Anti-Sex Trafficking Law Endangers the Health of All Sex Workers

In 2018, the United States senate passed the Stop Enabling Sex Trafficking Act (SESTA) and the US House passed the Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). The SESTA/FOSTA package amends a previous law which protected websites from liability for actions taken by individual users on their sites. Under the new law, websites can be held responsible if any users are found to be using the platform for activities related to sex trafficking. It also specifies that “participating in the venture” of sex trafficking constitutes a criminally punishable offence.

At first glance, this seems like a reasonable step towards stopping sex trafficking in the US and some anti-trafficking organizations lobbied extensively in support of the law. However, the American Civil Liberties Union and even the United States Department of Justice released statements in opposition to the law and many sex worker rights advocates argue that the law endangers the health and wellbeing of both autonomous sex workers and victims of sex trafficking.

One major issue with the law is that it conflates sex trafficking with autonomous sex work. As a result, even sex worker advocates like SWOP-USA can be prosecuted for providing condoms to sex workers, an act which can be interpreted as “participating in the venture” of sex trafficking (read: sex work). Activities like distributing condoms and organizing free HIV and STI testing campaigns for sex workers serve to improve the sexual and reproductive health of autonomous sex workers and, when they can be reached, victims of sex trafficking as well. In the new climate created by SESTA/FOSTA, these activities are threatened. 

Another unintended consequence of the law is that sex workers who once solicited clients online (where they were better able to screen them) are being driven back onto the streets where transactions are less contemplated and more risky. This not only makes them more vulnerable to the pimps and sex traffickers that the legislation purports to protect them from, but also limits their ability to negotiate important SRH measures like condom use.

Although certain sites like Backpage were known sites of solicitation for both autonomous sex work and involuntary trafficking, the free internet provided forums on which autonomous sex workers gathered to exchange information on clients and safety measures in order to better protect themselves from physical and sexual violence. In the wake of SESTA/FOSTA, websites like Tumblr and Craigslist have (to different extents) limited the posting of sexual or sex-adjacent content on their sites. This has also invoked questions about how the law is having “unintended” consequences for free speech and self-expression on the Internet.

Text “Resist” to 50409 to get in on the fight against SESTA/FOSTA if:

• The human rights and health of sex workers and victims of sex trafficking are important to you;
• You value the right to free speech and self-expression on the Internet; and/or
• You think laws should be driven by fact and not by what is considered politically expedient

Gun Violence in America

America has a problem with gun violence. Every year 30,000 people are killed with guns in the USA, a staggering 80% of all gun related deaths worldwide. In addition to the loss of life, gun violence is estimated to cost Americans over $229 billion each year. This epidemic has recently garnered more social attention due to mass shootings at schools, social, and concert venues. It is estimated that we have had 1300 school shootings since 1970, with 82 accounting for 51 mortalities in 2018 alone.

Mass shootings occur all over America on a near daily basis

Despite these staggering economic and social costs, America continues to have some of the laxest gun control laws worldwide. Two specific pieces of legislature are particularly obstructive to research (the 1996 Omnibus spending bill aka the ‘Dickey Amendment’), and accessibility of gun registration records (the ‘Tiahrt Amendment’). This year marked the first federal gun control law being passed in over 3 years, with the Bipartisan Background Checks Act of 2019 requiring federal background checks on all firearm sales.

The staggering toll of gun violence in America

This legislature is encouraging but insufficient. It is estimated that 50% or more of mass murderers would have passed a federal background check. The American Psychiatric Association has noted that most perpetrators of gun violence begin with non-gun violence, which as a misdemeanor does not appear on a federal background check, so would not disqualify these individuals from gun ownership with the current legislature. Additionally, 4.6 million children live in homes with loaded and unlocked firearms, thereby providing unintentional and unregulated access.

An incredibly costly epidemic

As a concerned community member, physician, and father, I implore you to act on this issue. Please contact your congressperson and ask them to support tighter gun control by:

1. Repealing the Dickey Amendment so the CDC can study gun violence, and potential interventions.
2. Repealing the Tiahrt Amendment to allow law enforcement agencies to better track individuals with licensed firearms and intervene early to prevent violent crimes.
3. Implement extended background checks such as exist in the state of California where violent misdemeanors preclude firearm purchase.
4. Implement criminal penalties for storing an unlocked firearm in a home which houses children under 18.

Prevention of HIV transmission in Kenyan Female Sex Workers

Kenya has one of the highest burdens of HIV/AIDS in the world. Female sex workers(FSWs) have particularly high incidence and often face significant obstacles in prevention of HIV transmission. Advocating for the development of policies that protect FSWs is of paramount importance to prevent transmission of HIV among women in Kenya. 

Over 30% of sex workersin Kenya are living with HIV, giving this group of individuals the highest prevalence of the disease compared to all other groups. ~³/₄of sex workers report having access to HIV servicesand ~92% report condom use. 

High rates of HIV among sex workers persist despite access care and widespread use of basic preventative measures. This disproportionately high risk of transmission among sex workers is directly linked to intimate partner violence. 

Studies have shown that intimate partner violence significantly increases the risk of HIV transmission. FSWs areat particularly high risk given that Kenyan gender roles promote male dominance and choice and justify violence against FSWs as punishment for immoral behavior. 

It is estimated that ~17% of all new HIV infectionsin Kenya could be prevented if sex workers were not subjected to violence. Sex workers who experience violence are less likely to seek out medical and legal counsel, are less likely to receive regular HIV testing, and are less likely to adhere to treatment if they are infected due to stigma against sex workers. Additionally, despite the existence of laws penalizing intimate partner violenceand reckless transmission of HIVin Kenya, law enforcement is more likely to convict the FSW for sexwork rather than the individuals who commit acts of violence against and transmit HIV to FSWs. 

Therefore, elimination of the intimate partner violence that leads to increased transmission risk among FSWs in Kenya is dependent upon stronger enforcement of legislation such as Section 14 of theHIV and AIDS Control Actand Sexual Offences Act. It is the duty of influential organizations working towards improved HIV/AIDS prevention in Kenya to advocate for such change. One such organization is Pathfinder International, which has an ongoing project, the PITCH Program, which focuses on advocating for the rights and health of FSWs and other at-risk populations in Mozambique. Pathfinder International should scale up the PITCH Program to support FSWs in Kenya who are at particularly high risk of suffering from HIV and associated stigmas.

Increasing Access to HPV Prevention and Education Services in Rural Mississippi

Rural communities are often disproportionately affected by disease due to their proximity to healthcare services. Black women, in particular, seem to face even greater challenges to accessing Ob/Gyn healthcare services. In 2008 less than 7% of all Ob/Gyn providers were practicing in rural communities. In general, black women are 50% more likely to die of cervical cancer than their white counterparts. In rural communities, this margin grows even larger.

(Image source: cnn.com)

The state of Mississippi has the most African American residents out of any state and more than 50% of those residents reside in rural communities. Additionally, more than half of the residents of Mississippi are female. These statistics highlight that there is a very significant risk to black women in rural Mississippi communities for developing and dying from cervical cancer.

It is well known that cervical cancer is caused by the HPV virus. In a study on racial differences in HPV knowledge, it was noted that only 24% of black women were even aware of HPV and 20% of these women had knowledge of the HPV vaccine. There is clearly a large window for HPV prevention education.

One big issue with adopting prevention and education policies within rural Mississippi communities is that Mississippi has predominately abstinence-only based sex education programs in their school systems. Given that more than 20% of the rural population of Mississippi has not completed high school there is a gap in access to sex-education materials.  Educational materials would give black women in these communities’ knowledge of both HPV and cervical cancer prevention strategies.

The Mississippi Division of Medicaid and Medicare has recently prioritized women’s health initiatives. These policies should be expanded to include HPV prevention and education initiatives within the rural black community. The Medicaid and Medicare division has a unique position that would allow them to advocate for expanded educational initiatives in the face of abstinence-based education practices. More than 33% of the Mississippi African American population is below the poverty line and relies on Medicaid and Medicare services for their healthcare. Finally, the cost of treating cervical cancer significantly outweighs the cost of HPV vaccination. Adopting prevention and education policies can save countless lives and reduce the cost burden for cancer treatment to the state of Mississippi.

Helpful Links:

Mississippi  Sex-Ed Policy

Missippi Dept. Of Public Health- HPV

Rural Ob-GYN Services

Racial Differences In HPV Knowledge

http://worldpopulationreview.com/states/mississippi-population/

 

Nigeria’s Untapped Resource: Traditional Birth Attendants

Nigeria’s mothers are facing a crisis. The country currently has the fourth highest maternal mortality ratio with 814 maternal deaths/100,000 births and without drastic changes, Nigeria’s women will continue to die from preventable causes. Training and regulating the traditional birth attendants (TBA) in the country may be one step in radically changing the care these mothers receive.

Map showing the maternal mortality ratio by country. Nigeria has the fourth highest ratio behind Sierra Leone, Central African Republic, and Chad.

Particularly in the most rural areas of the country, a large percentage of women are not seeking maternal care from health facilities or skilled providers but are rather choosing to seek care from traditional birth attendants (TBA)  in their communities. In fact over 20% of all births in Nigeria are attended by a TBA, with some regions of the country reaching as high as 85%. Women are choosing this route of care for a number of reasons including cost, access, and cultural preference and as such ignoring their important role undermines efforts to improve care. This fact has been recognized by several international agencies, including the WHO, and programs supporting the training and integration of TBAs into the health system have been implemented by these agencies in other countries.

TBAs trained in Lagos by the Kabash Love Foundation

Utilizing TBAs in Nigeria on a national level would not be simple and would require the full support of international agencies already working in the country. However, with this support, Nigeria could accomplish the task. A limited model of how this could work is being developed in Lagos State under the regulation of their state-level traditional medicine in order to meet the needs of those in areas with limited access to facilities. Nigeria’s House of Representatives is working to pass a bill to form a traditional medicine council that will be tasked with establishing regulations for traditional practitioners and promote cohesion with the conventional health system for the improved health of the population. If fully supported by international agencies, this council could be the launching point for creating a national program that regulates and trains TBAs based on evidence-based recommendations and bring them in harmony with the conventional health system. When combined with other health reform in the country, the training and regulation of TBAs in Nigeria could change the tide towards better maternal health care and improved outcomes for mothers in even the most rural parts of the country.

Support Funding to End HIV/AIDS in the Dominican Republic

The Caribbean has the second highest prevalence of HIV in the world, and in 2016 the Dominican Republic (DR) accounted for 1/5 of these cases, according to reports from the United Nations Programme on HIV/AIDS (UNAIDS). In recent years, the DR has made significant strides in its response to the HIV/AIDS epidemic through its National Strategic Plan to Prevent and Control STIs and HIV/AIDS, but like many nations continues to rely heavily upon donor aid for program funding. As it moves away from Global Fund support toward domestic financing, additional donor funding will be needed to sustain programming.

2017 estimates show that out of the 67,000 Dominican men, women, and children living with HIV, only 52% receive treatment with lifesaving antiretrovirals (ARTs). Despite current HIV/AIDS programming, an upward trend continues. 2017 saw at least 2400 new cases. Heavy migration of Haitians to the country–many in need of care for HIV/AIDS–has placed increased demands upon the DR’s healthcare system.

The UNAIDS “90-90-90 target,” states that by 2020:

• 90% of Dominicans living with HIV must know their status
• 90% of Dominicans diagnosed with HIV infection must be on sustained antiretroviral therapy
• 90% of those on ARV must have viral suppression

The DR cannot come close to meeting this goal without sustained and expanded financial support of prevention and treatment programs. With a projected funding gap of US $17.8 million (equal to DOP $856 million, and including donor funding) in 2018 alone, HIV/AIDS programming remains in need of support from the Government of the Dominican Republic, in addition to donors such as The Pan American Health Organization (PAHO), The United States Agency for International Development (USAID), the AIDS Health Foundation (AHF), the United Nations Children’s Fund (UNICEF), and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

Join us in advocating for continued and expanded funding for HIV/AIDS prevention and treatment programs in the Dominican Republic.

The banning of Alcohol sell within 500 meters to schools in Thailand, It is time to take action.

Credit: “Failure of Alcohol Selling Ban Near School” Thairat 

“ Did you know that Thai people only take 7.5 minutes to get the alcoholic drinks ?” Moreover, the mean age of people who start drinking alcohol keeps getting younger and younger.

Although we know that Alcohol increases the risk of other risky behaviors such as road traffic accidents, Unsafe Sex which result in teenage pregnancy and HIV infection, Physical Violence etc. Even though several efforts have been made including “The Alcohol Beverage Control Act (2008)”

Thailand is still remaining in the Top rank Asian country drinks most. Due to, the enforcement impact of these measures is low.”  In 2009 The public sectors (Ministry on public health, education, Interior and Educational Institute) also concern about this problem especially adolescents got the consensus to banned alcohol selling within 500 meters of educational institutes which proven to reduce alcohol consumption. 

Credit: “which Asian country drinks most? ”       

Till now in 2019, 10 years after the 2009 consensus “Alcohol outlet density still increased and the average distances between alcohol outlets and educational institutions decreased with evidence of clustering near educational institutions.”.

Credit: interesting research on Alcohol Density around  15 universities in Thailand comparing immediate the Alcohol Act time (2552BE or 2009)  vs 5 years follow up  (2557 BE or 2014) found that there are several old shops still open since 2009 and new shops opened in 2014.

It was a cruel joke among Thai people who worked in policy field that Thailand was a big “Paper tiger” which is from is a Chinese phrase zhilaohu 纸老虎. Referring to something that seems threatening but is ineffectual. I could not deny it.

Therefore, I would like to urge stakeholders to prove them wrong that we have the power to help our future of a nation to be free from alcohol.

For the policymakers/managers to not only passing the regulations but also add funding/emphasis on Regulation enforcement.

For the educational institutes to emphasis and build awareness of the harm of alcohol to their students.

For the Royal Thai Police to focusing on serious enforcement of the regulation.

How many death we need to endure, To transform this giant tiger “Paper” into “Practice”?

Credit: Eagles11eyes’s Blog

California Policy on Standing Electric Scooters is Rolling in the Wrong Direction

Standing electric scooters can be founding whizzing across cities around the world. You may have seen commuters, tourists, or even friends on a night out riding them. But, if you live in a city with electric scooters, your most common encounter is likely jumping out of their way.

Image Source: NYT

While they are a promising solution to city congestion, the crashes and safety concerns are piling up as fast as the discarded scooters on busy sidewalks. The medical community has noted serious and common injuries from the scooters are increasing, including head injuries and fractures.  Yet, legislation around the safety of these scooters is slipping away.

The American College of Emergency Physicians encourages universal helmet laws as a way to decrease head injuries during any type of scooter crash, and especially crashes with cars.  Because electric scooters have a smaller profile than bikes, they are less noticeable to cars and more likely to crash over bumps in the road. By this logic, helmets are even more important for scooter riders than for bikers.

Yet, one scooter company, Bird^TM, recently backed a California law in the U.S. that removed the helmet requirement for riders over age 18. While this allowed the scooters to become even more popular, it removed any incentive for the scooter companies to improve safety. Similarly, groups that support fewer cars on the road, such as California Walks and Bike East Bay agree that helmets should not be required, stating that increased legislation will hurt the scooter companies.  Yet, through fights with the San Francisco Transit Authority, the scooter companies have shown they will adapt and create safer policies when needed. Innovation is what they do best, and scooter companies should be held liable for the hazards they create.

Transportation advocates and Californians need to tell the State Legislature that filling emergency departments with scooter-related injuries is not the way to ease congestion in our cities.  Likewise, the scooter companies need to take ownership of the problem they have created. If the vision of Bird^TM, Lime^TM, and Spin^TM is truely to create better cities, they should be leading the charge in getting helmets to consumers in a convenient way, not backing laws that roll back safety.

Screen at 23—call for supporting resolution in New York State

It may not be common knowledge that Asian American (AA) populations are at a higher risk of diabetes at a lower BMI. However, given the research and evidence supporting this trend, the American Diabetes Association (ADA) revised its diabetes screening guidelines in 2015 to recommend screening for AAs at a BMI of 23 instead of the standard BMI of 25. These guidelines have also been supported by various national organizations including the Centers for Disease Control, the American Medical Association, and the National Council of Asian Pacific Islander Physicians.

Asian Americans have the highest prevalence of undiagnosed diabetes amongst all racial/ethnic groups

Research has shown that AAs are at a higher risk of developing diabetes compared to both Caucasian Americans and Asians residing in Asia. These statistics are likely influenced by a combination of pathophysiologic and environmental factors, such as Asians having a disproportionately higher amount of visceral body fat which is linked to insulin resistance and cardiovascular disease, as well as the acclimation of AAs to the typical American diet and lifestyle.

With over 50% of AAs with diabetes who remain unaware of their status, screening at a BMI of 23 is estimated to uncover an additional 215,000 undiagnosed cases of diabetes, with even more cases of pre-diabetes. Additionally, because the AA population is the fastest growing racial/ethnic group in the United States, this number is projected to increase.

ADA Diabetes Screening Guidelines for AAs

Since the revised ADA guidelines, the state governments of Hawai’i (2016), California (2016), and Massachusetts (2018) have passed their own state resolutions supporting these new guidelines. New York state currently holds the second largest population of AAs in the U.S. with over 7% of the state population identifying as AA. Furthermore, reversing the diabetes epidemic through prevention is one of the key strategies advocated by the New York State Department of Health.

Therefore, the New York state government should follow suit in passing a state resolution supporting the screening guidelines for diabetes at a BMI of 23 for AA populations this year. If passed, this state resolution would further facilitate the prompt diagnosis and management of diabetics and pre-diabetics in this vulnerable population.

Why The Unsafe Abortion Protections Act Should be Repealed

In 2014, the Louisiana State Legislator passed a proposal referred to as the Unsafe Abortion Protections Act that would limit the number of providers and clinics eligible to provide abortions in the state. The law would require providers to be within 30 miles of a hospital where they had admitting privileges, and register and obtain state licensure if providing more than five abortions each year. Additionally, all abortions would have to be reported anonymously to the state Department of Health and Hospitals.

Planned parenthood rally’s in Louisiana in support of reproductive rights (image source)

Organizations supporting protections of unborn human life or “pro-life” organizations quickly released statements of support, with National Right to Life calling it “common sense regulations on the abortion industry to protect the lives and safety of pregnant women”. Meanwhile, the National Abortion and Reproductive Rights Action League, one of the largest national groups in support of reproductive rights, called it a measure that “corners women into using dangerous back alley procedures, unlicensed practitioners and the black market drugs already seen peddled on the streets of New Orleans”.

There are only 3 abortion clinics currently in the State of Louisiana (image source)

From a public health perspective, Louisiana is already among the most restrictive states for abortions in the country. In 2014, there were only 4 clinics providing abortion services in the state, and at the time of this writing there are only 3. If allowed to take effect, there would only be one provider at one clinic with the qualifications necessary to provide the estimated 10,000 abortions needed each year in the state, an impossible task.

In 2017, a district judge struck down the act based on evidence that it would close nearly every clinic in the state. However, the 5th US Circuit Court of Appeals did not believe the requirements were of substantial burden and reversed the decision, allowing the law to take effect. Recently, on March 4, the US Supreme Court temporarily blocked the Louisiana Law, leaving the possibility it will be considered in the future. As the court decides how to proceed, Louisiana residents should petition state legislators and work with legal efforts of the local clinics, and state chapters of Planned Parenthood, Center for Reproductive Rights, and others to repeal the act entirely, and ensure women will continue to have access to abortion in the future.