Archive for the 'Public Health' Category

Move Upstream

Wednesday, September 28th, 2016


“Many children in this area have families that are unable to care for them. Fortunately, there are orphanages here in town that are able to care for small babies until their families are able to care for them again. The situation here is desperate, and many of the babies brought to the orphanages are severely malnourished.”                                                                        Phil and Laura Olaniyi

            Laura and Phil formerly lived in Durango but moved to Mozambique where they are starting an orphanage, “Heart for the Needy”. Let’s look at some of the statistics for this East African country.

Mozambique is one of the fastest growing countries in the world; women there have an average of almost 6 children. The country’s infant mortality is tragic, with 83 of every thousand children dying before they reach one year of age. This is one reason for the high fertility, since couples usually don’t choose to have small families until they know their children will live to adulthood. The maternal mortality rate is also very high. The average per capita income is only $3 a day.

These statistics don’t begin to tell the anguish of a mother who cannot care for her child, or the grief of a family who cannot care for a baby whose mother died in childbirth. Fortunately there are compassionate people such as Laura and Phil to care for these abandoned children. Even though they are far away I feel close to them in a way since I have worked with both of them—and I helped when Laura was born.

I agree with a statement Laura made on her blog: “Let’s be honest for a second, though. An orphanage is only putting a Band-Aid on the real problem – poverty & oppression.”

I admire Laura for being so perceptive, but I want to add another cause of “the real problem”—undesired fertility. In Mozambique only a quarter of girls are enrolled in secondary school, and only 11% of married women use modern contraception. The fertility of non-educated women is twice that of women with secondary school education, 6.8 and 3.4, respectively. This is an example of the wonderful power of educating women!

In the developing world young women often have very little power or control over their lives. Older men approach them with offers of money or coveted goods in exchange for sex. Rape is also common. The story of such an unfortunate young woman is told in the short YouTube video “Not Yet Rain”, filmed in Ethiopia.

“An ounce of prevention is worth a pound of cure.” Karen Shragg has used a similar expression in the title of her book: “Move Upstream: A Call to Solve Overpopulation”. In it Karen points out that so many of the problems we face, including climate change, ocean fisheries depletion, and extinction of species, are caused by increasing human overpopulation. Similarly, the need for orphanages is (in part) a symptom of unwanted fertility.

I have two friends who live in Bayfield who spent part of their childhoods in orphanages. Both are productive citizens who might not have survived if there had not been institutions to care for them as small children. In addition, relatives adopted a boy from the Democratic Republic of Congo when he was 3 years old. Mason’s birth parents died when he was small, so his grandmother took over his care. Unfortunately, she was unable to meet his needs then he was well cared for in an orphanage. Mason has joined a loving family in Durango who are giving him opportunities that would be impossible in Congo.

Orphanages provide a wonderful opportunity to care for some of the world’s most vulnerable children. There are few orphanages left in the U.S.A., but in developing countries there are many, and there is much need. As Laura points out, however, orphanages are just a Band-Aid for the real problems—terrible poverty, low status of women and many unplanned pregnancies.

We should “move upstream” to get at the root of the problem rather than just using Band-Aids. Steps that will help include supporting international family planning organizations such as the Population Media Center, and help the Population Connection terminate the Helms amendment, which restricts government funded agencies from even talking about abortion.

Until we have solved the problem of unplanned pregnancies, the only humane action is to care for orphans the way Laura and Phil are. I am sending them a check to help them as they build Heart for the Needy. What a boon it will be for orphans in Mozambique!

© Richard Grossman MD, 2016

Evaluate “Facts” Carefully

Thursday, July 28th, 2016


Image courtesy of

In 1999 the CDC listed “Ten Great Public Health Achievements of the 20th Century”. Family Planning is one. Another is “Fluoridation of Drinking Water to Prevent Dental Caries”.

The CDC report summarizes the science: “Fluoridation of community drinking water is a major factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century…. Although other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level.”

Last month three well-respected Durango citizens collaborated on an op-ed for the Opinion page of the Herald. Unfortunately much of what they wrote is not well supported. I know and respect all three—but feel that they didn’t do their homework well.

The first author wrote: “The fluoride we add to Durango’s water supply is Hydrofluorosilicic Acid.” In December I asked the City’s staff what is used to fluoridate Durango’s water supply and received this answer: “Dr. Grossman: The fluoride additive utilized is Sodium Fluoride (NaF) with a finished water fluoride concentration goal of 0.70 ppm.” Message #1: ask questions.

The assertion is made that water fluoridation causes arrested brain development, ADD and ADHD, decreased IQ, autism, learning disabilities and cancer. Writer #1 states: “More than one in six children are effected [sic] by these conditions.” What are the sources for this information? Presumably one journal, “Fluoride: Quarterly Journal of the International Society for Fluoride Research”. I find articles in this journal to be strongly biased—they all seem to be against fluoridation.

How can one tell if a scientific journal is reputable, since many periodicals seem to be trustworthy, but are not? First of all, look to see if articles in it are peer reviewed. If they are not, the information is less credible. I check one thing before deciding on the credibility of a medical journal: is the journal listed in the National Library of Medicine? “Fluoride” is not.

The second writer, a dentist, states “…I have never been able to distinguish which children (or adults) grew up in a fluoridated community or a non-fluoridated community.” This is not the sort of information with which to make educated decisions that affect the public’s health. Rather than just an impression, it would be more believable to have records of the rates of cavities where water is fluoridated and where it isn’t.

I admire this writer for checking with the Cochrane review on water fluoridation. These reviews are the standard for evaluation of the quality of medical knowledge. He quotes: “There is very little contemporary evidence, meeting the review’s inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries.” Message #2: the research on the effectiveness of water fluoridation is old, but still valid.

The third writer states that fluoride is “…an endocrine disruptor that is wreaking havoc with our thyroid glands….” This interests me for two reasons. The topic of endocrine disruptors is important, as there are many (especially organic) chemicals that cause subtle but serious problems. Additionally, I have taken thyroid medication for decades. I did some research to find out if there is good evidence that fluoride is an endocrine disruptor.

What I found is that, indeed, preliminary evidence suggests that fluoride may have an effect on thyroid function. Some of the information is from England, where most salt is not iodized. Fluoride may make lack of iodine (which is essential for thyroid function) worse. This supports the idea that it is healthy to use iodized salt, but doesn’t necessarily go against water fluoridation.

What is not mentioned by any of the three writers is that many of the studies showing bad effects of fluoride were done in places where the levels of water fluoride are very high. Those studies are not relevant to Durango, where the level is much lower. Message #3: read original studies to find relevance to our community.

Public health’s goal is to facilitate health for all people. My understanding is that the Durango City Council made the decision to continue with a low level of fluoride in its water supply. This was a good decision from the standpoint of public health because it will benefit those who have the greatest need—people who can least afford dental care, and who may have the poorest diets. Those who feel strongly that fluoride is bad can arrange to drink water without it.

© Richard Grossman MD, 2016

Don’t Get Pregnant

Wednesday, March 2nd, 2016


Image courtesy of the CDC

“The Zika virus provides a glimpse into a future we should do everything possible to avoid, a terrifying reminder why the fight for a stable physical planet is the fight of our time.” Bill McKibben

“Don’t get pregnant until 2018” is the advice given women in El Salvador. Yet only two thirds of married women there are using modern contraception.

The Zika virus, declared “public health emergency of international concern”, is the cause of the Salvadorian government’s warning against pregnancy. “We’d like to suggest to all the women of fertile age that they take steps to plan their pregnancies, and avoid getting pregnant between this year and next….” This quote from Deputy Health Minister Eduardo Espinoza is frightening.

Although it hasn’t caused an epidemic in Africa where it was first identified, it is raising havoc in the Americas. Zika virus symptoms are usually mild: eye inflammation, fever, rash and joint irritation—but the majority of infected people have no symptoms at all. There is no treatment for Zika disease. Mosquitoes of the Aedes genus spread Zika, dengue and other diseases, and it may also be spread by sex.

The best way to avoid getting Zika is to avoid being bitten by mosquitoes—insect repellant, dress appropriately and avoid areas where mosquitoes live. So far Colorado is safe from Aedes.

Climate change has recently increased the range of Aedes mosquitoes. Air travel has allowed the virus to spread like lightning. Humans have destabilized the planet, as McKibben states.

The Zika story in the Americas is still being written, but began last year. Brazilian doctors noticed a huge increase in the incidence of babies born with small heads—microcephaly. They found an association with the mothers having had Zika virus infection early in pregnancy.

I am terrified that brain scans of affected babies show other serious abnormalities usually associated with profoundly impairment. There are dozens of causes of microcephaly, but most of them are associated with cognitive and other problems.

The CDC recommends avoiding Zika when a woman is, or could become, pregnant. If the mother could have been exposed to the virus during pregnancy, it recommends ultrasounds to monitor fetal head growth.

What is so concerning is that where Zika is found, family planning services may be spotty. Fortunately El Salvador, where women are supposed to abstain from pregnancy for the next 2 years, has had a pretty successful reproductive health program. It is regrettable, however, that El Salvador is one of only 6 countries worldwide that outlaw abortion for any reason.

Beloved Pope Francis recently gave Catholic women who are at risk of Zika virus permission to use “artificial” contraception. This is great news for the millions of women where Zika is a threat, and will hopefully encourage governments in those areas to make contraception easily available.

One of the reasons that the U.S.A. liberalized of our abortion laws was that we had a viral epidemic that caused severe fetal damage. Fortunately, immunization has made rubella a disease of the past.

What happens if a woman is infected with Zika in pregnancy and ultrasound shows that her fetus has microcephaly? The Salvadorian punishment for having an abortion is 2 to 8 years in prison for the woman and up to 12 years for the doctor. Nevertheless hundreds of women risk having an illegal abortion. Often they cause their own abortions by thrusting a knitting needle or piece of wood into their uterus. Tragically, suicide is not uncommon among pregnant women in El Salvador.

Here is a hypothetical situation. Luisa, a Salvadoran campesina, has two healthy children. She was taking birth control pills, but her clinic ran out. Shortly after conceiving her third pregnancy she had what she thought was a cold with a mild red rash. During a routine ultrasound at 5 months the doctor said everything was ok except the fetus’s head seemed small, and she could see calcifications in the brain. What can Luisa do? If this baby’s brain was severely damaged she couldn’t afford to take care of it, and her other two children would suffer because of the family’s very limited resources.

What is wrong with a society that puts women in such a difficult bind? Rape is common in El Salvador, yet a woman who has been raped or is carrying a terribly compromised fetus has no legal recourse. Climate change and international travel make it more important that women everywhere have access to family planning and safe abortion services.

© Richard Grossman MD, 2016

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