Advocate for LARC (Long Acting Reversible Contraception)

June 28th, 2016

IUD

This is a picture of an IUD in a mockup of a uterus.

The potential of LARCs (Long Acting Reversible Contraception) is so great that I am advocating that all voters advocate for them to be paid for by government. The savings–both financial and in terms of human potential–are enormous!


 

Your doctor tells you that she can prescribe either of two treatments, but that one is 20 times as likely to fail as the other. Which would you choose?

Over a quarter of women in the USA use birth control pills, which fail much more frequently than Long Acting Reversible Contraception. LARCs, as they are nicknamed, are amazingly effective yet not used as frequently as one might hope.

IUDs (Intrauterine Devices) are the most commonly used LARCs. There are four available now; they are all made out of flexible plastic in the shape of a “T”. Three emit a tiny amount of hormone into the woman’s uterus, where it is most effective. The fourth IUD uses copper to gain effectiveness. IUDs are usually well tolerated, although sometimes they can increase cramps or change menstrual flow. The best medical knowledge is that IUDs do not work by aborting pregnancies.

IUDs can stay in place for a maximum of 3 to 10 years, depending on which type. Since there is a string attached, they are usually easy to remove. The string also allows the woman to check that it is in the correct place. The pregnancy rate is vanishingly small—only a couple of LARC users in 1,000 will conceive each year. This statistic for “the pill” is much higher—almost 50 per thousand will experience an unplanned pregnancy. Apparently the high failure rate of oral contraceptives in the USA is due to noncompliance. In Europe the failure rate is significantly lower; European women take their birth control pills more regularly.

There are two major drawbacks to both IUDs and the implant: they are expensive and they need to be placed by an experienced clinician. IUDs have a further drawback—bad press.

It used to be that only women with health insurance or a plump checking account could afford LARCs, but that is changing. Thanks to the Affordable Care Act (“Obamacare”), any woman with insurance, including Medicaid, can get her chosen birth control without copay. In addition, one IUD, Liletta®, is priced much lower than the others. Here in Colorado there is a program that provides contraception, including LARCs, at little or no cost.

Placing an IUD is not difficult for a trained practitioner. The opening of a woman’s cervix may be tight is she hasn’t borne a child, but a little local anesthesia and gentle dilatation will help with the insertion.

The other type of LARC is the implant, Nexplanon®, which is as effective as an IUD. It is a thin plastic rod that is inserted under the skin of the woman’s arm, where it can stay for up to 3 years. It emits a hormone that is very effective in preventing pregnancy. Although it is in a very low level in the woman’s blood, it is sufficient to change menstrual patterns; most women with Nexplanon® will have spotting or breakthrough bleeding. Perhaps this is why less than 1% of women in the USA choose an implant, whereas about 6% use an IUD.

Unfortunately, reproductive health has become a political football. Here in Colorado a grant demonstrated that access to LARCs can give young women a better chance in life by decreasing teen pregnancies. By taking away the consideration of expense, the use of LARCs expanded 4 fold. Nevertheless, the false fear that IUDs might abort pregnancies kept our legislators from continuing funding to provide this effective contraception. The best way to prevent abortions is with effective birth control!

Ohio took a tip from Colorado with a program to provide LARCs. Part of that state’s motivation is to lower their infant mortality rate. They are targeting young teens and women who have just had a child, since these two groups are at high risk of having an infant die if they were to get pregnant. They also note that the state saves almost $6 for every dollar invested in LARCs.

Ohio has been proactive in another way. Some healthcare providers have misconceptions about IUDs. They think that they should only be used if a woman already has delivered a baby, or that an IUD makes a woman more susceptible to sexually transmitted infections, or teens shouldn’t use IUDs, or that IUDs can lead to sterility. All of these perceptions are wrong! Indeed, almost every woman can safely use an IUD, and start her family as soon as it is removed.

Safe, effective contraception is an important step in empowering women. We should advocate for making LARCs available to all women!

© Richard Grossman MD, 2016

Responding to my Climate Change Denying Friends

May 24th, 2016

Curves of pop & CO2 in air

Please note the two curves above. Although the graph of CO2 concentration in the atmosphere (Keeling curve) on the left starts in 1958 and the one on the right (human population) starts in 1800, they follow the same trajectory of steep increase over the past 50+ years.

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

Upton Sinclair

            A recent Letter to the Editor of the Herald got my attention. It would seem that its author and I are living on different planets.

The writer calls Dr. James Hansen’s statement that the world would “overheat” because of carbon emissions “a ridiculous assertion”. NASA has a web page devoted to statements from our country’s foremost scientific organizations. For instance, the American Association for the Advancement of Science states: “The scientific evidence is clear: global climate change caused by human activities is occurring now, and it is a growing threat to society.”

The LTE was in response to Herald article about the wager between Roger Cohen and me. Dr. Cohen (former manager of strategic planning at Exxon Mobil) earned a PhD in physics and is a member of the American Physical Society, which states: “The evidence is incontrovertible: Global warming is occurring.”

Let’s go back to the other planet where the writer of the LTE seems to be living. He asserts that polar bears are thriving. The International Union for the Conservation of Nature lists the status of polar bears as “vulnerable”, This would not lead me to believe that they are thriving. Dr. Steven Amstrup, head scientist with Polar Bears International, wrote: “One of the most frequent myths we hear about polar bears is that their numbers are increasing and have, in fact, more than doubled over the past thirty years.”

“The polar ice caps, both of them, are robust” according to this LTE. Unfortunately, Earth’s ice caps are not healthy. Indeed, a large freighter recently navigated the fabled Northwest Passage through the Arctic Ocean!

There is mixed news from Antarctica. Although ice in west Antarctica is melting, the amount of ice is increasing over the continent. That is a bit of a paradox since the average temperature there has gone up by almost 1 degree Fahrenheit—but it is just so darn cold in Antarctica.

Studies find rising levels of CO2 help some plants but hinder others. Studies of phenology (when plants and animals wake up after the winter) find that climate change is already causing problems that may lead to decreased crop productivity. Many places in the world are experiencing decreased precipitation from climate change. Overall, the bonus of increased CO2 seems to be overwhelmed by other aspects of climate change.

The LTE ends up by stating “…the standard of living of some of the world’s poorest of the poor has risen because of increased vegetation to feed themselves and their animals….” Try telling that to the people who are starving in Madaya—where the Syrian revolution was triggered, in part, by drought caused by climate change. The Horn of Africa is also suffering from chronic malnutrition, as are many other places in Africa and Asia. Drought caused by climate change has worsened starvation in these places. Although the percentage of people who are undernourished in the world has decreased, the improvement is not generally attributed to increased CO2.

People are also suffering from climate change closer to home. Residents of Isle de Jean Charles, Louisiana, will be relocated because their community is disappearing under the rising ocean.

What I find amazing is that, although people deny climate change (or perhaps deny that climate change is anthropogenic), I have yet to read any refutation of the observation that the atmospheric concentration of CO2 is rising, and that its rise is anthropogenic. We all understand that this gas, along with methane and water vapor, are greenhouse gases. Without GHGs our planet Earth would be 60 degrees Fahrenheit colder—and totally unable to support life. Doesn’t it make sense that, as the CO2 level rises, the temperature will also rise?

Perhaps we can excuse some of the denial of climate change thanks to the findings of a recent study of people’s reaction to the climate. Apparently the warming that we in the USA have experienced actually has made the climate more agreeable—although that is far from true in other parts of the world.

Greenhouse gases released by people cause climate change; the more people, the faster the climate will change. Family planning is part of the solution! Another part of the solution is convincing our political representatives to support legislation to slow climate change. The Citizens’ Climate Lobby (http://citizensclimatelobby.org) has an effective plan to do this. A local chapter has just been formed; you can contact them at: durangoccl@gmail.com.

© Richard Grossman MD, 2016

Consider Human Inhabitants When Creating Nature Reserves

April 24th, 2016

tiger closeup 4

Last summer a big game hunter from Minnesota shot Cecil, a famous male lion, in Zimbabwe. The Zimbabwean officials didn’t press charges against Cecil’s killer.

Many people in this country were outraged that such a rare and beautiful beast had been murdered. The response in Africa was different, however. For us a lion—especially a noble and handsome male—symbolizes freedom and wildness. In Africa, however, a lion means danger.

We live in a protected bubble from which most predators have been excluded. It is true that occasionally a mountain lion will injure or kill a human, but fortunately that is a very rare, newsworthy incident. Black bears are also responsible for a few injuries and rare deaths here in Colorado. The real killer is not a predator but the sweet, innocent herbivore—deer.

Biologist E. O. Wilson has recently written a book advocating that half of the planet become a nature reserve. He wrote: “…I propose that only by committing half of the planet’s surface to nature can we hope to save the immensity of life-forms that compose it.”

I grieve for the loss of biological diversity (biodiversity). Although we cannot know exactly, it is estimated that species of plants and animals are going extinct at 1000 times the normal rate; we are in the 6th mass extinction. There have been five prior mass extinctions, the last one being about 65 million years ago when a huge meteor hit off the coast of Mexico. The resulting explosion changed the climate for centuries, killing off dinosaurs. What is different about the current mass extinction is that it is caused by a single species—ours.

Each species has evolved strategies to maximize reproduction, to gather nutrients efficiently and to ward off other species that imperil it. We are no different, except we have been so amazingly successful. Sadly, our success endangers nonhuman species—and probably ourselves, since our livelihood depends on the web of life.

I have a problem with those who are “prolife”. Our human success is causing the extinction of other animals and plants. By preventing women from access to family planning and safe abortion services, the people who claim to be “prolife” are actually destroying the biodiversity that makes our planet habitable.

Although I haven’t read Wilson’s “Half-Earth: Our Planet’s Fight for Life”, its premise troubles me. Yes, it is important to do what we can to protect other species. Yes, the major cause of loss of species is loss of habitat. Yes, preserves (both terrestrial and marine) have shown their value in preserving biodiversity. The Center for Biological Diversity has a brilliant record of protecting endangered species by preserving habitat.

Turning half the Earth into preserves would slow the loss of biodiversity. But what about the people who currently live on that land—many of whom live in overcrowded, developing countries? what would happen to them?

We had the good fortune to visit the Ranthambhore preserve in India where we observed a Bengal tiger in the wild. We also heard about people who were forced off that land and repatriated to a nearby village. They now make their living by making and selling souvenirs to tourists. This model would not work for half of Earth’s surface, however. Where could all those people settle?

This conundrum is one of the plotlines of “The Hungry Tide” by Amitav Ghosh. This wonderful novel takes place in the Sundarbans, the deltas of four major rivers where they empty into the Bay of Bengal. Thousands of squatters settled on Marichjhanpi Island, an Indian animal refuge, in1979. Piya, a protagonist, biologist and protector of animals, is distressed when settlers kill a man-eating tiger. Forest Guards moved in and destroyed the settlement—and the settlers. Thousands of people were killed in this genocide. Although this sounds incredible, it is based on history.

Thanks to the foresight of Americans a century ago, we have the National Park Service, one of the agencies that take care of our public lands. We should be proud that 14% of our land is currently protected. Costa Rica may have the highest percentage of land preserved for nonhuman use at 25%. It is important to preserve what we have and to continue to protect more wilderness, parks, forests and roadless areas for our enjoyment, and especially for the benefit of other species. However, it is important to keep human rights in mind when considering making new protected areas. Voluntary family planning will help achieve that goal by decreasing population pressure.

© Richard Grossman MD, 2016

Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.