Washington State, Limiting Measles Vaccine Opt Outs.

May 20, 2019 by

And it’s about time!
On April 19th, Washington state Senate passed a policy change in an existing bill that would make it harder for parents to opt out of vaccinating their children against measles in response to the state’s worst outbreak in more than two decades. This change in existing policy would eliminate personal or philosophical exemptions from the measles, mumps and rubella (MMR) vaccine. Religious and medical exemptions will still be allowed for all vaccinations, including MMR. Parents will still be able to cite personal or philosophical exemptions to avoid other required school vaccinations for children.

This will be the first time in four years a state has removed personal exemptions in the face of growing anti-vaccine sentiment. The unfortunate reality today is that many people embrace conspiracy theories and alternative facts more readily than proven science. I would be elated to see this change in policy, for the state of Washington. Given the state’s demographic population and current high risk situation, I argue, community immunity takes priority over personal freedom.

Even when the risk of disease may be low for a fully vaccinated child or adult, the risk still exists because it cannot be predicted which individuals do not fully respond to the vaccine. Containing outbreaks of infectious disease is not only time-consuming, it’s also costly. At a time when our country is bracing for large cuts in public health funding, our best defense is a strong offense, and that can be achieved through prevention and immunization.

As a society, we don’t condone behavior that puts others at risk for injury or death. There are no exemptions for laws that prohibit drunk-driving, for example. Refusing vaccination for reasons other than a serious medical condition is unfair and dangerous to those who can’t protect themselves.

Eliminating personal belief exemptions will prevent suffering and save lives. It is the right thing to do. Educate yourself, educate your neighbors. VACCINATE YOUR FAMILY. For the latest CDC press briefing, click the link below.


Maternal Mortality on the Rise in the United States

May 17, 2019 by


The United States is one of the few developed nations that still boasts a high maternal mortality rate (MMR). According to America’s Health Rankings, “Compared with other high-income countries in North America and Western Europe, the United States has the highest rate of maternal mortality despite a global trend of decreasing maternal deaths” (2018) [1]. The number of reported deaths has been gradually increasing, despite technological advancements, since 1990. On average in 2017, about 17 women per 100,000 women were likely to die from childbirth or other pregnancy complications after childbirth. In 2018, that rose to an average of 23.4 women per 100.000 women [2].

This image has an empty alt attribute; its file name is cdc-us-trends-mmr.png
Source: CDC Pregnancy Mortality Surveillance System [a]

Some factors include unnecessary and over-utilization of C-sections [3]. In the post-birth side, there can be inadequate attention to post-partum depression, preeclampsia, dangerously high blood pressures (that increase risk of seizure or stroke), infections or clots. This is all the more complicated by the complicated health-care system women are asked to navigate; depending on the patient’s insurance, a pregnant woman may be asked to attend pre-/post-natal care or give birth at a hospital with inadequate resources, such as staffing or best-practices/patient care competencies.

The federal government has taken steps to combat this issue in the Preventing Maternal Death’s Act, providing monetary resources to all states. The American College of Obstetricians and Gynecologists (ACOG) has published studies to improve best-practices and made best-practices recommendations, including recommending less C-sections [3].They go one step further, by creating, on a national level, the Alliance for Innovation on Maternal Health (AIM). This advocacy group combats MMR through a comprehensive program. They offer many resources including quality improvement toolkits, educational material and other resources for healthcare facilities to decrease MMR [4]. There are also national level female health advocacy groups to promote access to resources, including the National Advocates for Pregnant Women (NAPW). AdoptionServices.org which lists general resources for pregnant women and new-mothers to get Women, Infants and Children (WIC) benefits, and the US Women’s Health Alliance.


California has been a leader in combating this issue with only 4.5 deaths per 100,000 women. They have instituted a maternal mortality review commission, which included stakeholders such as hospital administrators, doctors, nurses and midwives to decrease the MMR rate.

A similar commission should be instituted across the nation, especially on a state-level for states with high MMR rates, such as Georgia (50/50th place in the US). This is to help achieve the goal of Healthy People to reduce the maternal mortality rate to 11.4 maternal deaths per 100,000 live births.

However, there needs to be more in-the-trenches help to directly reach women in need. The Georgia Department of Public Health, Georgia Senator(s) with other pollical leaders, healthcare organizations and Insurance Providers (Medicaid, HMOs, PPOs) should invest in a state-coalition to combat state-specific MMR issues. For example, increasing access to pre-natal and post-natal care. Hospital-based coalitions, like a smaller-scale AIM, should be instituted across the states to improve MMRs in Georgia.

Zero by 30

May 17, 2019 by

The Global Strategic Plan to end human deaths from dog-mediated rabies by 2030

Orignially posted May 12, 2019

“The world called for action by setting a goal of zero human dog-mediated rabies deaths by 2030, worldwide” (WHO.org). The partnership consists of 4 organizations – WHO, the World Organization for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO) and the Global Alliance for Rabies Control (GARC).

A Global Yet Local Approach

Why this goal? Rabies is a neglected but preventable disease that can be eliminated. Worldwide those at highest risk from rabies are the poorest communities and particularly children. Targeted rabies programs result in stronger governance systems, health care systems, and population equity. Countries and stakeholders will take the lead. Those countries prioritizing rabies with a viable program, plans and political momentum will be supported with global tools, professionals, structures and rabies stimulus packages by the initiative.

3 Basic Objectives

  1. A program based on education, mass canine vaccination, increased medical access, and availability of prophylactic medicines and vaccines.
  2. Policies for governance harmonized and rely on science, surveillance and technology.
  3. Target areas of high risk. Demonstrate successes. Sustain the engagement of multiple stakeholders.

Policy Position

We urge all stakeholders working on the rabies problem to:

— Adhere to evidence-based rabies guidelines and program activities.

— As a country join the “Zero by 30” global campaign.

— Commit to ending human death from rabies by 2030.

Image result for photo of dog in bali vaccination

Participants in the mass vaccination program, Bali, Indonesia.

Strategy: Build on the Success of Countries & Stakeholders

A Program to End Rabies in Bali, Indonesia

Daniel Haydon and colleagues at the University of Glasgow evaluate large-scale infectious disease interventions — such as anti-rabies mass dog vaccination programs in Africa and Asia. For rabies control in Bali, Indonesia, a computer model tested different strategies and identified critical components of successful. The resulting program led by a local NGO of mass vaccinations of canines and post-exposure prophylaxis reduced the human death rate by 90 percent.

Rabies incidence and spread in Bali prior to island-wide mass vaccination. (A) Cases in humans and dogs and corresponding control efforts. (B) The month that rabies was first confirmed in each village. The black dot marks the village where the index case occurred. Regencies are outlined in black.
Image from Townsend & Sumantra et al, 2013. doi:10.1371/journal.pntd.0002372.g001

Financing is available for Zero by 30

One hundred countries are targeted for this program. It is best to join early. Not all will participate all at once but rather through a three phase plan. Zero by 30 includes three phases:

START UP – where early initiator countries are identified and pilot projects are yielding information. National plans need to be identified, budgeted by the country and supported. Next is

SCALE UP – where countries with the heaviest disease burden are identified and engaged. The third phase is

MOP UP – where lessons from the first two phases will be applied to the remaining countries (WHO.org).

Further Reading

A step-wise approach assists countries to identify their stage of controlling the disease and to define what next steps are needed to progressively control and ultimately eliminate the disease 

The strategic approach of the rabies control program

The SARE country self-assessment 

A case study in Bali, Indonesia

Assessment of the Middle East 

Vaccination coverage in Bali

An NGO takes the lead


Mandi, a beloved pet poisoned in Bali out fear of rabies

Zika Executive Use Authorization for U.S Territories should Include Definitive Screenings and Testing with an Emphasis on Pregnant Patients

May 16, 2019 by
A woman who is six months pregnant shows a photo of her ultrasound at the IMIP hospital in Recife, Pernambuco state, Brazil. Photo Credit to Felipe Dana / AP
An ultrasound photo of a six month pregnancy provided by a patient from the IMIP hospital in Recife, Pernambuco state, Brazil. Photo Credit to Felipe Dana/AP.

In Feb 2016, HHS provided a program notice “Determination and Declaration Regarding Emergency Use of in Vitro Diagnostic Tests for Detection of Zika Virus and/or Diagnosis of Zika Virus Infection.” The FDA was granted EUA for in vitro diagnostics to detect or diagnose Zika virus among U.S citizens to assist with emergency preparedness guidelines for active Zika transmission. To effectively prepare for future Zika outbreaks, lessons learned must be part of the discussion that will open doors for opportunities for research, collaboration, and revising current strategies. We will take a look at some program policies that can help with( but not limited to) better management of the Zika Virus. Note that as an analysis of each is done, consider the amount of time, money and effort invested. Most of all think of which policy option will provide the most benefit.

Funding and engagement from research partners and stakeholders to continue pursuit of Zika vaccines with legal and ethical considerations

Presently, there is no vaccine for the Zika virus. However, there is a growing opportunity in research and collaboration. Currently the National Institute of Allergy and Infectious Disease is working on potential vaccine options such as a DNA based vaccine like the flavivirus vaccine for West Nile virus infection and conducting experiments on a live attenuated vaccine using genetic engineering to create a chimeric virus composed of genes from various viruses. This option calls for commitment from all research partners and stakeholders. In addition, there are implications that one must consider such as providing transparency in the framework for the vaccines, ethical considerations in human trials for effectiveness, and providing a reasonable amount of data which have validity and reliability during clinical trials. Lastly, considering the allocation of resources with a Zika virus vaccine. Prioritizing who gets access to the vaccine would be problematic, presumably, if a vaccine is available.

Expanding on current policies to include definitive screening and testing with an emphasis on pregnant patients.

In 2017, MMWR publication reported pregnancy outcomes for patients with possible Zika virus infection during their pregnancy. Based on the analysis from the literature, there are issues with data collection due to the narrow scope regarding screening criteria for pregnant women. For example, number of brain abnormalities with or without microcephaly were higher during the second and third trimester. Current guidelines from the CDC require routine testing for asymptomatic pregnancy for Zika virus at the first prenatal visit and a second test for those in their second trimester whose initial test was negative. Only pregnant women in high risk areas are subjected to testing and therefore data collection. There is currently no mandatory postnatal test for Zika unlike for Thalassemia, for example.

Mosquito Abatement

Much of this policy requires efforts from community participation and through education to help with breeding reduction of the Aedes mosquitos. However, getting rid of the true source, such as identifying and then eliminating Aedes mosquitos is a challenge. Note that such abatement programs are facilitated from the state level. It is up to the state to enforce their constituents to follow the abatement programs/ policies. CDC does recommend using pesticides for eliminating Aedes larvae early on during breeding season and take aggressive measures in pesticides for areas with confirmed Zika cases. The issue with the CDC recommendation becomes open to public debate on possible side effects that could be detrimental to the environment, food and water supply.


All policy options do target the desired objective of dealing with the Zika virus. They are beneficial in helping revise preparedness guidelines that would better align with the virus transmission patterns. However, the costs differ as do the ethical concerns. One of the major difficulties of an emerging virus is the inability to identify all the different vectors of the disease; transmission of the disease is dependent on timing and severity of the virus as well as on populations and geographical location.

By focusing on expanding screenings , there is room to transform weaknesses such as proper training and technical support to an actual strength for the overall public health workforce. Incorporating improved preventive screenings into the EAU provides an opportunity for improved accuracy in data capture in a timely fashion. Most U.S. patients during the emergence of the virus presented with symptoms after returning from international travels. The CDC guidelines were primarily written to target populations in areas considered high risk; they were not written to address populations, particularly pregnant women, who have/do travel to/from high risk areas nationally and internationally but reside in low risk areas.  While men and women are equally at risk, pregnant women are at even higher risk. If a pregnant woman has a positive diagnosis of the virus, multiple ethical considerations arise, primarily concerning the fetus. Since states are responsible for laws and governance of their constituents, policies can and will be varied across the nation, making a consensus difficult to come by on the “proper” protocol, particularly any policies that surround abortion (i.e. ethical concerns about abortion vis-a-vis the societal cost of raising a child with the effects of Zika and the costs to that individual child as well versus right to life).  If part of the policy is revised from a national level as a requirement to incorporate definitive screenings and testing for pregnant patients in all trimesters, pregnancy outcomes can be useful in writing guidelines for maternal/ pre-natal care at a state level with little ambiguity. This is an opportunity for states to put clarity on their EAU for current and future Zika cases and potential additional outbreaks.

Women’s Reproductive Rights – The Impact of Abortion Bans

May 16, 2019 by

On Tuesday, May 7, 2019 the Georgia state governor, Brian Kemp, signed into law a bill that will ban abortions once a doctor is able to detect a fetal heartbeat in utero.  The detection of a fetal heartbeat usually occurs in the sixth week, before most women even know that they are pregnant yet, effectively eliminating access to most first term abortions. 

This law has not gone into effect, but is scheduled to be enforceable in 2020.  The current expectation is that this bill will be fought in court.  There has been much public outcry against this bill, on both sides.  This significantly impacts women’s rights, especially to their own bodies.  However, the other side of the discussion will assert they are arguing for the rights of the unborn child.

This public outcry is over a very current, political, personal, public health issue.  Especially with the addition of Alabama’s near total abortion ban bill signed on May 15, 2019.  Some of the loudest voices that we are hearing, outside of women’s rights and equal rights groups, are coming from Hollywood, who is showing their voice in the power of their business.  No less than 3 production companies have pulled their productions out Georgia, in response to the signing of this bill. 

We are also hearing several concerns being voiced about how these new state laws will impact the federal landmark decision of Roe v. Wade.  For now we will have to wait to see what impact these laws will ultimately end up having, if upheld.  But in the interim we need to examine the ethics surrounding both sides of this issue.

Social Health Insurance- Potentials for Universal Healthcare in Egypt?

May 16, 2019 by

Introducing a new concept

Egypt is one of those countries where, until recently, the concept of any kind of health or social is simply unheard of. To get any kind of care or government assistance, a large sum of cash had to be paid, up front. Many people are constantly turned away from hospitals and clinics because they cannot pay “a down payment” in the event of an emergency and many injuries worsen or go untreated and many lives are lost. The country has become susceptible to many diseases and illness mostly caused by overcrowding and poor conditions in hospitals due to a lack of resources, mostly brought on by a lack of funding. Most of the general population has a hard time with going to a healthcare provider because the conditions can be so bad and so many places charge so much money that people simply do not possess. There is great importance in having a health/social insurance policy in Egypt. This law would need to address many aspects including organization of the healthcare system and the quality of care in addition to the aspect referencing the important of social and health insurance/assurance.

Potentials for change in the region

The MENA region (Middle East and North Africa) is one of varying health and social standards. Across the region, countries have different resources and regulations in relation to their healthcare. Some countries offer more benefits to their citizens but this mainly because these countries have access to more resources. As the center of the League of Arab Nations, Egypt is described as a “benchmark nation”, with hopes that change and reform in Egypt will spark change and reform in other parts of the region.

What this means for Egypt?


As mentioned, there is great importance in having a health/social insurance policy in Egypt. The policy is very new and needs much attention and editing as it will potentially change the structure of the healthcare system in Egypt. Egypt’s healthcare system is a complex “Pluralistic” system. The main players in it being the private and public providers and the financing agents. To ensure a smooth transitions, regulations must be created and agencies must be held accountable with regular checks and mandates. The World Bank has already set in place a financial plan of action as long as the action takes place correctly. It is mainly the responsibility of the Egyptian Ministry of Health in conjunction with the Health Insurance Organization (HIO) to ensure policy is set in placed with the most effective plan for citizens but also will create a mandate for how hospitals/ clinics will run.

Health Care Giant and State Attorney General Battle Over Consolidation and Public Interest

May 16, 2019 by

The Pennsylvania Supreme Court is set to hear arguments this month on a case that has health care conglomerate University of Pittsburgh Medical Center (UPMC) pitted against the state attorney general (AG) on an issue that has sparked concern amongst residents of Pittsburgh over the last decade, but has also been closely watched by stakeholders across the country.  With the passage of the Affordable Care Act (ACA), insurers and providers began exploring new opportunities to lower cost and improve quality for their patients.  As a result, we are seeing unprecedented consolidation between providers and insurers that has led to monopolies and unchecked market power.  

Pittsburgh has always been a health care city in equilibrium with its world-renowned hospitals at UPMC and a powerhouse health plan, Highmark Blue Cross Blue Shield (BCBS).  In 2011 however, Highmark affiliated with another local health system, placing itself in direct competition with UPMC who has offered their own, smaller insurance plan since 1996.  Since then, the business relationship between the two health care giants has quickly gone south, culminating with UPMC refusing to provide coverage to anyone on a Highmark Plan and making Highmark Medicare Advantage members pre-pay for services pending tenuous reimbursement.  

Residents in Pittsburgh have been bracing themselves for the pending UPMC/Highmark break-up set to occur June 30th of this year.  These are residents who have long sought doctors at the prestigious UPMC hospitals, including the Hillman Cancer Center and the only children’s hospital in Pittsburgh.  The break-up would force patients who are actively being treated for specialized health needs, or who have been followed by UPMC physicians for decades, to have to seek care elsewhere or switch to Medicare Advantage and pre-pay for all of their services, nearly breaking the bank.  Lawmakers have been pleading with federal agencies to take action, however current regulations have limited their actions.   

Patients find themselves caught between dueling health care giants.

The state AG has filed a lawsuit against UPMC, claiming that their refusal to negotiate coverage for those with Highmark insurance directly contradicts their responsibility as a charitable, non-profit organization by acting against the best interests of the public.  UPMC has counter-sued and asserts that the AG is overstepping his authority and that his requests to force UPMC to contract with Highmark would violate current federal and state laws including key antitrust laws.  Hopefully, the hearing at PA Supreme Court will draw attention to the need for updates to these laws as the health care landscape and policies continues to change, ensuring that much needed checks and balances are in place to counter the manipulation of meaningful health care reform. 


May 15, 2019 by

Female Genital Mutilation (FGM or FGC) is gender-based violence ingrained in some cultures. According to the United States Office on Women’s Health, FGM means “piercing, cutting, removing, or sewing closed all or part of a girl’s or woman’s external genitals for no medical reason”. FGM is classified into four types: clitoridectomy, excision, infibulation and any other procedure that is harmful to a woman’s genitalia. FGM is usually carried out on infants and adolescent girls.  WHO estimates that each year, three million girls are at risk of undergoing FGM. Per UNICEF statistics, 35 million women and girls in Eritrea and Sierra Leone have been mutilated. Given that powerful norms such as the practice of FGM are hard to change, policy is very important. FGM is one of the violent acts against women fabricated by some cultures, with negative health impacts that have attracted the attention of the international community to develop policies to end these manmade health problems.

During the 57th UN Convention on the Status of Women, countries where FGM is practiced were encouraged to develop policies to end this human rights violation.  Though Sierra Leone is signatory to conventions such as the Convention on the Elimination of Discrimination Against Women, the prevalence of FGM continues to be high in the country. There is no law in Sierra Leone that specifically prohibits FGM https://www.refworld.org/pdfid/54bce6334.pdf. I support a total ban of FGM in Sierra Leone. Whether FGM is done by professional health care providers or traditional female circumcisers, the procedure endangers the health of women. Often, these procedures are performed under unsterilized conditions.  FGM causes problems such as pain, hemorrhage, psychological problems, infections, and death. I join others around the world to request a ban to FGM. Though WHO, UNICEF, UNFPA and local organizations such as AMNet (http://amnet-online.org/)  are working to end FGM, the Soweis, members of the female secret society in Sierra Leone do not want FGM to end https://www.opendemocracy.net/en/5050/sierra-leone-female-secret-societies-allies-fight-against-fgm/

With no government laws to abolish FGM, I call on Sierra Leoneans in the diaspora who are against FGM and other activists, to flood the Ministry of Health and Sanitation (https://www.facebook.com/pages/category/State/Ministry-of-Health-and-Sanitation-Sierra-Leone-281064805403702/), the Ministry of Social Welfare, Gender and Children’s Affairs (info@mswgca.gov.sl) and the Office of the Attorney-General and Ministry of Justice in Sierra Leone (enquiry@lawofficers.gov.sl) with letters recommending laws to ban FGM.



Sensitize your friends and neighbors; block by block, village by village to


FGM is not a taboo subject. Talk openly about the dangers so that perpetrators will


Whole Genome Sequencing for Everyone

May 15, 2019 by

Whole Genome Sequencing for Everyone


Image source: wired.com

What is Whole Genome Sequencing?

Whole genome sequencing, also known as WGS,is a type of test that determines the complete DNA sequence of a human-being at once. The information a WGS testing obtains includes an a humanbeing’s chromosomal DNA and DNA contained in the mitochondria.

Why is Whole Genome Sequencing beneficial?

Whole genome sequencing is finding more clinical utility as it is being applied to more clinical settings such as in pediatricsand other clinical areas. Recent breakthrough research has proved that WGS can save lives and lifetime healthcare expenditurewhen applied to neonates with suspected genetic diseases in ICU. Every year, more than 8 million babiesare born around the world with birth defects, with 90 percent of them in low and middle income countries. Many of these birth defects are related to genetics. 60 to 80 percent of deafness are due to genetics and many are caused by adverse drug reactionsof people with certain genetic mutations. If these parents are children had knowledge of their genetic information, a great amount of tragedy can be avoided

Main Obstacle to Whole Genome Sequencing was cost, but not for much longer


Image source: NHGRI

Since the completion of the human genome project which cost approximately $3 billion dollars to sequence one genome, the cost of genetic sequencing has been rapidly decreasing with the advancements in technology. Illumina broke the $1000 mark for WGS in 2014 and BGI drove the cost further down with offers of $600 for WGS. As someone working on delivering the benefits of WGS to more people, I already see the price of the testing going further down at a rapid pace. In November 2018, Veritas, a company founded by Harvard geneticist George Church, released a promotion campaign with 1000 WGS testing quotas for $200. The 1000 kits sold out in a few hours. Clearly, when the price drops down, consumer adoption of the WGS skyrockets.

WGS is still a privilege for a few

Roughly only a little under 1.5 million people around the world have got their whole genome sequenced as of today. This shallow penetration stands in stark contrast with the overall population of the world and the huge unmet demand.

WGS Coverage Requires Coordinated Effort

CMS and FDA have supported the expansion of whole genome sequencing with reimbursement coverage expansionand streamlined regulatory approval process, but they can do much more. Particularly, industry and academia have voiced strongly for CMS to enhance reimbursement for WGS.

As shown through CMS’ recent reversion of its national coverage determination on reimbursement amount for whole genome testing, collective industry action is crucialfor increasing access to WGS. Organizations such as the ACLA, AMA, and ACMGG should continue to push for enhanced WGS coverage through CMS and private insurers.



Rescoping the Emergency Department

May 15, 2019 by

by Lura C. Lunsford

An estimated 13% – 27% of emergency department visits could be managed at another level of care, saving $4.4 billion in health care costs annually. (https://doi.org/10.1002/cncr.21214).  The intent of EMTALA was not to make the ED a de facto free primary care convenience center.  The intent was to prevent transferring (“dumping”) medically unstable patients to another facility based on their inability to pay for emergency medical care.  

The Emergency Medical Treatment and Labor Act (EMTALA) (https://www.federalregister.gov/documents/2012/02/02/2012-2287/medicare-program-emergency-medical-treatment-and-labor-act-emtala-applicability-to-hospital#print) requires hospitals to see all patients presenting to the emergency department regardless of the complaint. This conflicts with healthcare transformation strategies obligating hospitals to reduce unnecessary utilization.  I say EMTALA is overdue for a rewrite to align the law with the triple aim: to improve the quality of care, enhance the experience of care, and reduce the total cost of care. (http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx)  

The American College of Emergency Physicians (ACEP) plays a critical role in championing the EMTALA re-write.  Emergency physicians brought “dumping” to the forefront in the 1980’s, resulting in the original EMTALA legislation. (10.1016/j.annemergmed.2016.08.433) ACEP serves as a key stakeholder in rescoping the Emergency Department by taking two key actions by December 31, 2019. First, develop a communication strategy to influence and support front-line emergency medicine providers to not interpret EMTALA beyond the actual statutory language as it refers to medical screening exam, emergency medical condition, stabilization, and transfer without regard for the ability to pay by October 1, 2019. (https://www.acep.org/patient-care/policy-statements/interpretation-of-emtala-in-medical-malpractice-litigation/).  Second, combine efforts with the Maryland Hospital Association (https://www.mhaonline.org/docs/default-source/Resources/ED-Diversions/an-integrated-care-delivery-approach-for-low-acuity-patients.pdf?sfvrsn=2) to develop a joint position statement by December 31, 2019 of their collective intent to design a population health strategy that includes alternatives to care for patients determined not to have an emergency medical condition based on medical screening examination.