The Social Medicine Portal

Incomplete: How Medical Schools are Failing Doctors and How Doctors are Failing Women

2010 AECOM Student-Run Social Medicine Course

January 6th, 2010 will mark the beginning of the Albert Einstein College of Medicine student-run Social Medicine Course. This course is a unique opportunity for the Einstein students to cover “essentials of medical practice not taught in medical school.”  This year’s list of speakers amply illustrates the connections between clinical practice and social activism.

The opening speaker will be Dr. Joia Mukerjee of Partners in Health who will discuss “Social  Forces in Medicine.”  This event will take place at 5:30 PM at the Riklis Auditorium and will be followed by a reception. Subsequent sessions will take place each Wednesday (with one exception) at the 5th floor Forchheimer Auditorium at 5;30PM. Dinner is provided.  All events in this series will be listed at the top of our blog roll.

At last year’s course several local readers of the Social Medicine Portal dropped by.  Please feel free to come, but write to Ms. Karp (see below) so that we can inform security.

The list of speakers and topics is as follows:
Jan 13 ∙ History of Social Medicine ∙ Matt Anderson, MD, MS.
Jan 20 ∙ LGBT Health and Community Organizing ∙ John-Paul Sanchez, MD, MPH
Jan 27 ∙ Race and Health in the Bronx ∙ Robert Fullilove, EdD
Feb 3 ∙ Harm Reduction in the Bronx: Dealing with the Hepatitis Epidemic among IV Drug Users ∙ Donald Davis
Feb 10 ∙ Motivational Interviewing and Nutrition in the Bronx ∙Yasmin Mossavar-Rahmani, PhD, RD, CDN
Feb 17 ∙ The Impact of Hep B on Pregnancy in the Asian American Community∙Tomoaki Kato, MD; Maya Gambarin-Gelwin, MD
Feb 24 ∙ Abortion Care in NYC∙Marji Gold, MD
Mar 3 ∙ Native American Health ∙ Donna Perry, MD *Price Center Auditorium
Mar 10 ∙ Separate and Unequal: Medical Apartheid ∙ Neil Calman, MD and Nisha Agarwal, JD
Mar 16* ∙ Liberation Medicine ∙Lanny Smith, MD, MPH, DTM&H  *Tuesday at 7:15pm*
Mar 17 ∙ Reentry: Old Fears, New Hopes ∙Meekaelle Joseph
Mar 24 ∙ Street Medicine ∙ Jim Withers, MD
Apr 7 ∙ The History and Practice of Community Psychiatry ∙Thomas Betzler, MD
Apr 14 ∙ Nyaya Health: A Case Study in Developing a Healthcare NGO∙ Ryan Schwarz and Bijay Acharya, MD
Apr 21 ∙ Refugee and Asylee care: Human Rights for Torture Survivors ∙ Nicole Sirotin, MD
Apr 28 ∙ Ayurvedic Medicine ∙Bhaswati Bhattacharya, MD, PhD
May 5 ∙ The War on Women: Criminalization of Reproduction in the United States ∙Robert Roose, MD

For any questions or kosher meal requests, please contact Jessica Karp at jkarp@einstein.yu.edu.

Posted by Matt Anderson, MD

Maternal Mortality, Equity and Allan Rosenfield, advocate for Women’s Global Health and Human Rights

In late 2006 I saw Dean Allan Rosenfield for the last time, in his office of the Columbia University School of Public Health, where he had served as dean since 1986. Diagnosed with ALS, he was breathing with supplemental oxygen. His presence—always inspiring to me in its lucidity of what is necessary and possible in the struggle for health and social justice—now showed unmistakably a quality which I realize had been there since long before I met him in 1993: the determination to make every minute alive count positively toward the lives of others.

Maternal Mortality—A Neglected Tragedy: Where is the M in MCH?” he shouted in an article in 1985 The Lancet 2 (8446): 83–85, with Deborah Maine startling and shaming a public health world which had since 1980 been reducing primary care to ever more selective programs targeting children and ignoring others, including those who give children birth and all who rear them, young and old. Alas, the question still stings and will until a comprehensive health approach to all humans, including mothers, comes with health acknowledged, planned and effectively funded globally as a basic human right.

According to Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and The World Bank (http://www.unfpa.org/upload/lib_pub_file/717_filename_mm2005.pdf), the United States has an MMR (Maternal Mortality Rate, i.e. maternal deaths for 100,000 live births) of 11 (11.5 according to the CDC, while for African-American women it is cited as 29.6, see http://www.cdc.gov/od/oc/media/pressrel/r010511.htm), putting the USA at number 41 in the world (the best is Ireland with an MMR of 1). Sierra Leone has an MMR of 2,100, while several other countries in Sub-Saharan Africa have rates above 1000 (examples: Niger 1,800; Angola 1,400; Rwanda 1,300; Burundi 1,100; Malawi 1,100). In short the numbers are atrocious, the realty of pregnancy as a risk for death around the world (even in the USA) evident to anyone who has worked with pregnant women outside the industrialized world and to many who have worked with pregnant women within the USA. The fifth Millennium Development Goal, MDG, is to decrease Maternal Mortality “by 75% by 2015 (starting in 1990).” Alas, even that would leave a terribly high number of women dying preventable deaths. Currently, the lifetime risk of a woman dying in childbirth in Africa is 1:26, with Niger having a lifetime risk of 1:7. (Ireland’s lifetime risk is 1:48,000, a demonstration of what is possible.

It was his characteristic kindness that led Dean Rosenfield to accept my invitation to write the Introduction to Women’s Global Health and Human Rights, WGHHR (http://www.jbpub.com/catalog/9780763756314/), “Global Women’s Health and Human Rights,” together with Caroline Min and Joshua Bardfield. He had always been kind to me, serving at the birth of Doctors for Global Health, DGH on the Advisory Council, and eventually becoming a major donor to DGH through a mechanism that doubled his donations. I have since learned that his kindness as author and co-author spurred many a renowned health professional to publish her or his first paper—one being the Director of the Residency Programs in Primary Care and Social Medicine at Montefiore Medical Center, Dr. Hillary Kunins, co-founder of Medical Students for Choice, MSFC (http://medicalstudentsforchoice.org/), with “Abortion: A Legal and Public Health Perspective” (Annual Review of Public Health, 1991; 12: 361-82).

In a recent lecture (1 June 2009) for the Global Health Course of Montefiore Medical Center and Albert Einstein College of Medicine, Dr. Joia Mukherjee, Medical Director of Partners in Health (www.pih.org) and an author in WGHHR, made the point that any woman who has had a C-section, received antibiotics or gotten blood during delivery or post-partum would likely have died in most parts of the world and consequently should, along with her partner and anyone else who loves her, be fighting for and demanding access to adequate birth-care for women worldwide as a matter of personal to global solidarity

I am certain that Dean Rosenfield would have affirmed that logic of sharing good fortune. His actions, literally to his dying day, embodied and encouraged such solidarity. In addition to his work promoting women’s health, he dedicated much of his professional life to fighting the AIDS epidemic. His vision extended to health equity for all, health in its largest sense of wellbeing including education—especially for women. “People should have access to the same care in a poor country as in a rich country,” he stated in an interview with Charlie Rose in 2006 (http://www.charlierose.com/view/interview/325), also saying: “I think it’s obscene that in our country 15-18% of people are uninsured.”

Dean Rosenfield enhanced Women’s Global Health and Human Rights, the book and the concept, by direct action throughout his professional life. Alas, the health and human rights reality worldwide for women—and thus for all persons–remains abysmal. In terms of global Maternal Mortality we have Ireland’s example as a target–why not? Equity, not just diminished misery, should be our goal—for women, for every human, anywhere in the world. That goal is Dean Rosenfield’s legacy. Making that goal happen is his challenge for all of us, now.

Dr. Siobhan M. Dolan:“Direct to Consumer Genetic Testing: Are We Ready?”

Tuesday February 24th’s Social Medicine Rounds brought Dr. Siobhan Dolan to the Residency Program. Dr. Dolan is double-boarded (Obstetrics and Gynecology, Clinical Genetics) as well as having an MPH. She currently works in the Montefiore/AECOM clinical genetics testing service.

Dr. Dolan began by discussing the difference between traditional clinical genetics and the current field of genomics.  Genetics was originally concerned with single gene defects, usually associated with rare diseases. These mutations were usually of high penetrance (i.e. having the genetic mutation usually caused you to be sick) and caused conditions (like Down’s syndrome) in which environment played a relatively minor role.  Genomics, on the other hand, typically involves multiple (often interacting) genetic variants  that are associated with common conditions. These genetic variants often confer only a modestly increased risk of the disease.  The diseases in question are ones (such as lung cancer) in which the  environment plays a large role.  (For more on this distinction, see the article by Alan E. Guttmacher, M.D., and Francis S. Collins, M.D., Ph.D. in the November 7, 2002 issue of the New England Journal of Medicine entitled: Genomic Medicine: A Primer).

Genomic medicine promised to make genetics relevant to everyone.  In a 1994 article in the American Journal of Human Genetics, Dr. Eric Hoffman predicted “[t]he day of the personal DNA profile provided at birth, complete with calculated risks of various cancers, heart disease, and many other conditions could be actuality by the time that current first-year medical students begin to practice medicine.”   While this prediction proved premature, a few years later genomics entered the mass market with internet-based direct-to-consumer advertising.

Dr. Dolan expressed considerable skepticism regarding the value of many genetic tests.  In order to assess their clinical validity she recommended use of the ACCE criteria developed by the Foundation for Blood Research for the CDC.  These criteria evaluate:

• Analytic validity: Does the test actually measure the genetic variation it is supposed to measure? (“ability to accurately and reliably measure the genotype of interest. “)
• Clinical validity: Is the genetic variation actually predictive to the disorder of interest? (“ability to detect or predict the associated disorder (phenotype)”)
• Clinical utility: What are the risks and benefits of introducing the test into clinical practice?
• Ethical, Legal and Social Consequences of the Test

The ACCE criteria suggest 44 specific questions that should be answered in considering a given genetic test.

Several genetic tests have not lived up to their initial promise. For example, Roche’s AmpliChip CYP450 test was touted as a breakthrough that would allow individualized dosing, particularly of psychiatric medications.  But the clinical utility of the test has been questioned (The Medical Letter, 47(1215/1216), August 15/29, 2005).  In 2007 the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group writing in Genetics in Medicine concluded that: No evidence was available showing that the results of CYP450 testing influenced SSRI choice or dose and improved patient outcomes, or was useful in medical, personal, or public health decision-making.” [SSRI's are a common class of anti-depressant drugs].

Similar concerns have been raised about pharmacogenetic testing for warfarin.   Reviewing commercial tests for CYP450 polymorphisms associated with differences in warfarin metabolism, The Medical Letter concluded in May of 2008 that: “Currently available data are probably insufficient to recommend pharmacogenetic testing just yet for all patients taking warfarin, but these tests may be helpful, especially in selecting an initial dose and in some patients with unexpected therapeutic responses to the drug. Whether they improve clinical outcomes remains to be established.” (The Medical Letter, 50(1286), May 19, 2008)

Regardless of these cautions genomics has now entered the world of direct to consumer advertising and Dr. Dolan reviewed the major categories of this fascinating “brave new world”.  [Please note, we are not endorsing the use of any of these websites.]

1. Determining Paternity.  DNA Lab Centers features a smiling baby on the home page with the caption: “Does he really have your eyes?”   Results can be used to “provide Maternity, Paternity, Immigration, Grandparent and Sibling Testing/Verification.” The use of DNA for immigration cases is, apparently, a growing field.

2. Sites like Ancestry.com offer genetic testing which purport to allow one to investigate ancestry.

3. Dating and Social Networking: Sites like Gene Partner and Scientific Match claim to match people based on genetics.  Gene Partner bases its system on HLA matching and the site provides references to 11 scientific publications. Four of these were non-human studies and three of the studies are listed twice (ouch!).  Of the remaining four studies three relate to female preferences for different male odors and only one associates HLA types with romantic involvement, a study involving 48 couples.  Not a particularly strong evidence base.  Scientific Match seems also to use the HLA types, but the site is less explicit.

4. Sites looking for specific medical disorders: Sites like DNA Direct and 23 and me provide comprehensive genetic testing services include whole genome tests.  Again, the clinical utility of most of these tests has yet to be demonstrated.

It is a shame that the development of genomics in the United States is being left to the marketplace.  The British are rightly proud of their National Institute for Health and Clinical Excellence (NICE) which evaluates new drugs and devices prior to their adoption by the National Health Service.  NICE’s decisions has been controversial at times, but this is to be expected given the nature of the decisions it makes.   The new Federal stimulus bill sets aside $ 1.1 billion dollars for effectiveness research.  This is a welcome move and long overdue.

Concluding thoughts:

Maybe major histocompatibility genes truly explain romance. But in the market, let the buyer beware.

I prefer poetry and will close with the thoughts of Edmund Spenser:

Amoretti XXX: My Love is like to ice, and I to fire

My Love is like to ice, and I to fire:
How comes it then that this her cold so great
Is not dissolved through my so hot desire,
But harder grows the more I her entreat?
Or how comes it that my exceeding heat
Is not allayed by her heart-frozen cold,
But that I burn much more in boiling sweat,
And feel my flames augmented manifold?
What more miraculous thing may be told,
That fire, which all things melts, should harden ice,
And ice, which is congeal’d with senseless cold,
Should kindle fire by wonderful device?
Such is the power of love in gentle mind,
That it can alter all the course of kind.

Posted by: Matt Anderson, MD

Family Centered Maternity Care

Our colleague, Dr. Rebecca Williams, has set up a website exploring Family Centered Maternity Care (FCMC).  Family Centered Maternity Care, as she explains it, is “a philosophical approach to prenatal care and delivery providing care to the pregnant woman in the context of her family. FCMC is prenatal care that considers, includes, and fosters the development of families. Historically, practitioners have also promoted natural childbirth.” While the site is primarily towards the teaching and clinical needs of our Family Practice residents, Dr. Williams updates it on a regular basis, making it a valuable resource.

The movement for Family Centered Maternity Care is several decades old.  Interested readers may want to consult Celeste R. Phillips‘ book  Family-Centered Maternity Care some of which can be read on Google Books. Phillips, a pioneer in the field, defines FCMC as “a way of providing care for women and their families that integrates pregnancy, childbirth, postpartum, and infant care into the continuum of the family life cycle as normal, healthy life events.”  She developed the following 10 principles for FCMC:

Principle No.1: Childbirth is seen as wellness, not illness. Care is directed to maintaining labor, birth, postpartum, and newborn care as a normal life event involving dynamic emotional, social and physical change.

Principle No. 2: Prenatal care is personalized according to the individual psychosocial, educational, physical, spiritual and cultural needs of each woman and her family.

Principle No. 3: A comprehensive program of perinatal education prepares families for active participation throughoutthe evolving process of preconception, pregnancy, childbirth and parenting.

Principle No. 4: The hospital team helps the family make informed choices for their care during pregnancy, labor, birth, postpartum and newborn care, and strives to provide them with the experience they desire.

Principle No. 5: The father and/or other supportive persons of the mother’s choice are actively involved in the educational process, labor, birth, postpartum and newborn care.

Principle No. 6: Whenever the mother wishes, family and friends are encouraged to be present during the entire hospital stay including labor and birth.

Principle No. 7: Each woman’s labor and birth care are provided in the same location unless a Cesarean birth is necessary. When possible, postpartum and newborn care are also given in the same location and by the same caregivers.

Principle No. 8: Mothers are encouraged to keep their babies in their rooms at all times. Nursing care focuses on teaching and role modeling while providing safe, quality care for the mother and baby together.

Principle No. 9: When Mother-Baby care is implemented, the same person cares for the mother and baby couplet as a single-family unit, integrating the whole family into the care.

Principle No. 10: Parents have access to their high-risk newborns at all times and are included in the care of their infants to the extent possible given the newborn’s condition.

Dr. Phillips currently runs a healthcare consulting company, Phillips + Fenwick, which assists hospitals in implemented FCMC programs.  The company website – www.panf.com – has some resources on FCMC, such as a short reading list.  Of particular interest, is her 1999 article Family-Centered Maternity Care: Past, Present, Future which discusses the history and current of FCMC. Readers may also wish to consult the WHO’s document on Care in normal birth, although this document is now 12 years old.

posted by: Matt Anderson, MD

Reproductive and Sexual Health

The Department of Family and Social Medicine hosts a Reproductive Health Fellowship. For information on this fellowship please contact Dr. Marji Gold. This posting, originally published in March of 2005, was prepared by Dr. Louisa Hahn, one the (now former) fellows:

Sexual and reproductive health have been defined in different ways depending on the political and social climate of the times. In the last few decades, most social and international organizations have recognized the merging of health and human rights. This means in part that the state cannot violate people’s rights to sexual health. Governments must also assure that no other organization or person violates those rights and create the conditions in which people are able to fulfill the right to sexual health.

The right to sexual and reproductive health used to be viewed mainly in negative terms (freedom from disease and disfigurement) but is now also viewed in positive terms (freedom to enjoy pleasure and fulfillment). The US Surgeon General, Dr. Satcher, in 2001, sought to establish that “sexual health is not limited to the absence of disease or dysfunction, nor is its importance confined to the reproductive years.” The World Health Organization defines reproductive health as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.

The choice for women of whether or not to go through pregnancy and childbirth is an important reproductive right. Looking through the lens of social justice (PDF), we know that the women most harmed by lack of safe reproductive choices are those without financial means or social connections. Moreover, when women can make their own reproductive choices, it opens up opportunities to them for education and employment. To make these life choices, women must have full access to family planning methods and abortion for unplanned and unwanted pregnancies.

Abortion is a simple, safe medical procedure that saves lives when it is available. The risk of death associated with abortion performed by trained professionals is approximately 0.6 per 100,000 abortions, and the risk of major complications is less than 1 percent. Almost 90 percent of abortions are performed in the first trimester of pregnancy (within the first 12 weeks after the first day of the last menstrual period), and fewer than 2 percent of abortions are performed after 20 weeks. Currently in the United States, there are two safe and effective methods of first trimester abortion: medical abortion and suction abortion. Medical abortion uses pills called mifepristone or RU-486 and misoprostol that essentially induce a miscarriage. Suction abortion is performed with a plastic cannula and hand-held syringe or vacuum. For a description of these procedures and their differences, go to: The Access Project or Brandeis Medical Center.

Women can find themselves with an unwanted pregnancy for many reasons. For many, effective family planning is out of reach. At least 350 million couples worldwide do not have access to information about family planning and the full range of contraceptives options. The contraceptive methods that we have to offer are often not easy to use and sometimes fail even when used perfectly. Between 8 and 30 million pregnancies each year occur because of contraceptive failure. And unfortunately, sexual coercion or rape is common around the world. Between 20% and 50% of all women and girls report sexual abuse, rape or sexual coercion. Women also choose to have abortions due to a variety of social and economic reasons that include: being unmarried, abandoned by their partners, being too young, unstable partnerships, having too many children to support already, and living in poverty.

Of the estimated 45 million pregnancies worldwide that are terminated by abortion every year, about 19 million involve unsafe procedures performed by women themselves, by unskilled providers, or in settings with inadequate medical standards. Approximately 68,000 women die from complications resulting from unsafe abortion and even more suffer from infections, infertility, and long-term damage to their reproductive tract. Unsafe abortion deaths account for 13% of all maternal deaths globally and over 25% in some countries. Evidence from countries where women have full access to safe services shows that these abortion-related deaths and disability can be virtually eliminated with appropriate policies and programs.

But even where it is legal, safe abortion is not always available. In many developing countries, health workers, doctors and nurses do not have adequate training or equipment. Some refuse to refer or perform abortions because they do not understand the laws or because they personally do not support abortion. And when women have complications from an unsafe abortion, adequate medical support is often unavailable, and family planning is not discussed. As one of his first acts as president, George W. Bush re-imposed the global gag rule (or the “Mexico City Policy”) on January 22, 2001. This policy restricts foreign non-governmental organizations from using their own, non-U.S. funds to provide legal abortion services in order to receive U.S. family planning funds. It also prevents them from lobbying their own governments for abortion law reform, and prevents them from providing accurate medical counseling or referrals regarding abortion services.

In the United States, abortion has been a legal right of women since the court case of Roe vs. Wade in 1973. The conclusion held that a woman’s right to an abortion falls within the right to privacy protected by the Fourteenth Amendment. The decision gave women the right to abortion during her entire pregnancy and defined different levels of state interest for regulating abortion in the second and third trimesters. Since then, the number of deaths in the US per 100,000 abortion procedures declined five-fold between 1973 and 1991.

Significant barriers still face a large number of US women seeking this service, including the determination of viability, cost and insurance coverage, waiting periods and parental consent laws, restrictions on medical abortion, provider unavailability, harassment, refusal clauses, anti-choice laws, and the fetal legal rights movement. Federally subsidized abstinence-only sex education, which has not been shown to decrease the rate of unintended pregnancy (and may increase it), has expanded and access to a full range of contraceptive options has been limited. Eighty-six percent of US counties have no abortion provider. There has been a steady decline in abortion providers over the past two decades. Only 12 percent of all Obstetrics-Gynecology residency programs require training in first trimester abortion and 91 percent of residents report having no experience with abortion procedures. Currently, almost half the pregnancies in the United States are unintended, and teen pregnancy rates are much higher than other developed countries, and even many developing countries. Women of reproductive age currently spend 68 percent more in out-of-pocket health care costs than men, primarily because of reproductive health-related costs.

The policies of the current administration have strengthened barriers to abortion both at home and abroad. Preserving women’s right to choose in the United States will require improved public and professional education, legislative and legal efforts, and advocacy by physicians and other health care professionals. To eliminate these negative outcomes for women, health care workers and activists need to work to ensure universal access to family planning services, especially for young people and women at risk of sexual abuse, rape and violence. Our communities need to be educated about unsafe abortion, social disparities in reproductive health, and their consequences, and work to reform restrictive laws and policies that deny access to family planning, health and abortion-related services.

For more information about organizations that advocate for reproductive rights and choice, visit these websites:

United States:

• National Abortion Federation
• Planned Parenthood
• Physicians for Reproductive Choice and Health
• Association of Reproductive Health Professionals
• Center for Reproductive Rights
• Abortion Access Project
• National Organization for Women
• American Civil Liberties Union
• Women’s Reproductive Rights Assistance Project
• Feminist Majority Foundation

International:

• International Planned Parenthood Federation
• Marie Stopes International
• Ipas
• International Women’s Health Coalition
• Center for Reproductive Rights Worldwide

See also Martin Donohue’s article Increase in Obstacles to Abortion: The American Perspective in 2004, published in the Journal of the American Medical Women’s Association.

— By Louisa Hann, MD, Family Planning Fellow in Family Medicine