Archive for August, 2014

No more babies born in church – Proposed New Health Bill in Akwa Ibom State Nigeria

August 26, 2014
A traditional birth attendant treating a pregnant client

A traditional birth attendant with a pregnant client

Why in 2014 do pregnant women in oil-rich Akwa Ibom State still prefer to deliver in churches or with traditional birth attendants? Apparently to protect themselves from spiritual attacks and the negative attitude of health workers says one study. The latest Nigerian Demographic Health Survey found that only 43% of women in the state delivered in a health facility while 47% were assisted by a traditional birth attendant (TBA) during delivery. According to Commissioner for Health Dr. Emem Bassey, child deliveries by TBAs and churches are contributing to maternal mortality in the state and he has proposed a new health bill to restrict the practice.

A proposed new maternal, child and newborn health bill, will make it illegal for churches to deliver babies and will prevent TBAs from keeping pregnant women in labor for more than 6 hours. Additionally, the bill will make antenatal care (ANC) and deliver care services free, addressing another major issue women cited for not delivering in health facilities: COST. For many, such as the Association of General and Private Medical Practitioners of Nigeria (AGPMPN) and the National Association of Nigeria Nurses and Midwives (NANNM), this will be a welcome bill, with free ANC and delivery services being a major selling point. A bit more controversial will be putting an end to non-registered, church based maternity homes as some see churches as a safe and protected place, even for child delivery. Another group to watch out are the TBAs, who earn a living from delivering babies. Neither group is likely to stop taking deliveries, even complicated ones, and many women prefer delivering their babies with TBAs and churches rather than in health facilities as they often provide the emotional and spiritual care and support that health workers often don’t.

Overall, the bill is a step in the right direction of improving maternal health indices in the state and country overall. With 1 in 29 Nigerian women at risk of dying due to pregnancy or childbirth, it’s about time that we see a firm stance on some of the issues impacting maternal health in Nigeria.

Regulation of E- Cigarette Social Marketing

August 19, 2014


           Vaping is the newest fad amongst adolescents and is further glamorized by its use by popular celebrities. While proponents market e-cigarettes with the potential benefit of being bereft of tar and smoke-related side effects, serving as a bridge to quitting, and more environmentally friendly, they have been responsible for increasing usage rates among school kids in the US. The CDC found experimentation and recent use of e-cigarettes doubled among middle and high school students from 2011-2012 with an average of 1.78mn students. Data regarding pulmonary, cardiac and carcinogenic side effects are still obscure; however there has been a definite increase in nicotine overdose.

           On August 6, 2014, Senate Democrats urged the FDA to impose stricter regulations on the advertising and marketing of e-cigarettes. The Legacy study found e-cigarette companies spent $59.3mn/year in marketing in 2013, an increase of 150-350% over one year. Most were TV and radio ads during major sports games, music shows, awards and celebrity shows with an audience comprising of approximately 35% teenagers and college-age students. A study by Research Triangle Institute International revealed an increase of e-cigarette marketing directed toward school and high school kids by up to 300% in the last 2 years.

            There are many who defend the measures used to advertise and market e-cigarettes such as e-cigarette companies, tobacco retailers, ad merchants and the binding groups such as Smoke Free Alternatives Trades Association by claiming to direct ads mainly towards adults and providing young adolescents with safer and more environmentally friendly alternatives when compared to cigarettes. The parallel increase in rates of marketing and vaping among school-age children, however, clearly indicates that an immediate action by the FDA regarding the sale and marketing of e-cigarettes must be enforced as was done with regular cigarettes through the 2009 Family Smoking and Tobacco Control Act.

Impact of the Affordable Care Act on Access to HIV Medications

August 19, 2014


Image Source

HIV is a disease with several unique characteristics; stigma may be unfairly attached, vulnerable populations are often affected (such as the economically disadvantaged), and effective treatment requires strict adherence to a combination of medications. These characteristics can act synergistically to challenge one’s ability to access effective treatment. This is not only a problem on the individual level, but also a problem of great public health concern, as effective HIV treatment through medication-induced suppression of the virus is not only life-saving to the individual, but has also been proven an effective method of infection prevention (preventing transmission of the virus to uninfected individuals).

Despite great advances in the treatment of HIV, of the 1.1 million HIV-positive individuals within the US:

  • Less than 40% are retained in regular medical care, with only 25% having undetectable levels of the HIV virus in their blood (signifying effective medication-induced suppression of the virus)
  • Almost half depend on Medicaid for medical coverage, which has been limited to those who either qualify financially or qualify due to a disabling AIDS diagnosis
  • Less than 15% have private health insurance coverage, but even these individuals often face challenges of preferred HIV medications being placed on high cost-sharing tiers, making them unaffordable

The Affordable Care Act

The Affordable Care Act (ACA) was passed in an effort to support health for all, with the expectation that all Americans would have health insurance. Changes within the health insurance industry that came as a result of the ACA include:

  • Private Market Reforms, which:
    • Prohibit insurers from denying coverage and/or charging higher premiums based on pre-existing conditions
    • Limit annual out-of-pocket expenses to $6,350 per individual and $12,700 per family
    • Mandate coverage of certain preventative health services without cost-sharing
  • Expansion of Medicaid Eligibility – State-specific inclusion of adults ages 19-64 at or below 133% of the Federal Poverty Level (FPL) (individual states to choose whether to expand their Medicaid programs)
  • Establishment of Health Insurance Marketplaces (or Exchanges) – To provide a “one-stop shop” for individuals to:
    • Compare qualified health plans to find that which best fits their health needs
    • Determine eligibility for affordability programs (such as Medicaid)
    • Determine eligibility for cost-sharing reductions and/or premium tax credits to help pay for private health insurance (available to certain individuals with incomes of 100-400% of the FPL)

As a result of the ACA, qualified health plans are also mandated to provide essential health benefits (EHB), including certain prescription drugs. When it comes to the coverage of prescription drugs, health plans are determined to provide EHB if they provide the greater of the following two options:

  • Coverage for at least one drug within each category/class of drugs in the United States Pharmacopeia (USP) OR
  • Coverage for the same number of drugs within each USP category/class as compared to the EHB benchmark plan (a benchmark plan is selected by each state to determine EHB that must be offered within that respective state)

Unintended Consequences

While the ACA prevented the exclusion of those with HIV as a pre-existing condition, ultimately expanding medical coverage for thousands of people within the US, prescription drug costs to HIV-positive patients continue to be unaffordable. This often comes as a result of these medications being placed on high cost-sharing tiers, with patients required to pay a percentage of the drug cost (up to 50%), as opposed to a flat copay (approximately $30-$45 per prescription for most other medications). To put these “unaffordable” costs into perspective, two of countless examples are provided below:

  • Within Ohio, Blue Cross Blue Shield, Coventry, Humana, and Medical Mutual placed all HIV medications on the highest cost-sharing tiers and/or categorized them as specialty medications, leading to patient copayments of 20-50% of the drug costs after satisfying deductibles. For example, one patient prescribed Isentress plus Truvada (a recommended first-line regimen in the National HIV Treatment Guidelines) could be expected to pay $1,200 per month after meeting a $6,000 deductible, under Humana’s qualified health plan.
  • Within Illinois, Aetna, Coventry, Health Alliance, and Humana placed most HIV medications on the highest cost-sharing tiers, requiring copayments of up to 50%, leading to out-of-pocket expenses for Atripla (again, a recommended first-line regimen in federal treatment guidelines) of over $1,100 per month.

Concern has been voiced regarding the potential of these high cost-sharing designs being used by health insurance companies as a means to discourage HIV-positive people from enrolling in their specific health plans, a practice that is not only discriminatory but also illegal. Much attention has also been given to pharmaceutical companies for high drug pricing. While pharmaceutical companies state the need to support new research and development, it has been noted that the costs of some medications to treat HIV have increased substantially. For example, the newest combination medication, Stribild, was recently given a price 33% higher than that of the older, yet comparable combination medication, Atripla.


  • Comprehensive HIV Medication Coverage – Another unique characteristic of HIV is that the medications to treat HIV are not interchangeable, meaning one medication cannot be automatically substituted for another medication, even within the same class. Therefore, the ACA mandate of coverage for at least one drug within each class of drugs in the USP is not sufficient in the setting of HIV, as it may be for other disease states, such as high blood pressure or cholesterol. The HIV Medicine Association (HIVMA) and the American Academy of HIV Medicine (AAHIVM) recommend coverage of all HIV medications according to the nationally recognized treatment guidelines.
  • Access to HIV Medications – The HIVMA and AAHIVM urge all stakeholders to work together to do their part in promoting access to HIV medications, often required by the United States’ most vulnerable populations. This includes insurance companies implementing reasonable cost-sharing designs, with recommendations for flat-fee copayments over those consisting of a certain percentage of the HIV medication cost. This also includes pharmaceutical companies setting prices that support access for populations most in need, as well as sustaining and expanding their copay assistance programs to be available for all HIV medications, especially supporting those patients facing high cost-sharing copayments. The HIVMA and AAHIVM also bring attention to the significant adverse consequences that come as a result of HIV treatment delay and/or interruption, including drug resistance and the development of opportunistic infections, which lead to hospitalizations and other interventions more costly than that of monthly prescription drug costs.

While the ACA has had the positive effect of providing insurance coverage to those who were often previously excluded due to having pre-existing conditions, the unintended consequence of unaffordable prescription drug coverage needs to be addressed. Optimism lies in the fact that there have been steps forward in promoting access to HIV medications; within Maryland a bill passed that limits cost-sharing for specialty drugs to $150 per month, and within Illinois a bulletin was published to notify insurers that plans with unreasonable prescription restrictions could be considered discriminatory. With the continued acknowledgement of the unintended shortcomings of the ACA and a teamwork approach to solving them, health insurance for all Americans, including prescription drug coverage, can become an affordable reality. HIV patients often unfairly face many challenges simply as a result of their HIV diagnosis; access to medications need not be one of them.

China’s One-Child Family Policy…Let’s Make it a Thing of the Past

August 16, 2014


China administered the one-child policy in 1971 in response to the country’s concerns with rapid population growth due to decline in death rate and increase in elderly population.  The policy has met its intent by reducing at least 250 million population growth by 1999.[1]  However, the policy’s “success” is not without some painful sacrifices.  The Chinese culture of preference for sons has been manifest prenatally through selective abortions as well as postnatally through female infanticide and neglect and abandonment of girls.  The 2005 national intercensus survey showed a significant imbalance in gender ratio where males under age of 20 exceeded females by more than 32 million, and more than 1.1 million excess births of boys occurred.[2]

Economically, Deng Xiao-ping’s assertion that China “will not be able to develop our economy, and raise the living standards of our people unless birth rate falls rapidly” is a flavor of the past.[3]  For the first time, China’s work force shrank in 2012 in decades and that this trend is likely to continue.[4]

In 2013, the Chinese Communist Party Central Committee started loosening the one-child policy (essentially becoming a two-child policy).[5]  While this is a step forward to the right direction, it is still in direct conflict with a fundamental human right [choice to reproduce].  The Chinese government needs to reconsider the notion of “illegal pregnancy” and remove its right to determine how many children a family should have.

Informational Links:


  1. Kane, Penny; Choi, Ching Y. China’s one child family policy.  BMJ 1999; 319:992-994.
  2. Zhu, WX; Lu, L; Hesketh, T. China’s excess males, sex selective abortion, and one child policy: analysis of data from 2005 national intercensus survey.  BMJ 2009; 338:b1211.
  3. China’s one child policy, the policy that changed the world. BMJ 2006; 333:361-362.
  4. Riley, C. The economics of China’s one-child policy.  Information can be found on URL
  5. Re-Education through labor, one-child policy in China. Human Rights Watch; November 17, 2013.  Information can be found on URL

Aluminum Phosphide Kill Rats, and Human too!

August 16, 2014

In 2013, some cases of Aluminum Phosphide Insecticide poisoning were diagnosed in Jeddah, Saudi Arabia. Unfortunately, many lost their lives due to the poison. This insecticide was supposed to be used to kill insects and rats in warehouses and farms.

    It’s very effective in killing rat, thus, people started to use it inside houses and buildings. Public Health professionals and Health Care Workers started campaigning in Saudi Arabia to control this chemical. The campaign was successful to increase peoples’ awareness about this issue and emphasized on similar event happened in 2011 and no body took action to stop it. Also, in 2012, two Canadian young sisters lost their lives in a resort in Thailand, when the hotel used this chemical to kill resistance bedbugs. Death of Quebec girls caused by Phosphine


Aluminum Phosphide comes in tablet, once exposed to water or humidity, it starts to produce phosphine gas. The gas it self is colorless and odorless. The substance get absorbed through the skin, eye contact or through inhalation. Once inside the body, it causes corrosive damage to the proteins and enzyme, which is responsible for carry oxygen. The Pesticide can kill a human in few hours. It was used in Southeast Asia for Homicide and Suicide purposes.


The Saudi Arabia ministry of Commerce and Industry banned the selling of the chemical, after the campaign produced a video, which had more than 4 million views. Although, the pesticide is now prohibited in the stores, still few cases of Aluminum Phosphide Poisoning are coming to the Hospitals in Jeddah City, until now. The pesticide was sold in the black market after the  YouTube campaign (it’s price jumped from 7$ to 170$), and some claim that Migrant South Asian workers bring it with them in the luggage.


More coordination needs to be done between different government agencies to crack down the importation of the substance, as leaving it labeled controlled substance is causing more deaths in the society.



Adolescent reproductive health in Ethiopia

August 16, 2014

The Ministry of Health of Ethiopia established a National Reproductive Health Strategy with the goal of meeting the sexual and reproductive health needs of the youth who are socioeconomically and demographically disadvantaged. In 1994, the International Conference on Population and Development (ICPD) broadened the definition of reproductive health to include the social and cultural aspect of reproductive health (RH) such as respect and protection of human rights and gender roles. This broader definition addresses the key socio-cultural issue related to reproductive health – the low status of women in Ethiopia. Sadly, gender inequality in Ethiopia disproportionately impacts young girls. 

Efforts from various organizations support the issue of RH. For example, collaborations between US and Ethiopia Universities conduct research, publish, and provide training on RH to female MPH students in Ethiopia. Other organization such as International Medical Corps incorporates RH along with HIV/AIDs, and adolescent youth programs into all of its programming. 

While these are all good efforts, in order for the National Reproductive Health Strategy to make a significant impact on adolescent RH, more focus and resources need to be directed towards addressing the issues of gender inequality. There is a need for more programs like the one from Pathfinder International who partners with local NGOs and IPOs in Ethiopia (with the support of USAID) to not only train women on RH but, empower them to strive for gender equality. I found the quote below is inspiring.   

 “Women have only been important for one thing: to bear and raise

children. We have not been considered productive and have not

stood equal to men. But, our community is very poor, and we cannot

develop without the involvement of women. Family planning is key to

that. Some women in our area have 12 or 13 children, and they do

not know any other way of life. As a Community- Based Reproductive 

Health Agent, I will be working for the next generation and their

daughters and their sisters, not just fighting poverty, but making

them equal to men.”

—A CBRHA trainee  in Assasa town, Gedeb Assassa Woreda, Ethiopia

A physician is mutilated and tortured for allegations in malpractice. A call for justice.

August 16, 2014

Screen Shot 2014-08-16 at 4.04.08 PM

A doctor that works for a governmental hospital that assists public health in Mexico (IMSS) was the victim of brutal violence and human rights violations this past month in Mexico. As The Justice in Mexico Project and multiple newspapers, like El Universalreported: “Doctor “M” was abducted the night of Thursday, July 31 as she left the hospital.  The doctor was kidnapped and held hostage for six days, until neighbors reported to the Red Cross they heard somebody was screaming next door.  During her time held captive, the abductors tortured, beat, and mutilated her. Doctor “M” was the presumed target of such violence because she was involved in a patient’s care weeks before. According to the hospital staff, “The woman arrived at an advanced stage in her pregnancy, and the baby was already dead inside her womb. That happened because the mother waited too long to seek medical attention…” Yet, the patient’s family instead accused the staff of being negligent in their care, and thus responsible for the death of the child. The kidnappers cut off the Doctor fingers, and made severe lacerations to her abdomen, trying to mimic the common operation known as a cesarean section (“c-section”). They also cut her breast, uterus and ovaries. They then forced Doctor “M” to write a warning on the wall of the patio where was being held to the other hospital staff, reading, “The other gynecologists that killed my son will follow.””

There have been different views by different organizations. Advocates that defend physicians and human rights include Mexico’s National Commission of Human Rights (CNDH), IMSS, and Yo soy medico #17. You would expect that the authorities would be the ones in support of apprehending the suspects, but not in Mexico. The General State of Justice (PGJE) and state goverment have recently denied the crime. They stated that after several investigations they concluded the doctor faked being kidnapped and she beat and mutilated herself.

This has caused an outrageous reaction from the society who knows the lack of justice there is currently in Mexico and how the government protects strong groups that typically commit this type of brutal violence.  Let’s hope that the CNDH and other social groups continue to put pressure on the government and PGJE to put their act together and start working for a new Mexico where there is justice and respect for human rights.

LARC’s in Oklahoma

August 15, 2014

49% of pregnancies in the United States are unintended. Adolescents are at higher risk for unintended pregnancies with rates approaching 98%. In the State of Oklahoma, unintended pregnancies cost taxpayers an estimated $214 million dollars a year. Long-acting reversible contraception (LARC’s) have been shown to have higher continuation rates than short-term contraception. ACOG endorses LARC’s as a first line contraception for adolescents.



Immediate postpartum LARC placement is insertion of an IUD (see image, courtesy of Wikmedia Commons) or implantable device prior to discharge after delivery. This practice is endorsed by ACOG as safe and effective. It results in increased compliance with contraception especially in at-risk populations such as adolescents. The largest barrier to this type of LARC placement is billing and reimbursement. The State of Oklahoma Medicaid program uses a single DRG (diagnosis related group) code for billing and has previously not allowed reimbursement for a separate procedure such as in-hospital LARC placement. Recent advocacy efforts by providers and patients in Oklahoma have compelled a change in Medicaid policy that allows for separate reimbursement for immediate postpartum LARC placement. Challenges still remain to encourage hospitals to stock LARC’s and incorporate the new practice into their billing. Few providers place LARC’s immediately postpartum and efforts will need to be made to educate them on the policy change and create a shift in practice habits to support this practice. With implementation of this practice, there will be an opportunity to decrease the unintended pregnancy rate in at-risk women in Oklahoma.

Where Have All the Doctors Gone? 10 Years Passing

August 15, 2014

Yes, they have dreamed this moment for six years since they entered medical schools. Finally being a doctor-in-training. One of the most important question for them is “Where shall I practice?”

10 years passed by since medical school graduates in Japan were mandated to go through two years of rotating junior residency before they choose their own specialties. Hospitals, medical schools and local governments have kept close eyes on their workforce census, and multiple studies report that there are shortages in physicians of primary care specialties in rural area, while trainees and practicing physicians increased in major six metropolitan areas. According to one report from Harvard School of Public Health, the number of pediatrician per population increased dramatically in urban areas, but the increase in rural areas remained marginal.

Ministry of Labor and Welfare has attempted to re-distribute the number of postgraduate trainees by decreasing the position in the six metropolitan areas by approximately 10%, but they still account for 38% of total positions available. However, because of high position:applicant ratio, further decrease in the number of positions in urban hospitals needs to take place. (Source)

Source: Ministry of Labor and Welfare

Source: Ministry of Labor and Welfare

Some medical students voice their concerns that trainee distribution process may limit their chances of working at urban hospitals known for quality education supported by lucrative human resources. It is clear, however, that Japan needs to distribute physicians strategically due to its low number of physician per population.

At the same time, each program should strive to improve the quality of its education, and the community should support the hospitals employ mid-career staff physicians interested in educating future generations. Quality and number of staff physicians in teaching hospitals have consistently been named top priorities for medical students to choose their training site.

While communities outside the six metropolitan areas need to increase its educational demand, strategic relocation of postgraduate trainees need to continue. As trainees in rural areas increase, staff physicians are also expected to increase, leading to positive cycle that attracts medical school graduates to the area.

Experimental Drugs in the Face of Epidemic

August 15, 2014

The death toll from the Ebola virus has now broken 1,000 including native and foreign health workers. On 11 August the World Health Organization (WHO) determined that “…provided certain conditions are met …it is ethical to offer unproven interventions with as yet unknown efficacy and adverse effects” (source)


This release was swiftly followed by a report that the last doses of the experimental drug, ZMAPP, which may have played a role in two Ebola-stricken Americans’ recoveries, had been exhausted. One wonders how the WHO’s decision will impact the distribution of other experimental drugs if the Ebola problem gets further out of hand. (source)

In 2012 Sanofi-Pasteur (the world’s largest vaccine manufacturer) conducted a study in Thailand involving 4,000 children and an experimental Dengue vaccine. The study was largely a flop; it provided protection against three of four dengue fever strains- but no protection against the one most common in Thailand. (source)

According to the CDC and follow-up studies, this trial involved a vaccine candidate that has left child-volunteers with “…a significant… risk factor forsevere illness among children in a dengue hemorrhagic fever endemic region.” (source)

A bioethics expert from Johns Hopkins points out, there are many reasons to pursue using experimental drugs as a tactic to slow Ebola (source) and if there’s a chance it will help, why shouldn’t be offered to those infected?

Right now, the supplies of Zmapp have been exhausted. Imagine if we had the capacity to produce large quantities quickly. Since it is widely accepted that we don’t know if Zmapp contributed to the two American recipients’ improving conditions- or even if they improved despite Zmapp, what would that mean for the people elsewhere if they were also administered it? What if Zmapp or another experimental Ebola drug caused an unforeseen increase in transmission? 

The media has amply covered the potential benefits to using experimental drugs. There has been little discussion of the potential risks. These drugs need to be understood more comprehensively as they stand to hurt an unknown number of people as they stand to help.