Thursday, March 29, 2012

Reproductive Rights -- and wrongs

The “debate” on reproductive rights has taken a turn to the far right with recent laws passed in several states that create greater obstacles for women who wish to obtain abortions. Probably the most famous commentary is a series of Doonesbury strips that ran (or didn’t run, or ran on the editorial page, depending upon your hometown paper) from March 12-16. Its focus is the Texas law requiring, among other things, that women have a transvaginal ultrasound examination before obtaining an abortion. It also requires that they receive “counseling” scripted not by their physician but by the state legislature and governor (see the final strip in the series, March 16).

Unquestionably, the “Doonesbury” strips are effective but face an uphill struggle in the effort to counterbalance the extremely well-funded efforts of right wing organizations. Their “think tanks” have been writing bills that are introduced in many states with virtually identical language. For an excellent discussion, see Paul Krugman’s “Lobbyists, Guns, and Money” (itself a parody of the title of a Warren Zevon song), about the American Legislative Exchange Council, ALEC, in the NY Times, March 26, 2012. Kansas, my home state, is in the process of passing a bill that will require doctors to inform women of the increased risk of breast cancer from having an abortion. This might seem reasonable, except that it is simply not true.  How can they get away with this? Well, we can examine the syllogism, which goes something like this: there is a somewhat higher rate of breast cancer in women who have never had a term pregnancy, so if you have an abortion instead of carrying to term you might be in this higher risk group. Of course, this misses a whole lot of bases. Women who have abortions frequently have had previous term pregnancies (which sometimes contributes to why they want the abortion), and or they may have term pregnancies later. Even if they never have a term pregnancy, no one has ever studied whether having a pregnancy at all (even one ending in abortion) puts one in the higher or lower risk group, or in the middle. Most important, for this discussion, most of women who never get pregnant do not get breast cancer, and many (probably most) women who do get breast cancer have had babies. Having a term pregnancy, or multiple pregnancies, is not protective.

Of course, this is not really the issue. The issue is that anti-abortion forces wish to prevent abortions by making it more difficult for women to obtain them. Thus, the veracity of the information that the laws written by ALEC promote is not important to its supporters. There has been some discussion about the fact that these laws that affect women but are written and passed primarily by male lawmakers. The suggestion is that it indicates a profound misogyny. I agree. These guys are often flagrant hypocrites who indulge in sexual (as well, of course, of financial) shenanigans, but feel no compunction about limiting the rights of women. This view is prominent in both the Doonesbury cartoons and in this creative effort by Salt Lake City Dispatch political cartoonist Pat Bagley in which he attaches the “I thee rape” Doonesbury, not run by that paper, to his own critique of this hypocrisy. It is the same misogyny which not only leads to abortion restrictions, but to restrictions on the availability of contraceptives, one of the two things that actually reduces the abortion rate (the other being accurate and widespread sex education, another “no-no” for the right), through insurance plans.  While, of course, ensuring that that these same plans cover Viagra and other drugs that help old guys get erections. It is part of worldview that sees men and women as not only different, but hierarchically related with men firmly in control. Women are subsidiary, not supposed to make noise, do what they are told, and certainly not make any decisions about their own lives, health or reproduction.  

Those who oppose abortion, but also support contraception and sex education, have a coherent position. The imaginary story line is that once a woman is forced to have a baby, she will want to keep it and care for it and be able to do so, or, at least put it up for adoption where someone else will do so. But while sometimes one of these two things happens, it is obviously a fantasy to think that it is the norm. We all hope that all children can be brought up in a loving, supportive, and financially secure family, whether birth family or adoptive, with all options open to them. But this is simply not the case for too many children, and those opposed to abortion are not doing anything to make it more likely by cutting support for health care, childcare, and education. Which is, of course, one reason it is hard to call them pro-life (along with their support for war and capital punishment).

Another part of the Kansas law forbids state employees from doing abortions. This might seem unnecessary, since it is already state law that abortions cannot be performed (with some rigid exceptions to save the life of the mother) at the University of Kansas Hospital, the only state owned facility. It also might not prevent medical school faculty from doing abortions at other facilities for which they are paid with funds that come from the physician practice plan rather than the state. It does, however, directly affect residents, physicians in training, especially in obstetrics and gynecology (OBGYN). The accrediting body for OBYN requires that residents receive training in abortion (which they may opt out for religious or moral reasons) and in evacuating the uterus when there are stillbirths (which involves the same procedure), which they may not opt out of. Currently, OBGYN residents at KU who do not opt out of abortion training receive this in an out-of-state program, but if this bill passes intact it would forbid them from doing that, as the residents are state employees. This would put the entire OBGYN training program in jeopardy, and it would likely be placed on probation, potentially closed, a problem noted by even some usually anti-abortion legislators. But to the anti-abortion movement, this is not a problem. They see this collision course as desirable and hope that a series of such state laws would force the OBGYN accrediting body to eliminate this requirement. Then, ultimately, there would be no one being trained to do abortions, there would be no one doing abortions, and voilĂ ! -- there would be no abortions! Without the admittedly effective, but messy, need to encourage crazy people to assassinate them, as was done with Kansas physician George Tiller.

According to the Kansas City Kansan article, “Brownback mum on KU Med Center, abortion issue,
Gov. Sam Brownback refused to say where he stood over legislative efforts aimed at stopping Kansas University Medical Center medical residents in obstetrics-gynecology from training in abortion-related procedures. “I’m studying the issue,” Brownback said at a news conference. Abortion rights advocates, and even some legislators who have opposed abortion, say the medical residents need the training to maintain KU’s accreditation and to be able to handle emergency pregnancies. But anti-abortion advocates disagree. Brownback has signed into law several anti-abortion measures and has welcomed the Legislature’s work in this area.” Yes, he has. Funny he hasn’t yet read the one-page bill.

Of course, the biggest flaw in this logic, beyond its complete arrogance and lack of respect for women, is the assumption that eliminating officially sanctioned training of physicians in abortion would end, or even significantly decrease, the number being done. What it would do is to decrease the safety of abortions, to increase the number of women who seek and obtain “back alley” abortions. It would, quite simply, kill many women.

But the proponents of such policies and legislation seem to have no problem with that. They are, after all, not fetuses.

Saturday, March 24, 2012

Beyond Flexner Conference on the Social Mission in Medical Education

"Beyond Flexner: Social Mission in Medical Education", to be held in Tulsa May 15-17, promises to be a major conference in addressing and enhancing the social missions of medical and other health professions education.

Chaired by Fitzhugh Mullan, MD, of George Washington University and the Medical Education Futures Study, and Gerald Clancy, MD, President of the University of Oklahoma - Tulsa and Dean of the School of Community Medicine there, feature speakers will include David Satcher, MD and H. Jack Geiger, MD.

I have no idea whether others will bring this up, but I am again motivated by having recently reviewed the literature on why under-represented minority college students who want to become doctors don't end up applying. Barr, et al, found a negative experience in a chemistry course was the single largest cause[1]. How much is the ability to use complex chemistry important in a physician compared to commitment to meeting social missions? Indeed, other than passing the first two years of classes and USMLE I, is it useful at all?

I hope that these are the kind of issues we address.

I will be there and look forward to joining a lot of enthusiastic and creative colleagues!

[1] Barr DA, Gonzalez ME, Warant S. The Leaky Pipeline: Factors Associated With  Early Decline in Interest in Premedical Studies Among Underrepresented Minority Undergraduate Students, Acad Med, 2008; 83:503–511.

Saturday, March 17, 2012

The 2012 Matthew Freeman Social Justice Awards

In my blog, “Alabama, “illegals”, and hate: We must take back the narrative” on March 11, 2012, I discussed some of the points made by Oscar Chacon, Executive Director of the National Alliance of Latin American and Caribbean Communities (NALACC), in his talk “Latinos and the Justice System: Challenges and Opportunities”, the 2012 Matthew Freeman Memorial Lecture on Social Justice at Roosevelt University on March 8. Chacon describes the purposeful development of a social narrative over the last 30 years that has served to demonize immigrants, and particularly those from Latin America.

In that piece, I note that this is part of a larger narrative that has been created affecting health, reproductive and women’s rights, and the substitution of belief for evidence. I also note that there is opposition. I mentioned the Occupy Movement, and I want to cite the work done by the two Roosevelt students who won the Matthew Freeman Social Justice Awards. On a smaller scale than “Occupy”, these two students, as those who have won in prior years, have done incredible work to help create a more just and tolerable world, the kind of world that we want to live in.

Daniel Smrokowski, an undergraduate journalism major, is the founder and executive director of the blog, for which he is the host and producer of the Special Chronicles podcast. He is a Special Olympics athlete and a global messenger (speaker) for Special Olympics Illinois. At WRBC:The Blaze, the student-run radio station at Roosevelt, he is the station director and an on-air personality. Daniel enjoys spreading the message to respect those, like himself, with intellectual disabilities.

Sarah Heeger, a graduate student in school counseling, has renovated and developed a program at Jones College Prep to guide undocumented students through the college planning process. By establishing relationships with college representatives and faculty, she has been instrumental in ensuring students receive the help they need to pursue their education. As a result of her advocacy efforts, and the creation of a nonthreatening environment, undocumented students are able to express their future goals and concerns and receive counseling, guidance, and support to pursue their dreams.

These are two amazing young people. I almost said extraordinary, and they are, but they are also, in the best sense, “ordinary”, regular human beings who are not “well-funded” by billionaires but who are motivated by caring and concern and love and respect for themselves and others. Missouri may be considering placing a bust of Rush Limbaugh (clearly someone who is bought and paid for) in their state Hall of Fame, but all for the rest of us there are Daniel and Sarah.

Congratulations, and may you continue your great work and be roles models for others across the US and the world. 

Sunday, March 11, 2012

Alabama, “illegals”, and hate: We must take back the narrative

The state of Alabama has outdone Arizona with an anti-immigrant law that is even more anti-human in its degrading approach to and impact on people who are immigrants, visitors, and native Americans with Spanish surnames or who “look” Hispanic. H.B. 56, documents Allen Perkins, MD, Chair of Family Medicine at the University of South Alabama in Mobile in his blog, Training Family Doctors, “…requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.”

 He also notes that “…there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future): ‘It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.’” In a later blog entry, he describes specific incidents of harassment by regular people (e.g., store clerks) of – regular people, even American-born, because of their ethnicity. In other words, H.B. 56 has given folks in Alabama a license to be racist, which many in the state feel is particularly shameful given its history of slavery, Jim Crow, and opposition to civil rights.

Dr. Perkins worked to get the 2013 national conference of the Family Medicine Chairs’ organization, the Association of Departments of Family Medicine (ADFM) to Mobile, which he considers a diverse and vibrant city that was also in need of some economic boost, particularly given the recent hurricanes and more recent oil spills that have ravaged its shores. The agreement for the conference was all signed when H.B. 56 became law, and many members of the organization protested. This included Latino chairs, who felt that, in addition to opposition to the law, they might well be in personal danger. The conference will be moved, at considerable expense to the organization – and to the city of Mobile. Dr. Perkins includes in his blog a political cartoon (reproduced here) from the Mobile Press-Register, which also had a strong editorial about it.

The Alabama law does not stand in isolation, nor do Alabama and Arizona together. Both laws were, as it turns out, largely written by an ambitious attorney and law professor from the University of Missouri-Kansas City who now is serving as Secretary of State for Kansas, Kris Kobach. Kobach’s work is only one of the most recent chapters in a 30-40 year effort funded by incredibly wealthy right-wingers such as the Koch brothers of Wichita, Richard Scaife, and others, to rewrite American values. They have used the vehicles of conservative “think tanks”, talk radio and TV outlets such as Fox, funding individual organizations, and paying for lots of messaging (including the Super-PACs now thriving in this election season thanks to the Supreme Court’s Citizens United decision allowing unlimited corporate funding of political advertisements, one of the greatest “victories” of this effort) to create a narrative that, while essentially false, is widely believed by many Americans.

The development, implementation, and impact of this narrative as regards immigrants was the topic of discussion by Oscar Chacon, Executive Director of the National Alliance of Latin American and Caribbean Communities (NALACC), who gave the Matthew Freeman Memorial Lecture on Social Justice at Roosevelt University in Chicago on March 8, 2012. Our history in the US includes immigrants of all national backgrounds being vilified, persecuted, and demeaned (see, as just one instance, my discussion of some of the events surrounding the Boston police strike of 1919 described in Dennis Lehane’s novel “The Given Day”, Immigration and the US: Happy New Year, December 30, 2010). African-Americans, brought here as captives, along with our only non-immigrants, American Indians, have occupied a special places of discrimination and oppression. Nonetheless, during and after World War II we began to see ourselves as a “nation of immigrants”, symbolized by the beckoning torch of the Statue of Liberty, and its inscribed sonnet "New Colossus" by Emma Lazarus. We realized that the US had grown strong by this continuing infusion of the boldest (they emigrated, right?) from other nations prospering in this land of opportunity (the continuing oppression of African Americans and American Indians notwithstanding).

Mr. Chacon noted that, in 1970, immigrants of Latin American origin (which term he prefers to “Latino” or “Hispanic”, words not used outside of the US) were a minority of immigrants, and Mexicans a minority of those. The perception of Latinos in popular culture was generally positive, represented by handsome, suave, and debonair actors such as Cesar Romero and Ricardo Montalban and the character of Ricky Ricardo portrayed by Desi Arnaz. (Of course, many of those without accents, such as Anthony Quinn, Raquel Welch, and Martin Sheen felt the need to change their names, a practice also common among many minority performers such as Jews and Italians.) Since that time, immigrants from Latin American have become the majority (over 50%, but still less than 60%) of immigrants to the US, with Mexicans becoming the majority of those (over 30% of the total). The narrative that has been purposely developed over this period has served to redefine them as less than human, swarms coming to our shores who would all be here if they could, who are all Mexicans (Chacon, who is from El Salvador, is often asked what part of Mexico that is in!)

The narrative has created the term “illegals” to refer to people, when in fact only things or acts, not people can be illegal. People can do illegal things, including entering the US without official permission, or stealing, or committing assault, or driving over the speed limit and running red lights, but they do not become illegal people. This type of narrative serves to dehumanize them and thus makes it easier to oppress them. It has long been a common strategy adopted by the powerful to convince a portion of the powerless (say, Euro-Americans) to side with the rulers against other powerless people. It was very successfully done with Africans to make it acceptable for them to be slaves, and it has been a very conscious strategy to change the perception of immigrants of Latin American origin.

This narrative, pushed by right-wing ideologues, led to the passage of “IRA-IRA”, the “Illegal immigration and immigrant responsibility act” of 1996 – before 9/11 and under Democratic President Bill Clinton. In addition, major funders of the demonization have been the for-profit prison companies such as Corrections Corporation of America, that make huge amounts of money, paid for by US taxpayers at rates several hundred percent higher than their costs, to “house” arrested “illegals”. Latinos are arrested for “being illegal” but they also commit crimes and are imprisoned; their time served is, on average, less than that for African-Americans or even whites not because their sentences are shorter, but because they are regularly deported.

Has this narrative been successful? Read the news. Read this quotation from an article in the NY Times Magazine about an undocumented student (a young man who journeyed “…from cleaning windshields at stoplights and sleeping under a bridge in the Honduran city of San Pedro Sula to attending the sixth-largest university in the United States,”) who ran (and lost) for student body president at Texas A&M University: “…[a] professor, discussing the growth of Hispanics in Texas, said the state could have a Hispanic governor in the future. A number of students in the class hissed.” Note that the professor was not talking about an undocumented immigrant, or even an immigrant, just someone of Hispanic ethnicity.

This well-funded narrative is not limited to immigration of course. It has been largely successful in changing the words and terms of discussion in reproductive rights, women’s rights, and the entire vocabulary of liberal-conservative. And of course they have major impact on people’s health; after all, should we provide health care services to “illegals”? There is of course opposition to all these mythologies, and that opposition is growing. It is not as well-funded by the incredibly wealthy -- who are the real beneficiaries of suspicion and animosity among the 99+% -- but the Occupy Movement was and is real.

Alabama doesn’t need politicians passing laws that validate a new form of racism as it still struggles to move forward from its Jim Crow past. Nor does Arizona. Nor does Kansas, or Oklahoma, or any other part of the US, or the US as a whole. We must take back the dialogue, take back the words, and make the values of diversity and inclusion the ones that America and the American people represent.

Sunday, March 4, 2012

ACA benefit programs: will state to state variation be good or bad?

With the passage of the Affordable Care Act (ACA) a larger portion of Americans will be getting health care coverage. For some, such as young adults who can now be kept on their parents’ insurance until 26 (provided their parents have insurance that covers family members!), there has already been benefit. As the 2014 roll-out of the most significant benefits gets closer, there is a lot of focus on the details, including the flexibility given to states to determine the benefits package that companies will have to offer, and whether it will be good or bad.

Writing in the New England Journal of Medicine, Alan Weil, MPP JD (“The value of federalism in providing essential health benefits”)[1], provides a positive slant on the “federalist” approach to ACA roll-out, in which individual states will have flexibility in choosing which of 10 plans for providing “essential health benefit” (EHBs) they will use. While there are 10 EHBs that must be included, and the state insurance exchanges’ benefits must be based on a “typical insurance plan”, states will have considerable latitude in determining both what is “typical” and what scope to offer for these services; in addition, states will decide whether these plans need to cover benefits beyond those 10, and which they will be. Weil sees this as a good thing, citing the “states as a laboratory for good policy” in the sense that there will be different approaches. He cites 3 benefits: 1) different states, trying different approaches, will see which work “best” in the real world. For example, a single decision made by the federal government on what benefit package to offer (seen as the alternative) would, perhaps, cover treatments that turn out to not be of real benefit to people (he cites autologous bone marrow transplantation as an example of a treatment that was widely covered before it was found to be ineffective); 2) the “typical insurance plan” mandate would make people “have a plan similar to what their neighbors already have”; and 3) it would be consistent with local values. This last is somewhat problematic, since states are hardly very “local”, and have proven themselves to be very willing to enact policies that punish minority points of view (or even majorities, since much power resides, as at the federal level, with those constituencies with the most resources).

In the same issue of NEJM, Jennifer Prah Ruger PhD, writes “Fair enough? Inviting inequities in state health benefits[2]. She makes many points about potential lack of equity in treatment that are not only possible, but are likely to result from allowing such state-to-state variation. The fact that Weil feels he has already dispensed with the “equity” argument: “The most common, but least convincing, argument against the secretary's federalist approach has to do with equity. It is a truism that state flexibility will yield differences within the country and that those differences cannot be defended on the basis of differing basic human needs for health care services. But those inequities must be viewed in context…” does not make such criticism illegitimate. In fact, Weil is making Prah Ruger’s point, that individuals will suffer negative health consequences because they live in one state rather than another. He sees this as acceptable; she does not. The strongest point that Weil makes is that a single national decision on a benefits package may yield a bad one; Prah Ruger argues that at least it would be consistent. I tend to agree more with her. While some states may have more generous benefits (and even better, since “more generous” is not always better if it provides access to ineffective or harmful services), many – and probably more -- will offer less than a federal program would. The current Medicaid program is a good example of how widely disparate benefits packages can be between states and how much people can suffer from a lack of benefit.

The most important point that Prah Ruger makes derives, interestingly, from Aristotle, the principles of horizontal and vertical equity. Vertical equity means that people with different sets of needs receive different quantity and quality of services (she uses the example of the difference between the treatment needed by people with conjunctivitis and glaucoma to restore “normal ocular function”; perhaps a better one would be between those with myopia and glaucoma). Horizontal equity would require that different people with the same needs have the same treatment options available. She makes clear that such principles do not require that everyone get the same benefits or the same outcomes, but that the principle of proportionality should apply, “…that similar cases should be treated similarly and different cases differently, in proportion to their differences.”

Vertical equity, in which everyone gets the same services whether they need them or not, obviously does not make sense. While the same services should be available to everyone when they need them, whether employed by ACA, a national health insurance system, or private insurance companies, it does not make sense to offer the wrong services to people when they are more expensive, nor is it reasonable to offer inadequate services because they are less effective. Understanding the relative cost and benefit of services to different people in different sets of circumstances is critical to both containing cost and increasing quality. A very interesting “Viewpoint” on this issue is offered by Robert H. Brook, MD ScD in JAMA (“Do physicians need a ‘shopping cart’ for health care services?”[3]). He describes the on-line shopping most of us are familiar with, which gives us the cost of the items that we are interesting in purchasing, offers us both alternatives and other options that “people who bought this item might be interested in”, and tabulates what we have ordered in our shopping cart. And gives us at least two opportunities to not order, by asking us to confirm our intention. He does not argue that physicians should always order cheaper tests or therapies, but by knowing what the “basket of services” they are ordering for patients would cost, both for the patient and the insurer (“For example, if the insurance company paid the pharmacy $80 and the patient paid $8, the cost of this service is $88,”), they would have a better sense of what was of most value.

Horizontal equity, however, is really the most important issue. The absence of this characteristic is the fatal flaw in our current “system” and is likely to continue even with ACA. It means that everyone doesn’t get the most appropriate therapy for their condition, but rather that some people do not get enough, while others may get too much and even suffer ill effects as a result. Despite scare stories about rationing, the fact is that we have always had rationing, but it has been on the basis of the resources (mainly financial) a person has rather than on the basis of need. The problem with having different options in different states is that it will be the most disenfranchised who lose out in the states with meaner benefit packages, while those with resources will be able to access care.

Making the right care available to all the people who need it is the only reasonable goal for a health system. The rest is distraction.

[1] Weil A, The value of federalism in defining essential health benefits.,N Engl J Med. 2012 Feb 23;366(8):679-81

[2] Ruger JP, Fair enough? Inviting inequities in state health benefits.,N Engl J Med. 2012 Feb 23;366(8):681-3

[3] Brook RH, Do physicians need a "shopping cart" for health care services? JAMA. 2012 Feb 22;307(8):791-2.

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