Category: Public Health

Categories
Clinical Emotion Public Health

The Day I Took off my White Coat

The man in scrubs stands in the middle of the room. He has a blood-filled syringe in one hand and hand-written lab notes on the back of an envelope in another. He scans the room, looking for someone or something. I follow his gaze. A young man is curled up in a ball on the floor, rocking himself back and forth while groaning in pain (gangrenous wound on leg). A man is throwing all his weight on his wife and yelling in pain (renal colic). A woman is holding a piece of red, soaked gauze tightly on the hand of her screaming 7-year-old son (amputated finger). An older woman in a wheelchair is drooling from one side of her mouth and has a drooping shoulder (stroke). A young man, handcuffed to a police officer, has circular marks around his neck and blood dripping from his mouth (suicide attempt with hanging and ingesting barbed wire). A young woman sits limply in a wheelchair, eyes rolled back, and blood on her clothes between her legs (severe anemia – abortion days prior). In this room no bigger than my mother’s walk-in closet, the suffering is palpable and audible, but the man in scrubs does not find what he is looking for, and begins to walk out. Before he reaches the door, an unconscious man is carried in to the room (antifreeze ingestion). Without missing a step, he reaches over and gives the man a rough sternal rub to wake him up, to no avail. He exits the room.

The man in scrubs is the sole medical resident in charge of the stabilization and triage of incoming patients at this Emergency Department situated in a Low and Middle Income country. As a visiting medical student, I am wearing a white coat, and although I should fit in, my general ignorance about the majority of relevant things makes me feel like an imposter. I shouldn’t be here. I shouldn’t be wearing this white coat.

‘You! You can help me!’ exclaims a woman in a wheelchair as she reaches towards me. Her face is covered, but somehow I know that she is in pain. Reluctantly, and with as much grace as a fish on land, I walk towards her. I walk towards her knowing that the only care I can provide is a hug, a tear, or a smile; the only prescription I can write is a kind word, and the only order I can put in is a prayer to the heavens.

I came to medical school to gain the skills that I need to better care for my neighbors, to share moments of humanity, of suffering and healing with my neighbors, to be meaningfully curious – to ask and answer questions that benefit my neighbors and our community, and to use medicine as a platform to implement meaningful social change. The irony is, I see none of that now; all I can do is stand defeated as I watch my neighbors suffer. I watch because I don’t have the money to cover the 15 pounds admission fee for every patient that is turned away at the door of the ED. I watch because I don’t know whether that comatose child who was just intubated is in trouble because his stomach is inflating instead of his lungs. I watch because I don’t know if that medical student just injured that woman’s radial nerve while trying to get an arterial blood sample.

With tears in my eyes, I fumble out of my white coat and head for the exit. I’m done watching, I tell myself. I’m done watching and I’m ready to learn. I’m ready to learn how to care for the suffering. I’m ready to be a part of the change I want to see in the world. As the door of the ED closed behind me, I managed to catch a final peek of the chaotic scene, as if to tell myself, ‘I will return when I’m ready.’

Looking back, I wish I had kept my white coat on, even if just to care with a tear, heal with a kind word, and pray for the well-being of my neighbors.

Photo Credit: Alex Proimos

Categories
Clinical General Public Health

Medical Residents: A Dream Career Can Be Yours If You “Choose Sleep”: Dr. Ilene Rosen, President of the American Academy of Sleep Medicine

Now is the time that many medical residents are considering future plans, and hopefully giving thought to a sleep medicine fellowship. The truth is, we need you. Millions of Americans suffer from chronic sleep disease, and now more than ever there is an increasing demand for sleep physicians. As awareness of sleep health increases, millions of new patients will be seeking evaluations from sleep physicians.

Sleep medicine is an intriguing field with long-term growth potential and the opportunity to have a positive effect on the health of a huge population of patients. By diagnosing and treating sleep disorders, you can directly improve patients’ health and quality of life. In addition, because sleep is still a relatively young field, many research questions still exist. These questions can lead to involvement in cutting-edge basic, translational, and clinical research.

As a new sleep medicine physician, you may have the opportunity to practice in diverse settings. Opportunities abound in teaching hospitals, community hospitals, and independent sleep centers, allowing you to cultivate a work schedule that best fits your lifestyle. In addition, you can expect a call schedule that is quite manageable, as trained technologists at an accredited sleep center monitor most overnight sleep studies, and patients often self-administer their own sleep studies at home.

Another great thing about sleep medicine is the constant collaboration. As a sleep specialist, you will work closely with physicians from other disciplines and lead sleep teams of other health care providers – including nurses, physician assistants, psychologists and technologists. You may find many opportunities to collaborate with multidisciplinary teams, treating patients in coordinated efforts using the latest technology. I think you will find these collaborations eye-opening and educational.

So, the choice is yours and the options are plentiful to pursue your dream career, just as I did. There are 83 sleep medicine fellowship training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Learn more at www.ChooseSleep.org.

Categories
Public Health The Medical Commencement Archive

“Circles of Compassion”: Dr. Kinari Webb, 2017 Commencement Address of Yale School of Medicine

This week, the Commencement Archive features Dr. Kinari Webb’s speech titled “Circles of Compassion.” She delivered the keynote address at the 2017 Yale School of Medicine Commencement.

Kinari Webb, M.D. is the founder of Health In Harmony, an organization that establishes links between the health of humans, ecosystems, and the planet in order to solve problems of poverty, poor health, and environmental destruction. During a life-changing experience in Indonesia studying orangutans, Dr. Webb encountered not only a beautiful and threatened natural environment, but also the dire health needs of the people surrounding the National Park. After her experience in Indonesia, Dr. Webb decided to become a physician and return to Indonesia to work together with local communities to improve their health and preserve their natural environment.

After graduating from Yale University School of Medicine with honors, Dr. Webb completed her residency in Family Medicine at Contra Costa Regional Medical Center in Martinez, California. Dr. Webb founded Health In Harmony in 2005 to support the combined human and environmental work that she planned in Indonesia. After a year of traveling around Indonesia looking for the best site for this program, Dr. Webb co-founded the ASRI program in West Kalimantan Indonesia with Hotlin Ompusunggu and Antonia Gorog. Dr. Webb currently splits her time between Indonesia and the U.S.

 

Dr. Webb did not take the typical path towards a career in medicine. She went—as she simply puts it—“against the grain.” Despite excelling as a top student at a top-tier medical school, she was drawn back to Indonesia, where she previously studied orangutans as an undergraduate. This time, however, she returned with a much greater vision: using medical approaches to improve the health of humans and the planet.

Dr. Webb argues that our medical knowledge base and clinical skills are applicable to all species:

“I first came to know just how profoundly lucky I was during the year that I spent deep in the rain forest of Borneo when I was 21. I discovered there that people were often forced to cut down rain forest trees in order to pay for health care. I found myself feeling angry and deeply sad that such an injustice was occurring in the world. After residency I founded a non-profit called Health In Harmony and I have spent the last twelve years working on this issue. You may not have thought of your stethoscope as a tool to help heal the lungs of the earth – otherwise known as the rain forest – but it turns out it can be.

Your medical skills have all kinds of unexpected powers and I want to argue that we actually all need to become planet doctors. We are at an unprecedented time in the 4.6 billion year history of the planet: this is the time when a species that actually has the capacity to understand what it is doing is dramatically altering life on earth. And the health of our planet is the greatest threat to your patients’ health that they are likely to face over your career. Without a stable climate, enough drinkable water, food to eat, and healthy air you will have a very hard time keeping your patients well.”

Before I finished reading Dr. Webb’s speech, I found myself on her organization’s website, out of sheer curiosity. Health In Harmony is unique because of its dual efforts to promote environmental and healthcare reform in rural, impoverished communities across the globe. From training organic farmers to establishing tuberculosis treatment programs, the organization substantiates the role of “planet doctors”, one of whom Dr. Webb considers herself.

As Dr. Webb continues in her speech, she discusses the steps necessary to further a career as a physician, which she refers to as “Circles of Compassion.” The first circle emphasizes self-care. Regardless of the direction a career takes you, Dr. Webb argues that you are the most important patient.

“The first circle is caring for yourself. Most of you are about to go into indentured servitude, so this isn’t going to be easy. I remember massive sleep deprivation, feeling pushed beyond the limits of my skills, terrified I’d make a mistake, and being right in the middle of profoundly traumatic experiences. I encourage you to prioritize taking time to soothe and care for your body and soul even in the midst of all that. In my own journey of personal and spiritual growth, I have found help in faith communities, meditation, time with loved ones, therapy, and maybe most especially, being in nature. There might be nothing better for healing the soul.”

Dr. Webb’s next circle of compassion underscores the care we provide to patients:

“As a doctor, the second circle of compassion beyond you and your family is caring for your patients – both their physical well-being and their capacity to be their fullest selves. In Borneo, when we hire medical staff, we are looking for people who know they don’t know everything, who will be life-long learners, and most especially we want providers who will care for their patients as though they were their own family.”

Dr. Webb leaves the audience with the following concluding remarks:

“I wish to leave you with three key points:

First, don’t be afraid to take the road less traveled – or as my classmate Margaret Bourdeaux used to say: the deer path less traveled. The expectation superhighway is hard to resist but if you can see it all laid out in front of you, it likely isn’t your path. And this earth needs all of us to do whatever we are most passionate about – even if your deer path leads you to beautiful North Dakota.

Second, compassion matters. It starts with you, it spreads to those around you, and then to the whole planet.

Third, I encourage you to ask yourself: “Am I willing to be one of the sacred planetary healers that the earth so greatly needs?”

Congratulations again on this amazing accomplishment. May you go forth and heal!”

Read the full speech in the Commencement Archive: https://www.themspress.org/journal/index.php/commencement/article/view/291/308

Categories
General Law Lifestyle Public Health

Keeping Abreast of Lactation Laws

“Infant forced to go without milk, Mom says it’s not her fault.” This seems like the kind of terrifying headline that would be on the five O’clock news. Yet this is exactly what happens every day when the rights of women to breastfeed or express milk on the job go unprotected. One politician, Representative Carolyn Maloney (D-NY), has made it her mission to make sure that women can breastfeed without repercussions. I have to admit that when I first heard about Representative Maloney’s Supporting Working Moms Act, I was baffled to think that in the year 2017, breastfeeding in the workplace could cost a woman her livelihood. With a little research, I started to realize just how ill-informed I was on the legality of breastfeeding.

I was surprised to learn that currently, no federal legal protections exist to protect public breastfeeding. Furthermore, only 47 states have laws that legalize public breastfeeding.[1] Of those states, Michigan’s law is a mere three years young. Astonishingly, Iowa offers no legal protections for breastfeeding. Even though public breastfeeding might be legal in most states, it wasn’t until 2010 that breastfeeding in the workplace received its own set of protections. A federal breastfeeding provision called “Break Time for Nursing Mothers,” which was added as an amendment to the Affordable Care Act (ACA), makes it mandatory for companies with 50 employees or more to provide “reasonable” break time for women to express milk during the first year of their child’s life. This same provision also requires companies to provide a clean and dedicated space for breastfeeding in the workplace.[2] However, this provision only ensures the rights of “nonexempt” workers, meaning only those who earn hourly wages as opposed to salaries are protected. Even with the laws that protect the right to breastfeed in public, women can still face repercussions that range from fines to docked pay to even termination as a direct consequence of breastfeeding in the workplace . With the ACA in jeopardy of being repealed (possibly by the time this article is published), the future of breastfeeding is more vulnerable than ever. The Supporting Working Moms Act is meant to provide federal breastfeeding laws independent of the ACA, as well as expand protection to 12 million additional women, including public school teachers.[3]

The issue of breastfeeding is close to my heart, not only as someone who hopes to one day become a mother, but also as a future physician: I know the powerful impact that breastfeeding can have on a child’s health. In their policy statement on the use of human milk, the American Academy of Pediatrics affirmed their position that infants should be breastfed exclusively for the first six months of their lives whenever possible.[4] Breastfeeding can be challenging for a number of reasons, and it is important to respect the fact that not all mothers are able to breastfeed their children. However, for those who can and choose to do so, the benefits can be profound for both the mother and the child. According to the National Institutes of Health, breastfeeding helps infants fight infection, lower their risk of Sudden Infant Death Syndrome, and could possibly serve as a protective factor against developing asthma, allergies, and even diabetes.[5] Studies show that babies who are breastfed attain better educational achievement than their non-breastfed peers by the age of five.[6] From an economic perspective, breastfeeding has been shown to lower healthcare costs by reducing disease burden in the population.[7] Even though many of us will not be pursuing careers in obstetrics, at some point in our careers, we will all establish some connection to a new mother, whether she is your patient, your partner, or yourself. Being informed about the legality of breastfeeding can help us to provide these women with support and guidance and make sure that our littlest patients have the healthy start in life that they deserve.

References:

[1] http://www.ncsl.org/research/health/breastfeeding-state-laws.aspx

[2] https://www.dol.gov/whd/nursingmothers/Sec7rFLSA_btnm.htm

[3] https://maloney.house.gov/issues/womens-issues/breastfeeding-0

[4] http://pediatrics.aappublications.org/content/129/3/e827

[5]https://www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/benefits.aspx

[6] https://ora.ox.ac.uk/objects/uuid:13bde0c7-0070-43c6-9ae3-307478e8c42c

[7] http://www.reuters.com/article/us-breastfeeding-study-idUSTRE6342ZG20100405

Photo Credit: Roberto Saltori

Categories
Emotion Empathy General Humanistic Psychology Narrative Public Health

Guter Mann

This city is so peaceful. As the bikes whiz by, I notice the absence of the cacophony and polluting fumes of traffic. I’m walking down the sidewalk in brown leather shoes and a tucked-in dress shirt while eating bougie gelato. I love gelato. I look up and notice the blue sky. It’s a deep blue and the clouds have distinct borders. I’m in Salzburg, Austria for a conference and I’m loving this city. Just as I marvel at the clean streets and begrudge the abundance of luxury vehicles, I turn the corner and see my sister on the floor asking for money. I immediately cross the street and reach in my pocket to hand her the change I received at the gelato stand. My sister is donning the flag of Islam on her head and I greet her with the anthem of Islam, a greeting of peace. She smiles and says, “Allah yijzeek al-khayr” – God reward you with the good. As I walk away, I smile at the beauty and seamlessness of our interaction.

I continue walking back to the conference hall. I review my rehearsed words as I finish my gelato. My presentation is on the data I generated regarding the controversial use of bisphosphonate anti-resorptives in the setting of chronic kidney disease mineral bone disorder. The nephrologists in the crowd won’t be too thrilled. In my head, I am considering all the different questions I could be asked, when I see another of my friends on the corner of an intersection. As I approach him, he brings his hands together and bows his head. When he raises his head again, I smile at him. I don’t have any more change so I reach into my pocket and hand him 5 euros. He has a cup in front of him, but I decide to hand him the money. I think this might make the money more of a gift than a charity. I can see hurt in his eyes as he tries to find a way to thank me. Reaching out I put my hand on his shoulder and squeeze, pointing up with my other hand, trying to tell him that I will pray for him. While my hand is on his shoulder, he turns his neck and kisses my hand. I say, “No, no!” and withdraw my hand. I feel ashamed. I know I should be the one kissing his hand for accepting my miserly gift of 5 euros while knowing full-well that I have another 10 laying comfortably in my pocket. Ten euros that I will, over the next couple hours, undoubtedly spend on a sacherwurfel from the bakery next to my fancy hotel and then on another helping of overpriced gelato.

Lost in my thoughts of embarrassment, I begin to walk away, and as I do, he yells in German, “Guter mann!” – good man. Halfway across the street, I think to myself, I may not be a good man, but I have the opportunity to try, and so I turn back around.

Ten euros was all the money that I had left on me. But 10 euros was all it cost to earn the respect and love of a man I had only met minutes ago. Excitedly, the man begins to talk to me in German. His name is Damien. (We spend a good 5 minutes on my name. I would say, ‘Mo-ham-mad’, and he would then repeat after me, ‘No-han-nam’). Damien is a father of 3 kids. He was doing well for his family until his wife lost her vision. He said, “Now my heart is still good, but children’s stomachs are empty, so my hand is outstretched.”

I notice the tears in my eyes. I had never heard German spoken before, and I shouldn’t know what he’s saying to me, but I understood every word. Home is where the heart is, and this man is my neighbor. As I leave Damien for the second time, I point up again and then turn my palms up to the Heavens in prayer. He says, “Allah.” And I repeat, “Allah.”

On my second day in Salzburg, I take the long way to the conference center, hoping to run into my friend Damien. I turn the corner and there he is, sitting at the end of the block. My stride lengthens and my steps quicken. As I approach him, I see him leaning left and right, squinting his eyes; he’s trying to see if it’s me. He leaves his corner and yells, “Nohannam!!” while jogging towards me and we embrace each other as brothers and lifelong friends. And as my neighbor and friend embraces me, I realize I may not be a good man, but Damien is willing to show me how to become one.

Photo Credit: Sam Rodgers

Categories
Clinical Lifestyle Public Health

What’s the Deal with Vaginal Breech Delivery?

Back in May, I attended the 2016 American College of Obstetrics and Gynecology (ACOG) Annual Scientific and Clinical Meeting in Washington, D.C. On my first day, I watched Dr. Annette E. Fineberg, a board certified obstetrician and gynecologist from Sutter Davis Hospital in California, present a short film on upright vaginal breech delivery. The movie featured a woman at term deliver in the operating room by resting on all fours on her hands and knees. She swayed her bottom from side to side in order to promote fetal descent and as a way to cope with pain, as she did not receive an epidural. The baby crowned, bottom first, and then slowly spontaneously delivered its legs, trunk, arms, and finally, head. A successful vaginal breech delivery (VBD)!

Ever since watching that amazing film, I have been interested in reading and talking about VBDs. But on the residency program interview trail, I have begun to notice a trend that some providers seem to have strong, negative attitudes regarding VBDs of singletons. One person even glared and incredulously responded, “No one in the country does those.” I think Dr. Fineberg and the other clinicians I have met that do would disagree.

But I do wonder why providers feel so strongly about a particular position regarding more controversial topics in reproductive health. In regards to vaginal breech delivery, I think that a big prejudice is the absolute horror stories every seasoned OB/GYN has to tell about the time they saw a baby’s head get stuck. These accounts are upsetting, sad, and help explain why someone might think me ridiculous for even asking about training in vaginal breech delivery.

The most common response, though, that I receive is something like, “We don’t do those. But you will probably not find many programs that do since ACOG does not recommend vaginal breech deliveries.” This reply is less emphatic and more accurate if following the 2001 ACOG committee opinion, which states, “planned vaginal delivery of a term singleton breech [is] no longer appropriate.”1 The reasoning in 2001 was largely based on results from the Term Breech Trial, a large, multi-institution, randomized control trial comparing planned vaginal birth with cesarean deliveries for term singletons with breech presentation. This study indicated that neonatal morbidity and mortality significantly increased with vaginal breech versus cesarean section delivery.2

Since the 2000 Term Breech Trial, clinicians have begun to question if vaginal breech deliveries should have a strict ban. Instead, there is evidence suggesting that vaginal delivery is a safe option in select women with breech presentation. The authors of the Term Breech Trial performed two prospective studies in which they examined maternal and child outcomes at both 3 months and 2 years post-partum. At two years post-partum, there was no longer a difference in mortality nor neurodevelopmental delay in the children born by vaginal breech delivery versus cesarean section.3 Retrospective studies with specific protocols similar to those described in the Term Breech Trial have shown excellent neonatal outcomes for vaginal breech delivery of term singletons.4-6 In 2015, Berhan and Haileamlak published a meta-analysis of 27 articles with a total population of 258,953 women comparing the morbidity and mortality of term singleton breech mode of delivery between 1993 and 2014. While the relative risk of perinatal mortality and morbidity was 2-5 times higher in planned vaginal delivery versus cesarean, the absolute risks of several variables, including perinatal mortality (0.3%) and fetal neurologic morbidity (0.7%), were low.7

In the updated committee opinion on vaginal breech delivery published in 2006 and reaffirmed in 2016, ACOG states that “planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.”8 The Royal College of Obstetricians, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Society of Obstetricians and Gynaecologists of Canada report similar recommendations.9-11 According to the ideal candidate for a term, singleton vaginal breech delivery is the following:12-14

  • Frank or complete breech presentation with flexed or neutral head attitude;
  • Estimated fetal weight between 2500 and 4000 grams;
  • A patient willing and comfortable with a trial of labor;
  • Clinically adequate maternal pelvis.

Contraindications to vaginal breech delivery are categorized as a fetal, maternal, or provider factor:12-14

Fetal Factors

  • Incomplete breech;
  • Hyperextended neck;
  • Cord presentation;
  • Fetal growth restriction or macrosomia;
  • Congenital anomaly incompatible with vaginal delivery (e.g. thyroid mass).

Maternal Factors

  • Patient unwilling to attempt/uncomfortable with a trial of labor;
  • Clinically inadequate maternal pelvis;

Provider Factors

  • Lack of operator experience.

Obstetrics governing bodies agree that external cephalic version—whereby a provider uses their hands on the abdomen to rotate the fetus in utero from breech to vertex presentation—should be recommended and attempted first before considering vaginal breech delivery. And all leading sources recommend that an experienced provider needs to be leading the delivery.

But if there are few opportunities in residency to practice vaginal breech delivery, how will there BE any future providers who qualify as experienced?

First and foremost, I hope to enter a residency program that provides me with the training I need to be a competent women’s health provider. But I also intend to seek training in vaginal breech deliveries, whether it is via simulations—which RCOG notes is an appropriate way to build experience 9—or via an elective at another institution where there may be further opportunities. My goal is twofold: (1) offer the best individual options for mode of delivery to my future patients; and (2) help lower cesarean section rates in the United States. Hopefully, I will get the right match!

References

  1. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.340: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2006 Jul;108(1):235-7.
  2. Hannah ME, Hannah WJ, Hodnett ED, Saigal S, and Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet. 2000;356(9239):1375-1383.
  3. Whyte H, Hanna ME, Saigal S, et al Term Breech Trial Collaborative Group, Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191:864-871.
  4. Guiliani A, Scholl WM, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol. 2002;187:1694-8.
  5. Alarab M, Regan C, O’Connel MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407-12.
  6. Borbolla Foster A, Bagust A, Bisits A, Holland M, Welse A. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Autralian and New Zeland Journal of Obstetrics and Gynaecology. 2014;54:333-339
  7. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: A meta-analysis including observational studies. BJOG 2015: DOI; 10.1111/1471-0528.13524
  8. American College of Obstetrics and Gynecology. ACOG Committee Opinion No.265: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2001 Dec;98(6):1189-90.
  9. Guideline No 20b: The Management of Breech Presentation. Oxford: RCOG, 2006.
  10. Kotaska AK, Menticoglou S, Gagnon R. SOGC Clinical Practice Guideline No. 226: Vaginal Delivery of Breech Presentation. JOGC. June 2009.
  11. RANZCOG, Cobs-11: Management of the Term Breech Presentation. Melbourne: RANZCOG, 2009.
  12. Hofmeyr JG, Lockwood CJ, Barss VA. Overview of issues related to breech presentation. UpToDate: Accessed 10/11/2016
  13. Hofmeyr JG, Lockwood CJ, Barss VA. Delivery of the fetus in breech presentation. UpToDate: Accessed 10/11/2016
  14. Secter MB, Simpson AN, Gurau D, et al. Learning from Experience: Qualitative Analysis to Develop a Cognitive Task List for Vaginal Breach Deliveries. JOGC 2015

Photo credit: MIKI Yoshihito

 

 

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/

Featured image:
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
General Narrative Public Health

Storytelling and Patient Advocacy

Yesterday, I received a perfectly-timed message on a group thread. My friend wrote that she loves patient advocacy.

“Me too,” I thought, as I filed away notes from a Planned Parenthood of Southwest and Central Florida Meeting hosted by the Leadership Action Team (LAT). What was the purpose of that meeting? To train volunteers on how to employ storytelling in their advocacy work. Planned Parenthood trains all of its staff members, and now volunteers, in the “Story of Self” curriculum created by Get Storied® , which is a program designed to teach businesses how to create social change through the art of storytelling.

The meeting began with introductions and a moment to safely process the recent shooting in our hometown. A young volunteer explained how the event affected her and her family:

I learned about the shooting on Facebook…And honestly, all I saw was, ‘Massive Shooting,’ and thought, ‘Oh, another shooting,’ and kept scrolling. I didn’t understand the gravity of the situation, until that night while watching the news with my mom. I looked over at my mom and she was crying. She just said, ‘I am afraid for you.’ She’s never before expressed concern about my activities. But now she says, ’I am afraid for you.’

This volunteer was young, but her voice carried a surprising amount of assuredness. I felt her confusion and fear. The next attendee shared their story, and then the next, and so forth as the meeting progressed.

We learned that there are three key components to one’s story of self: a challenge, a choice, and an outcome. Zac, the chair of the LAT, shared his story of self, which described the healthy relationship with his mother and the openness with which she educated him regarding sexual matters when he was an adolescent male. The two-to-three-minute story, complete with a joke about educational materials containing graphic penis pictures, ended powerfully with the line,

When I walk into a Planned Parenthood, it’s the same kind of environment my mom created for me for talking about sex.

We received our first assignment, which was to reflect on the experiences in our lives that have shaped the values which call us to leadership. The program will later have us refine the various details of our stories, practice in one-on-one and group sessions, identify ways in which we plan to use storytelling in our advocacy work, and take action. We had five minutes to silently reflect.

Ok, what is my campaign? Women’s health. Yeah, but what specifically? To help women access and achieve the best reproductive health care possible. Nice. So why do you want to do that? Because reproductive health is the most important thing in the world! Ok, but why?

Figures of maternal morbidity and mortality popped into my head. I could see again the absence of a clitoris and labia in my Nigerian patient who underwent female genital mutilation as a young girl. I remembered the way the vaginal introitus feels beneath my hands—stretched and strong—as a baby’s head begins to crown. The voice of an adolescent girl echoed, “I mean I want to have sex, but like, I’m not a slut.”

It is easy for me to think of patient stories that depict why I am pursuing a career in Obstetrics and Gynecology. But a story of self is just that. A story of SELF. I struggled to think of inspiring personal experiences.

Time is up! No.

Each person in my small group shared their story and received feedback. My turn circled around and I rambled on about women’s health. I managed to state two strong lines, “I volunteer at Planned Parenthood because it still remains the one place to offer judgement-free care. Not even my own gynecologist can say that.” But my story lacked focus and a compelling personal example.

That night after receiving my friend’s text, I began to think more about the meaning of patient advocacy. As a medical student, I think my primary role in patient advocacy is to ensure that my medical team knows about our patients’ health histories and needs. During my internal medicine/family medicine clerkship, in order to help care for a patient, I compiled a short document of excerpts from the World Health Organization, Centers for Disease Control, and American College of Obstetrics and Gynecology regarding HIV prophylaxis treatment in pregnant women with negative HIV status who have regular, unprotected sex with an HIV positive partner. In that instance, helping my resident defend her treatment plan was my way of advocating for my patient’s health. Patient advocacy means that I volunteer monthly to escort patients safely into Planned Parenthood clinics. It is the reason why I study exercise and pregnancy, so that I can advocate for pregnant athletes seeking to find a balance in the pre- and post-partum periods. Additionally, patient advocacy means that I write on the MSPress Blog about topics that matter.

Stories in medicine can break stigma, help people relate to the struggles of others, and empower someone to raise their voice.  Stories identify why we should care about an issue, and can inspire others to take action. Although I do not yet have an organized understanding of the many personal experiences that inspire me daily to fight for reproductive health care, I think I am well on my way to becoming a strong patient advocate. Fortunately, I do have a clear goal: support the improvement of access to reproductive healthcare and higher quality of reproductive healthcare for all.

Quoted persons in this paper gave permission to be on the record.

Featured image:
Story by Alexander Affleck