Stop child marriage in Lebanon

Lebanon has no civil code or law regulating the minimum marriageable age and women starting the onset of puberty are pushed into marriage. Six percent of women in Lebanon are found to be married before they turned 18, according to UNICEF. Child marriage primarily involve girls under age 18 is documented to extend cycles of poor economic and social development. According to WHO, consequences of minor girls ‘marriage are poverty, low education, high fertility, and poor health . 

Reasons behind child marriage in Lebanon are socio-cultural, legal, religious and economic. Families marry their daughter often times for financial incentives or to save the family’s honor linked to preserving girls’ virginity and eliminating the possibility of premarital affairs. Child marriage may also help forge strategic family alliances especially when the groom comes from wealthy descendants. Lebanese laws pertaining to “Personal Status” (including marriage) vary according to the number of religious, with each of the 18 religious communities have its own personal status law. There is no one unified law for marriage and different laws are applied to girls, according to their religious belongings.

Efforts have been made to address this issue however we need more. For instance, International agencies like the Committee for the Rights of the Child and the Committee for the Elimination of All Forms of Discrimination Against Women have made clear positions against child marriage however needs to constantly enforce and monitor the implementation of national strategies and policies. Additionally, Abaad , a local Lebanese NGO which mission is to achieve gender equality has dedicated programs in the country for women’s sexual and reproductive health and has helped spread awareness against child marriage. The role of the media is undeniable to sensitize the public and advocate to set a minimum age for marriage. A film entitled Noor has discussed in depth the problem of child marriage in Lebanon in attempt to shed light on this topic.

Breaking the cycle of child marriage in Lebanon can only be achieved through consolidated efforts.  Having the different religious communities agree on setting a minimum marriageable age and lobbying so that politicians promulgate a unified law that criminalizes or bans early marriage in Lebanon is an essential step.

The Polio crisis in Syria: targeting healthcare workers in the chaos

On October 29, 2013. The WHO reported the first polio case in Syria since 1999. 36 polio cases were reported inside the areas out of the government control in Syria, 26 of those cases were in Der el Zor (eastern Syria).  Vaccination rate in Syria dropped from 99% to 52% in 2012, leaving many kids under certain age with no immunization. The WHO report in 2014 estimated around 500,000 children under the age of five in Syria with no vaccination. According to UNICEF, despite vaccinating around 1.6 million children until the end of 2015, many were left un-vaccinated especially in the areas north of the Euphrates.

It is estimated that 60% of the hospitals in Syria have been affected. Many of the healthcare providers have been killed, injured, or left the country. In 2015, it was reported that there are only 40 doctors for every 2.5 million people comparing to 2000 before 2011.

On top of the major shortage in healthcare providers, around 700 medical workers have been killed since the conflict started in 2011. More than 300 facilities were hit by missiles or bombs.

The first Geneva convention in 1864 sat a principle to protect healthcare workers and medical space from violence and armed attacks. In 1949, 196 countries including Syria agreed on the update of this principle during the four Geneva convention. Since 1990, multiple violations to this principle have been reported around the world and most recently in Syria where multiple organization are risking human lives to deliver the Polio vaccine to children under the age of five.

Syrian American Medical Society (SAMS) has established multiple medical sites in the areas out of the Syrian regime control to provide medical care to both armed and non-armed population. They also have medical providers localized in Turkey that cross the Syrian border to offer medical help funded mainly by Syrian physicians in the US. They also established collaboration with multiple humanitarian organizations both international and local.

Smoking Epidemic Among Children in Indonesia. Who is to Blame?

ALDI 2 years old. Smoked 40 cigarettes per day in 2011.

In 2011 a video went viral of a 2-year-old smoking in Indonesia. They dubbed him the “smoking baby.” While the international community was outraged, it was not much of a surprise to local Indonesians. This is just the tip of the iceberg. Approximately 67% of males smoke while 41% of youths between 13 and 15 also smoke. 20% of smokers begin before the age of 10. This is an ongoing epidemic that needs to be dealt with.

Unlike other countries, Indonesia does not have many regulations. Children under the age of 18 can freely purchase cigarettes. Cigarettes are also very cheap, less than $0.10 per cigarette or less than $2 per pack of 20. Cigarette advertising is also not highly regulated. Billboards, television advertisements, and advertising at social events are all permissible.

Cigarette Ad: “Men understand better that Respect is number 1”

There is also a cultural belief among men in Indonesia, regardless of age, that masculinity is defined by smoking. Among the general populace smoking is seen as something trendy and cool. Many youths are encouraged to smoke by adults, even by their parents and relatives. Due to a lack of health education, many Indonesians believe that smoking can provide many benefits.

However, no individual or organization is specifically to blame for the smoking epidemic among youth in Indonesia. It is a culmination of lack of regulations, cultural acceptance, lack of health education, and false advertising. In order to remedy this, the government’s policy makers (ministry of health, finance, agriculture, and legislation) need to be more involved. They should enact a 2-5 year plan increasing regulations for cigarettes over time as soon as possible beginning with limiting the age for purchasing cigarettes to 18 or older. This should be followed by increasing the price of cigarettes to at least $4-5 per pack. Limiting or abolishing cigarette advertisement targeted towards youth would follow. And cigarette companies can then be forced to limit their involvement in cultural, recreational, and educational venues. Also, organizations outside the government, such as NGOs, can be encouraged to be more involved in educating youth under 18 on the dangers of smoking.

 

Ohio Should Withdraw Its Waiver Request for Medicaid Work Requirements

At the end of June, a federal judge blocked a Kentucky proposal to impose work requirements for Medicaid recipients. US District Judge James Boasberg did not mince words in overturning the Trump Administration’s decision to approve Kentucky’s waiver, saying it “… never adequately considered whether [the policy] would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid. This signal omission renders [the] determination arbitrary and capricious.”

Ohio’s waiver request would require “able-bodied” adults receiving Medicaid under the Affordable Care Act eligibility expansion to work or volunteer for a minimum of 20 hours a week. The legal status of Ohio’s waiver will likely remain in limbo while Kentucky’s works its way through the courts.

Even if Kentucky’s work requirements ultimately survive, Ohio might face its own costly legal battles. Ohio’s waiver exempts residents of certain counties, based on unemployment rates. The population of these mostly rural exempted counties is 95% white, while many non-exempt cities within more urban counties face similarly high unemployment rates. This means that work rules will be disproportionately applied to majority black or non-white communities.

Similar work requirements instituted as “welfare reform” since the 1990s succeeded in cutting the number of people receiving assistance, but did little to increase long-term employment or reduce poverty rates. Policy Matters Ohio has shown how the Center for Medicare and Medicaid Services (CMS) has deceptively cited academic research in trying to make the case for Medicaid work requirements, presumably to disguise the fact that there is no good evidence supporting them.

Source: Policy Matters Ohio

There is no evidence that Ohio’s waiver request would improve access to medical care or health outcomes. What it would do is add burdensome regulatory hoops for low-income people of color, exacerbating the already stressful and time-consuming nature of life in poverty. Ohio residents should contact Governor John Kasich and tell him to rescind employment requirements for Medicaid recipients.

Maryland setting a trend for other states in contraceptive coverage

Maryland Contraception Equity Act

The Maryland State legislature made history when in 2018 they passed the “Maryland Contraception Equity Act” (MCEA), This law protects the contraceptive rights of Maryland women and their partners from insurance companies’ prior restrictions on reproductive converge. The law enshrined some of the protections of the Affordable Care Act so as to protect women even if the ACA were to be repealed.

Source: Mirena

Groups such as NARAL¹ and Planned Parenthood support this law because the law reduces cost barriers to services and medications and therefore eases access. Under the law, all reproductive medications and services are covered equally and without restrictions from insurance companies. Other state legislatures should follow Maryland’s lead and pass this sort of law to improve the reproductive rights of women and their partners.

Source: Urology Care Foundation

 

One of the most powerful provisions of this law is that insurance payers now fully cover both male and female sterilization—and charge no co-pay to patients. The coverage of male sterilizations is new and previously there was an additional charge to the patient. When a co-pay is present patients may not proceed with the service due to high cost. Additionally, vasectomies, which are an outpatient procedure, are safer and more cost effective for a male than female permanent sterilization.

In addition to the coverage of sterilization, health insurance companies now also cover, long acting reversible contraceptives (LARC), IUDs and implants, with no co-pay or prior authorization. The removal of prior authorization eases access to these medications by decreasing office visits and up to weeks of wait time, thus improving patient compliance.

MCEA allows providers to prescribe a 6-month supply of contraceptive methods, instead of month-by-month dispensing that insurance previously covered, which provides convenience and improves compliance. Lastly, the Maryland law requires payers to cover over-the-counter medications such as Plan B, therefore the cost is not shifted to the woman for this emergent pregnancy prevention.

The Maryland law is even more important in light of the many recent troubling threats to women’s recent reproductive health. One example, is Judge Kavanaugh who may be added to the Supreme Court and is thought to be a threat to Roe v. Wade. Therefore, it is more important than ever that a woman’s reproductive rights are protected. We know these laws work as unintended pregnancies are reduced with the use of no-cost contraceptives and the most effective contraceptives². A woman should be in control of her reproductive rights and plan her family by choosing the contraceptive option that best fits her lifestyle. State lawmakers should stand with women and pass common sense laws that protect women’s reproductive rights.

¹ NARAL: https://www.prochoiceamerica.org/state-law/maryland/#family-planning-insurance

² https://journals.lww.com/greenjournal/Fulltext/2012/12000/Preventing_Unintended_Pregnancies_by_Providing.7.aspx

 

 

 

Insurance Coverage for Living Kidney Donors

Living kidney donors (LKDs) are an at-risk population for developing kidney disease, such as end stage renal disease (ESRD) and hypertension, and needing chronic dialysis. A 2016 study shows that 15-year observed risk of donors developing kidney disease is about 3 to 5 times more likely than 15-year projected risk in the general population. As such, continued monitoring and follow-up with a primary care physician (PCP), nephrologist as needed, may be considered medically necessary preventive low-cost care measures to mitigate high cost care, such as dialysis and transplant that are both paid for by Medicare under the ESRD coverage provision. Early monitoring can be accomplished through basic urinalysis and creatinine and hemoglobin A1C blood tests at a routine physical exam, but the problem is that the services are typically not covered through insurance. Even if some coverage exists, lack of preventive care guidelines, such as those developed by the U.S. Preventive Services Taskforce (USPSTF), for kidney donor follow-up care creates variability in coverage between payers and across states.

Figure 1: U.S. trend of annual living kidney donors; source: OPTN, HRSA

Currently, the United Network for Organ Sharing (UNOS) and Organ Procurement Transplantation Network (OPTN) has a policy that requires transplant centers to report on 6-month, 1-year, and 2-year donor outcomes. The reimbursement for these follow-up time points is explicitly excluded from the Standard Acquisition Cost (SAC) portion of the Medicare Cost Report and cannot be billed to the transplanted patient’s insurance. As such, services pertaining to donor follow-up are costs that the hospital absorbs or are billed to the donor’s insurance. Depending on the insurance, the latter case typically results in the altruistic donor paying out-of-pocket. For these reasons, donors may be discouraged from adhering to follow-up monitoring until much later when symptoms start to present. Furthermore, some donors may be at greater risk for chronic complications due to having lower education/income and other demographic factors such as race. Proactive monitoring and follow-up offers the opportunity to provide continuous engagement and education about healthy habits and lifestyle management.

Figure 2. Stratified risk after donating a kidney, source: Am J Transplant. 2018 Feb 2. DOI: 10.1111/ajt.14678

Since the passage of the Patient Protection and Affordable Care Act (PPACA) provision outlining coverage of certain preventive care services, defined under section 2713 of the PPACA, a greater number of at-risk Americans now have access to medically necessary preventive care. To protect the health of LKDs and the future of living donor kidney transplants, outcomes for which are markedly better than deceased donor kidney transplants, the USPSTF should use evidence to develop and adopt preventive care guidelines that support PPACA-mandated insurance coverage for LKDs.

Figure 3: The Big Ask, The Big Give helps prospective donors make informed decisions, source: The National Kidney Foundation.

 

 

 

Rwanda flies to the future of healthcare

Source: Technology Review

In Rwanda, drones are increasingly being utilized to deliver essential medical supplies to remote hospitals, cutting the average procurement time from the nearest major medical center from four hours down to 15 minutes. Employing drones, through a partnership with Zipline, to deliver medical supplies to underserved and remote areas represents an exciting opportunity to address Rwanda’s unique healthcare challenges. Using drones serves the interests of rural communities by enabling medical personnel to access life-saving treatments and connecting them to transfusion centers in a timely manner and with the ease of ordering with only a smartphone.

Source: Technology Review

While drones seem like a win-win for local medical organizations and international humanitarian organizations, the use of drones in Rwanda has some unanswered questions. Critics of drone technology question why authorities have invested so much money into drone technology while basic infrastructure, including roads and ambulances services are wanting. In addition, suppression of dissent and violation of basic human rights has become increasingly common in Rwanda. Neither the Rwandan government, nor Zipline, have revealed how much the project collaboration costs, raising suspicion further. Drones are also linked with concerns over surveillance; many populations are skeptical of their presence routinely overhead. Nonetheless, the Rwandan Ministry of Health and local hospitals remain supportive of the technology. Access to blood products helps rural hospitals treat post-partum hemorrhage, which is a significant cause of maternal mortality in Rwanda, where maternal mortality rates are 20 times higher than in the United States.

Source: TIME

It is in the best interest of local communities in Rwanda, the national government, and international aeronautical organizations to encourage the use of drones to deliver medical equipment. Using lessons learned in Rwanda will aid the development of infrastructure for unmanned systems in other locations impacted by natural disaster or other emergencies. Establishing rules and regulations for the use of unmanned aircraft systems is a crucial first step in the development of this innovative and life-saving delivery system. Rwanda’s embrace of drone delivery to ensure every member of its populace has access to essential medicines within 30 minutes should be supported and replicated by international agencies.

West Coast to East Coast: Following San Francisco’s Lead in Banning Flavored Tobacco in New Jersey

On June 6, 2018, San Francisco became the first city in America to ban the sale of all flavored tobacco products, including e-cigarettes and vapes. The Campaign for Tobacco-Free Kids led the coalition in support of the ban by voicing concerns about the increased prevalence of e-cigarette use among high school students and its pathway to cigarette use. It’s time for the State of New Jersey to follow San Francisco’s lead and ban all flavored tobacco products.

Health care costs in New Jersey directly attributable to smoking are estimated at $4.06 billion per year. Approximately 12% of high school students reported they use e-cigarettes, but only 8% reported they smoke cigarettes. Over a quarter of cancer deaths in our State are attributable to smoking, with 11,800 adults dying each year. New Jersey cannot afford the emotional or financial toll to increase any further, which could happen with the new e-cigarette to cigarette pipeline.

(Campaign for Tobacco-Free Kids)

Children, parents, teachers, health care providers, and law enforcement can work together to overcome the influence of big tobacco companies (which spends an estimated $181 million each year in New Jersey), and begin curbing e-cigarette usage by limiting any flavoring. While vape companies continue to hide behind minimal reductions in adult cigarette usage due to e-cigarette conversion, our children are subject to successful ads for tropical, mint, and other sweet flavors, similar to candy.

We cannot let special interests like big tobacco and vape companies use their money to overpower our voices.

We all must join the Campaign for Tobacco-Free Kid’s coalition and lobby our legislators to send a bill to Governor Murphy’s desk by the end of this year ending flavored tobacco sales once and for all. The health and safety of our children is not a partisan issue. As a matter of fact, just last year Republican Governor and Presidential candidate Chris Christie signed a bill into law that raised the age to purchase tobacco products from 19 to 21.

(Matt Cardy-Getty)

Together, we can follow in San Francisco’s footsteps and stand up to big tobacco. Join the coalition today and let your voice be heard that tobacco will not continue to take years off our children’s lives. More information about the Campaign for Tobacco-Free Kids successful efforts in San Francisco can be found here. New Jersey can further rid itself of the burden of big tobacco by banning the sale of flavored tobacco products – join the coalition today!

Providers’ role in the opioid crisis

According to estimates in a new report by the by the Centers for Disease Control, opioids are now deadlier in the US than guns, car crashes and HIV combined. The opioid problem in New Haven, Connecticut continues to evolve, with the small town making big news as recently as last week, when emergency personnel responded to over 70 opioid overdoses on one day in a 24-hour period.

Emergency personnel resuscitate one of many simultaneous overdoses on the New Haven Green in New Haven, CT.   Fentanyl-laced synthetic marijuana was blamed for sending over 70 people to the hospital in a 24-hour period.  Photo: Brian A. Pounds/AP.

Clinicians are poised to make an impact in controlling the opioid epidemic. The American Hospital Association, which represents and serves all hospitals, healthcare networks, and their patients, recently published guidelines stating their views on prioritizing the advancement of provider education in opioid use disorder. This includes recognizing those at risk for addiction, prescribing appropriately, understanding medication-assisted treatment, and understanding and addressing stigma.

Similarly, the American Medical Association, the largest association of physicians and medical students in the United States, has an Opioid Task Force dedicated to addressing the opioid crisis with a focus on the physicians’ role in reversing the epidemic.

Yale New Haven Hospital (YNHH), the primary tertiary care facility in New Haven, has also taken a stance in regulating prescribing patterns. A recent publication by investigators from YNHH details a pilot study investigating the effects of implementing a new standard of inpatient opioid prescriptions, demonstrating that this new protocol significantly reduces opioid exposure while in the hospital.

Dr. Gale Onofrio leads a discussion on management of opioid addiction at a symposium held at the Yale School of Medicine.  Photo: Digital First Media.

The momentum is strong in New Haven, but more focus needs to be placed on policy that addresses provider education. The introduction to opioids is very frequently in the hands of prescribers who may or may not be aware of their impact. The City of New Haven has already launched a fight against addiction by filing a lawsuit against numerous pharmaceutical companies for deceptive marketing of prescription opioids, but more can be done.

Within the next few months, policy should be established by City of New Haven to address formalized provider training in opioid prescription and addiction treatment, beginning at YNHH. It is particularly important that continuing education is mandatory for providers of all specialties.  All providers prescribe narcotics, and all have patients who are addicts, whether they are aware of it or not. Training should be aimed at recognizing these patients and providing the appropriate avenues toward treatment for them.

The Golden Gate Binge

Yes, San Franciscans like to drink. In fact, a whopping 50% of male residents binge drink. In the short term, binge drinking is associated with increased motor vehicle accidents, intimate partner violence, and alcohol poisoning. Over many years it can lead to memory problems, cancer, liver disease, and stroke. Because of its social acceptance, alcohol-related disease and costs are often swept under the rug and ignored as a major public health problem. The reality is, however, that there are more than 2,300 alcohol-related hospitalizations and emergency room visits per year.  That’s more than hospitalizations for diabetes, COPD, or hypertension. This leaves the city with an estimated 17.7 million dollars in unreimbursed medical expenses each year.

SFDPH Community Needs Assessment 2016

Cue taxation for intoxication. Or for hospitalizations, whatever you’d like to call it, excise alcohol tax is proven to reduce alcohol consumption. California has one of the lowest alcohol taxes in the nation. The tax on liquor is just $3.30 per gallon whereas our neighbor Oregon taxes at $22.78 per gallon. No city within California imposes a higher alcohol tax than the state requires; however, with the unreimbursed costs to the city of San Francisco an increased tax would recover most of the costs to the city. A measly 5 cent tax per drink could annually pay back the majority of alcohol’s financial burden on the city.  A larger 25 cent tax (when was the last time you walked past a quarter on the ground and actually picked it up?) could reduce alcohol consumption by 9%!

Our city has been ignoring the growing problem of alcohol abuse which is taking a toll both physically and financially. For a city with such a strong dedication to public health, it is embarrassing to have one of the lowest alcohol tax rates in the nation. It’s time to step up and reduce alcohol-related hospitalizations. Spare a quarter for San Francisco?