Archive for the 'Public Health' Category

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

Walk Carefully

Sunday, March 26th, 2017

Walk Carefully

            This month’s column has almost nothing to do with human population. It details an event that was life-changing for me, and could have been life-ending. However, getting bumped off by a careless driver is no way to solve overpopulation! I write to help others be safer.

Back in November my wife and I were crossing Main Avenue in the crosswalk on the way to one of Durango’s restaurants. We weren’t sure if it was north or south of 7th Street, and I remember looking to the left to see if the eatery was in that direction.

The next thing I knew was waking up in the CT scanner at Mercy. I had been hit by a car whose driver “didn’t see me”. Fortunately he stopped; unfortunately he parked with my foot under a tire.

Happily the results of the CT scan and other tests showed nothing terrible was done. I had a broken bone in my right ankle in addition to multiple bruises and “road rash”. The concussion saved me from remembering the accident, and its aftereffects are gradually resolving. There was a large bruise on my left leg where the car had probably first hit me. The hematoma became infected and had to be drained.

The hematoma and dead skin that covered it seeded another infection. I went back to the operating room to have that removed, leaving an open wound. Now, almost 4 months after the accident, I am still recovering but am almost healed.

I am very fortunate: my injuries could have been so much worse. Searching the Herald archives since my accident I found 4 more pedestrians who had been hit by vehicles in Durango and one in Hermosa, so mine was not an isolated misfortune. It would seem that it isn’t safe to be a pedestrian in Durango!

There are several lessons when looking at my accident from a public health standpoint. Everyone knows that drugs and alcohol are among the most common causes of motor vehicle accidents. Texting and talking on a cell phone are frequent causes of accidents. Apparently none of these possible factors was pertinent to my accident.

One possible contributing factor is that I was wearing a blue jacket and dark jeans. These are less visible than lighter colors. Although the “dark skies” initiative is admirable, I think that the lights in downtown Durango are dimmer than they should be.

The care I received has been excellent. A woman who was working at a store close by came and kept my neck from moving and made sure I was responsive. My wife and others told the driver that he was parked on my foot and got him to move the vehicle. The police and ambulance arrived quickly. They started two IVs and drove me to Mercy with all the proper precautions. An emergency physician evaluated me and ordered appropriate tests. Then they applied a splint to the broken ankle.

There was a surprise in the ER—a bouquet of flowers brought by unknown well-wishers. It turned out that they had just started one of new restaurants where Francisco’s had been. We ate dinner there a month or so after the accident; their chile rellenos are excellent!

I have several suggestions to try to prevent pedestrians from being hurt in the future. Individuals can avoid trauma by being more paranoid when crossing streets—even in the crosswalk. Wear light-colored clothes at night; even better, wear clothes that have reflective markings.

The City of Durango already is concerned about lighting. From Christina Rinderle’s column “From the Mayor” in the January 29th Herald: “Other items were placed in the high impact/low effort quadrant that we hope to be “quick wins”, like enhancing downtown lighting to make it safer and more inviting….”

A traffic light at the corner of 7th and Main would help. My wife, Gail, has a suggestion for a less expensive solution. Mount spotlights aimed at the crosswalks on poles at the corners of Main that do not have traffic lights. When a pedestrian wants to cross, s/he would push a button to turn on the spotlight for long enough to safely cross the street.

I feel very fortunate that my injuries were no worse, but even with relatively minor trauma it is taking me 3 surgeries and over 4 months to recover. Please be careful!

© Richard Grossman MD, 2017

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