Wednesday, June 29, 2022

Abortion is health care. It must be safe and legal.

Quite a number of years ago, before the murder of George Tiller, MD in 2009 (see my post In Memoriam George Tiller, May 31, 2009), the Students for Choice group at the medical school where I worked had a forum with a speaker who was the minister that counseled potential abortion patients in Dr. Tiller’s practice. (Yes, he had a minister to do counseling. He was murdered while acting as an usher in his church. Don’t forget that!) During the discussion, one student stood up to identify himself as a person who was adopted as a baby, and how he was so glad that he had not been aborted. He talked about the wonderful love and support he had gotten from his adoptive parents, and how it had made it possible for him to get to medical school.

I was very happy for him, but it is a specious argument in two important ways. First, one can never know what “might have been”, and who a baby born would have been. In addition, this in no way begins to address the pregnancies with fetuses who have conditions incompatible with life, or the trauma of giving birth to a 12-year old who is the victim of incest, or indeed any pregnant person. A person carrying a baby to term is 14 times more likely to die than one having an abortion, and in some circumstances (Black women in Mississippi) 118 times more likely to die! (cited by Michelle Goodwin in an excellent piece in the NY Times, June 26, 2022, “No, Justice Alito, Reproductive Justice is in the Constitution”).  

The second flaw in his argument, personal as it was to him, is that all children are not guaranteed such an outcome if they are born and adopted. It would be incredibly wonderful if all children had terrific, loving, supportive parents, when biologic or adopted or of any other combination, especially if they also have the financial and emotional capability of raising a (or another) child. But this is far from always the case, for any kind of parent. It is a romantic pipe dream of the  “pro-life” movement that being given the opportunity to be born means anything is possible for the child. This is the position taken recently by, for example, the Cornell Republicans, who tweeted '“Hundreds of thousands of children will now have the opportunity to live life to their fullest potential” (Cornell Daily Sun, June 26, 2002). This is nonsense; having that opportunity requires more than being born. It requires love, and safety, and food, and housing, and education, and nurturance. The kind of things that the medical student above apparently had. The kind of things that millions of children born already do not have access to. And, clearly, the kind of things that many Republicans (and others, likely; I didn’t want to make this about political party, but it was the Cornell Republicans who issued the statement) have completely refused, continuously, to support for children born in the US. The meme that “pro-lifers” love only unborn, not born, life, is sadly, the effective truth. (Note that I do not mean that all, or even most, people who identify as “pro-life” feel this way, but it is the effective practice of those they elect to Congress and state legislatures. Of course, if we were going by what most people believe, over 60% of Americans believe abortion should be legal in all or  most cases.)

People who are pro-choice also use specific examples, individual stories, and they are also gripping. A post making the rounds on FB since the Dobbs decision says: ”Overturning Roe does not stop abortions, it stops SAFE abortions!” and this is absolutely true. As much as the anti-abortion forces would like to prevent all abortions (they think), abortion have been part of human life since...forever. But they have not always been as safe as they have become since the Roe decision, and now they are about the safest procedure that can be done, and even safer when done with medication. I thought I’d include a few of those stories, anecdotes, that accompany these posts because they are each as real as the story of that medical student, written in the voice of one who says that they are not “pro-abortion” but “pro-life” as in:

·        I'm pro-Becky who found out at her 20-week anatomy scan that the infant she had been so excited to bring into this world had developed without life sustaining organs.

·        I'm pro-Susan who was sexually assaulted on her way home from work, only to come to the horrific realization that her assailant planted his seed in her when she got a positive pregnancy test result a month later.

·        I'm pro-Theresa who hemorrhaged due to a placental abruption, causing her parents, spouse, and children to have to make the impossible decision on whether to save her or her unborn child.

·        I'm pro-little Cathy who had her innocence ripped away from her by someone she should have been able to trust and her 11-year-old body isn't mature enough to bear the consequence of that betrayal.

·        I'm pro-Melissa who's working two jobs just to make ends meet and has to choose between bringing another child into poverty or feeding the children she already has because her spouse walked out on her.

·        I'm pro-Brittany who realizes that she is in no way financially, emotionally, or physically able to raise a child.

·        I'm pro-Emily who went through IVF, ending up with SIX viable implanted eggs requiring selective reduction to ensure the safety of her and a SAFE number of fetuses.

·        I'm pro-Jessica who is FINALLY getting the strength to get away from her physically abusive spouse only to find out that she is carrying the monster's child.

·        I'm pro-Vanessa who went into her confirmation appointment after YEARS of trying to conceive only to hear silence where there should be a heartbeat.

·        I'm pro-Lindsay who lost her virginity in her sophomore year with a broken condom and now has to choose whether to be a teenage mom or just a teenager.

·        I'm pro-Courtney who just found out she's already 13 weeks along, but the egg never made it out of her fallopian tube so either she terminates the pregnancy or risks dying from internal bleeding.

The post concludes:

You can argue and say that I'm pro-choice all you want, but the truth is:

I'm pro-life.

Their lives.

Women's lives.

You don't get to pick and choose which scenarios should be accepted. It's not about which stories you don't agree with. It's about fighting for the women in the stories that you do agree with and the CHOICE that was made.

Women's rights are meant to protect ALL women, regardless of their situation!

Overturning Roe does not stop abortions, it stops SAFE abortions!

Abortion is healthcare.


It is health care. And it is critical that be available. To all.

Thursday, June 9, 2022

Technology and other obstacles to getting health care: it’s capitalism, of course!

I saw this cartoon posted recently on Facebook, and am sorry that I can find neither the cartoonist nor the original site of publication. It is, as is the case with most good humor, both funny and sad, in that it cuts close to the reality of the lives of people seeking health care. This particular cartoon emphasizes the technology obstacles to receiving care, which represent another layer of obstruction beyond insurance, distance, availability of providers, and, generally, a system that favors the corporations involved in health care over the people (also known as ‘patients’) seeking it, or the clinicians who provide it. One of the biggest complaints and stressors (and reasons for physician burn-out) is the Electronic Medical (or Health) Record which consumes enormous amounts of clinician time inputting data (many clinicians report at least a 1:1 ratio of charting on-line to seeing people).

It take so much time and is so onerous in large part because it involves, in addition to charting the note recording what the person was complaining of (“Subjective”), what was found on exam, lab, imaging (“Objective”), what was diagnosed (Assessment) and what was done (Plan), many click boxes have to be filled out to record specific data digitally. While this includes things that are sensible because they enhance easy retrieval (e.g., a flu shot), and things that are otherwise ostensibly documenting preventive care for certain issues (e.g., alcohol or tobacco use), they also include many things that ensure compliance with specific government regulations or insurance companies rules, and extensive and complex documentation and clicking to ensure that maximum reimbursement is received by the employer.

There are benefits to having data stored in a searchable and easily retrievable digital format. However, on balance, patients find their access to medical care, already strained by financial, time,  and distance constraints, further limited by technologic obstacles, and doctors find them terribly burdensome and of less utility,  but yet they proliferate. Patients do not usually want to blame their doctors or other clinicians, most of whom they value and trust, but cannot understand why those obstacles have been put in place.

Let us go back to “maximum reimbursement is received by the employer”. Most doctors and other clinicians are no longer in solo or small-group practices, but rather are employed by corporations (both for-profit and ostensibly not-for-profit) or by large groups that, even when physician owned or managed, have the same incentive to maximize reimbursement, even at the cost of efficient use of the clinician’s (not to mention the patient’s!) time and effort. Of course, for the corporation, the most efficient use of a physician’s time is that which generates the greatest reimbursement, which is not necessarily the same as that which generates the greatest marginal health benefit for the patient. This is an issue I have written about many times before, but it bears repeating. People who are willing to vote against an administration because gasoline prices are high, even though that is a result of corporate greed and is most supported by the administration’s opponents, are not always ready to think deeply. Indeed, physicians and other clinicians retain a great deal of respect and admiration despite the violence done to people in their name (usually not, of course mainly physical violence, although making it difficult or impossible for folks to access health care can certainly result in physical damage!)

People often want to take credit for what is seen as good, and to deflect blame onto others for what is seen as bad. This is a particularly common trait in those called “leaders”, although they are often just bosses, not leaders. It is so common in this group, in fact, that we are often shocked when a person in a position of real authority takes responsibility for their – and their subordinates’ – mistakes, and gives credit to others for accomplishments; this is why Harry Truman’s sign “The Buck Stops Here” became so famous. In the case of health care, such duplicity by the “leaders” often takes the form of the corporation wrapping itself in the mantle of “caring for and about your health”, while actually creating obstacles (including those technological ones) to accessing care, particularly if you are not a high-profit-margin patient, and even blaming those doctors, nurses, and others who actually do provide care for the problem.

In a different context, this theme has been replicated in Mexico, by the government rather than the corporation. Doctors (and their patients) in rural areas are being kidnapped, killed, and otherwise abused by drug gangs, as reported in the NY Times. In a cynical political move to seem to address this problem, the government is talking about bringing in 500 Cuban doctors. ‘“They [that is, the rural physicians] forget about a patient’s primary right, which is to be cared for wherever they are, and it’s because of this that we needed to resort to contracting foreigners,” Dr. Jorge Alcocer Varela, Mexico’s secretary of health, told reporters at a recent news conference.’ Safe in his cabinet office in Mexico City. This generated an appropriate response: ‘The announcement about the Cuban doctors provoked outrage among many Mexican doctors, who said the problem was not a lack of physicians or an unwillingness to work in rural communities, but the life-threatening conditions they must work under.’

The lower your own risk, the easier (but more ignoble) it to criticize those who are at risk. The less value you (as, say, a CEO) bring to the actual provision of health care, the more you can feel free to blame those who do, or who criticize the way that you have organized systems to maximize your profit, not to improve people’s health. Such CEOs love to brag about their great programs that bring highly-reimbursed care to well-insured people, but are rarely willing to spend much on high-value (as opposed to high-profit) care for the most needy.

Healthcare is scarcely unique in having been seemingly overtaken by systems that have the goal of limiting human-to-human interaction and replacing it with often difficult-to-navigate (especially for the older or less computer-savvy person) human-to-machine systems. “They” want you to download their app (after upgrading your operating system), go to their website, and do anything that does not require them to pay a person who can actually help you. Almost no actual people prefer that, but we’re usually stuck. When they can’t force you off the phone and on to the computer, they can sure make you wait – at your doctor’s, at the pharmacy, at the airport – and maybe you’ll give up. It does not just happen in health care, but when stakes are your life and health, it seems particularly bad.

Just remember who and what is at fault; usually not the doctors and other clinicians, who actually want to help you, but corporate capitalism, motivated by greed.

Saturday, June 4, 2022

Where has all the caution gone? COVID infection is still common!

Most infections diseases in people get passed from one person to another, although sometimes animals and insects are the vectors. More rarely (as in the case of COVID-19) an ‘enzootic’ infection (one that resides in animals) can ‘make the jump’ to people, although after that the transmission continues to be primarily person-to-person. If there is an outbreak of an infection it can spread rapidly among ‘susceptibles’ (people who do not have immunity through either prior exposure to the infection or from vaccination against it), particularly in crowded conditions.

Many of us are aware of this from our children. In winter, young children in school and day-care bring home infections that can make them sick and often infect other members of the family. Luckily, most of these are minor and transient (the ‘common cold’), but in the past included many serious and potentially fatal diseases such as polio, measles, mumps, whooping cough, rubella, diphtheria, Hemophilus influenza, chickenpox, and others. The frequency of these diseases has gone down dramatically as a result of vaccines that have been incredibly effective. Outbreaks still occur in places and populations where an insufficient percent of the children have been vaccinated to result in ‘herd immunity’. In the US, this is, sadly, most common not in communities which do not have access to vaccinations, but in which large numbers of people have, for whatever their reasons, chosen to forego vaccination for their children.


Dave Caverly, Speedbumps


The way that outbreaks of any infectious disease, from colds to influenza to chickenpox to sexually-acquired infections to COVID-19, occurs depends upon the route through which that organism is transmitted – sometimes by respiratory droplets (cold, COVID, pneumonic plague, polio), sometimes through fecal-oral contamination (think young children), sometimes through sexual contact involving exposure to blood or other body fluids, sometimes by more than one of these. Respiratory transmission is particularly great in crowded indoor environments, such as schools, concerts, restaurants, clubs, and family gatherings. And gyms, where people working out are breathing heavily. And singing (such as the karaoke sessions enjoyed by the NY State judges before many came down with COVID). Sexual transmission is, of course, less likely to be incidental and requires close and often prolonged contact.

But there is a similarity. This is that we are at risk for exposure not only from symptomatic individuals with whom we have contact, but often from those who are not, or not yet, symptomatic but who have been infected by someone else. In the case of sexually acquired infections, the idea that when you have sex with someone you are not only having sex with them, but potentially anyone else they have had sex with, or the people those people had sex with. Monogamy, is of course, protective, provided, of course, that it is actually practiced. It does not necessarily take many outside episodes to introduce an infectious disease.

In the case of COVID, we are not talking about sex, but about high-risk exposures. And also about what we assume should have been low-risk exposures but were to people who themselves may have taken greater risks. You may be pretty careful, not go out much, wear your mask if you are indoors with groups of people that you do not know, but be less careful if you are with close family members, especially those in your home. But just as a child can bring home a cold from daycare, or a sexual partner can bring home an STI from a relationship that you did not know they had, a family member can bring home COVID from a concert, club, restaurant, airport, social gathering, or other event in which others, who you (and maybe they) do not know were infected, unvaccinated, unmasked. If you happen to be more vulnerable: older, sicker, immunocompromised, and especially (because this is usually fixable) unvaccinated, the outcome can be not just infection but hospitalization and even death.

Minority communities have higher rates of all of these problems – infection, hospitalization, and death. Some of this can be tied to greater prevalence of chronic disease, some could possibly be lower rates of vaccination, and much may be related to having a higher rate of low-income and jobs that require actual presence and cannot be done from home by ‘Zooming it in’. It can also be true that poorer families may be more likely to have multiple generations living in the home, with various sources of infection (school, work, social activities) increasing the likelihood of COVID being brought into the home and infecting family members who are more at-risk.

Most of us want to see and interact with our family members. But if those family members have contracted infection, whether by “choice” (adopting higher-risk behaviors, not wearing masks, especially not being vaccinated) or by bad luck despite taking precautions, seeing them puts us at greater risk. Some of that risk may be unavoidable, but some can definitely be mitigated. COVID is NOT gone, but people are taking more and more risks, including me. I returned from a trip to Europe a few days ago, and while I wore an N-95 mask on the plane and in the airports, it was risky (the line for passport check in the Madrid airport crowded despite ironic signs on the floor asking people to maintain a 2-meter distance, between which were many people, was surely a potential super-spreader event). But I seem to be one of the few people worried about it. In the gym, no one else is wearing a mask, even as they huff and puff on machines which definitely increases the likelihood of spread, and I take no reassurance from their carefully wiping them down, since this is not really how COVID is spread. The front desk has even taken down the plastic barrier that has long been in place.

If all this were occurring because the rate of infections, and thus hospitalization and death, were down, this could be a good sign. Unfortunately, it is not. A recent headline in my local paper, the Arizona Star, on June 3, 2022 is “AZ COVID numbers continue to rise”, and daily published an update on number of cases. Yes, vaccination has definitely reduced the rate of hospitalization and death among those who have been infected, but the greater the number of infections the greater the risk of those really bad outcomes.

Death is now less likely, at least among the vaccinated. Be vaccinated. But COVID is still there, and in many places cases are increasing. Continue to exercise caution, and try to not take unnecessary risks.


Total Pageviews