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Entries in health (4)


When Health Care Providers Refuse Care, Whose Rights Are At Stake?


Recently, an appeals court in Scotland ruled that a wide range of service providers have a right to object to helping with the provision of abortions, even if the care they provide is not directly related to the termination of a pregnancy. In the original ruling, last year, the duties carried out by the two Catholic midwives who brought the case had been considered so removed from the actual abortion that there could be no objection. The appeals court, however, disagreed. Everyone even tangentially involved, it said, has the right to object to providing a wide range of services. The only exception would be life-saving care.

This ruling highlights issues that have relevance beyond Scotland.

The tragic death of Savita Halapannavar in Ireland last year crystallized that no one really knows for sure when a woman is dying from pregnancy-related complications. Over the years, I have interviewed dozens of medical providers in countries with restrictive abortion laws. A key concern for the vast majority of them was how to make sure their actions were legal. Those working in countries where only life-saving abortions are permitted often expressed fear that they would either turn too many women away, with fatal consequences, or ultimately lose their license for providing care to someone who wasn’t “dying enough.”

Let’s apply this notion in a context where anyone involved, however tangentially, in the provision of abortion services, can refuse to treat a woman who is not dying.

This situation raises questions which, regardless of the answers given, compromise quality care. Who gets to determine how lethal each pregnancy is? Can a treating doctor compel assisting midwives or nurses to intervene if she or he believes the patient otherwise will die? And would midwives and others have the right to sue if they had been compelled to help provide an abortion to a woman who ultimately survived? There are no good answers to these questions, and any regulatory solution would almost inevitably lead to substantial delays in care.

Another key concern with a broadly defined right to conscientious objection in the context of health care is access to care in remote—or sometimes not so remote—areas. In the United States, much anti-choice activism is directed at making abortion impossible rather than illegal. Legislators, judges, and other officials in states including Mississippi, Virginia, and North Carolina have made it their goal to run every last abortion provider out of their state. Already, 35 percent of the U.S. population lives in counties without an abortion provider.

Moreover, broad conscientious objection clauses in combination with the stigmatization of abortion generally can stifle the provision of care anywhere. In small communities where everybody knows each other and where abortion is thought of as “evil,” doctors, nurses, and midwives often object to providing care out of fear rather than faith. After all, they still have to make their living where they are.

When I researched access to abortion for rape victims in Mexico, I came across various innovative “solutions” to this problem. In one area, abortion teams were circulated between public hospitals to ensure that no one had to provide care in his or her home town. In another, abortions were provided with the knowledge only of the senior-most officials at selected hospitals, with the result that many women in need of urgent care were turned away because “we don’t do that here” (even at hospitals where they, in fact, did).

Neither of these approaches solved the underlying problem: that abortions are seen as separate from other medical care (which they are not), and that abortion providers are considered different from other medical providers (again, not true). As a result, patients had to seek legal care in a clandestine manner, and in many cases the additional option of conscientious objection for anesthesiologists or nurses—who were not part of the core teams—made abortions virtually impossible to obtain.

Everyone has the right to freedom of thought, religion, and conscience. But international human rights standards do not protect our right to express those thoughts or that conscience in a manner that infringes on other people’s human rights. The more I learn about the concrete repercussions of conscientious objection in the context of health care, the more it is clear to me that there is no room for it. Ultimately, if you don’t want to provide the obstetric or gynecological services your patient needs—which may include an abortion—maybe you should choose another field of specialty.


Giving Thanks For Times the United States Has Fought Back Against Discrimination


It’s that time of year again: turkeys get pardoned or, more frequently, eaten. Malls get raided. Football gets ignored. Meanwhile, life goes on. And while it is easy to be cynical and disheartened by global news in light of so much hostility and inhumanity, for those of us living in the United States, this is also a time for giving thanks.

It is in that spirit that I have gathered a list of some of my favorite pieces of U.S. news on overcoming discrimination over the past couple of months:

  • On April 9, 2012—Equal Pay Day—we could celebrate that the pay gap between Latina and black women and men had been reduced slightly compared to the year before. The over-all pay gap between men and women stayed more or less then same. (Of course, in June 2012, Senate Republicans blocked a bill that would have created better remedies for workplace discrimination through unequal pay by banning companies from retaliating against workers who ask about pay disparities, and by permitting punitive damages where discrimination is proven. But for now, let’s be thankful that the race/gender pay gap is diminishing).

  • August 1, 2012, marked the day the provision of the Affordable Care Act that requires employers and insurers to cover preventive health care services, including contraception, in their policies without a co-pay took effect. This, in particular, is good news for women, because women often are stuck with the bulk of contraceptive responsibilities.

  • In September 2012, a national study (citing 2011 data) was published, showing that lesbian, gay, bisexual, and transgender youth (LGBT) in U.S. school face less harassment than they used to. Granted, a whopping third of LGBT youth still say verbal harassment or bullying takes place often or frequently, which is outrageous (and probably reflects under-reporting). Still, given the fact that this number is down from almost 41% in 2009, it is certainly good news.

  • In early November 2012, U.S. voters in four states came out in support of marriage equality, passing same-sex marriage in Maine, Maryland, and Washington state, and rejecting a constitutional amendment to define marriage as between one man and one woman in Minnesota. It should be obvious why this is good news, despite the fact that same sex couples still are denied equal rights at the federal level.

  • Also in November 2012, the American College of Obstetricians and Gynecologists, the national OB/GYN organization of the United States, recommended that oral contraception be made available over the counter. This is great news, if translated into reality, especially since it will mitigate some of the consequences when employers don’t want to offer comprehensive health insurance to their employees.

  • And last but not least, the U.S. Court of Appeals for the Sixth Circuit declared that Michigan’s ban on affirmative action policies is unconstitutional. Or put differently: there is nothing discriminatory about seeking a race (or gender) conscious way to overcome entrenched inequalities.

You may have noticed that none of this news is unpolluted. For every thanks we give, there is another mountain to move.

I am, however, an eternal optimist. Perhaps the best news of all is that when we look at gender and race discrimination in the United States over the past 4 or 5 decades, while it is still prominent and rife, it is gradually becoming less and less acceptable in law and in practice.

This year, for Thanksgiving, I celebrate Title VII of the Civil Rights Act of 1964: it’s been almost half a century since Congress codified the fact that we are all equal, at least on paper. I trust it won’t take us another 50 to really make it a reality.


Crime and Obesity: Let's Get to the Heart of the Problems


There is something deceptively simple about New York City mayor Michael Bloomberg’s blanket initiatives. Whether it is giving the police unfettered discretion to stop and frisk anyone they think might look like a potential criminal because “it saves lives,” or banning the sale of large-container sodas because, well, that saves lives too, the initiatives promise easy fixes to complex problems.

They are, however, based on a blindness to prejudice that is compelling precisely because it is wrong.

In short, Mayor Bloomberg’s initiatives purport to be color- and class-blind. If the stop-and-frisk program affects mostly men of color, Bloomberg argues, this is purely coincidental. And if most of New York City’s overweight population lives in the poorest boroughs, that is also just by chance. Maybe, this line of argument implies, it is just that men of color and the resource-poor make appallingly bad decisions about their lives and health.

Incidentally, I am not arguing that our definitions of what should be subject to punitive measures and what constitutes a “normal” weight are perfect or even always good. The point I am making is about policy effectiveness. And in that sense, even a cursory look at correctional and obesity statistics in the United States reveals deep-seated disparities which knee-jerk reactions — in particular those that blatantly ignore color and class —cannot fix.

For example, 87 percent of those stopped and frisked in New York City in 2011 were either black or Latino and mostly male, even though drug possession and use — the ostensible reason for most stops — is equally prevalent among whites. And on health, compare the pricing of a Happy Meal and a pound of organic locally grown apples and you might have an idea of why the poor constitute the majority of the nation’s obese, and why many of them, at the same time, are malnourished.

Here’s a hint: It’s not because we don’t know better. 

Obesity, like being caught in the criminal justice system, is a condition disproportionately suffered by the poor and the relatively powerless. And it is self-perpetuating. Extra padding, much like a criminal record, is easier to acquire than to shed.

To articulate these truths is not to say that overweight individuals and those in conflict with the law are immoral, stupid, or devoid of agency and responsibility. It is not even to say that the decisions that led to the obesity and punishable behavior necessarily all are bad.

It is simply to acknowledge that all of us make decisions within our specific constraints, and that policy initiatives that seek to influence these decisions must look for ways to eliminate the constraints.

In the current case, our approach to crime and weight is better understood as wilfully ignored discrimination. The Supreme Court has pretty much systematically sidestepped and ignored racial profiling in the criminal justice system, resulting in continued discriminatory outcomes. And though discrimination against overweight individuals is prevalent in the workforce — in particular when it comes to obese women — only the state of Michigan and six cities ban this type of discrimination directly. This creates a vicious cycle of discrimination which perpetuates existing class and color disparities — a reality that policy initiatives to end both crime and obesity will have to contend with to be effective.

So why do politicians push for color- and class-blind initiatives? A key reason is that solutions to discrimination are more complex (and thus harder to sell to the public) than those which punish individual choice.

Take public school lunch. Many children depend on public schools almost entirely for their culinary development.  In New York City, for example, 62 percent of all children qualify for free school lunch, and many who don’t qualify still eat both breakfast and lunch at school. As a result, if food at school is overly fatty, salty, or sweet, this is what our children’s palates become accustomed to. The federal government has issued new guidelines to address this issue, but cooking healthier food in school cafeterias requires time, and time requires better benefits and higher salaries for cafeteria workers. Meanwhile, schools blame parents for not contributing, and increased money for school lunches is not high on the political agenda.

My point is: It should be.

Instead of spending money on policing serving sizes for sodas at the gas station, New York City Hall would do well to help instil healthy eating habits in children in the first place. And focusing on effective anti-obesity measures will probably save more lives than any amount of stopping and frisking. After all, heart disease has been the leading cause of death in New York City for at least the past decade.

Either way, there is no excuse for the discrimination that is inherent in current approaches to both crime and weight.


Is Criminalization of HIV Transmission Effective? Swedish Case Reveals Why the Answer is No


Earlier this month, a 31-year-old woman in Sweden was sentenced to one and a half years in prison for having unprotected sex without disclosing to her partner beforehand that she is living with HIV.

Even a perfunctory news search reveals that this is not the first time the Swedish justice system has applied criminal sanctions to potential HIV-transmission. In January, a 20-year-old man was sentenced to eight months in prison for having unprotected sex without disclosing his status. In December 2006, a 34-year-old woman got two months, and in January 2003, a 32-year-old woman one year. All of these sentences also required the person living with HIV to pay monetary damages to their former sex-partners.

For anyone who cares about human rights from a health and discrimination angle, these cases raise multiple red flags.

For starters, consensual sex between consenting adults should, in principle, never be subject to government control or regulation. Moreover, the criminalization of HIV transmission has multiple negative outcomes. It leads to distrust in the health and justice systems; it can discourage people from seeking to know their HIV status; it adds to the stigmatization of those living with HIV; and it is ineffective in bringing down HIV transmission.

In fact, UNAIDS (the Joint UN Programme on HIV/AIDS) recommends that governments limit criminal sanctions for HIV transmission to cases where all of three conditions are met: the person charged 1) knows he or she is living with HIV; 2) acts with the intention of transmitting the virus; and 3) actually transmits it. UNAIDS also recommends that cases of such intentional HIV-transmission should be tried under generic criminal provisions for bodily harm or assault, and not under HIV-specific provisions.

Public health and human rights activists are clear on this. That is why the Swedish Embassy in France was defiled with paint-filled condoms in protest against the 2003 ruling. And that is also why my own reaction to the ruling was to declare it “bad” over twitter, a statement that was re-tweeted several times.

A closer read of the cases highlighted in the Swedish media, however, leads me to reconsider, at least in part. 

If the media-accounts are accurate, the Swedish government has, in fact, partially followed UNAIDS recommendations. The convicted individuals all knew their HIV status and the cases were brought under general criminal law provisions on grave assault, physical abuse, and attempt to cause physical harm. So far so good.

The two remaining questions — intent and actual transmission — are more difficult to gauge.

Consider this.  

In most of the cases, the convicted person either has multiple convictions over several years for the same thing, or the conviction is based on multiple unprotected sexual interactions with different partners without disclosure. It is perhaps valid for prosecutors to ask if, absent proof of intent which is hard to produce, the fact that an individual living with HIV repeatedly and knowingly exposes someone else to a deadly virus shouldn’t count for something.

Further, actual HIV transmission may not be the only harm caused. The 20-year-old convicted man was charged with having unprotected sex with eight women, none of whom ultimately ended up HIV-positive, though they all claimed to have suffered severe emotional trauma as a result of the experience. In cases of domestic violence we often ask prosecutors to consider emotional distress as real harm, so why require actual transmission in order to prove harm in this case?

Then again, consider this.

The 20-year-old man was born HIV-positive and is being charged as an adult also for those unprotected sexual encounters that occurred when he was a teenager. He was initially placed in solitary confinement, seemingly because of his HIV status.

Also, one of the convicted women alleged she had been raped.  The male partner produced evidence to the contrary and she later withdrew the allegation. Nevertheless, coercion and fear is highly relevant when it comes to decisions about how and when to disclose HIV status. Research indicates that many women in fact are reluctant to disclose their HIV status because they quite legitimately fear abuse.

And with regard to actual harm caused, it is at least possible that the ramped-up attention to the cases have contributed in some part to the severity of the emotional distress of the sex partners.

It is, of course, reckless to knowingly expose anyone to real danger, also through potential HIV-transmission, even if the danger ultimately does not materialize. This is a notion the UNAIDS recommendations to a large extent fail to acknowledge.

But the highly publicized use of the criminal law in Sweden to punish those living with HIV for being timid about their health status does not make it easier for anyone to disclose. So perhaps the real question with regard to any government’s approach to HIV transmission should not be whether it follows UNAIDS recommendations, but rather if it is effective.  An educated guess says, not so much.