Archive for the 'Medical' Category

Condemn “Assembly Line” Sterilizations

Saturday, January 3rd, 2015

News media focused in November on deaths in India after women had surgery at a sterilization “camp”. Authorities suspect that the surgeon caused more than a dozen deaths, so he is in prison.

More people are added to the population of India each year than to any other country. India has family planning programs, but abuses occur. This epidemic of deaths may have occurred because of disregard for established standards.

Indian gynecologist Pravin Mehta holds the world’s record for the number of tubal ligations that one doctor has done—over a quarter million. He told me how he could do 300 surgeries in one day; Henry Ford would have been amazed!

I didn’t realize how crude Mehta’s process was until I saw a movie of him working in a surgery camp. Operations were performed in a tent, and conditions were very primitive.

Nevertheless, Dr. Mehta’s safety record was remarkable. He offered a reward for anyone who reported a problem, including pregnancy, after his surgery, but gave out very few rewards. Indeed, I believe that his complication rate was lower than surgeons doing tubal ligations under modern conditions.

Were all these surgeries truly voluntary? During the era when Dr. Mehta worked—1970s and 1980s—India had aggressive sterilization programs for both men and women. Acceptors were given a small stipend if they agreed to the surgery. Recently the stipend for a person getting sterilized was equivalent to less than $10—a small sum by our standards but more than a villager might see in a month.

Reports of the recent sterilization tragedy frequently mention that women wanted to limit their family size, but that they were not given information about temporary methods of family planning. Even if women knew about temporary methods, they were not available.

Many problems were found after these Indian surgeries that killed many young mothers. The operating room was not clean, the staff were untrained, the medicine was contaminated. The same syringe and needle were used to inject local anesthesia for many women. Even worse were systemic problems: almost all of the funding was used for administration and too little paid for actual health care, there was little counseling or informed consent, no access to temporary contraceptive methods, and providers were pressured by numerical targets.

Two Americans are making a documentary about sterilization. Quartz published quotes from some of the Indian women they interviewed; here is the link: http://qz.com/299712/these-are-the-voices-you-did-not-hear-after-the-chhattisgarh-sterilization-tragedy/. One of the women, Archana, said:

“I was 19 when I got married and I have 3 kids. I don’t have much income, that’s why I got sterilized. When our income is limited what’s the use of having so many kids? ASHAs [Accredited Social Health Activists] came to visit me and told me about sterilization. When I got sterilized I went with my sister-in-law to the hospital and was given Rs600 in compensation. My husband and my mother-in-law were supportive. It took me about a month to recover fully. After a week I had to cook for my kids and take care of the house. I would have liked an entire month to recover, but we didn’t have anyone else to do the work. I chose this method because I had so many kids, and I didn’t know of other methods of contraception at that time. Now I’ve learned about more temporary methods. Copper T is not available here, you have to go to the cities, but you can get pills and condoms here.”

Please remember that conditions and standards in developing countries are different from what we know. Nevertheless, people must be respected and well informed about their health care.

Can family planning programs provide services to millions of people and yet assure that care is truly voluntary? Delegates at the International Conference on Population and Development 20 years ago felt that it is best if family planning were a part of comprehensive reproductive health programs. Since then our population has grown by 1,600 million people, with consequent increasing problems. Much of this growth is in developing countries, but remember that it is we in the rich countries who cause the worst impact because of our consumption!

Some of the family planning workers have real concern for the people they serve. After this tragedy one ASHA (health activist), Mitanin, is quoted as saying: “with what face we will tell people to go for sterilization?  Now, even if they come to us for it, we will hesitate.”

A new program, FP2020, is working to provide quality family planning services while respecting reproductive justice. More about FP2020 soon.

© Richard Grossman MD, 2014

Woman after sterilsation surgery in Bilaspur

Integrate Population, Health and Environment

Sunday, September 7th, 2014

            If we had unlimited resources we wouldn’t need to be concerned about human population. We live in a wonderful, rich world, but we need to share with such a large number of people and other living beings.

Some of the richest places on Earth have been called “biodiversity hotspots”. These 35 special areas are home to many endemic species—species that are unique to that one area. Although the hotspots make up only a small fraction of the Earth’s surface (about a 40th), they are home to such a variety of life that isn’t found anywhere else. The sad thing is that much of this wonderful diversity is already lost, and what is left is threatened with extinction.

Hotspots are also fertile spots. People are attracted to settle in them to exploit this productivity. Indeed, it is this humanity that threatens to destroy the fecundity. Fortunately a relatively new constellation of services offers help in a very humane way.

Population-Health-Environment (PHE) programs are the new way to slow damage to hotspots. Starting with the “E”, the first step is to help the local people be more aware of the value of the wonderful place where they live. The locals learn how they depend on ecosystem services, such as mangrove trees that serve as nurseries for fish. A clinic provides simple health care and health education, which are unusual in hotspots. Voluntary family planning is made available along with other health services. Often local women learn to be advocates for family planning and can administer certain modern contraceptive methods.

Many years ago we visited a PHE in Peru. It is the brainchild of an eccentric research scientist turned humanitarian, Eleanor Smithwick. Peru Amazon Conservation is based the small town of Atún Cocha. As Eleanor points out, the mestizo people there have lost their indigenous respect for nature. In the past they felled trees to sell for lumber, but didn’t replant; Eleanor taught them the value of raising saplings.

Eleanor recruited a local bilingual man, Clever Hoyos, to be the health educator. He taught about conservation as well as sanitation and nutrition. Together they set up a clinic that serves 14 villages and about 2500 people.

Their innovation was their family planning program. Most of the people live far from Atún Cocha along the river where the only means of transportation is a slow dugout canoe. On a certain Thursday every 3 months Clever would travel by boat to give DMPA (DepoProveraâ) injections. The women knew when to expect the boat and would be waiting at the dock. This was a very popular program, but unfortunately the cost of the medication rose so high that the program wasn’t sustainable.

A more recent and elaborate PHE program is half a world away in Madagascar. A British physician who loves to SCUBA dive became distressed by the destruction of the ocean life. Blue Ventures has an interesting combination of a nonprofit funded by a for-profit business. The for-profit arm features ecotourism and especially diving, but the nonprofit is more difficult to outline.

Blue Ventures not only conserves endangered species such as sea turtles and sharks, but engages the local children in conservation. They provide school scholarships to be certain that future generations are well educated. Because of the risk of overharvesting crops of fish, octopi and sea cucumbers, they have successfully instituted temporary fisheries closures, which have increased total yields—and the fishers’ incomes.

Health services focus on the basics—water and sanitation—as well as clinical services. They use many modalities to reach the people about health and conservation, including radio, interactive village presentations and school workshops using sports and theater.

Blue Ventures have trained 40 local women to provide voluntary reproductive health services to over 20,000 people in 50 communities. The contraceptive prevalence rate has gone from 10% to 55% in just 6 years. They calculate that voluntary family planning has averted more than 750 unintended pregnancies during this period. Most important, perhaps, is that the vast majority of people recognize the links between reproductive health, family size and food security. I wish that were true for more people in the USA!

To quote from the Blue Ventures’ website, “PHE programmes address the interconnected challenges of poor health, unmet family planning needs, environmental degradation, food insecurity, gender inequality and vulnerability to climate change in a holistic way.” They have great potential to keep biodiversity hotspots from being overrun by people. Just as important are the benefits to the people who live in these rich and beautiful areas.

© Richard Grossman MD, 2014

Vasectomy

Saturday, October 12th, 2013

“Can vasectomies really make a difference? Mine made a big difference in my life, and to this day, I consider it the single most important contribution I have personally made to the wellbeing of future generations….“ Paul Ehrlich.

 

It was time: I walked across the hall, lowered my pants and lay down on the exam table. Dr. Sam Callaway took good care of me.

We had two great sons and our family was complete. Although my wife volunteered to get her tubes tied, I decided to practice what I preached and went for the vasectomy. That was thirty years ago, and I’ve never regretted that decision.

My largest fear was that Sam’s office nurse would be around still, but Judy had already left. Sam talked to me as he worked and I barely felt any discomfort. He explained that he used a very thin needle for the local anesthesia, made tiny incisions and he was gentle. In a few minutes it was all over and I was on my way.

I’ll admit to some soreness that evening when I spoke at the prepared childbirth class my wife was teaching. And I moved carefully the next day when I needed to perform a cesarean. All in all, I took just a few aspirins (that was before ibuprofen!) and never had any ill effects.

Men have an anatomical advantage when it comes to sterilization. Whereas a woman’s tubes are deep inside her body, a man’s tubes, the vasa deferentia (singular: vas deferens) are much more accessible. When they are interrupted, sperm cannot get released, and the man is unable to cause pregnancy. Fortunately, sperm are only a tiny fraction of the male ejaculate, so sex is unchanged—or better, for lack of fear of pregnancy.

A vasectomy takes only a few minutes, is done with local anesthesia and is amazingly safe and effective.  The main hitch is that it takes several months to wash out all the sperm, and the man should be tested to be sure that he really is shooting blanks before trusting the surgery. Fortunately, the failure rate is less than one in a hundred.

Tubal ligation is more common in the USA than is vasectomy. Among married couples, one in 7 men is sterilized while one in 5 women has had the surgery. Since many sexually active people are not married, the overall statistics show a larger preponderance of women taking control of their fertility—more than a half million women are operated on every year while only half that number of men get snipped.

The popularity of vasectomy varies by country. It is rare in many parts of the world such as in Africa, but a quarter of men in New Zealand have had the surgery.

In Durango perhaps only one physician is left performing this important procedure after Centura took over the family practice group at Mercy. Dr. Mark Forrest has performed hundreds of vasectomies, including on some of my friends—and they have all done well. He says that it usually takes two visits: a consultation, then the actual surgery. He will check semen samples two and three months later, and if both are negative for sperm, the surgery can be considered a success. If this protocol is followed, the failure rate is lower than the rate of pregnancy after tubal ligation.

Furthermore, vasectomy is much less expensive. Nationwide, the price of male sterilization is $350 to 1000. Female sterilizations can now be done without an incision. Essure™ is an office procedure performed through the woman’s cervix, with mild sedation and local anesthesia. Unfortunately, its overall cost is about the same as tubal ligation—$1500 to 6000.

The first World Vasectomy Day will be observed October 18th of this year. This event was decreed by Jonathan Stack, an award-winning documentary filmmaker. The event will be celebrated by Dr. Doug Stein performing his favorite operations—you guessed it!—live from Australia. Dr. Stein has performed over 30,000 vasectomies, perhaps a world record.

Mr. Stack went to Dr. Stein for his own procedure, and thus got the idea for the film. His reasons for favoring vasectomy include: “…it’s time for men to share the burden of family planning” and “…we have to do a fairer job of sharing the planet’s finite resources.”

You can find out more at: www.worldvasectomyday.org, including links to the film’s trailer. They need money to finish this important film. I donated already, and hope that you will also consider supporting this film—because it is time for men to share the burden of family planning!

© Richard Grossman MD, 2013

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