Archive for the 'Public Health' Category

Avoid these Causes of Infertility

Sunday, September 30th, 2018

A solution has been found for overpopulation! Unfortunately, this is not a reason for celebration.

This essay is another in my all-too-long series of bad ways to control population. It joins essays on genocide, the Doctrine of Discovery and gun violence.

Sperm counts are declining around the world. Fortunately, most men still have enough sperm to become fathers when they want, but that might not be the case forever. There are even predictions, if the current trend continues, that the human species will cease to exist! Just how worried should we be about declining sperm counts?

A review article suggests that the average sperm counts in European and other “western” countries has declined markedly. The overall count has declined 50 to 60% from 1973 to 2011. Another study found the same—or worse—is true for Africa. Between 1965 and 2015 they found a decrease of more than 70%! Fortunately, as you remember from biology class, only one pollywog fertilizes an egg. However fertilization requires that a crowd accompany that one lucky sperm.

I look at these studies with some concern about their accuracy. However, it seems that men truly are making fewer sperm. In addition to this decrease, genital abnormalities and testicular cancer have become more common. What is affecting men so badly? Perhaps we can learn something by consulting “man’s best friend”.

Veterinarians have studied the reproduction of a group of guide dogs for decades, and found decreases in sperm quality and increases in genital abnormalities and testicular cancer. The dogs seem to reflect the same problems as men are facing! The question is: what is causing these problems?

The vets did something that most men would object to—testicular biopsies. These little bits of tissue were tested for several chemicals with names such as “PDBE28” “PCB153” and “DHEP”. The chemicals were found in the dog food, and in the biopsy tissue, too, in levels that inhibit fertility.

These chemicals have been developed in the last few decades to promote “better living through chemistry”. They are some of a huge number of organic chemicals that have beneficial uses and have found their way into our homes—and into our bodies.

Although we may not be aware, when we bring home new furnishings, they are often treated with chemicals such as PDBE28 to decrease the rate at which they burn. These chemicals are also in building materials, vehicles and plastics—they are ubiquitous. They may have saved lives because of their fire retardant properties, but they may also have changed many lives because of their biological effects. Almost all—97%—of people in the USA have detectable levels of this group of chemicals in their blood!

The shape of these artificial molecules is similar to the shape of some hormone molecules. Hormones are chemical messengers that tell distant parts of our bodies what to do. They fit into receptors that receive hormonal molecules and activate cells. The analogy of lock and key is often used because the hormonal molecule is usually specific to certain receptors on certain cells. Because their shape is similar, endocrine disrupting chemicals fit in receptors. The disruptor can either stimulate the cell or, if the “key” gets stuck in the “lock”, the disrupting chemical can block the action of the real hormone.

Switching to women, now. Female fertility is also decreasing. The epidemic of  obesity is affecting fertility, as is some women waiting too long to have children. Their bodies are also sensitive to the effects of endocrine disrupting chemicals. In a study of California women, those with high levels of PCBEs took longer to conceive a pregnancy than women with lower levels. 

There hasn’t been enough written in the press about endocrine disruptors, perhaps because this subject is very complicated. Two facts that stick in my mind are that endocrine disruptors have their strongest effect when they are very, very dilute— because of their combination of stimulating and blocking effects. This means that the usual testing done by the FDA may find little risk because they didn’t dilute the chemical enough—the opposite of the usual when testing for toxicity. Indeed, endocrine disruptors may have an effect when they are equal to a pinch of salt in an Olympic-sized swimming pool!

I plan to write more about endocrine disruptors since they are so pervasive and have so many bad effects. Time will tell if these chemicals will cause a significant decrease in our population. If they do, it will be involuntary—which is tragic.

©Richard Grossman MD 2018

Recognize Family Planning as a Human Right

Tuesday, May 29th, 2018

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Family planning was declared to be a basic human right fifty years ago this month. The right to family planning was included in the International Conference on Human Rights held in Tehran, May 1968.

The concept of universal human rights started after World War II with the United Nations. Its charter included the obligation “…to promote… universal respect for, and observance of, human rights and fundamental freedoms for all without discrimination….” The Tehran conference was held 23 years later to define what those rights are. One of several points states:

“The protection of the family and of the child remains the concern of the international community. Parents have a basic human right to determine freely and responsibly the number and the spacing of their children”

The 84 countries attending this Iranian conference agreed to be bound by the decisions, but the world has changed radically since then. For one thing, there are more than double that number of countries. Furthermore, global population has more than doubled from 3,600,000,000 to 7,500,000,000 people. On the good side, there are more, safer and more effective methods of contraception available. The right to family planning is supported by many programs, including FP2020 which works in many developing countries. Planned Parenthood and the federal Title X (ten) program in the USA are under jeopardy because of a proposed law limiting healthcare providers from mentioning the word “abortion”.

Unfortunately the right to family planning is being limited or taken away in many countries. Funding for many organizations working internationally has been barred by the Global Gag Rule. The GGR prevents the US from funding any foreign agency that provides abortion services anywhere—or even mentions the word “abortion”. Because of the lack of these services women will go without birth control and there will be millions of unplanned pregnancies, and thousands of women will die from complications of pregnancy—and, ironically, there will be more abortions!

The Tehran Proclamation has 9 standards to uphold the human right to family planning. These include non-discrimination, availability of information, accessibility of services and supplies, quality, autonomy of decision making, privacy and confidentiality. I am happy to report my experience has been that these standards are upheld everywhere I have worked,. 

It is difficult to envision a UN conference being held in Iran now—there have been many changes since 1968. The Shah was overthrown in 1979 and the country became an Islamic theocracy, lead by a “Supreme Leader”. A pleasant surprise came about a decade later.

High level government and university experts held a conference in 1988 to discuss Iran’s population, which was increasing rapidly at that time. Attendees agreed “…that the rate of population growth in the Islamic Republic of Iran was high and this would have a negative effect on the welfare of the people. Hence, the participants strongly urged the Government to set up a family planning programme and integrate population factors in policy-making.” (quoted from “A New Direction in Population Policy and Family Planning in the Islamic Republic of Iran”)

The High Judicial Council of Iran decided “family planning does not have any Islamic barrier” so long as abortion was not involved. New laws were passed to promote small families. Couples were required to take birth control classes before they could get a marriage license. Government clinics were set up offering a wide choice of methods, including vasectomy. In addition, the government discouraged childbearing before age 18 and after 35 and recommended that children be spaced 3 or 4 years apart. The family planning program urged couples to have no more than 3 children; government employees lost some of their benefits, such as maternity leave and food coupons, if the family had more than 3 children. 

The TFR (the average number of children that a woman bears in her lifetime) in Iran had been as high as 7.0, had decreased to 5.5 in 1988 and now is less than replacement at 1.8—the same as the USA. It doesn’t mean that population is shrinking—there are millions of children and teens whose reproductive years are still ahead of them—so it will take decades before the population stabilizes.

A dictatorship can use its influence to slow population growth. Although there are many dictators in the world today, I think Iran is the most successful in slowing its growth. That sort of heavy-handed governing wouldn’t work in the USA. Indeed, I believe that people should have the right “…to determine freely and responsibly the number and the spacing of their children.”

© Richard Grossman MD, 2018

Keep Children Healthy

Saturday, September 23rd, 2017

I am writing this column in Northern Ghana, where 1 in 16 children dies before 5 years of age. Although that number is high when compared to developed countries, there has been amazing progress since 1960 when one in 5 died.

The under-five mortality rate is a valuable statistic because it gives an overall idea about the state of health and healthcare in a country. It reflects the social, economic and environmental conditions in which children live. It is defined as the number of children who die before their 5th birthday per 1000 live births, and is also called the child mortality rate.

The UN set 8 Millennium Development Goals, one of which was to: “Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.” In Ghana during that period the rate went from 127 to 62 deaths per 1000 births. This halving reflects global progress; worldwide child mortality dropped from 90 to 45 in this period. Although we didn’t hit the goal, cutting the death rate in half is still an amazing accomplishment. Sadly, worldwide almost 6 million young children still die each year.

There is hope, however. Ghana recently trained several thousand Community Health Workers (CHWs). These “barefoot doctors” live close to the people they serve and treat illnesses as well as advocating prevention.

I traveled with a midwifery training-team to a village clinic. This part of the country has more than its share of maternal and infant deaths. Two midwives from the Baptist Medical Centre did an excellent job of teaching the clinic’s staff, which included 2 midwives and 3 midwifery students. Two rooms away another student midwife performed a delivery so quietly that I was amazed when a nurse brought out the healthy baby who was just minutes old.

While in the health center I saw a bottle of high-potency vitamin A capsules and was reminded of a remarkable study performed in this region. The overall death rate of children was lowered by 20% if they were given vitamin A supplementation. It appears the vitamin helps children fight infections such as measles and diarrhea, even where vitamin A deficiency is not prevalent.

If we are concerned about overpopulation, why should the death of children trouble us? Of course there are humanitarian reasons to keep children alive and healthy—they are our future! Demographers have found that people choose to have large families where there is a high child mortality rate.

It may appear paradoxical that preventing deaths will help eventually to slow population growth, but it is true. One of the best-known demographers of Africa, John Caldwell, cited three requirements before people will choose to have smaller families: educating girls and women, making effective contraception available and reducing the under-five mortality. He said that people only consider having a small family when child mortality is less than 130 per 1000. I could understand that number better when I converted it to a percentage—13%. That means that one in seven children dies—the thought is distressing!

In addition to training midwives, Ghana has instituted other ways to have healthier children. As I walk to the hospital I pass a nutrition center where small children are fed healthy, local food. Young kids with kwashiorkor (protein deficiency) and marasmus (severe malnutrition) are referred from the hospital, from outlying clinics and by CHWs. They spend 2 weeks or longer there being fed; many are still breast feeding. Every child is accompanied by a parent who is taught many ways to promote health, including nutrition and good hygiene.

Three days ago a young pregnant woman came to the hospital complaining of headache. Her blood pressure was elevated and the doctor noticed that she kept bumping into things, as though she couldn’t see well. Her mother gave the history that the patient had had an episode of shaking—a seizure. The doctor diagnosed eclampsia, the worst form of Pregnancy Induced Hypertension (PIH), with cortical blindness—a type of stroke. It was necessary to induce labor to save the mother’s life and hopefully her vision will improve. Unfortunately the very premature baby didn’t survive.

I am in Ghana studying PIH because it is more common here than in the USA. PIH can endanger the mother’s health and life, and has no treatment other than delivery of the baby. It is one of the most common causes of loss of life for babies and mothers, yet is poorly understood. Perhaps my study will shed light on this cause of obstetrical tragedies.

© Richard Grossman MD, 2017

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