Category: Opinion

Categories
General Lifestyle Opinion

Too Many Eyes Between the Thighs: Sex and Surveillance

There’s a special bond between students and their teachers. As someone who used to teach young children, I know firsthand how students can trust teachers with certain aspects of their lives that they don’t feel comfortable disclosing to other adults. But, students in the Salem-Kaiser school district in Oregon may want to think twice about what they tell their teachers. That’s because district policy stipulates that teachers are mandatory reporters of all student sexual activity. This policy means that teachers who have knowledge or suspicion of students’ sexual activities must file a formal report with the Department of Human Services, local law enforcement, or a school resource officer. What’s more, because they are mandatory reporters, a teacher could actually face disciplinary action and fines if they fail to report known student sexual activity. This law even applies to faculty members making reports on their own children if they are students in the district. The year is 2017, but this puritanical policy is straight out of the 17th century.

As a former high school student, I’m appalled by this policy. As a future doctor, I’m deeply troubled. When culture permits our libidinous drive to become an object of surveillance, sex becomes a deviant activity. In criminalizing the natural and healthy exploration of sexuality, we imbue sex with shame.

I could not help but see a link between this policy and the reports of sexual violence that have been dominating the media over the past month. My immediate reaction was that this attitude of surveillance around sex is the fertile soil from which the Harvey Weinsteins of the earth spring forth. In an article about the Harvey Weinstein scandal published in New York magazine, Rebecca Traister writes “What we keep missing, as we talk and reveal and expose, is that this conversation cannot be just about personal revelation or speaking up or being heard or even just about the banal ubiquity of abuse; it must also address the reasons why we replay this scene, over and over again.” Traister sees the perpetuation of crimes of sexual abuse as indicative of a foundational gender injustice; I see them as the result of a culture that was built upon austerity.

America is littered with vestiges of our Puritanical culture. The very fact that we can’t show the bare breast on Instagram, or that we’re still trotting out the story of Janet Jackson’s costume malfunction from Super Bowl 2004 is, to me, an indication that the body is subjected to surveillance when it’s recognized as a vessel of sexuality. Sarah Silverman’s June 2017 appearance on Jimmy Kimmel Live! illustrates this. She holds up a picture of a penis that she drew while hospitalized and correctly assumes that the picture is intentionally blurred to viewers at home, per FCC regulations. She then facetiously tells producers that what she actually drew was a stalk of asparagus, and the picture instantly becomes clear. The image is, in a way, treated as criminal, and is subject to surveillance via pixelation, and yet that surveillance is instantly removed when the association with sexuality is removed.

In a way, we’re all responsible for allowing crimes of sexual violence to occur. My intention here is not to negate the free will of an individual who chooses irresponsible, repugnant behaviors, but to suggest that we have fostered a culture which, in a way, suggests that abhorrent sexual behaviors may be the basest way to get one’s needs met. When two 16-year-olds are in a healthy, consensual sexual relationship, and this relationship gets reported to the authorities, we are sending the message that even an appropriate sexual encounter is considered an act of deviance. And it starts even at a more localized level than the school. If kids are not hearing about sex in their households and are not raised with the understanding that sexual appetite is as normal a bodily function as urination or defecation, the overwhelming message is, at the very least, that sex is something that needs to be hidden away, or more damaging still, that sex is shameful.

Sexual violence is borne from the “sex = shame” mentality. When we classify the perpetrators of these crimes as being “sex addicts,” it excuses these damaging and vile behaviors as an unfortunate error of biology rather than viewing them as a product of learned behavior. This is not to say that sex addiction isn’t a real pathology, but rather to point out that we may be confounding biology with behavior. Though sex addiction has never been classified as a diagnosis in the Diagnostic and Statistics Manual (DSM), most experts agree that the diagnosis of a sex addiction would require a higher-than-average sex drive coupled with compulsive sexual behaviors even in the face of negative consequences. Sexual drive is a difficult feature to quantitatively measure, but I suspect that a high sex drive is not the cause for most crimes of sexual violence. I strongly believe that by committing acts of sexual violence, perpetrators are primitively attempting to meet their needs. In other words, while the sexual appetite is normal, the internalization of the “sex = shame” mentality is so embedded in the psyche that the sexual act becomes a part of this narrative. When one believes that one’s sexual drive is shameful, libidinous urges cannot be openly discussed, and instead may be dealt with in a way that is clandestine and non-consensual. Larger issues of power and privilege, though out of the scope of this writing, come into play when individuals are enabled to act out these violent behaviors.

Sexual violence is systemic. If we don’t change our cultural attitudes toward sex, we will continue to foster an environment which is likely to create sexual criminals. Young people who are just beginning to explore their identities as sexual beings through relationships with others are most susceptible to the internalization of the “sex = shame” narrative. If we don’t learn to shed our Puritanical vestiges and celebrate the healthy, safe, and consensual sexual exploration of these young people, we will continue to support a society of people who are reduced to committing crimes of sexual violence.

References:

YThe Conversation We Should Be Having: https://www.thecut.com/2017/10/harvey-weinstein-donald-trump-sexual-assault-stories.html

Internet sex addiction: A review of empirical research: http://www.tandfonline.com/doi/abs/10.3109/16066359.2011.588351

Is Sex Addiction Curable? http://www.newsweek.com/sex-addiction-curable-kevin-spacey-seeks-rehab-condition-does-not-exist-703541

Salem-Keizer staff told to report student sexual activity, including own kids: http://www.statesmanjournal.com/story/news/education/2017/10/31/oregon-mandated-reporter-salem-keizer-staff-told-report-student-sexual-activity-including-own-kids/798865001/

Sarah Silverman on Near Death Experience: http://abc.go.com/shows/jimmy-kimmel-live/video/featured/VDKA3871414

Photo Credit: Wyatt Fisher

Categories
Clinical General Lifestyle Narrative Opinion

In the Business of Medicine, Be Your Own Boss

As medical students, we exist between two worlds. On the one hand, we’re tasked with learning as much as we can about the practice of medicine from our preceptors, many of whom have decades of experience. On the other hand, we’re always thinking about our place in the future of medicine and fantasizing about what our unique style of practice will look like. While I feel indebted to the seasoned physicians who graciously give of their time to teach us, a recent interaction reminded me that I am the boss of my own practice of medicine.

It started out as a morning just like any other. I needed to finish rounding on my patients before a noontime meeting where I was slated to give a small presentation. The last patient on my roster had been particularly troublesome for our service. She had been admitted for worsening congestive heart failure and although she was relatively young, and had a very supportive family, she did not seem willing to make any of the lifestyle changes that would improve and possibly prolong her quality of life. Nurses, doctors, and respiratory therapists had been trying to get her to wear her CPAP mask during this hospitalization, but for reasons that we didn’t completely understand, she had been refusing to wear it for the past two months.

After a quick exam and what seemed like a futile imploration to try her CPAP again that night, she started telling me a bit about her life prior to becoming ill. I knew the time was coming closer and closer to my meeting, but I couldn’t leave while she in the middle of divulging such personal information. Our conversation dwindled, and I stepped toward the door, when she tearfully mentioned that her dog had recently died. Again, my thoughts drifted toward the upcoming meeting, but I also wanted to be sensitive to this very meaningful event in my patient’s life. Trying to be polite, I asked when her dog had died.

“Oh, about two months ago,” she replied.

I paused. “Is that about the time when you stopped wearing your CPAP mask at home,” I asked.

She stopped to think. “Yes, I think it was exactly around that time.”

Thinking that the timing of her dog’s death coinciding with when she stopped using CPAP might be more than coincidental, I offered my condolences for her loss, and assured her that I wanted to come back later in the day to talk more about her dearly departed pet. I felt relieved to see that I had only run a minute late, so I hightailed it to the meeting. As I stopped to pick up the materials for my presentation, I heard my attending calling my name from the hallway. I couldn’t wait to tell him that I had stumbled upon a very useful piece of information to help us understand why she stopped using her CPAP machine.

“I know I’m a minute late-I got stuck with our patient,” I explained. “I couldn’t just couldn’t leave when she started talking about her dog who recently died, but I may have a clue as to why she won’t wear her sleep mask.”

He looked dismayed. “You have to figure out how to get out of those conversations,” he told me curtly. “That’s just the business that we’re in.”

His last words “the business that we’re in” struck me so profoundly that I can still replay them in my head as clearly as if he was standing right across from me. I have not had a temper tantrum since childhood, and yet, in that moment, everything inside me wanted to shake my head and bang my fists in passionate disagreement. I understood immediately that whatever business this physician is in is not the same business I’m planning to go into. As a student, I still have a lot to learn, but one thing I know for certain is that patients should always take precedence over meetings. After all, without fostering the relationships we have with our patients, medicine would be a business in bankruptcy.

Medicine has a rich history of being passed down from generation to generation, but like anything else, aspects of medical practice may become antiquated. As the next generation of physicians, it’s up to us to hone our judgment and decide whether we will accept the status quo or make a new path forward. We get to decide what the business of medicine means to us. Whether we work for a large corporation or go into private practice, each one of us is a boss-in-training of our own future practice. It took some not so sage advice from a preceptor to remind me that meaningful and collaborative relationships with my patients are the cornerstones of my business of medicine.

 

Photo credit: Christophe BENOIT

Categories
Clinical General Law Opinion Patient-Centered Care Pharmacology Public Health

Access to Contraception

Contraception is essential to a woman’s health, empowerment, equality, and independence. This belief is championed by the Center for Reproductive Rights, Guttmacher Institute, Planned Parenthood, and others. More importantly, governing bodies of health care overwhelmingly defend access to contraception:

 “Contraception is a pillar in reducing adolescent pregnancy rates.”

  • The American Academy of Pediatrics [1]

 “Clinicians should discuss all contraceptive methods that can be used safely by the patient, regardless of whether a method is available on site and even if the patient is an adolescent or a nulliparous woman.”

  • American Academy of Family Physicians [2]

“The American College of Obstetricians and Gynecologists [ACOG] supports access to comprehensive contraceptive care and contraceptive methods as an integral component of women’s health care and is committed to encouraging and upholding policies and actions that ensure the availability of affordable and accessible contraceptive care and contraceptive methods.”

  • American College of Obstetrics and Gynecology [3]

“Access to safe, voluntary family planning is a human right. Family Planning is central to gender equality and women’s empowerment, and it is a key factor in reducing poverty.”

  • United Nations Population Fund [4]

“This policy supports the universal right to contraception access in the United States and internationally.”

  • American Public Health Association [5]

“Family Planning, an integral component of sexual and reproductive health, is a critical pillar for health and development; it is also a human rights issue…When women are denied their right to and choice of family planning methods, they become trapped in a vicious cycle of poverty, poor health outcomes from ill-timed pregnancies and limited capacity to fully realize their potential.”

  • World Health Organization [6]

 

Contraception is regarded by the CDC as one of the 10 greatest public health achievements of the 20th century.[7] Of the many reversible contraceptive options available, implant and intrauterine device are most effect, with less than 1% risk of failure for both perfect and typical use compared to an 18% failure rate for typical male condom use.[8] Of course, condoms are the only available contraceptive method that also protects against transmission of infections, including the human immunodeficiency virus (HIV) and human papilloma virus transmission through certain makes of condoms.

Benefits of contraception include: improved health and well-being, reduced global maternal mortality, pregnancy spacing and subsequent health benefits, increased participation of females in the workforce, and economic independence for women.[9]

In the United States, 70% of women ages 15 to 44 years old are sexually active and do not want to become pregnant. Thus, 70% of reproductive aged women are at risk of unintended pregnancy. The Guttmacher Institute, a leading researcher of reproductive health, reported that consistent and correct use of modern contraception (i.e. condom, hormonal contraception, long-acting method, or permanent method) without any gaps in use during all months a woman is sexually active resulted in 68% of sexually active reproductive age women avoiding an unintended pregnancy.[10] These women accounted for only 5% of unintended pregnancies that occurred in 2008. In comparison, 41% of the 3 million unintended pregnancies were a result of inconsistent modern contraceptive use and 54% resulted from nonuse.[10]

Sadly, in addition to other Catholic-based religious organizations, the United States Conference of Catholic Bishops argues that contraception does not prevent unintended pregnancy nor reduce abortion rates.[11] The USCCB also does not believe that contraception is basic health care.[12] Instead, the USCCB states,

 “Contraception is an elective intervention that stops the healthy functioning of healthy women’s reproductive systems. Medically it is infertility, not fertility, that is generally considered a disorder to be treated.”

Let me be clear. Access to contraception is basic health care. 222 million women globally have an unmet need for modern contraception.[4] This burden is highest in vulnerable populations such as adolescents, those from low socioeconomic households, those with HIV, and internally displaced persons.[4]

The WHO issued guidance and recommendations on “Ensuring human rights in the provision of contraceptive information and services,” in which officials outline nine priority actions policy makers and providers need to take to ensure that human rights are protected in the provision of contraceptive information and services.[13] These steps include:

  1. Non-discrimination in provision of contraceptive information and services
  2. Availability of contraceptive information and services
  3. Accessibility of contraceptive information and services
  4. Acceptability of contraceptive information and services
  5. Quality of contraceptive information and services
  6. Informed decision-making
  7. Privacy and confidentiality
  8. Participation
  9. Accountability [of programs that deliver contraceptive information and services]

In regards to current politics and policy proposals, accessibility of contraceptive options includes affordability.

Under the Affordable Care Act (ACA) healthcare law, preventative women’s health services—including well-woman visits; screening for gestational diabetes; human papilloma virus testing; counseling for sexually transmitted diseases; counseling and screening for HIV; contraceptive methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for interpersonal and domestic violence—are covered without any co-payment, co-insurance, or deductible.[14] For reference, if the ACA healthcare law were not in place, the average out-of-pocket cost for birth control would be $78-$185 per year.[14] For myself, my oral contraceptive pills cost $30 per month, totaling $360 per year! This was a financial burden as a student—but essential for my overall health—and so, I budgeted. But not everyone has that capability.

The ACA’s expansion of health care coverage and improved access to care also resulted in reductions in delayed care, as well as improved maternal and newborn outcomes. From 2010 to 2014, the proportion of women who reported delaying or forgoing care due to cost concerns dropped by 3.4%.[15] The health care law also funded the Strong Start for Mothers and Newborns Initiative, a collaboration between the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Administration on Children and Families. The initiative aims to reduce preterm birth rates and improve maternal and newborn health outcomes. This is key because full-term babies have improved outcomes compared to those born in an early, term elective delivery.

The United States Human Health and Services notes that actuaries, insurers, and economists generally estimate that contraception provisions are at least cost-neutral and may, in some cases, result in cost-savings when taking into account the costs and benefits of unplanned pregnancies.[14] In 2009, the UNPF and Guttmacher Institute published a detailed report explaining how family planning and maternal and newborn health services saves lives and money. Preventing and/or postponing unintended pregnancies results in fewer expenses due to the decreased need for maternal and newborn health care and the management of unsafe abortions.[16] In addition, ensuring standards of maternal and newborn health care reduces the rates of complications and subequently incurred high costs.

Keeping these considerations in mind, our current political climate is of great concern because on January 20, 2017, President Donald Trump issued an executive order to repeal the ACA.[17]

I received an email update this week from ACOG reporting that the AAFP, American College of Physicians, AAP, ACOG, and American Osteopathic Association mailed a joint letter representing over 500,000 physicians asking the White House and Congressional leaders to “stand with us and for America’s women” because “healthy women can better participate in our economy and our workforce, and can reach higher levels of educational attainment.” The letter also identifies four priorities moving forward, one of which is to ensure that women have affordable access to evidence-based care.[18]

ACOG’s committee opinion on access to contraception emphasizes full implementation of the ACA requirement that,

“…new and revised private health insurance plans cover all U.S. Food and Drug administration-approved contraceptives without cost-sharing, including non-equivalent options from within one method category (eg. levonorgestrel as well as copper intrauterine devices).” [3]

Throughout the next few months and years when you are voting or exercising your right to debate the very real challenge we face to reduce health care costs, please remember that investing in family planning and maternal and newborn health care services saves money. And remember that leading healthcare organizations—the very governing bodies who set the standards for evidence-based care—strongly advise that the White House and Congress to write healthcare laws that ensure affordable women’s health care and access to contraception. I urge readers to fight for access to contraception, a necessary and significant human right.

For more information about available contraceptive options, please see the “Birth Control (Contraception): Resource  Overview” published by ACOG, available at http://www.acog.org/Womens-Health/Birth-Control-Contraception#Patient.

References

  1. Committee on Adolescence. Policy Statement: Contraception for Adolescents. Pediatrics. 2014
  2. Klein DA, Arnold JJ, and Reese ES. Provision of Contraception: Key Recommendations from the CDC. Am Fam Physician. 2015;91(9): 625-633.
  3. American College of Obstetricians and Gynecologists. Access to contraception. Committee Opinion No. 615. Obstet Gyneco.l 2015;125:250-5.
  4. United Nations Population Fund and Center for Reproductive Rights. Family Planning. Available at: http://www.unfpa.org/family-planning. Accessed November 29, 2015.
  5. American Public Health Association. Universal Access to Contraception; Policy 20153. November 2015. http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/12/17/09/14/universal-access-to-contraception. Accessed: November 28, 2016.
  6. World Health Organization. Family Planning Summit, 11 July 2012: WHO’s Commitment. Available at: http://www.who.int/reproductivehealth/topics/family_planning/WHO_commitment_fp.pdf?ua=1. Accessed: November 30, 2016.
  7. Sonfield A, Hasstedt K, Kayanaugh MI, Anderson R. The social and economic benefits of women’s ability to determine whether and when to have children. New York (NY) Guttmacher Institute; 2013. Available at: http://www.guttmacher.org/pubs/social-economic-benefits.pdf. Accessed: November 29, 2016.
  8. Guttmacher Institute. Contraceptive Use in the United States. September 2016. Available at: https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states. Accessed: November 29, 2015.
  9. Starbird E, Norton M, and Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016;4(2):191-210.
  10. Guttmacher Institute. Infographic: Contraception is highly effective. July 2013. Available at: https://www.guttmacher.org/article/2013/06/infographic-contraception-highly-effective. Accessed: November 28, 2016.
  11. Emergency Contraception Fails to Reduce Unintended Pregnancy and Abortion. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/emergency-contraception-fails-to-reduce-unintended-pregnancy-abortion.cfm Accessed: February 2, 2017.
  12. Fact Sheet: Contraceptive Mandates. Available at: http://www.usccb.org/issues-and-action/human-life-and-dignity/contraception/fact-sheets/contraceptive-mandates.cfm Accessed: February 2, 2017.
  13. Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations; 2016. Available at: http://apps.who.int/iris/bitstream/10665/102539/1/9789241506748_eng.pdf?ua=1. Accessed: November 28,2016.
  14. S. Department of Health & Human Services. Fact Sheets: Women and the Affordable Care Act. Available at: https://www.hhs.gov/healthcare/facts-and-features/fact-sheets/women-and-aca/index.html. Accessed: November 28, 2016.
  15. Simmons A, Taylor J, Finegold K, Yabroff R, Gee E, and Chappel A. The Affordable Care Act: Promoting Better Health for Women. ASPE Issue Brief;2016:1-10.
  16. UNFPA and Guttmacher Institute. Adding it Up 2014: The Costs and Benefits of Investing in Sexual and Reproductive Health. UNFPA, Guttmacher Institute. 2016;1-56.
  17. The White House Office of Press Secretary. Executive order minimizing the economic burden of the patient protection and affordable care act pending repeal. Available at: https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and. Accessed: January 2, 2017.
  18. Healio Family Medicine. AAFP, ACP, others join forces in new effort to protect women’s health. Available at: http://www.healio.com/family-medicine/womens-health/news/online/%7B1b88e282-cd33-402c-a97a-bea5ef45238f%7D/aafp-acp-others-join-forces-in-new-effort-to-protect-womens-health . Accessed: January 2, 2017.

Photo credit:

Blue coat photos

Categories
Opinion Psychology Public Health

Take a Stand against Domestic Violence

October is Domestic Violence Awareness Month. This is particularly relevant at the moment, because on October 7th the Washington Post published a 2005 recording of President-Elect Trump bragging about kissing and grabbing women without permission. Since the leak, the president-elect has consistently referred to such comments as “locker room talk.” In a recent interview with Anderson Cooper, Melania Trump further dismissed the seriousness of her husband’s comments by stating, “I heard many different stuff—boy’s talk. The boys, the way they talk when they grow up and they want to sometimes show each other, ‘Oh, this and that’ and talking about the girls.”

It is time to be clear. Trump’s comments may echo in locker rooms or be the status quo among young men, but that does not make it forgivable to joke about sexual violence. And to imply that joking about sexual violence against women is somehow more tolerable when it is said by an immature male or in a sporting environment only further encourages the perception that men have an implicit ownership of a woman’s sexual rights.

In a 2010 report entitled “Preventing Intimate Partner and Sexual Violence Against Women,” the WHO emphasizes the need to understand and target the factors that commonly lead to intimate partner violence and sexual violence against women. Unfortunately, an overwhelming burden of intimate partner violence and sexual violence against women occurs at the hands of men. This becomes unsurprising when one identifies the factors that promote violence against women. The WHO lists “patriarchy, power relations, and hierarchical constructions of masculinity and femininity as a predominant and pervasive driver of the problem.” The paper further argues that “dismantling hierarchical constructions of masculinity and femininity predicated on the control of women, and eliminating the structural factors that support inequalities are likely to make significant contribution to preventing intimate partner and sexual violence.”

Several examples of such social and cultural norms are cited in the report, but one appears to be particularly relevant in the setting of Trump’s recent comments: the idea that a man has a right to assert power over a woman and is considered socially superior to her. In the leaked video, Trump supports his right to kiss and grab women with the argument that “when you’re a star, they let you do it. You can do anything.”

No, Mr. Trump, you cannot.

The WHO highlights methods to prevent intimate partner violence and sexual violence against women, stating that there are three main approaches for changing social and cultural norms: correcting misperceptions that the use of sexual violence is normal and common among peers, media awareness campaigns, and directly working with men and boys to educate them on the topic. I hope that the media storm surrounding the video’s release, as well as the responses to it by prominent figures will serve to raise awareness, because women, men, and children alike should be able to live a life free of violence.

Readers, take a stand against domestic violence of all forms. Challenge jokes that diminish the seriousness of such acts. To fail to question only perpetuates the pervasive social and cultural acceptance of violence against women. Do not tolerate the perception that men are socially superior to women. Educate others that domestic violence, including intimate partner violence and sexual violence against women, is a global epidemic that affects us all.

I encourage current and future medical providers to seek the education they need to be a first resource for survivors of domestic violence. Make preventing and responding to intimate partner violence and sexual violence a priority in your clinical practice.

The National Intimate Partner and Sexual Violence Survey (NISVS) 2010 Summary Report defines five types of sexual violence:

  • Rape – “any completed or attempted unwanted…vaginal, oral, or anal penetration through the use of physical force, threats to be physically harmed, or when the victim was drunk, high, drugged, or passed out and unable to consent.”
  • Being made to penetrate someone else
  • Sexual coercion – “unwanted sexual penetration that occurs…after being pressured in ways that included being worn down by someone who repeatedly asked for sex or showed they were unhappy; feeling pressured by being lied to, being told promises that were untrue, having someone threaten to end a relationship or spread rumors; and sexual pressure due to someone using their influence or authority.”
  • Unwanted sexual contact
  • Non-contact unwanted sexual experiences – “unwanted experiences that do not involve any touching or penetration, including someone exposing their sexual body parts, flashing, or masturbating in front of the victim, someone making a victim show his or her body parts, someone making a victim look at or participate in sexual photos or movies, or someone harassing the victim in a public place in a way that made the victim feel unsafe.”

According to the NISVS, nearly 1 in 5 women (18.3%) and 1 in 71 men (1.8%) in the United States (U.S.) have been raped at some point in their lives. And nearly 1 in 2 women (44.6%) and 1 in 5 men (22.2%) in the U.S. experienced sexual violence other than rape. Worldwide, this rate is higher, with 1 in 3 women (35.6%) experiencing either physical and/or sexual intimate partner violence or non-partner sexual violence.

Domestic violence can refer to intimate partner violence, but also encompasses child abuse, elder abuse, or abuse by any member of a household. The World Health Organization (WHO) identifies four forms of intimate partner violence: acts of physical violence, sexual violence; emotional (psychological) abuse; and controlling behaviors.

Intimate partner and sexual violence disproportionately affects women worldwide, and can significantly impact a woman’s reproductive health and the health of her baby if she is pregnant. Women who have been physically or sexually abused by their partners have a 16% higher risk of having a low birth weight baby (16%). They are twice as likely to have an induced abortion, and almost twice as likely to experience depression.  In some regions, women who experienced partner violence were 1.5 times more likely to acquire HIV and 1.6 times more likely to have syphilis. Of women who experienced non-partner sexual violence, they were 2.5 times more likely to have alcohol use disorders and 2.6 times more likely to have depression or anxiety.

In 2013, the WHO produced a clinical and policy guideline entitled “Responding to intimate partner violence and sexual violence against women,” noting that health care providers are identified by survivors of intimate partner violence as the first and most trusted professional contact they would seek. These WHO guidelines emphasize the need for undergraduate medical curricula to include education on how to recognize, manage, and treat issues of IPV and sexual violence. Providers need to be prepared to give survivors immediate access to post-rape care, ideally within 72 hours, which includes psychological support, emergency contraception, and HIV and other STD prophylaxis.

For more information about domestic violence or how you can help please see the resources below:

If you are in immediate danger, please call 911.

If you or a loved one think that you are a victim of abuse in any form, please call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY) now for anonymous, confidential help available 24/7.

REFERENCES

  1. Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
  2. WHO/LSHTM. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2010.
  3. WHO/LSHTM. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva/London, World Health Organization/London School of Hygiene and Tropical Medicine, 2013.
  4. Violence against women: Intimate partner and sexual violence against women. Fact sheet. Reviewed September 2016. Accessed on 10/14/2016 at http://www.who.int/mediacentre/factsheets/fs239/en/

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utopia banished by kr428

Categories
Opinion Public Health

Is health a moral responsibility?

L0070041 Public Health Centre

“The preservation of health is a duty. Few seem conscious that there is such a thing as physical morality.”
Henry Spencer (1)

We are in charge of our lives. We choose what job we go into, what friends we invite, what clothes we wear and what food we eat. This is what we tell ourselves every morning as we drag ourselves out of bed, every night when we gaze up at our ceilings and think back on our day with pride. After all, if we were mere puppets on a string, what would be the point of it all?

For the past few decades more and more money has been pumped into public health campaigns (1). Our health is not based solely on our wealth, our family or our doctor, but upon the choices we make, and public health campaigns aim to nudge our choices in healthier directions.

Knowing that we are responsible our health, how does it feel to have such a responsibility? How do we react to this immense control that we hold in our hands; this ability to decide how many years we will live, how quickly we will age – the knowledge that the health choices we make today may well have an impact five years down the line? And how much responsibility do we really have for our own actions, considering all of the external forces acting on us, many of which are acting at a subconscious level?

To illustrate my point, allow me start with an example. If I knew I was going to die of lung cancer in twenty years if I continued to smoke, would I be encouraged to give it up? This simple question illustrates how very complex our lives really are. Giving up a habit – whether it is smoking tobacco or eating fast food – is rarely simple. Some of us may well choose to place the responsibility upon the smoker, but such a simplification masks the more intricate webs of that person’s life: what made them start in the first place, what made them continue and where does their motivation now lie? Are they smoking as a way to escape their feelings? To chase after a certain persona? If we place responsibility at the person’s feet, then we ignore the more subconscious desires that have led them towards their supposedly autonomous choices. We all engage in risky behaviours to some degree. A quick glance at the past few days will highlight many ‘unhealthy’ decisions that we have all made on the spur of the moment. Are we to blame for our decisions?

The idea of being in charge of our health has become particularly popular in the mainstream media. A quick Google search will uncover articles on how to build the perfect body, ten-minute guides to eating more fruit and vegetables and quick tips to help us lead more healthy lives (2). Even closer to healthcare, the idea of patient-centeredness has become almost an ideology within healthcare circles; words that are repeated ad infinitum to both students and professionals. This idea of being responsible for our own bodies illustrates our desire to place the power to determine our health back into our own hands, as opposed to relying wholly on the modern medical apparatus to do everything for us.

The numbers back this up even more. The World Health Organization (WHO) has stated that lifestyle-related diseases accounted for 86% of deaths and 77% of disease burden within the WHO European Region. This includes diseases such as cardiovascular diseases, cancers, chronic respiratory problems and mental illnesses (3). Furthermore, leading geneticists have pointed out that the “current increase in obesity has nothing to do with genes and everything to do with how we live” (4). These statistics are further supported by the fact that prevention is far more cost-effective than any intervention that healthcare professionals can undertake; from health education within our schools to exercise regimens into our forties – these are the most impactful activities we can do to positively impact our health. And because these are activities that we choose to participate in, it follows that we are sitting in the pilot seat; we have the power to get off our sofas and put on those Lycra shorts.

So what would it mean if we believed that we are all 100% responsible for our bodies? On one end of the spectrum, it may encourage people to lead more healthy lives – to perhaps avoid that drive to McDonald’s on the way home, or to insist on an early morning run despite the rain pattering on the window outside. But at the other end of the spectrum you have those people who have simply stumbled down the black hole of unhealthy lifestyle, whether it is drugs, fast food or a sedentary lifestyle. And the more we push for a culture of individual responsibility, the more needless blame we may place upon those who ultimately need help and not judgment. Do you think you would treat a person differently if you believed their illness was entirely their choice?

By placing responsibility on individuals, we walk down the road of assuming that to be ill is to be guilty, thereby further stigmatizing the unwell. A good example of this is mental illness, which has a long history of blame ranging from the relationship with the mother to the relationships within an entire family, until eventually we decided to fall back upon neurobiological theories in an attempt to absolve people of blame altogether.

As human beings, we are creatures of habit; as much as we would like to believe that becoming healthy is as simple as creating a New Year’s Resolution, half of all individuals who begin an exercise regimen quit within six months (4). The environment in which we grow up as children has a profound influence upon our behaviours. The habits we learn from our parents and those closest to us, whether they be about smoking, exercise or eating unhealthily, can stay with us subconsciously (3). When we decide to stay at home and watch another episode of Game of Thrones rather than go out for a run, how much of that decision was ours? How much control do we have over our personalities, whether they be impulsive or habitual?

Health is more than just a decision. It lies at the center of many threads: genetic, environmental, social and psychological. Although we live in a world where six of the ten leading factors contributing to the burden of disease are lifestyle related (5), we must appreciate the fact that these are indeed factors, not a solid line that we can draw across other peoples’ lives to claim that they are wholly responsible for what happens to their bodies and mind.

So what do we do about these opposing forces acting on us? On one end of the spectrum lies the idea that we have a dictatorial control over and responsibility for our decisions, while on the other end there lies the more deterministic way of viewing things, where ‘whatever happens, happens – I can’t do anything to change it’ is the prevailing belief. Which one is right? Which one should we accept?

The answer, I believe, lies not within abstract philosophical questions about morality and free will. Rather, I believe the answer is different for each and every one of us. It is up to us to decide how we view our bodies, our minds and the world in which we live. Do we want to live healthily? Why? Are we doing it for ourselves? To be able to fit into our new wedding dress? To allow our children to live in a smoke-free house? We all have our own reasons for the choices we make, and no doctor can make these decisions for us. Instead, we need to take a step back and think about what is most important in our lives, and do what we can to realize our goals with that in mind.

“Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. [..] That is why I recommend that the Statue of Liberty on the East Coast be supplemented by a Statue of Responsibility on the West Coast.”
Viktor Frankl (6)

References

  1. The Lancet. Is health a moral responsibility? The Lancet; 1996. 347:1197
  2. Cappelen, A.W., Norheim, O.F. Responsibility in health care: a liberal egalitarian approach. Journal of Medical Ethics; 2005. 31:476-480
  3. Brown, R.C.H. Moral responsibility for (un)healthy behaviour. Journal of Medical Ethics; 2012. 10.1136
  4. Minkler, M. Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century’s End. Health Education & Behaviour; 1999. 26:121-141
  5. Resnik, D.B. Responsibility for health: personal, social, and environmental. Journal of Medical Ethics; 2007. 33:444-445
  6. Frankl, V. Man’s search for meaning: the classic tribute to hope form the holocaust; 2013. Ebury Digital.

Featured image:
L0070041 Public Health Centre by Wellcome Images

Categories
Clinical Opinion

Mental Disorders: Are We Over Medicating?

In 1948, the World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” However, mental illnesses are not seen in the same light as physical illnesses. People who get labeled with psychiatric diagnoses often carry a heavy burden of social stigma regarding those diagnoses, and are generally uncomfortable disclosing and/or discussing them openly.

In ordinary conversation, it is not considered strange to mention that you had an appendectomy or discuss how you’ve been dealing with your diabetes for years. However, saying that you’ve been manic-depressive for years or that you’ve been desperately trying to overcome panic attacks is something that typically generates a negative response, and raises red flags for some people.

Why is mental health perceived so differently than somatic and physical health?

My inspiration for writing this piece was a debate about mental disorders held at the Emmanuel Centre in London, entitled: We’ve Overdosed. Psychiatrists and the Pharmaceutical Industry are to Blame for the Current Epidemic of Mental Disorders. Psychoanalyst Darian Leader, and accomplished author on the issue Will Self, argued for the “overdosed” side, while Dr. Declan Doogan and Professor Sir Simon Wessely, president of the Royal College of Psychiatrists, argued against it.

Is it true that mental disorders are made up by big pharma? Or is it just that we have a difficult time accepting that our psyche can, indeed, be a subject (or object, depending how you see it) of pathologic deviance and aberration? And that such aberration could and should be subjected to medical treatment?

Some critics view mental disorders as illnesses that have no definitive pathomorphological substrates. Are physicians overprescribing these agents to satisfy big pharma interests? Do they purposefully try to make the psychiatric bible (a.k.a. Diagnostic and Statistical Manual of Mental Disorders – DSM) thicker and thicker in each subsequent edition by bloating it with irrelevant and artificially fabricated diagnoses?

No one is claiming that every form of deviation from the “gold standard” of behavior (if such thing exists at all) is and should be proclaimed as a psychiatric disorder. No one is saying that every psychiatric disorder needs to be treated pharmacologically. No one is denying that many psychotropic drug treatments, unfortunately, fail among some patients. No one is saying that some classes of psychotropic drugs don’t induce debilitating side effects.

However, as future physicians we always have to remember that we will have a person with a problem sitting in front of us. This person will be seeking our help. We only have what is available to help them. We can only fight with the weapons that we have. Yes, sometimes treatment in psychiatry feels like we are trying to kill a mosquito with a rocket launcher. But it is the only thing we have got and for some it can be a salvation, regardless of the collateral damage.

My psychiatry professor once said, “if there is an equivalent of hell on Earth, it would be in a soul of a depressed person.”  I could not agree more.

Severe mental disease is not a joke. It is not something that can be solved with a thoughtful late afternoon conversation, by reading a line or two from Coehlo, or by reciting a poem by Neruda. Sure, activities like those are great adjuncts and can help ameliorate the situation to a degree, but people who are in trouble often need and demand much more from us.

Let’s not forget that when we’re talking about mental disease we are talking about the state of a diseased brain (physical) and mind (cognitive/psychiatric), which is most likely due to a neurochemical imbalance within the central nervous system circuits. This imbalance needs to be medically treated, especially in cases where it severely interferes with daily living. For some people, psychotropic medication is their only hope and the only chance they are going to get. For some people these medications perform miracles. We do not have a right to deny them such a possibility.

References

  1. Angermeyer MC, Matschinger H. The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatrica Scandinavica. 2003;108(4):304-9. doi: 10.1034/j.1600-0447.2003.00150.x.
  2. Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, et al. Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica. 2012;125(6):440-52. doi: 10.1111/j.1600-0447.2012.01826.x.
  3. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. Jama. 2010;303(1):47-53. Epub 2010/01/07. doi: 10.1001/jama.2009.1943.
  4. Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database of Systematic Reviews. 2009(3). doi: 10.1002/14651858.CD007954.
  5. Leucht C, Huhn M, Leucht S. Amitriptyline versus placebo for major depressive disorder. The Cochrane database of systematic reviews. 2012;12:Cd009138. Epub 2012/12/14. doi: 10.1002/14651858.CD009138.pub2.

Featured image:
Reeve041788 by Otis Historical Archives National Museum of Health and Medicine

Categories
Clinical Opinion Public Health

The Opiate Epidemic: A tragedy for patients is a warning to physicians

As student doctors, we are entering the medical field in the middle of a raging wildfire: an “opiate abuse epidemic.”[1] The media would have us believe that addicted patients are perpetuating the problem of opiate misuse and overuse, but opiate misuse and overuse might only be a symptom of a larger problem: a medical culture in which physicians fail to practice good prescribing habits.

Overprescription and subsequent overuse of opiates is undoubtedly further complicated by the ambiguous disease process of chronic pain, a topic which deserves its own time and attention. Questioning provider prescribing practices, however, may be the only path forward in making sure that the tragedy of this crisis does not escalate further. In my mind, there are several features that characterize ideal, quality prescribing habits. First, quality prescribing should place an emphasis on patient education about the drug being proposed. A patient should also be screened for the risk of developing any side effects. Included in this should be a review of any other medication that the patient is currently taking, and potential drug-drug interactions. If necessary, a pharmacist should be involved in this evaluation. Finally, a plan between the physician and the patient to manage care should be established. For medications known to be highly addictive, this might involve a phone call a week later, and a follow up in-office appointment to see how the patient is reacting to the prescribed drug. If at any point these benchmarks for safely prescribing a medication cannot be met, then the treatment choice should be reevaluated.

It was curious timing that in the middle of this epidemic, on May 5, Hawaii House Bill 1072 quietly died in the Hawaii state senate.[2] Bill 1072 “Relating to Prescriptive Authority for Certain Psychologists,” was meant to allow psychologists to have medication prescribing privileges in order to compensate for the Hawaiian physician shortage.[3] At first, I was relieved to read that the bill had not passed the Senate. As a future physician, it’s unsettling to imagine another profession encroaching on the special modalities that we have at our disposal to treat patients, such as our prescribing privileges. But then I had a second thought. If the average physician fails to exercise high-quality prescribing practices, then perhaps clinical psychologists, who by definition study human behavior, might actually make better opiate prescribers than the average physician. In general, psychologists spend time listening and learning about their patients’ history and behavior patterns, offer counseling education, and meet with their patients on a regular basis. This model of health care encompasses many of the aspects needed for ideal prescribing habits, as previously described.

You don’t need a medical degree to understand that opiates are powerful drugs that have many side effects and can lead to addiction.  What we don’t yet seem to understand, as a profession, is how to effectively communicate these risks, or evaluate the best patient candidates for the use of opiates. A 1992 study by Wilson et al. found that when physicians increased the time of their patient interactions by just 1.1 minutes, there was a statistically significant increase in the amount of health education that a doctor could incorporate into a standard visit.[4] While it’s difficult to get specific data about the average length of a typical doctor’s visit[5], a 2013 article from the New York Times suggests that the average new physician spends only eight minutes with each patient.[6] If you have ever participated in a standardized patient encounter as part of your medical school curriculum, you have undoubtedly experienced the struggle to perform a history, physical exam, and basic patient counseling in 14 minutes. When you take into account the level of patient screening and education that the prescription of opiates, or any narcotic, demands, it seems implausible that a doctor can satisfy the requirements necessary to safely discharge a patient with an opiate prescription in such a short span of time.

In response to the opiate crisis, the ultimate long-term goal for the medical community should be to better understand chronic pain, and devise alternative treatment modalities for this diagnosis. In the meantime, however, the medical community should view this unfortunate situation as a call to reevaluate the quality of our prescribing practices. Current and future doctors need to commit ourselves to being worthy of the privilege of the prescription pad, so that it remains a treatment tool and not a source of patient harm.

References:

  1. http://www.cnn.com/2016/05/11/health/sanjay-gupta-prescription-addiction-doctors-must-lead/index.html
  2. www.civilbeat.com/2016/05/2016-session-ac-for-schools-help-for-housing-and-homeless/#.VyzIubQqa3o.mailto
  3. http://capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1072&year=2016
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881485/
  5. http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/the-duration-of-office-visits-in-the-united-states-1993-to-2010
  6. http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/

Featured image:
Medication by Gatis Gribusts

Categories
Emotion Opinion Poetry

A poem

With our white coats on we feel the aura of pressure.
Pressure to be professional, to act accordingly.
We walk through the hospital with our heads held high, knowing we have a duty.

Tossing our white coats aside, true personalities shine through.
Most are gleaming of kindness and enthusiasm to learn,
Others are tainted.
These souls strive to reach a level of professionalism behind their white cloak,
but fail to reach expectations while unhidden.

What I see frightens me,
because these individuals will one day be responsible for the lives of others.
They lie to professors to get what they want.
They come to mandatory sessions, only to depart minutes later.
They cheat.
They sell prescription drugs.
They abuse prescription drugs.
They get intimate in the study spaces.
They do it all with a cheerful face.

What I see frightens me,
because I never want to be like them.

What can be done?
I’ve tried to approach them,
it ended friendships.
Administration knows,
yet I see no change.

Perhaps most terrifying,
these individuals exist at all medical schools.
They hide amongst the rest of us,
polluting the image of our profession.

So here I stand, turning a blind eye,
but what can I do?
I can’t change the mindset of others.
I can’t change their actions.

I only hope they aren’t my doctor.

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Rainbow pollution by gambler20

Categories
General Opinion Public Health

The Policy on Policy: Why Medical Students Need to Learn About Healthcare

A 27-year-old woman is woken up by a sharp, stabbing pain in her lower right abdominal quadrant. She feels feverish, nauseous and weak. If you’re a medical student, you want to get a thorough history and test for a positive Murphy’s sign or rebound tenderness. You’re thinking it sounds like appendicitis. If you’re a doctor, you want to examine the patient and consider an appendectomy as a treatment option. You’re thinking of all the cases of appendicitis you’ve seen, and how well your education prepared you to diagnose and treat this condition. Except, none of that happens if this patient is never seen by a doctor. None of that happens if this patient instead, uninsured and unemployed and alone, decides to wait it out because it seems like her only option. None of that training in diagnosis and treatment makes any difference if that patient doesn’t have access to the care that could have saved her life.

The issue of healthcare policy is complicated, and oftentimes controversial, especially when presented in the framework of a political debate. As healthcare providers, however, the issue becomes less of a political one and more of an ethical one. The reported number of uninsured Americans ranges from 29 million1 to 45 million2, with tens of thousands of preventable deaths caused every year by lack of access to care3. That could mean a young woman dying of sepsis when her appendix ruptures, or an inmate asking a parole board to keep her in prison so she can continue to receive cancer treatment, or any number of similarly startling stories being told every day, across the country, about people who we know how to treat if we’re just given the chance.

A good resource for information on healthcare policy is the Commonwealth Fund’s 2014 analysis of our healthcare system compared to 11 other industrialized countries.3 The U.S. spends the most on healthcare per capita each year ($8,745), yet has the highest rate of potentially preventable deaths (96 per 100,000 people) and the highest infant mortality rate (6.1 deaths per 1,000 live births). Given the state of our broken system, it seems strange that medical students are essentially unaware of these issues until they enter the working world. Why are we not exposed to the struggles of healthcare policy in medical school? While it is certainly true that students are already saturated with information, it seems there are few subjects more universally applicable to graduates than learning about the system they will be working in.

To get an expert’s thoughts on the matter, I spoke with T.R. Reid, a leading author and journalist in the field of health policy. His bestselling book, The Healing of America, explores foreign models of healthcare and how we can learn from those systems to reform our policies at home. He currently serves as the chairman of the Colorado Foundation for Universal Health Care, which has recently placed an amendment on the 2016 ballot that would create the first state-initiated universal healthcare system by opting out of the Affordable Care Act.

 

Why do you think it is important to teach health policy in medical school?

The United States has the most complicated, the most inefficient, and the least equitable healthcare system of any rich country. Doctors are graduating into it and they don’t know what a mess it is… I think we need to prepare doctors for what they’re going to face. The second reason is, as a country, we need to fix our healthcare system. It’s ridiculously expensive, it leaves 33 million people uninsured, and the impetus to change has to come from doctors.

Health policy can be very broadly defined. What is the most important element of policy to incorporate into medical education?

The most important point is that a decent, ethical society should provide healthcare for everyone who needs it… In almost all other rich countries, healthcare is considered a basic human right and if you think about what a human right means, a human right is something the government is obliged to provide for you. You have a right to an education. You have a right to vote. If you get charged with a crime, you have a right to a fair jury, a fair judge, and a defense lawyer. We provide that because we’ve decided those are basic rights that every American ought to have. All the other countries say that’s also true for healthcare. If you’re sick and need medical care, you should get it and we have to provide it. The United States has never made that commitment… If you don’t make the basic moral commitment to provide healthcare for everybody then you end up with the American healthcare system, where some people get the world’s finest care in the world’s finest hospitals with no waiting, and 33 million people barely get in the door until they’re sick enough to go to the Emergency Room.

What changes do you foresee in the next ten years, or how do you think the current healthcare landscape will change by the time current medical students are actually in practice?

In the first place, I’m absolutely certain that we will get to universal coverage in our country and I believe we’re going to do it at a much lower cost than what we’re spending now. I’m quite optimistic that we’re going to improve our system. I think that’s going to happen… I don’t think we’re going to get there nationally. I’m convinced the way we’re going to get there is state-by-state…That’s how we got to interracial marriage, that’s how we got to same sex marriage, that’s how we got to female suffrage, that’s how we got free public education. It all starts in two or three states, the rest of the country sees that it works, and says ‘let’s do that’… The reason I’m confident in this is that we’re about to do it in Colorado. We got the initiative on the 2016 ballot. When people see a good idea working in some states, they copy it. Colorado is going to prove to the country that this can work, I hope.

As you’ve been campaigning in Colorado for universal healthcare, have you noticed that misconceptions about socialized medicine are still pervasive in public opinion? Does this influence people’s level of support or questions they raise?

The notion of limited choice and long waiting times in Canada is an issue for us…Our critics say ‘they’re going to bring Canadian medicine to the United States.’ Well, Canada covers everybody, they spend half as much as we do on healthcare, they have significantly better population health, they live longer, they have lower rates of neonatal mortality. But they still keep people waiting. I think it’s wrong to say we’re going to put the Canadian system here but that is a powerful argument…My answer is in fact Australia and South Korea have exactly the same model and they have shorter waiting times and broader choice than the United States.

In your book you examine foreign models of healthcare in detail and you described in a 2009 article in the Washington Post several ‘myths’ the American public believed about health care abroad4. Do you think American misconceptions have changed at all since the passage of the Affordable Care Act?

I think Americans still don’t like socialized medicine. Even if they don’t know what it is, they know it’s bad. That’s still true. Many Americans think other countries have limited choice and long waiting times, which is true in some countries, but many countries have broader choice and no other country has the kind of in-network, out-network business that our insurance companies have created. No other country does that…American companies and device makers say government intervention stifles innovation. I think there’s no question that in other countries regulations drive innovation. Cost controls drive innovation because they have to innovate to make their products cheaper.

If medical students are interested in health policy, how can they get involved and learn more, especially as things change?

The best way is what several medical schools have done, which is to put into the curriculum a course on health policy… I say this to every medical school dean I ever meet, ‘you ought to have a course on health policy’ and many of them say ‘I wish I could do that’ or ‘I’m thinking about it’ but some say ‘I’ve got four years to teach the entire human body and everything that can go wrong with it, don’t get me into that mess. It’s beyond our jurisdiction.’

Final thoughts?

Everybody who is sick should have access to healthcare in the world’s richest country. We have to fix this system and your generation of young doctors is going to be a powerful force for change.

 

Sources

  1. CDC National Health Interview Survey Early Release (2015)
  2. Institute of Medicine, National Academy of Sciences (2009)
  3. Commonwealth Fund (2014)
  4. Reid, T.R. “Five Myths About Health Care in the Rest of the World” (2009)

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Healthcare Reform Initiative Announcement by Maryland GovPics

Categories
Clinical Innovation Opinion Technology

The 21st century Frankenstein Revival

Background

Human head transplantation (the head anastomosis venture project – HEAVEN) has been for a long time merely a neurosurgical and medical theoretical concept that did not enjoy much attention among the medical community. However, in recent times, there have been voices trying to revitalize this question. Italian neurosurgeon, Dr. Sergio Canavero, is one of the most prominent protagonists in this regard. The idea behind this concept is to help people who have severe physical disabilities (such as neuromuscular dystrophies or tetraplegia), but have an intact head and brain. There is a vast array of medical, ethical and physiological questions and obstacles that are ahead of this endeavor. Despite a lot of skepticism, Dr. Canavero has laid out a couple of transplantation protocols he believes can get the job done. In these protocols, he tried to answer and address every possible challenge that is expected to occur during this delicate and immensely complex procedure. The main purpose of this short article is to analyze the crucial components of his protocols and try to determine if they have any rational scientific relevance and ethical/medical justification.

Why do it?

Before you chop someone’s head off, you’d better have some good reasons, right? This is fundamental. In medicine, conditions are treated if the potential benefits of the treatment outweigh the potential risks. For each particular disease state, there has to be a justified medical indication and logical/rational foundation behind treatment. This is the sine qua non of every medical intervention. You have to bear in mind that anything you do has to lead, ultimatively, to a better quality of life. In that regard, I doubt that this procedure would accomplish that goal  at the present moment and it principally acts as an academic exercise, albeit lethal one. I generally do not support doing things just for the sake of doing them, especially in medicine where such behavior can be costly and unethical. Sure, you can become hero of the day and act in a „told you so“ manner if things go your way, but what if they don’t?

Even if you theoretically manage to overcome the technical and technological barriers that are inherent to this procedure, the question still remains: will this person experience improved quality of life? Dr. Canavero’s logic is that people who suffer from severe and/or progressive neurological conditions, e.g. muscular dystrophy or quadriplegia, could potentially benefit from this procedure. How? Well, if your peripheral nervous system does not work but you do have preserved cognitive functions (brain and brain stem), then you would be able to theoretically join healthy brain with healthy body of a deceased donor. The idea is that this body would be donated by those people who were clinically confirmed as brain-dead due to, for example, severe head trauma, but still had a fully functional body to offer. On the other hand, the „recipient“ of the body would give an informed consent that he/she is willing to undergo a body transplantation procedure, regardless of a high risk that this procedure could end in death. In  popular jargon – „people who have nothing to lose“ are the group of people that are targeted as candidates for this procedure in Dr. Canavero’s opinion.

Feasability

Dr. Canavero laid out 2 operative protocols that provide a theoretical framework for this type of experiment. One of them is called HEAVEN1 and addresses head-to-body anastomosis, while the other is named GEMINI2 and features a spine fusion protocol. The physiological obstacles that Dr. Canavero needs to overcome in order to succeed in this endeavour are tremendous, but I will try to briefly tackle the 4 major ones.

  1. Brain perfusion problems – in only a few minutes post-decapitation, it is expected that neurons will be exposed to a hypoperfusive state, ultimately resulting in brain tissue death.
  2. Fusion of two ends of the spinal tract – this has never been done before in humans.
  3. Reparation and regeneration of neuronal connections and spinal tracts/projections within the CNS and the restoration of the motor and sensory functionality.
  4. Post-transplantation complications – this includes potential tissue transplant rejection reactions that are immunologically mediated.

Should we do it?

At this point, we just do not know enough about the proposed procedures. Some of them have been performed on animal models and some were done only in a Petri dish. Results obtained through animal experiments and in-vitro molecular models might not correlate (and most commonly they don’t) with human physiology. In the early 1970s, American neurosurgeon Robert Joseph White performed the first monkey head transplantation onto a body of another monkey3. The recipient monkey lived for 8 days, and there were no surgical complications encountered. However, the monkey was quadriplegic since the surgical protocol did not address the problem of spinal fusion4. This resulted in a monkey who was completely paralyzed from the neck down, but who could still eat and follow objects with its eyes since the cranial nerves, brain stem and other brain structures were intact and perfused by the circulatory system of the donor’s body. Moreover, it was reported that the transplanted head could hear sounds and smell/taste food. However, immunologic reactions in the form of graft rejection ensued and the monkey died from them.

In this regard, Canavero’s protocol is essentially just a „compilation“ of biotech solutions for a wide spectrum of problems in medicine. Successful translation of any of these theoretical concepts into the clinical arena would be a giant leap in medicine. However, strictly lege artis, there is no strong evidence that these techniques will be successfull at all. Patients undergoing this procedure could be left in much more catastrophic and miserable conditions than those endured prior the procedure. Transplantation of a human head onto a new human body should not be perceived merely as transplanting a flower from one pot to another. We do not know how the brain would interact with the new neurochemical and biochemical milleu of the body that it just received. How would the brain integrate and process new signals arriving from the newly discovered periphery? How would the brain process perception and information coming from these new muscles and other body structures? These problems were emphasized in a recent letter written by Dr. Cartolovni and Dr. Spagnolo, published in the Surgical Neurology International journal. In this letter, the authors argue that Canavero’s perception of the human body functional framework is strictly mechanistic, and largely disregards the importance of body self-cognition, which plays a real part in the formation of human self.

Additionally, they state that head transplant procedures raise significant social and ethical problems in terms of organ donation. A leading medical ethicist, Dr. Arthur Caplan from NYU’s Langone Medical Center, states that the implications of this procedure are far-reaching and extremely dangerous from the ethical and medical standpoint. Similarly, Dr. Jerry Silver from Case Western University states that he perceives human transplants as a barbaric method at this point in time. Moreover, he said that he does not expect such procedures to be successfully performed for at least the next hundred years.

In my opinon, we are not ready for this type of procedure, at least in light of the most recent evidence-based medicine. Even if the tremendous technical difficulties could be surpassed, it still remains a question how the brain (center) would integrate with the periphery. At this point, I assume that the brain would be overwhelmed with the amount of input that it would receive from the periphery, ultimately leading the transplant recipient to derangement, pain and insanity. The prospects of this experiment are simply grim and unfavorable, with our present knowledge and, therefore, I would advocate for its halt.

References

  1. Canavero S. HEAVEN: The head anastomosis venture Project outline for the first human head transplantation with spinal linkage (GEMINI). Surg Neurol Int. 2013;4(2):S335-42.
  2. Canavero S. The „Gemini“ spinal cord fusion protocol: Reloaded. Surg Neurol Int. 2015;6:18.
  3. White RJ, Wolin LR, Massopust LC Jr, Taslitz N, Verdura J. Primate cephalic transplantation: Neurogenic separation, vascular association. Transplant Proc. 1971;3:602-4.
  4. White RJ. Hypothermia preservation and transplantation of brain. Resuscitation. 1975;4:197-210.
  5. Čartolovni A, Spagnolo AG. Ethical considerations regarding head transplantation. Surg Neurol Int. 2015;6:103.

Featured image:
Floating head, neck redone by TaylorHerring