Pipestone

https://reddaysblog.wordpress.com/2017/03/13/pipestone/.

 

Today, perhaps more than ever, we see an incredible proliferation of non-Western healing methodologies in the collective American socio-economic context. Many, including myself, might reference many of these attempts to prescribe healing pathways that are foreign to the “American body politic” as appropriation. Though, beyond this, and even more perplexing, if not ironic, is the fact that health systems are based on evidence-based practices – and it is not until a practice is appropriated into our positivist Western culture, that it is widely accepted, typically by way of publication in peer-reviewed journals. What we don’t know, however, will not kill us, it may make us stronger as a collective. Certainly, in my mind, this is the case of culture and healing for co-occurring disorders among American Indian and Alaska Native youth.

Despite not engaging in clinical trials, practice-based evidence and culturally appropriate services are oft cited as the critical healing mechanism and metric to which these debilitating co-occurring presentations require for any relief. In this case, traditional practices, cultural and tribal customs are understood to be the arbiter of health and healing in AI/AN communities. Unfortunately, however, the main actors (i.e., Indian Health Service) and federal regulations, as well as the movement of Evidence-based practice serves to only stifle the efforts of tribal and Indigenous communities to serve their communities, according to tradition and origin of their original teachings.

Right now, AI/AN communities are in the midst of a mental health crisis. Not only are AI/AN among the poorest, least educated and youngest of other U.S. races, they also suffer from disproportionate rates of substance misuse/abuse, suicide, depression, unintentional injury, domestic/interpersonal violence, etc.

Such circumstances within AI/AN communities are the result of generations of oppression steeped in a history of discrimination and genocide. The fate of young AI/AN people are in the hands of culture and tradition that breathe in embers, once a spirited fire that warmed each of the 567+ “Federally Recognized” nations. Many understand the co-occurring illnesses to be symptoms of colonization. Without acknowledging the sovereignty of our First Americans to practice their beliefs and own their healing, at any cost to American Society, the children may continue to be lost.

For this reason, it is important to allow space and rights for Indigenous people to practice customs, according to their traditional teachings in federal spaces, especially those spaces that are dedicated, by treaty and law, to the healing and wellness of AIAN people.

Epipen: An public health policy issue for the ages

Anaphylaxis is the severe and sudden onset of an allergic reaction triggered by allergies to a specific food, medication, insect bite/sting and/or latex. According to a press release by The Asthmas and Allergy foundation of America (AAFA), anaphylaxis is estimated to occur 1 in 50 Americans although it may be higher at 1 in 20. AAFA found many of these at risk individuals were not prepared to react to a reaction episode, due to the lack of ownership of an epinephrine auto-injector pen. Reasons for lack of ownership were not cited however in the past year attention has been drawn to its cost. Mylan, the #1 producer of the over the past 10 years, with their patented epinephrine auto-injector delivery system, the Epipen.

The Business Insider performed a cost analysis of the Epipen, citing a market price increase from $100 in 2007 to $600 in 2016. Mylan’s has had few competitors. Their main competitor was Auvi-Q by Kaleo until its recall in 2015. One competitor still exists on the market today, Adrenaclick by amedra pharmaceuticals with a price tag of approximately $200 with a good prescription coupon.

The FDA has made it easier for Mylan to hike up their prices by limiting manufacturer competition through the recall or blockage of other epinephrine auto-injector devices as well as the back log for generic drugs that has been occurring producing a delay of competitors entering the market. Such politics granted Mylan the ability to increase their prices astronomically however in this past summer they received extreme backlash from two major stakeholders. Congress asked Mylan CEO to justify Epipen price hikes and the dropping of the Epipen coverage by Cigna, a major insurance company. This pushback motivated Mylan to create a generic version of this drug delivery system as well as patient coupons (up to $300) in coverage of Epipen costs to address concerns about its price. These are steps in the right direction however there needs to be more action to keep advocate for whose healthcare coverage still does not grant them the ability to pay $300 or less in out-of-pocket expenses.

I challenge the FDA to uphold their mission to protect the public’s health by ensuring safety, efficacy and security of human drugs and medical devices while accelerating innovation to make medical products more effective, safer and more affordable. The FDA must amend their current policies and procedures to promote the presence of competitors for safe and effective epinephrine auto-injector pens to eradicate the monopoly. This can be done through the overhaul of the generic drug backlog to funnel competitors into the market as well as looking for additional ways for those without adequate health insurance coverage to more affordable epinephrine auto-injector pens and discounts. I challenge competitors to propose refillable epinephrine auto-injector pens, like Dr. Cathleen London in Maine, to provide patients with an feasible alternative. A refillable pen will drastically cut down on the burden of cost for those American citizens whose lives depend on the ownership and access to epinephrine auto-injector pens in case of an anaphylactic shock episode.

Missouri: Time to monitor prescription drugs

One might guess that being the only state without something may not be a good distinction to have. In the case of the map to the left they would be correct. Missouri, highlighted here, is the only state to not have a prescription drug monitoring program or PDMP. PDMPs are tools used by doctors to look up what narcotic and potentially addictive drugs like opioid medications a patient receives in the hopes of stopping those that are abusing them or selling them. Deaths due to opioid and heroin have reached epidemic proportions; Missouri needs a PDMP.

The Centers for Disease Control and Prevention estimate that approximately 91 Americans die every day from an opioid overdose and since 1999 the amount of pain medication sold has quadrupled! On its website the CDC even recognizes how important PDMPs can be to reducing prescription drug deaths.

Countless other organizations such as mental health groups, drug policy think-tanks and physician groups, including the nation’s largest doctor group, the American Medical Association, have come out in support of states establishing these databases. One scientific study showed that using PDMP reduced the supply and abuse of opioid medications.

Why then does Missouri not have one? The answer lies with political action groups and conservative statesman that have blocked legislative efforts that create PDMPs. United for Missouri and Missouri Alliance for Freedom both believe that legislation like this erodes a citizen’s right to privacy and constitutes government over-regulation. Their biggest ally, State Senator Robert Schaaf, has gone so far as to filibuster bills that introduce them.

The truth is the people of Missouri must establish programs that have decreased opioid deaths. Senator Schaaf should stand down and the legislature should join the rest of the nation in establishing a prescription drug monitoring program

 

 

No More Labs in Public Hospitals in China?

A Typical Day in a Chinese Hospital; Source: sixth tone

Prior to the 2009 health system reform, in the face of dwindling governmental health spending, Chinese public hospitals relied primarily on drugs with high mark-up and expensive laboratory tests as their sources of revenue. In fact, according to earlier estimation, lab testing expenditure alone costs the system 751.9 billion RMB in 2015. Unlike in the U.S. where lab tests are conducted in both hospital lab settings (62%) and independent laboratories, lab tests are completed almost exclusively within public hospital laboratories (99.3%) in China.

In the effort to improve healthcare quality and cost-effectiveness, the Chinese central MOH has recently published policy recommendations that call for labs within public hospitals to register as independent legal entity. In addition, the development of independent medical laboratory companies is also encouraged. However, actual implementation of such policy recommendations (not mandate) is at the discretion of individual provincial MOH, whose opinion is largely influenced by large public hospitals. In this case, public hospitals are unlikely to support such policy in fear that they will lose another source of revenue (in light of the recent “zero drug mark-up” policy). General publics have also voiced concerns related to whether all hospital laboratory services will be removed and how that might affect their care-seeking experience.

To maintain healthcare quality and mitigate the risk of national health insurance fund deficit , the central government of China should enforce such policy with no delay. However, in order to generate buy-in and reconcile the conflicts between different stakeholders, the CMOH should:

1. Change the “policy recommendation” to “policy mandate”, set pilot cities, start from small-scale implementation to national roll-out;
2. Subsidize public hospitals to help them go through the transition period;
3. Emphasize to the public that frequently used lab services will be available at public hospitals, only to be financially separated from the public hospitals’ revenue streams；
4. Set high quality control standard for independent lab services.

Group member: Ai Liu, Zhengchun Jiang, Shanshan Wang

The Global Gag Rule, a harmful human rights violation

The Global Gag Rule (GGR) is harmful to women and families and violates human rights. Originally known as the “Mexico City Policy” because it was enacted by Ronald Reagan in 1984 at a conference in Mexico City, the policy is more commonly known as the Global Gag Rule because of how it silences NGOs and health care workers. Specifically, the original policy dictated that no USAID family planning funds could be awarded to organizations that performed or promoted abortion and therefore prohibited them from even speaking about abortion.

The GGR is highly partisan- every Democrat president since Reagan has rescinded the policy and every Republican has reinstated it. The current administration, however, has not only reinstated the GGR but has dramatically expanded the funds that are affected.

Source: Human Rights Watch

Reagan’s version applied to USAID family planning funds; G.W. Bush’s version limited the GGR by exempting USAID HIV/AIDs related work. The latest iteration, however, greatly expands the affected funds to cover all foreign aid arising from any agency or department. The current version restricts up to $9.5 billion in aid, or 16x the amount of funds that would have been affected by previous versions.

Worse yet, beyond being a clear example of religious overreach in US politics and a violation of human rights, evidence suggests that the policy reduces sex education and contraception use while increasing both abortions and the proportion of abortions that result in health complications- maternal, family, and child health all suffer. There is a large coalition of organizations that oppose the GGR. You can take action today by learning more information about the GGR and volunteering or donating to organizations like IPPF, PAI, and the Bill and Melinda Gates Foundation who, together with UN member countries, are attempting to counteract the extreme funding deficit.

Neglecting Micronutrients in Zaatari’s Food Policy

Civil war in Syria has driven an estimated 2.8 million refugees from the country in search of sanctuary, primarily among neighboring countries. Zaatari camp in Jordan, currently the largest Syrian refugee camp, is home to over 79,000 Syrians. 

While all registered camp residents receive World Food Program food vouchers for the purchase of food items within the camp markets, studies conducted in the Zaatari camp have indicated a high prevalence of anemia in children and women (48.8% and 44.8%respectively). Displacement, lack of income, and poor access to nutrient rich foods are contributing factors to the poor nutritional status of some of the refugees in the camp.

According to WHO classification and in conformity of UNHCR operational guidance, anemia prevalence over 40% is classified as a HIGH public health significance and is an indication of need for preventive interventions with micronutrient supplementation, including iron, zinc, and vitamin A. 

UNHCR’s nutrition response intervention report of 2015 laid out a system for diagnosing and delivering targeted therapy for severe micronutrient deficiencies in both women and children within the Syrian refugee camps. Although medical personnel are trained to detect and manage severe micronutrient deficiencies, they still persist because there is no policy on universal supplementation or prevention.  

 
The current policy of securing food among refugees in Zaatari neglects important micronutrient deficiencies. While malnutrition is low overall (and thus a success of multiple aid agencies), micronutrient deficiencies are unacceptably high. We therefore propose inclusion of micronutrient packets and fortified flour to all families, and for this to be implemented as the standard in refugee camps. Jordan already has a national mandatory flour fortification program in place. We urge the World Food Program and the United Nations partners  who are heavily-invested stakeholders (UNHCR and UNICEF), to take a more sustainable approach, and focus on supporting the national fortification program to ensure that refugees have full access to fortified flour products.

 

Sugar-Sweetened Beverages’ Low Taxes in Maryland May Be a Poison for Children and Adults

Other group member: Mujan Varasteh Kia

In 2015, 30% of the people in Maryland were clinically obese. Sugar-Sweetened Beverages (SSB) is strongly associated with obesity which can lead to the number one leading cause of preventative deaths (1 in 4 deaths) due to heart disease, stroke, type 2 diabetes, and certain types of cancer, and can play a role in preterm delivery.

Image credit: San Francisco Medical society

A constructive SSB taxation policy can help to reduce many of the obesity-related health problems and alleviate the amount of money spent to treat these cases long-term. The goal is that “increasing [the tax] will discourage individuals, especially children, and teenagers, from excessive consumption of these beverages.” Currently, Maryland imposes a 6% sale tax on SSBs. No significant reduction in obesity has been recognized as a result of this taxation. It has been argued that the sales tax is too little to prevent people from reducing their bad habits which urges the need for a more substantial taxation to reduce soda consumption. In a study, they found that participants would buy fewer SSBs with 20% tax and would completely eliminate their SSB consumption if 50-100% tax was implemented.

Shortly after Mexico passed soda tax law in 2013, there was an average 12% decline in soda sales and a 4% increase in bottled water purchases. The soda industries have argued that soda taxation is not going to “change the behaviors that lead to obesity,” and that the public will find their calories elsewhere. However, in the studies they referred to the taxes were too small or they were applied in the form of sales taxes that could have gone unnoticed by the consumers.

Philadelphia was the first big city in the nation to pass a soda taxation policy in 2016. Despite the approximate $5 million advertisements against this taxation by The American Beverage Association, a non-profit campaign was created with the help of the former New York City Mayor, Michael Bloomberg to support the soda taxation law. We also urge the Maryland state legislature to support and follow the same initiatives as those of Philadelphia mayor’s 1.5-cents-per-ounce levy on SSBs. These policies may not fully eliminate the obesity crisis, but even a small reduction in soda consumption will make a difference.

Image credit: Philly.com

 

 

Rescind the Mexico City Policy

In 1984, President Reagan instituted what has been referred to as the “Mexico City” Policy. This policy prohibits any federal funds going to NGOs that provide family planning advice related to abortion. Its intent was to ensure that no U.S. taxpayer money was spent on any abortion related services. Depending on which political party is in power, the policy is periodically reinstated and then rescinded again. Recently, President Trump reinstated the Mexico City Policy. Reinstatement of this policy is often applauded by pro-life groups and religious institutions such as the Catholic Church. Other groups, such as Planned Parenthood and Doctors Without Borders, have come out strongly against reinstating the policy.

Although this policy is intended to reduce the number of abortions by not allowing funding to go toward organizations that advise women on abortion and other family planning services, evidence indicates that the policy results in an increase in the number of abortions over time. For instance, a study cited in The Economist indicated that Sub-Saharan countries with high exposure to this policy saw dramatic increase in abortions over time after it was reinstated by the Bush Administration in 2001 (see figure below).  Since this policy explicitly deprives organizations of all funding because they provide abortions or abortion related advice, it can also reduce the amount of funding available for contraceptives, HIV testing, and prenatal care.

Credit: The Economist

In summary, The Mexico City policy is counterproductive to reducing abortion and improving women’s health services as evidence has indicated the policy results in an increase the number of abortions when federal funding for NGO’s is reduced. Therefore, it would be better for women’s health and many pro-life groups if the policy is rescinded as it deprives funding for NGOs that provide other important services like contraception and STI testing.

Skyrocketing price of the “life-saving antidote” for the opioid epidemic in New York State; have the drug companies gone too far?

 (https://www1.nyc.gov/site/doh/about/press/pr2016/pr102-16.page)        

Data from the Center for Disease Control (CDC) shows a fourfold rise in overdose deaths related to prescription opioids in the United States since 2000 (figure 1). In New York State (NYS), opioid related hospital admissions peaked in 2014 (figure 2), prompting implementation of policies to address these concerns. One of the major executions by the NYS Department of Health was issuance of a standing order authorizing licensed pharmacists to dispense naloxone, an opioid antidote, to persons without needing a prescription.

Figure 1

Figure 2

Source: https://www.osc.state.ny.us/press/releases/june16/heroin_and_opioids.pdf

Naloxone counteracts the dangerous effects of opioids with minimal or no adverse events if mistakenly administered to persons not suffering an overdose. The demand for naloxone has significantly increased now that the State has requested widespread availability for the public to administer naloxone in cases of suspected overdose. However, the rising costs of naloxone have made it difficult to meet these demands. The injectable version of the drug has increased significantly over the past few years. The price for naloxone nasal spray in the CVS chain’s New York stores is up to $110 for people who buy it without a prescription and insurance. An auto-injector version of naloxone called Evzio, that works like Epi-pen, is $2,250 for a single-dose injector.

Increasing access to naloxone for the public is inadequate if prices continue to rise. The State and the manufacturers of these products are our stakeholders. These parties may reduce costs by increasing manufacturers, and offering consistent prices and discounts. Pushback from the manufacturers to lower prices thrives in that they are limited in number and have raised costs to meet rising demand. The community may argue that increasing the availability of antidotes may promote drug overdose. Thus we appeal for an alliance between the state and the manufacturers to reduce prices of these life-saving medications to curtail the opioid epidemic.

Written by Asma Akter, Elan Gorshein, Nidhi Madan

Rescinding the Mexico City Policy

Source: commondreams.org

The Mexico City Policy, also commonly known as the “Global Gag Rule,” was first introduced in 1985 during the Reagan administration and has been rescinded by most Democratic presidents and reinstated by most Republican presidents since then. This policy was most recently reinstated by President Trump, and prohibits foreign NGOs that receive US government funding from performing abortions, providing counseling and information on abortions as a method of family planning, or promoting any changes in a country’s legislation regarding abortion. The Trump administration’s reinstatement, however, does not apply only to family planning assistance. It expands to limit all U.S. global health funding, including global HIV and maternal child health (MCH) assistance.

Many organizations, including Marie Stopes International, Doctors Without Borders, Population Action International, and International Planned Parenthood Federation, have released statements in opposition to the Global Gag Rule. Foreign governments have also stepped forward, with some creating international funds or pledging money in an effort to fill the funding gap. While these are a good start, we need greater mobilization to fight for women’s health and empowerment.

Unsafe abortion is one of the main causes of maternal mortality worldwide, and disproportionately affects women in low- and middle-income countries and in vulnerable contexts such as refugee camps and conflict zones. Research has shown that policies preventing providers from educating women about abortion and family planning methods lead to more unwanted pregnancies, more unsafe abortions, and higher rates of STIs. This policy also threatens progress on many other fronts, such as HIV, child malaria, tuberculosis, and immunizations. Healthcare providers, public health professionals, and all concerned citizens need to speak out for global reproductive rights, support international aid organizations, and push Trump and US Congress for the repeal of the Mexico City Policy.