Mercy in Timor Leste

You may remember that I had posted a blog entry previously about my adventures in Timor Leste; it is a poor but beautiful country, just beginning to flourish after being freed from 20+ years of brutal Indonesian occupation. I've just returned from a 3 week trip there again this past month and this time, I had the opportunity to witness a floating hospital at work: the U.S. Navy Hospital Ship USNS Mercy, one of the U.S.'s largest portable trauma facilities. Anchored in the harbor for several days every few months, Mercy's crew provides humanitarian assistance and medical care to the citizens of Timor Leste, focusing on public health, preventive medicine, reproductive health, dental treatment, primary care, and health education. They even have a spay-neuter clinic where citizens can bring their pets to control overpopulation.

This is a wonderful idea; it is an inspiring picture of humanity at its best. It also raises a question in my mind -- if we are willing to do this for other countries (and I think we should), why are we not able to provide basic health care for our own in need in this country?

A disturbing prediction on cervical cancer deaths ...

Today's New York Times has an article summarizing the disturbing results of a new study looking at trends in cervical cancer morbidity and mortality in Latin America.

In an era in which most cases of cervical cancer can be prevented or detected early and treated, the study – sponsored by the Sabin Vaccine Institute, the Pan American Health Organization, and the US CDC, among others – concluded that cervical cancer-related deaths are likely to double in Latin America in the next 20 years. Fewer than five per cent of women in Africa, Asia and Latin America are screened for cervical cancer, as compared to 70% of women in North America and Europe. Most of these women also lack access to newly-approved HPV vaccines.

Does this truly have to be the case? Must we continue to needlessly condemn 250,000 poor women to death every year? Even if we accept the argument that current screening and treatment technologies – Pap smears and the HPV vaccine – are too costly to be used widely in resource-poor countries like Haiti and Nicaragua, what about lower cost screening technologies like VIA (visual inspection of the cervix using acetic acid)?

For almost a decade, it has been known that clinicians, usually nurse-midwives, can detect more than three-fourths of pre-cancerous and cancerous cervical lesions simply by wiping a patient's cervix with acetic acid (white vinegar) and examining it visually. That this method is not more widely used, particularly in light of a recent Lancet study showing that VIA is as effective as traditional screening methods in India, is shameful.

It's time to wake up and smell the vinegar ...

The “third tier” in US health care?

It’s a sickening situation. Physicians’ incomes are under attack: think lower reimbursements, higher costs for malpractice premiums and the like, greater business costs, claims processing hassles, and deadbeats.

What’s a poor doctor to do? One possible cure is the concept of Concierge Care.

Concierge Care (or Boutique Medicine, or Platinum Practices, one name hasn’t stuck) could offer a patient such privileges as 24-hour phone or pager access to the doctor, house calls, and guarantee of an appointment with your chosen doctor the same day you call.

The cost: a fixed annual fee that could range beyond $20,000 a year, depending on the services provided, and the patient’s age and health.

I’m not quite old enough to remember the days when doctors offered all the above and a lot more to everyone, for a lot less.

So there it is: to the other tiered services available in the US (UPS for the rich, the post office for everyone else; private schools for the rich, public schools for everyone else) we can now add a three-tiered “health” care system: no coverage at all for 45 million people, inadequate medical services for most of the rest of us, and Concierge Care for the lucky, wealthy few.

The real problem with our health care system: Female doctors ...

... now there's a Women's Bioethics Blog equivalent headline equivalent of those "Free Beer" postings on college campus bulletin boards. I only wish it was as facetious a headline.

What am I referring to? Why, an article in the April 28, 2008 issue of Businessweek, which you can hopefully read online here (although you may need a subscription). The take-home message: the looming shortage of doctors in the United States, estimated to be a deficit of 50-100K physicians by 2020, may be partially a result of the fact that female doctors work less than their male counterparts. They also see fewer patients, take time off to have children, and have the nerve to ask to work flexible schedules so they can actually nurture those kids they so unwisely produced. Thank god we've still got a couple of upstanding men who can pick up the slack. As one anonymously courageous male internist from New York so righteously complained: "The young women in our practice are always looking to get out of being on-call ... The rest of us have to pick up the slack."

On the plus side, women are more likely to go into understaffed, low-pay specialties like family practice, pediatrics and obstetrics. 

So who's at fault here I wonder? Could it be those selfish women who want: 1) to provide high quality and attentive preventive care, something our current system neglects; and 2) make sure that their kids aren't raised by Sesame Street and Nintendo? Or, could it be the current system that rewards those men (and women) who: 1) enter high paying and lucrative specialties; and 2) only see their kids on weekends during court-ordered and -supervised visits? Guess we'll have to choose ...

From the WBP Book Club…

While I certainly do not call myself an expert on the latest “must read”, here's one I highly recommend.

Written from a feminist perspective, Susan Sherwin’s “No Longer Patient: Feminist Ethics & Healthcare,” is an in-depth exploration of medical and feminist ethics, and how each impacts the other.

Sherwin critically examines controversial issues such as abortion, reproductive technologies, invitro fertilization and surrogate motherhood and others, and how these matters, considered “traditional” by mainstream medical ethics groups, become larger, highly-charged feminist-rooted issues involving inequality of power and the powerlessness of women in directing and making their own healthcare decisions.

The book presents a powerful analysis of—and comparison—between “feminine” vs. “feminist” ethics in healthcare, defining what Sherwin calls an “oppressive” healthcare environment weighted-down by systemic barriers and other restrictions that threaten the rights of women to control the direction and ultimate destiny of their healthcare.

Biological reproduction is a major focus for all women, regardless of one's own personal position taken today in this new, still to be explored, arena of feminist bioethics. Sherwin’s perspective tackles the knowledge-base deficiencies currently in existence, the direct result of a clear lack of understanding and discussion of these issues. Sherwin issues a call to action to her readers to recognize these gaps and disparities in healthcare for women, and to become involved in initiating change. I found it difficult to put down.

Women's Health Care Unsatisfactory Nationwide, National Women's Law Center Report Card Says

Women's health care in the U.S. is unsatisfactory overall, according to a report card on the state of women's health released Wednesday by the National Women's Law Center and the Oregon Health and Science University, CQ HealthBeat reports.

The report card, titled "Making the Grade on Women's Health: A National and State-by-State Report Card," measured women's health in all 50 states and Washington, D.C., by using 27 health benchmarks designated by HHS' Healthy People 2010 campaign. According to the report, the U.S. overall fails to meet 12 of the 27 benchmarks, up from nine in 2004 (Bartolf, CQ HealthBeat, 10/17). Only three of the 27 benchmarks -- women receiving regular dental care, women ages 40 and older receiving mammograms and women ages 50 and older receiving colorectal cancer screening -- were met, Michelle Berlin, an associate professor at OHSU, said.

None of the states received a "satisfactory" grade in women's health. Three states -- Massachusetts, Minnesota and Vermont -- received a grade of "satisfactory minus," a decrease from 2004, when eight states were considered "satisfactory minus." Eleven states and the district received failing grades in women's health status, compared with six states in 2004. The 11 states are: Alabama; Arkansas; Indiana; Kentucky; Louisiana; Mississippi, which ranked last; Oklahoma; South Carolina; Tennessee; Texas; and West Virginia. The remaining states received "unsatisfactory" grades, Reuters reports (Steenhuysen, Reuters, 10/17).

Benchmark Disparities
The report found that several benchmarks -- including the percentage of women receiving prenatal care, infant mortality and the percentage of uninsured women -- varied significantly by race. American Indians and Alaska Native women were twice as likely as white women to be uninsured, the report found. Among white women, 16.9% were uninsured, compared with 22.7% of black women and 37.8% of Hispanic women, according to the report. The percentage of uninsured women increased by 1.7% since 2004, according to the report (CQ HealthBeat, 10/17). Minnesota had the lowest percentage of uninsured with 9.1%, and Texas had the highest percentage at 28.1%, the report said (Reuters, 10/17).

The report found 85.7% of white women received prenatal care, compared with 70.8% of American Indians, 75.9% of blacks and 77.5% of Hispanics. According to the report, the percentage of women nationwide who received prenatal care increased by 5% since 2004 but is still unsatisfactory. The report found that white women have an infant mortality rate of 5.7 deaths for every 1,000 live births, compared with 13.5 deaths per 1,000 live births for blacks and 5.6 per 1,000 live births for Hispanics. The overall infant mortality rate has remained the same since 2004.

The percentage of obese women increased in all states and the district (CQ HealthBeat, 10/17). Hawaii had the lowest percentage of obese women at 16.7%, and Mississippi had the highest percentage at 31.5%. The percentage of women ages 40 and older who received mammograms improved in all states (Reuters, 10/17).

The number of states with parental notification policies for minors seeking abortion decreased, as did the number of states that have mandatory waiting periods for abortions, the report found. The number of states that provide public funding for abortion for low-income women has remained constant since 2001, according to the report.

Comments
"The outlook for women's health is nowhere near approaching the nation's goals for 2010" set by the Healthy People campaign, Berlin said, adding, "Failing to meet these goals undermines not only the health and well-being of women, but the well-being of our country as well." Judy Waxman, vice president for health and reproductive rights for NWLC, said, "It's nothing to cheer when only a handful of states are meeting at least half of the policy goals" (CQ HealthBeat, 10/17).

Waxman called on states to implement policies to improve women's health (Reuters, 10/17). "It is evident that our health system needs mending," Waxman said, adding, "Lawmakers must take a comprehensive, long-term approach to meeting women's health needs" (CQ HealthBeat, 10/17).

The report is available online.

Reprinted with permission from kaisernetwork.org. You can view the Kaiser Daily Reports online, search the archives, and sign up for email delivery at www.kaisernetwork.org/dailyreports/. The Kaiser Daily Reports are published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2007 Advisory Board Company and Kaiser Family Foundation. All rights reserved.