Archive for August, 2016

Self-Determination in American Indian/Alaska Native health care

August 23, 2016


In 1975, the Indian Self Determination and Education Assistance Act (PL-93-638) was passed to allow for tribes to contract with federal agencies to govern their own services. Tribes, considered “dependent domestic nations”, have varied in how much they have taken advantage of self-determination opportunities in health care. For example, 99% of the Indian Health Service (IHS) funding in the Alaska Area is under tribal control, while very little of the Great Plains Area has been transferred to tribal control. Under treaty rights, the federal government is responsible for the “proper care and treatment” of members of recognized tribes in perpetuity. There exists some sentiment that self-determination is a way of letting the federal government out of its treaty responsibilities to Native people.  Others, like Donald Warne, MD, MPH, see so-called “638” tribally-managed health care as offering increased opportunities for third party revenue and grant funding, and increased local control versus IHS facilities, resulting in more services and better access.

AI/AN health care funds are not considered an entitlement like Medicare, Medicaid, or VA benefits, meaning that Congress must appropriate funding annually. In 2014, this was $3099  per user, which is less than that spent on federal prisoners. In comparison to the general US population, AI/AN people suffer higher age-adjusted death rates (from diabetes, chronic liver disease and cirrhosis, accidents, tuberculosis, pneumonia and influenza, suicide, homicide, and heart disease), as well as infant mortality twice the general population.  IHS is a severely underfunded and understaffed agency, which, at least in the Great Plains Area, is providing care which Senator John Barrasso (R-Wy) recently called “malpractice”.

I am calling upon the IHS to provide technical assistance, capacity development, and transfer planning for tribal control. I am also calling upon Congress to fund these efforts for the improvement of AI/AN health.


Decreasing Household Costs of Dengue Prevention at Low-Altitudes in Colombia: Redirecting Resources into the Hands of People Who Slap Mosquitoes Everyday

August 23, 2016


Photo by James Gathany

Colombia bears high burdens associated with dengue.  During the 2010 epidemic, disability-adjusted-life-years lost were 1178.93 (per 1 million inhabitants) versus just 88.38 averaged for 2011-2012.  Rodriguez et. al (2016) estimated economic burdens higher than $129.9 million USD each year, with most of the burden at the individual household level (46%, 62%, and 64%) for preventing/controlling mosquitos.

The Colombian Ministry of Health and Social Protection uses the 1,800m elevation mark when allocating money to low-altitude departments for dengue-related expenditures.  This suggests that only half of Colombia’s 47 million residents are at risk for dengue.  However, many people vacation at low altitudes where they risk becoming infected and bringing dengue back home.  If low-altitude residents were better equipped to control mosquitos, then both residents and visitors would be better protected.  Unfortunately, low-altitude residents shoulder a greater financial burden for mosquito prevention than the government.  Rodriquez et al. (2016) reported that almost $85 million USD was the highest household burden (for prevention alone) between 2010 and 2012, while the highest government burden was only $35 million USD (for prevention, awareness campaigns, and control combined).

If the Ministry of Health and Social Protection’s vision of equity-based protection and healthcare resources for all is to come to fruition, more money must flow into prevention and control.  Residents should not have to buy expensive sprays when they already live in poverty.  If Ministry-controlled finances were earmarked for inexpensive yet effective household supplies, such as curtains and water container covers, then less money would be required for treatment.  I advocate for reshuffling some of the dengue-related funds to reflect the prevention priority; increase amounts for household prevention and decrease treatment allocations.

Let’s not make low-altitude residents choose between buying expensive sprays or food to eat.  It’s hard enough already just to slap together supper.

Playing By the Rules: How to Address Attacks on Healthcare in Combat

August 23, 2016

The last decade has seen a rise in attacks on healthcare workers in areas of conflict. Alongside increasing attacks on civilians, ambulance drivers, doctors, and healthcare support staff also find themselves unwilling targets of modern warfare. Such attacks are a clear violation of International Humanitarian Law as stated by the Geneva Conventions and threaten to destroy our concept of human rights and civility.

As the nature of warfare changes, strategies to enforce the protection of civilians and healthcare workers must be adjusted. Ensuring that innocents are protected and access to health is not hindered must always be a priority.

In May of this year the UN Security Council took the first necessary step in protecting the lives of healthcare workers by adopting Resolution 2286 condemning attacks on medical personnel and facilities. However, until the perpetrators of these heinous acts are held accountable for their actions these measures amount to nothing more than empty words.

The Unites States has an opportunity to set an example of how attacks like these should be addressed. On October 3, 2015 an airstrike hit the MSF-run Kunduz Hospital in Afghanistan killing 42 and injuring more than 30. It has since been discovered that the attack was conducted in error by a US Airforce gunship. While the US government has conducted investigations, acknowledged errors and punished those who were involved, they have been rightly criticized by many for the inherent bias in such investigations and the reluctance to call these attacks crimes against humanity.


Medical staff after the attack on Kunduz Hospital – photo courtesy of MSF

If “even wars have rules,” as stated by Secretary Ban Ki-moon, then it should follow that all member states should abide by them. Until the US attack on Kunduz Hospital is treated as a crime against humanity and a transparent and independent investigation is conducted there will be no hope for rogue nations, terrorist organizations and other actors to respect these foundations of international law. The United States needs to recognize this challenge and play by the same rules it would readily enforce upon others.

Legalizing Cannabis Sales in DC is a Matter of Public Safety and Public Health

August 22, 2016

In 2014, voters legalized the personal possession of cannabis for adults 21 years or older via ballot initiative. However, unlike the states of Colorado and Washington which legalized in 2012, the District’s ballot initiative did not include a system to legalize the sale of cannabis. This is due to a clause within the Home Rule Act, the District of Columbia’s version of a constitution, which prevents ballot initiatives from containing provisions which affect the city’s budget. In an effort to close this gap, elected officials in the District were planning on implementing a system to tax and regulate commercial sales of the plant, when the United States Congress, which has historically had legislative and fiscal authority over the District, attempted to block the District from moving forward with this plan by restricting the use of city funds to implement the law. While this is the prevailing belief of most drug policy observers, the city has methods of creating a taxation and regulation system for cannabis in spite of the attempted Congressional blockade.


As previously mentioned, the Home Rule Act establishes the legal foundation for local government in the District. It also contains a provision which establishes a special fund, which allows the Mayor of the District of Columbia to use monies saved in the fund for unforeseen, nonrecurring, needs that arise during the fiscal year, including natural disasters, unexpected obligations created by federal law, new public safety or health needs identified after the budget process has occurred, and other fiscal shortfalls arising in the District’s budgetary process. Having a law which allows for the personal possession of cannabis, but provides no means for individuals to acquire cannabis has creates a situation where black market sales have proliferated, and individuals continue to find ways to undermine other public institutions, like the United States Postal Service, in order to circumnavigate the law. More importantly, by not having a system for regulated sales, citizens of the District of Columbia lack the safe guards and quality assurance that comes from making purchases in a storefront. Clearly there are matters of public safety and public health before the elected officials of the District of Columbia, and using monies from the special fund to legalize the sale of cannabis seems most prudent.  USPS

Advocacy organizations like the Drug Policy Alliance, DC Vote, and DC Appleseed have lobbied elected officials to take action on using special funds to establish a system to regulate cannabis in the city. The efforts have been reinforced by polling in the city which shows that approximately 80% of District residents want this change as well.


The political pressure has resulted in some action on the part of the elected officials in the city, as recently the DC Department of Health released a report calling for regulations to be established around cannabis in the city. Furthermore, the District’s Attorney General given the legal blessing to using the District’s special funds for this purpose. Currently the fund has $135.9 million, of which, only a fraction would be needed to pass this legislation. Mayor Muriel Bowser has been on record in support of creating a system for taxing and regulating cannabis in the District since as early as 2014. With all of this political, legal and fiscal support, why does she not draw down the funds to make the change happen? The public safety and public health of the citizens depend on it.

Food Security in Northern Nigeria: Is it Attainable?

August 20, 2016


Malnutrition is a significant concern in parts of Africa, including Nigeria despite its rich agriculture accounting for deaths and growth stunt in 50% of children under five in the country. It has been recognized as consequence of poverty and poor nutrition education. In 2004, Nigeria launched a 1o year strategic plan (National Plan of Action) on its newly adopted food and nutrition policy, the National Policy on Food and Nutrition (2001), to address the food crisis over the next decade. It aimed to reduce poverty by 10% by 2010 and reduce starvation, chronic hunger and increase access to food among many other goals and objectives. Majority of the time, nutrition policies in Africa tends to promote food importation rather than building domestic, high-quality food capacity however this policy includes goal of increasing production in addition to its imports based on nutrition research.


Neglecting domestic production and animal stock creates a missed opportunity to address the micronutrient undernutrition children faces.


Nigeria has been supported by numerous other organizations in address its undernutrition issue. In 2011, The Working to Improve Nutrition in Northern Nigeria program, funded by Department for International Development (DFID) and implemented by the Nigerian Government, was launched to improve nutrition in over six million children under the age of 5 years in northern Nigeria. This program mainly provides treatment of malnutrition in these children, thereby reducing the stunting, wasting and underweight, and reducing childhood mortality. In just the few short years of the program’s implementation, it’s been noted that there has been increased State and Federal government’s commitment in addressing this issue, not even up to a decade yet compared to the initial policy implemented by the Nigerian government.

Based on ongoing research, it is clear that for the issue of malnutrition to be adequately addressed, preventive rather than treatment strategies must be implemented. A big challenge facing the resolution of malnutrition as well as food security in the rural parts of Nigeria is the need for continued funding and support. To truly stop this issue and make a lasting dent in the undernutrition issue in Nigeria, the nation must take ownership and leadership in providing a sustained action in the continued improvement of nutrition and health of its citizens. Specifically, Nigeria needs to recognize the value of its domestic agricultural richness and revisit its nutrition policy to build its domestic food production and enforce fortification of its food to improve micronutrient deficiency. It would be ideal if the government and other aiding organizations can invest more in securing food security for all households as set forth but the implemented policy. It’s important to note that the region of the country in question is also the region of the country that is responsible for the majority of the nation’s agricultural production. Unfortunately, in a country where corruption is so rampant and has infiltrated all ranks of the government’s structure, including its agricultural department, and also with repercussions from the recent insurgency of the notorious Boko Haram organization in the northern region of the country, perhaps attaining food security is a goal that may be best left on paper.


The Federal government may benefit more from redirecting funds to building is agriculture in order to meet the goals of the policy. The nation’s published strategic plan does not include strategies aimed at improving its agricultural policies and food production. Doing this is not only a big step in achieving one of its set goals to attain food security in a sustainable manner but also, stimulates its economic growth that may address the poverty issue in the northern region of Nigeria, another one of the policy’s set goals.

Minority Youth, HIV and access to Pre-exposure Prophylaxis in NYC

August 20, 2016


The number of cases of HIV throughout the United States has decreased or stabilized among intravenous drug users and heterosexuals, but increased among men who have sex with men (MSM) especially minority youth and young adults. In 2014, 22% of newly diagnosed HIV cases were in youth between the ages of 13 and 24 years of age and more than 80% of those individuals were MSM/bisexual. There has also been significant increases in minority cases of HIV (87% increase in black MSM who are newly diagnosed HIV cases).  Reasons for increased HIV rates in this population include poor education (in the form of age appropriate sexual education), risk taking behaviors (low use of barrier protection, multiple sexual partners), increases in sexually transmitted disease rates, substance abuse, psychosocial issues (loneliness, fear of rejection, bullying) and poor screening habits.

In New York City, sections of the Bronx, Brooklyn and Northern Manhattan have some of the highest rates of new HIV cases and these areas are also the location of the poorest neighborhoods in the city. As with the national trends, the majority of these new cases involve minority youth and increases in new cases in these communities suggest that there are multifactorial issues that need to be addressed.



One preventative that has been successful in reducing exposure to HIV is pre-exposure prophylaxis (PrEP). There is controversy regarding its use in adolescents because of concerns about bone growth and other potential side effects. When taken properly, it can reduce the risk of contracting the infection in high risk individuals by 92% making it an option that cannot be ignored.


In NYS, minors do not have the same protections (NYS Public Health Law, Minors’ Consent Law) as those seeking reproductive health care or treatment for sexually transmitted disease. Individuals desiring this medication must have parental consent for treatment and many providers are unwilling to prescribe without some clear guidelines and protections from the state and the CDC. This requirement likely prevents minors from seeking care, making a powerful preventative unattainable to high risk youth. Amendments to the Minor Consent and Public Health Laws would set the groundwork for the introduction of PrEP to these populations in the city allowing clinicians to address this issue and hopefully see a reduction in new cases.



Addressing Canada’s Bill C14:Medical Assistance in Dying (MAID) Patient Eligibility Criteria

August 19, 2016

Canada is currently in the midst of a contentious debate regarding the validity and composition of a recently passed bill that permits suffering patients to consensually select a physician-mediated death. The bill, Bill C14: Medical Assistance in Dying (MAID), was passed during June 2016 by the Canadian Parliament and only applies to patients who suffer from a “grievous or irremediable condition” (Lancet). According to MAID, a patient must be at least 18 years old, have an incurable disease, be in an advanced state of irreversible decline and death must be reasonably foreseeable.

MAID was passed only after a narrowing of patient eligibility criteria deemed too expansive according to the Supreme Court of Canada, who stopped the original bill in 2015. It is our opinion that the current patient eligibility criteria, which does not include mature minors, patients with advanced mental disorders (ex. Dementia), or patients with advanced directives, should be expanded to include these vulnerable groups that are being unfairly excluded. We are on the side of a substantial stakeholder cohort that believes that an expanded patient eligibility criteria focusing on overall suffering and patient interpretation of their quality of life should be amended to Bill C14.

It is vital that leaders of patient advocacy groups, such as Dying with Dignity Canada, work with family members of individuals who could benefit from an expansion to raise public awareness and jointly formulate a strategy to engage influential peripheral stakeholders, such as the Canadian Medical Association (CMA). With regards to the CMA, clarification regarding patient eligibility and avenues by which physicians can refer patients, that they are uncomfortable in helping die, to another willing physician would help address barriers that the medical community have with respect to the implementation of a policy that they generally support on moral and ethical grounds (see figure 1)

strategic-session-on-endoflife-care-in-canada-dr-blackmer-14-638 (2).jpg

(Figure 1: Graph depicting survey responses of 595 Canadian Medical Association Members,Source:Dr. Blackmer, CMA)

Raising public awareness, combining patient advocacy into one voice, and addressing the logistical issues preventing a key stakeholder from supporting a cause that they morally support are just a few suggestions that may convince the Canadian Parliament to amend bill C14. Only an amendment would allow the MAID bill to achieve the spirit of justice and mercy that underlies its’ core goal.


Helpful links:

  1. Presentation regarding CMA physician regarding MAID:
  2. Lancet article arguing for MAID criteria expansion:
  3. Local stakeholders provide commentary on MAID to media:
  4. News release by Canadian Supreme Court articulating their rejection of original bill in 2015:

Can Children and Cricket Team Up with UNICEF for a Cleaner Odisha, India?

August 19, 2016

India has the largest prevalence of human open defecation in the world. Approximately 564 million people don’t use toilets. Consequently, as many as 1/10 of the deaths in India are caused by poor hygiene and sanitation, linked to open defecation. This issue is particularly problematic for children. Children are more vulnerable to disease by being exposed to open defecation areas near their communities and are at greater risk for childhood stunting or death from diarrhea.

In 2015, UNICEF and the International Cricket Council announced a 5-year partnership aimed at advocating on behalf of the world’s most disadvantaged children. The first public step the partnership developed was the launching of Team Swachh, a program aimed at changing experiential and instrumental attitudes and subjective norms around open defecation in India. Utilizing big name celebrities, Team Swachh teaches children the importance of practicing sanitary behaviors and using toilets.

Figure 1

One quick win for Team Swachh could be in Odisha. Odisha is a rural coastal state in India that has a high incidence of poverty and disease burden. Infant mortality is 50/1000 births. Reducing death in children under age 5 is a priority for the state. Odisha is also one of the lowest performing states in latrine coverage and only fifty percent of newly constructed latrines are used. While ~ 96% of households have access to piped, pumped or well water, sanitation remains a challenge. The state government has adopted the Swachch Odisha Mission to eliminate open defecation using a community-led approach, but more can be done to address this important issue.

Capitalizing on the influence celebrities have on subjective norms, members of UNICEF Odisha partnered with Team Swachh can increase utilization of existing latrines by recruiting more “sanitation champions” in 2017 to reach the 2019 goal of eliminating open defecation. Make Odisha a priority by tweeting “Bring Team Swachh to Odisha #toilets #health @UNICEF”


Updating Florida’s Vector-Borne Surveillance: Addressing the Growing Concern for Mosquito-Borne and Tick-Borne Illness

August 19, 2016

Vector-borne diseases make up some of the more common infections throughout the globe. The Centers for Disease Control and Prevention acknowledges mosquito-borne denque mosqdiseases, such as West Nile Virus, and tick-borne infections, such as Lyme disease, have a great impact on the United States. These vectors have found favor in climate change as they continuing to breed and pose a public health risk; carrying infectious agents that may be transmitted to humans through a bloodmeal.

In 2014, the State of Florida Department of Health published their mosquito borne diseases surveillance guidebook. Within these guidelines, specific mosquito-borne infections were addressed in regards to both detecting and preventing such diseases. Unfortunately, since this publication, the Zika virus outbreak developed and was found to have recently reached Miami-Dade county in Florida, where locally transmitted cases were confirmed. Given these locally acquired infections in Florida, the surveillance guidelines should be updated accordingly.

FL Zika

Number of Florida Acquired Zika Virus (gray line: per million)

While the Northeastern regions of the US are known to have their “tick season” in the Spring and Summer, Florida’s climate allows for a year-long risk of contracting a tick-borne diease. The standard lab diauos in newsgnostic criteria for Lyme disease, the ELISA, detects antibodies against the bacterium, Borelia burgdorferi sensu stricto. However, it has continued to demonstrate poor sensitivity and overall reliability. Research from the University of North Florida has identified different strains of Borrelia that cause disease in humans. Thus, should one be infected with one of the different strains of Borrelia, one’s test is likely to be negative despite having actual disease. In recent years, Florida was found to have a 140% increase in Lyme disease cases since 1993 while reports of other tick-borne diseases have also increased. Hence, Florida researchers and public health professionals must partner together to revise and implement more up-to-date/accurate screening and awareness for vector-borne diseases.

Curing the Hepatitis C Virus in the Veteran population

August 19, 2016

Hepatitis C Virus (HCV) is the leading cause of mortality among all causes of hepatitis in the United States (US). It is estimated that 3-4 million people in the US are infected with HCV, with a prevalence of about 1.8% of the general population compared to 5.4% in the Veteran population. Veterans born between 1945-1965 and those in the Vietnam war were at higher risk for HCV due to blood products and the use of air jet guns for mass immunization. About ~175,000 Veterans in 2013 had documented HCV, and is likely underestimated  due to marginalized patients.

Prior to 2012, treatment of HCV was limited to combination therapy with pegylated-interferon and ribavirin, which created several adverse effects. With the introduction of Direct Acting Antivirals (DAAs) to the drug market in 2013, we now have the ability to cure HCV with little to no side effects. These medications inhibit various stages of the virus life cycle, leaving the virus undetectable in the body. Gilead Sciences, Inc., is the pharmaceutical company in in charge of producing most of these novel medications. Some argue that the majority of people with HCV do not require treatment because they can remain in a chronically infected compensated state. The extremely high morbidity and mortality associated with the complications of HCV is reason alone to treat all patients.

Given that the Veterans Health Administration (VHA) is the “largest integrated healthcare system” with the highest proportion of HCV infected individuals, they must create an efficient process for identifying and treating those with HCV by 2017.  The VHA should also create a multidisciplinary team at each Veterans Affairs (VA) consisting of physicians, social workers, hepatologists, midlevel providers, and case managers who follow patients with HCV. The hepatology specialist should educate primary medical providers and the team about initiation and monitoring of HCV treatment for those who require it most. Lastly, while cost is the major barrier to treatment, policy makers must work with Gildead Science to close the gap between the marketing and production drug price. Let’s make it a priority to start taking care of those who took care of us.