Archive for the 'Reproductive Health' Category

Listen to Representative Coram

Sunday, January 24th, 2016


A recent Durango Herald article detailed the “New Year’s resolutions” of three Southwest Colorado lawmakers. There is an important issue that was not mentioned in this article, and Rep. Coram may have part of its solution.
Let me start by trying to summarize what is on each of the legislators has said. State Senator Ellen Roberts is focusing on rural healthcare costs—for good reason! Although we in the USA spend the most per capita of any country in the world, our health statistics lag behind many other countries. Senator Roberts is also concerned about problems brought up by the Gold King Mine spill. I am confident that her excellent legal mind can help pass a “good Samaritan” law for mine mitigation, and decrease barriers between states in dealing with emergencies. Finally, she is concerned about the monstrous wildfires we have experienced recently.
J. Paul Brown, our Representative in the Colorado House, rightly picks transportation and water as key issues for the legislative session that has just begun. He and I probably disagree about transportation because I support public transportation as well as highway improvement. But we definitely agree about water! J. Paul’s website states: “Water is the most precious resource on Colorado’s West Slope…. As your State Legislator, I will work tirelessly to protect our water.” Globally, water is the most precious resource.
Don Coram represents people a bit to the north and west of La Plata County, nevertheless he was included in this article. The only issue mentioned is voter registration, but I admire him for another topic. In 2015 he was one of the sponsors of a bill to provide safe, effective contraception to low-income women. A Republican, the bill had a Democratic cosponsor. Unfortunately, the bill failed. Fortunately, however, a coalition of private donors has temporarily picked up part of the slack.
You probably recall that a foundation funded provision of Long Acting, Reversible Contraceptives (LARCs) here in Colorado. LARCs consist of IUDs and a hormonal implant, all of which are safe and appreciated by women, but are usually out of the price range of those who don’t have insurance. They are much more effective than over-the-counter methods such as condoms, and are even 20 times as successful at preventing pregnancy as “the pill”. That grant was for a 5-year period which ended in 2015. This funding had a remarkable effect! There were fewer abortions in Colorado, and our teen pregnancy rate dropped by 40%.
Despite Representative Coram’s best efforts, the legislature would not approve funding to continue the program. The reason given for disapproval by other legislators was that IUDs sometimes cause abortions. The best medical knowledge is that IUDs do not cause abortions—but it is well known that unplanned pregnancies often end up being aborted.
Public health sources state that each dollar spent on family planning saves from 4 to 7 healthcare dollars. This is a better return on investment than just about anything else! Personal benefits, such as allowing a young woman to finish college are of even greater value. Other advantages, however, go beyond the obvious. The cost of insurance is lower if there are fewer unplanned pregnancies, Senator Roberts. Some of the highest healthcare costs are those associated with premature birth. The pregnancies that LARCs prevented in this study would have likely been to the women most likely to give birth prematurely—young and poor.
What is causing those terrible wildfires that we are having trouble paying for? Climate change is a major factor. What is the least expensive way to slow greenhouse gas emissions? You guessed it—family planning! Fewer people mean fewer emissions. LARCs won’t provide a short-term solution for either climate change or wildfires, but they can help in the long term.
Representative Brown, please remember that the more people who drive on our highways, the more costly they are to maintain. Likewise, the more people there are in Colorado, the greater the need for water. Most of the growth is on our state’s Eastern Slope. As its population increases, the pressure for them to get our Western Slope water will increase. Again, LARCs won’t solve transportation or water problems right away, but funding them can reduce the size of the problems that our children and grandchildren have to deal with.
Thank you for your courageous stand, Representative Coram. I am sorry that I cannot vote for you, but hope that you will find new allies in support of another bill to pay for LARCs.

© Richard Grossman MD, 2016

Preclude Abuse in Family Planning Programs

Wednesday, February 4th, 2015



Image courtesy of Pathfinder International

The London Summit on Family Planning in 2012 was the start of a new focus on family planning (FP). The last time FP had received so much attention was the Cairo conference in 1994.

Several factors had turned attention away from FP. The HIV/AIDS epidemic received a huge amount of attention and funding. Donor fatigue was another factor, since FP programs are expensive and the results can be difficult to measure. Perhaps abuse was the most important reason that people lost interest in FP programs. For instance, it became clear that people in many countries, including our own, had been sterilized without informed consent.

Long ago I assisted with infertility surgery on a woman who had had 3 cesareans in Texas and was unable to conceive a fourth child. We found that her Fallopian tubes had been surgically interrupted without her knowledge or consent. Apparently her doctor in Texas didn’t think she should have any more children and had tied her tubes.

The darkest chapter in the history of FP was eugenics, the practice of trying to improve human genetics. In some cases eugenicists mandated sterilization of “undesirable” people—people of color, people with birth defects or learning disabilities, and people with mental problems. Often the eugenics movement was allied with political goals; the enemies were labeled as “undesirables”. My personal experience is that some of my favorite patients might have fallen into an “undesirable” category.

A number of women in California prisons were sterilized without following proper legal procedure—and probably without respect for the women’s human and reproductive rights. There are also stories of widespread abuse from India and Peru among other countries. It is unforgivable that people have been taken advantage of, but that is no reason to halt all FP programs.

Last month I wrote about the women who died in India after tubal ligation surgery. The press has focused on the terrible conditions where the surgery was performed. Also disturbing is how the women were treated before the surgery—they were not given a choice of temporary contraceptive methods nor told about the risks of the surgery.

225 million women worldwide want to avoid pregnancy but don’t have access to modern contraception. How can services to these people be delivered without abuse?

The goal of the London Summit is monumental, but attainable: to reach 120 million new users of FP by the year 2020. This effort is nicknamed FP2020. The memory of past abuses triggered concerns that such an ambitious goal could lead to new abuses. One of the first steps FP2020 took was to consult social scientists about ways to decrease the chances of coercion. In their report they asked: “How can we ensure public health programs oriented toward increasing voluntary family planning… respect, protect and fulfill rights in the way they are designed, implemented, and evaluated?”

In response they developed an innovative plan. Instead of focusing on getting people to adopt FP, they recommend working from a basis of human rights. That is correct: family planning should be based on human rights.

Although this seemed revolutionary to me at first, I realized that a major reason I became interested in FP is to further human rights. On the individual scale the lives of parents are improved if they have the right to choose how large their family will be. Of course their children benefit, too! On a global scale people’s rights may be trammeled as population density increases.

The authors of the report define reproductive rights as reproductive self-determination; access to reproductive health services, supplies and information; and nondiscrimination. Self-determination is the key—people must be able to choose what method of family planning (if any) they use. Both information and supplies need to be readily available for this to succeed. In most of the world, including the USA, lower-income folks are less able to access FP, but this discrimination must stop.

How can policies be made so rights are more important than quotas? Standards will be made and enforced to deliver quality care. Supplies are often a problem in developing countries, but that problem can be solved with technology. Production should be judged not by the numbers of patients served but by how well they are served. For instance, clients can be given questionnaires before they leave a clinic to be sure that they were given information about all available FP methods.

So far, this is theoretical; it remains to be seen if reproductive and human rights can be honored consistently. Next month I’ll report on FP2020 in action.

© Richard Grossman MD, 2015

Reject these Old Memes—2-2014

Wednesday, February 26th, 2014

Recently a friend introduced me to the word “meme”. Now I run across this concept frequently.
The word “meme” is analogous to “gene”, but it is information in our culture rather than in our DNA. A meme is a building block upon which our way of life is built. One definition is: “an idea, belief or belief system, or pattern of behavior that spreads throughout a culture”.
An old example is the Pythagorean theorem—the square of the hypotenuse of a right triangle is equal to the sum of the squares of the other two sides. This meme is ancient.
One accidental meme is changing lives in Brazil. The average family size has dropped rapidly. In 1954, when I visited as a child, women had an average of over 6 children. Now the average is 1.8—less than replacement. This big change is largely because of TV telenovelas, where middle class families are all small.
Some memes are harmful. An example is a tradition in Nigeria that leads to the death of many children. For eons Traditional Birth Attendants used mud or other unclean substances to dress newborn babies’ umbilical cord stumps. If tetanus spores are present, the baby can die a horrible death from tetanus. This improved when TBAs were taught the advantages of cleanliness and sterile instruments. Now pregnant women getting prenatal care are immunized against tetanus and there are many fewer deaths.
Galileo, who was born 450 years ago this month, suffered because of a religious meme. This meme slowed the development of knowledge for centuries.
Ancient Egyptians thought that the sun rotated around them—the geocentric model of the solar system. A Greek may have first proposed that Earth revolved around the sun 2500 years ago—the heliocentric model. For centuries people believed that the earth was the center of the universe, supported by theology that interpreted the Bible thusly. One verse that supports this meme is found in Psalms 104:5: “(God) built the earth on its foundations, so it can never be moved”. There are still people who hold that the sun goes around the earth—including 26% of US citizens, according to a recent National Science Foundation survey!
In the early 17th century Galileo defended the heliocentric theory, for which he was accused of heresy and placed under house arrest for the rest of his life. The Inquisition’s ban on reprinting his works was only lifted a century later. It was not until the 19th century that the Roman Catholic Church removed books advocating heliocentrism from its Index of Prohibited Books. Pius XII was the first Pope to acknowledge the many important contributions of Galileo—in 1939. Yet there are people who believe that heliocentrism is a conspiracy ( It is amazing how long this meme has persisted!
Years ago I sold “green umbrellas” at a public health meeting. From a campaign in Bangladesh (where it rains a lot), these umbrellas carry slogans such as “stay well” and “take health services” in Bengali. A doctor from Bangladesh bought one, then a few minutes later returned and wanted his money back. I asked him what was wrong. He replied that one of the sayings is “small families”, and we should have as many children as Allah gives us. This is another case of a religious meme that has outlived its usefulness, since Bangladesh is very crowded.
I find it amazing that some religions have not yet recognized the benefits of contraception to individuals, to families and to the world. The official doctrine of the Roman Catholic Church is that only periodic abstinence (the “rhythm” method) is acceptable. This policy is ignored by many of the 1.2 billion Roman Catholics worldwide—and many women I have talked with have left the Church because of this policy.
In many Catholic countries, such as Brazil and in Western Europe, couples use modern contraception resulting in average family size less than two. There are places, including some of the poorest countries in the world where this prohibition against effective contraception is followed. They will continue to be stuck in poverty so long as people are prohibited from using modern family planning. Rwanda is an example; its rapid population growth was one factor leading to its genocide 20 years ago.
Memes can outlive their usefulness to society. It is time for women to have the same status and rights as men, and for all people to have the access to the means to manage their fertility.

© Richard Grossman MD, 2014

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