in areas of high need, underserved areas. The American Dental Association praised the report in a statement, particularly applauding the recommendation of increasing Medicaid reimbursement and support  for dental training programs.  If initiatives come forward that threaten the income of dentists in caring for less vulnerable, patients , it would not surprise me if ADA caused a ruckus.

I am glad that dental health care is being discussed nationally, but I can’t say the IOM report is cause for encouragement. Across town from the Institute of Medicine, major efforts are afoot to dismantle Medicare and Medicaid. I don’t see dental care becoming affordable for the vast numbers of Americans.

Memorial Day Comes Early: Notes on Gil Scott-Heron and Black Health in America

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I can’t give you the news the way poet Gil-Scott Heron would, but I can imagine some of the social realities that would move him to poetry and song.

It’s a nasty time for blacks and African Americans in the United States. At least, the Celebrity Apprentice is out of sight for now.

Thank you to Khadijah Britton, for her blog post on Scientific American this week, calling out Satoshi Kanazawa, for trashing black women as inherently unattractive, and calling Psychology Today to task for publishing it; thanks to Frank Oldham, Jr. http://www.patientpov.org/hivaids/national-association-of-people-with-aids-condemns-new-york-posts-violation-of-hiv-status-privacy-in-dsk-story for challenging the ugliness in the New York Post and the Dominique Strauss Kahn spin machine, for violating the maid’s and all her neighbors’ HIV status privacy. Get over it: we know who the victims are.

Yet the spinmeisters continue, while the litany of urban poverty and racial disparities goes on.

Health, housing, jobs not quite up to par.

  • Boehner proposing a $600,000 cut to the WIC (Women’s Infants’ and Children’s Program) nutrition program for the poor that improves health, while cutting costs.
  • Despite all the effectiveness of early intervention for HIV, ADAP (the AIDS Drug Assistance Program) is getting hit. Waiting lists in May 2011  soared to more than 8,000 people.
  • HIV disproportionally affects blacks, According to the CDC,  blacks/African-Americans account for 12 percent of the US population, but represent 50 percent of people living with HIV/AIDS. HIV also disproportionally affects the urban poor and folks in the southern United States.
  • Of women living with  HIV and AIDS, well over 80 percent are black/African-American.

It is not a pretty picture as we look at  “AIDS at 30.”  Racial disparities persist.

Gil’s poetry moved people. Rest in peace, Gil. I will always remember “Whitey On the Moon.”

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It’s a Sign III—Deaf Access to Health Care

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This post is a guest post by Billie Noakes, a freelance writer, storyteller, and children’s author living in Pinellas FL. She also makes lace, is learning to garden, and a blogger in this year’s Word Count Blogathon, aka #blog2011. She blogs regularly at http://billienoakes.com/the-billiegram/

When my friend “Lily,” who is 78 and deaf, visits her doctor, I go along to interpret. I’m not certified, but even my signing skill is better than having Lily rely on lip-reading.

Someone who relies on lip-reading catches only 30 percent of what’s said, and that’s on a good day.

Comprehension diminishes if the speaker turns away from the deaf person while speaking; uses exaggeratedly slow speech which distorts the appearance of words on the lips; has a beard or moustache which hides lip movement; or himself has a facial, nerve, or speech problem that distorts the lips.

Most deaf people cope by writing notes back and forth to shopkeepers or repairmen, and the development of the Video Relay Service now allows many deaf people to conduct a lot of business by phone.

But what happen in the doctor’s office or hospital, when a misunderstanding can have serious health implications?

Accommodations for Deaf Patients

The Americans With Disabilities Act (ADA) says health care professionals must make reasonable accommodations to ensure that a deaf patient understands what is going on.

The ADA leaves it up to the health care professional to decide whether a deaf person needs a certified interpreter. The deaf person can request one, but it’s the health care provider who decides. The cost of an interpreter can’t be charged to the patient, and not many health care providers are eager to take on this added expense.

Even when a doctor or hospital is willing, it’s not easy to find an interpreter on short notice. I learned this the hard way, when Lily had a medical emergency.

I started by calling our local deaf service center, but they don’t interpret: they provided me with a list of interpreting agencies.

Those agencies all required us to complete paperwork that had to be mailed or FAXed and then returned. They needed about a week’s notice to schedule the interpreter.

I bypassed that hurdle by calling a few friends who knew some interpreters from years back, and one of the guys was available to meet us at the hospital. He had another appointment in the middle of the day, so when we arrived at the hospital we were very clear about the need for someone to step in.

It didn’t matter. Despite Lily’s inability to explain her problems, the inability of nurses and doctors to understand her, and our repeated and emphatic requests, Lily never saw another interpreter for the entire five days she was hospitalized. Not even on a day when she was scheduled for a procedure that scared and confused her.

Nurses and aides couldn’t tell Lily how to reposition herself when they changed her bedding, and Lily couldn’t tell them they were hurting her.

No one noticed the painful lesions on her body, and she went home with an undiagnosed case of the shingles, which all of the expensive tests had not revealed.

Lily is better now, but she tells me that the barricades to competent, compassionate health care that she encountered are repeated every day, all across the country, and deaf people are dying for lack of simple communication.

It doesn’t have to be this way.

Strategies for Improving Access to Deaf Interpreters

Medical buildings across the country house the offices of primary care physicians and a wide range of specialists.

Maybe an enterprising interpreter could partner with the doctors in these medical buildings and establish “deaf friendly days,” days when doctors and interpreters can advertise the availability of a certified interpreter for medical appointments.

Commit to try this for about six months, with lots of information provided on deaf message boards, at deaf clubs, at deaf service centers. It’ll take a little while for the buzz to build.
Hospital emergency rooms can contact colleges with Sign Language Interpreter Programs and keep the names of instructors and recent graduates handy for emergency situations.

Classes in American Sign Language, with an emphasis on medical signs, could be added to the list of required courses for nurses and aides.

ASL students need “contact hours” with deaf people to help them hone their signing skills. They can work with hospital volunteer coordinators and offer their services on patient care floors, visiting deaf patients and letting nurses and aides know what the patients need.
There are many tools available for reducing the frustration that deaf patients encounter when they seek medical help. It would be great if more people made an effort to find and use them.

The Incredible Shrinking Oncology Workforce

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LC1, the insured lung cancer patient whose search for an oncologist described in
last week’s post, is not alone. If more Americans realized that they might not
find an oncologist or other specialist provider, they could help drive changes
that could remedy the situation.

Studies have consistently shown that cancer is strongly related to increasing patient age. Policymakers, lawmakers, and the oncology profession, are well aware that there is a crisis in cancer care that will escalate as the number of Americans age 65 and over continues to rise. The US Census Bureau projects that the population over age 65 will double between
2005 and 2030. Therefore, overall cancer rates will rise dramatically.

Here are some illuminating specifics from an analysis of supply and demand for
oncologists performed by the Association of American Medical Colleges Center for
Workforce Studies to the American Society of Clinical Oncology (ASCO) on the
Oncology Workforce. The study, which focused on supply and demand between 2005
and 2020, reveals:

  • a 48 percent increase in demand for oncology visits, assuming that there is no change in cancer incidence or use of services, whereas the number of oncologists will rise by only about 14 percent;
  • In terms of availability to see patients, this translates into a shortage of 9.4 to 15 million visits, or 2,550 to 4,080 oncologists (or about one-third of the 2005 supply of oncologists).
  • At the same time, there will be an 81 percent increase in cancer survivors; many of these people will not need regular visits to an oncologist.

How serious this shortage is right now remains unclear. Already, reports of Medicaid patients finding no specialists to see are increasing. LC1 has health insurance and he has not been able to retain an oncologist. So people should not be caught off guard if they have trouble finding an oncologist to follow them.

I asked Thomas J. Lynch, MD, director of the Yale Cancer Center, what he thought of
LC1’s difficulty finding an oncologist. He wrote in an email: “Gosh— this is not
my experience in lung cancer.  The reality is that in 10-20 years we will have
MD shortages in oncology and we will have to develop new strategies to deal with
the ever increasing survivors (good problem to have).  But I am surprised to see
this now.”

Solutions for the Shortfall in Oncologists

Readers may want to think about whether healthcare reform can help fix this crisis
or whether market forces will correct this. Health policymakers need to reach
out to Americans to educate them so they can weigh in about any programs that could potentially change this outlook. Is this a problem in your community?

Oncology care could look very different for many Americans in the coming years.
In addition to work by the American Association of Medical Colleges and American
Society of Clinical Oncology, the Institute of Medicine’s National Cancer Policy
Forum, the federal government’s Health Resources and Services Administration(HRSA) have been examining the issue. All of these groups are thinking about arange of strategies that could correct the situation, including:

  1. Ways to improve recruitment and retention of oncology-related professionals;
  2. New models of care to cancer survivors (some might reduce access to oncologists and have other health professionals follow patients. This is suggested, especially for people receiving palliative care, and family caregivers);
  3. Offering potential oncologists scholarships or loan repayment programs;
  4. Encouraging multidisciplinary cancer care payment models; and
  5. Promoting use of electronic health records as a way to improve efficient delivery of care.
  6. Changing physician reimbursement to encourage care for Medicaid patients.

What do you think about some of these plans? Do you know of any specific programs that could help people who develop cancer who may not be able to find an oncologist? What about patients on Medicaid, or patients without insurance?