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Exploring Human Potential

The 176 Year History Behind Today’s Attacks On Women’s Health.

Posted on | August 18, 2015 | 2 Comments

Mike Magee

In an editorial in this week’s NEJM, editors state, “We strongly support Planned Parenthood not only for its efforts to channel fetal tissue into important medical research but also for its other work as one of the country’s largest providers of health care for women, especially poor women. In 2013, the most recent year for which data are available, Planned Parenthood provided services to 2.7 million women, men, and young people during 4.6 million health center visits. At least 60% of these patients benefited from public health coverage programs such as the nation’s family-planning program (Title X) and Medicaid. At least 78% of these patients lived with incomes at or below 150% of the federal poverty level. Planned Parenthood’s services included nearly 400,000 Pap tests, nearly 500,000 breast examinations, nearly 4.5 million tests for sexually transmitted illnesses (including HIV), and treatments.The contraception services that Planned Parenthood delivers may be the single greatest effort to prevent the unwanted pregnancies that result in abortions.”

This is not the first time the organization has been enmeshed in controversy. The following is an excerpt from my soon to be published book, “Unholy Alliances”, which places current events in context, and shows that the antagonists in the struggle – conservative politicians, the Catholic Church, and others – have been engaged in this struggle for many years.

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“The war against Planned Parenthood and its’ predecessors has a rich history dating back 176 years to 1839. That was the year that Charles Goodyear was controversially credited with the discovery of vulcanized rubber. The chemical process that Goodyear stumbled on involved the introduction of heat and additives to standard rubber gum which induced new cross links and a fundamental alteration in the end product. The new material was more moldable, mechanically stronger, and all importantly, less sticky. The process involved the application of heat, thus the name “vulcanized rubber” after the Roman god of heat, Vulcan.(31)

Fortuitously for Goodyear, his discovery arrived during a twenty year period of intense interest in self-help called the Popular Health Movement beginning in 1830. One prominent figure of the day was Edward Bliss Foote who invented a device he poetically labeled the “womb veil”.(28) This rubber pessary, designed for easy insertion, was the forerunner of the modern diaphragm and cervical cap. It was actively marketed and distributed over the counter and through mail order beginning in 1863, and sold for the princely price of $6. It largely replaced a range of less sophisticated contraptions first available publicly in the 1830’s in the United States. Advertisements of the day promised that the womb veil could be “used by the female without danger of detection by the male”.(29) Interest in the device was reinforced by the actions of the AMA which first publicly opposed all abortions in 1859, followed by the actions of Connecticut, the first state to prohibit all abortions, which prior to this time were generally tolerated in the time period before “quickening” (the sensation of fetal movement by the mother).(30) “If not abortions, then contraception”, was the public mood.

Their ultimate opponent took the unlikely form of a New York City based U.S. Postal Inspector committed to stamping out vice named Anthony Comstock. His organizational vehicle was the New York Society for the Suppression of Vice created in 1873, with Anthony as both founder and chief vice hunter.(35) His efforts were supported by key leaders of the Young Men’s Christian Association (YMCA). The organizations mission was not only to hunt out vice but also to bring offenders to justice. The organization drew its powers directly from the New York state legislature which granted its agents the police authority to search, seize and arrest those who marketed, distributed or sold banned items.

Comstock’s lasting legacy however was not on the streets of New York, but rather in the halls of Congress. On March 3, 1873, he was able to harness the support of enough U.S. legislators to amend the Post Office Act to include the “Comstock Act”.(36) Multiple states followed suit creating together a host of laws collectively called the “Comstock Acts”, many of which remain unenforced on the books today. This legislation made it illegal to transmit “obscene” materials through the mail. Specifically the law declared:

“Be it enacted… That whoever, within the District of Columbia or any of the Territories of the United States…shall sell…or shall offer to sell, or to lend, or to give away, or in any manner to exhibit, or shall otherwise publish or offer to publish in any manner, or shall have in his possession, for any such purpose or purposes, an obscene book, pamphlet, paper, writing, advertisement, circular, print, picture, drawing or other representation, figure, or image on or of paper or other material, or any cast instrument, or other article of an immoral nature, or any drug or medicine, or any article whatever, for the prevention of conception, or for causing unlawful abortion, or shall advertise the same for sale, or shall write or print, or cause to be written or printed, any card, circular, book, pamphlet, advertisement, or notice of any kind, stating when, where, how, or of whom, or by what means, any of the articles in this section…can be purchased or obtained, or shall manufacture, draw, or print, or in any wise make any of such articles, shall be deemed guilty of a misdemeanor, and on conviction thereof in any court of the United States…he shall be imprisoned at hard labor in the penitentiary for not less than six months nor more than five years for each offense, or fined not less than one hundred dollars nor more than two thousand dollars, with costs of court.”(37)

The target of Comstock’s rage was not only pornography, but more specifically contraceptive equipment and reproductive health materials of the day. Sixty years later, in 1936, the Supreme Court would strike down the ban on contraceptives.(38) In addition, control of condoms would be brought under the auspices of the Food and Drug Administration as part of a national effort to control the spread of venereal diseases.(39)This allowed World War II U.S. soldiers to be supplied condoms, in contrast to their fathers who fought in World War I.(40) In 1937, the AMA also gave its stamp of approval to contraception stating “the intelligent, voluntary spacing of pregnancies may be desirable for the health and general well being of mothers and children.”(41)

As for women, by 1938, well stocked over the counter pharmacies offered over 600 brands of powders, gels, diaphragms and douches for “feminine hygiene”.(42) What all of these shared was a dual use as contraceptives with generally poor results. As for public maternal health, in 1935, the New York City Health Department catalogued an average of 5 to 10 cases of septic abortions per week.(43)

In the early years of the 20th century, however, the battle was full on between Comstock’s raiders and a new brand of aggressive women determined to control their own fates. Chief among them was Margaret Higgins Sanger, nurse and sex activist. Margaret was the sixth of eleven children born into an immigrant Catholic family that had settled in America in the wake of the Irish potato famine. Her mother, Anne Purcell Higgins, managed 18 pregnancies in 22 years, and died at age 49. Her early years were occupied with household duties and the care of younger brothers and sisters. Two older sisters financed her education which led to a Nurse Practitioner degree from White Plains Hospital in New York in 1901. The next year she married architect William Sanger and they had three children of their own.(44)

In 1911, the young family moved to New York City and Margaret took a job as a visiting nurse in the slums on the Lower East Side. After seeing the results of several botched abortions, she began to broadly distribute a wide range of how-to sex education materials as part of an organizing effort to involve the communities she served. Welcoming a confrontation, she published a monthly newsletter titled “The Woman Rebel”. If the title didn’t capture religious leaders attention, the slogan – “No Gods, No Masters” – surely did.(46) In 1914, the monthly led to accusations of violation of the Comstock laws. She fled to Canada and then to Britain to avoid arrest and remained there for a year.(47) Her husband was charged to release the published and yet to be released “Family Limitation”, a 16 page pamphlet with graphic images and descriptions of various forms of birth control. This earned him a visit from Anthony Comstock and 30 days in jail. The resultant publicity elevated both Margaret and her cause to national standing.(48)

She believed and loudly proclaimed that, each woman should be “the absolute mistress of her own body.”(49) In 1916, back in the United Staes, she opened the first birth control clinic in Brooklyn, NY, with two goals in mind. One was to limit the occurrence of dangerous back alley abortions, and the second was to help place women in a more equitable position with men by allowing them to determine whether or not to have children and how many to bear. Nine days after opening, she was arrested and went to trial in January, 1917. She was initially convicted with the judge declaring that women did not have “the right to copulate with a feeling of security that there will be no resulting conception.” But in appeal, Judge Frederick Crane spared her 30 days in the workhouse when he delivered a compromise ruling that included the statement that physicians could prescribe contraception to treat or prevent disease.(50)

Five years later, to further organize the effort, Sanger founded the American Birth Control League, and in supplying her clinic in New York, now complete with a team of all female doctors, directly challenged the Comstock Acts.(51) Sanger had reached out to a Japanese colleague to mail diaphragms and cervical caps to her physician colleague, Hannah Stone.(52) Stone not only provided care but was the Medical Director of a second entity, the Birth Control Clinical Research Bureau, which was engaged in studying, for the first time, the effectiveness of various forms of contraception. The package was intercepted by Customs officials, and Sanger was again arrested.

The case, United States v. One Package of Pessaries, narrowed the power of the Comstock Acts by deciding that the legislations intent was not “to prevent the importation, sale or carriage by mail of things which might intelligently be employed by conscientious and competent physicians for the purpose of saving life or promoting the well-being of their patients.”(53) This reinforced Judge Crane’s prior ruling.

These decisions pointed Sanger to a narrow corridor that she and her colleagues would pursue over the next 15 years. The price they paid was the “medicalization” of a movement that had begun as a “women’s rights” effort.(54) Her organization went to work defining a wide range of medical conditions that would justify the use of contraception including everything from multiparity to hypertension to tuberculosis to poor housing conditions. By the time they finished, nearly everyone qualified.

By the 1930’s, Sanger’s American Birth Control League was working hand in hand with another New York organization, the International Workers Order (IWO). This was a Jewish fraternal organization with strong Communist leanings that by 1935 had 100,000 members.(55) It provided sport and culture, and for the first time in America, prepaid medical care. The goal was to distribute the financial burden. They provided basic generalist health care services, discounted specialty care, dental care and discounted medications at 90 contracted pharmacies. In 1937 they added mass screening for syphilis and in 1939 instituted low cost chest X-rays to detect tuberculosis. That was three years after they had added a Birth Control Center in conjunction with Margaret Sanger. Over those first three years, 1200 women received service. The annual fee of $4 ($60 in today’s currency) covered all gynecologic exams, unlimited visits and all prescribed contraceptive supplies.(56)

As 1938 rolled around, Sanger’s American Birth Control League was growing in leaps and bounds. There were now 347 birth control clinics nationwide with 1/5 supported by public funds and the remainder supported by philanthropy and patient fees. The growth was fueled by a strong shift in public opinion.(57) A 1938 poll conducted by the Ladies Home Journal revealed a 79% support for birth control.(58) As impressive were the figures coming out of Sanger’s research arm. An American Birth Control League 1937 survey of 29,000 patients from 170 clinics demonstrated a 92% effectiveness of physician fitted diaphragms in conjunction with spermicidal jelly. This success contrasted with the 72% effectiveness of over-the-counter diaphragms and the 29% effectiveness of store bought douches. As for condoms, which were used by only 4% of the clients.(59) The American Birth Control League shied away from their use not because they were ineffective, but “because the woman is more likely than the man faithfully to carry out the method of control, the means may better be in her hands.”(60)

It is important to note that leaders of the American Birth Control League and the International Workers Union and others did not see Birth Control Clinics as their end game. Rather, as their experience grew with their understanding of their patients needs, they saw women’s services as part of a general move, as the IWO unabashedly proclaimed, toward “socialized medicine”.(61)

Noticeably absent from the original Social Security Act, FDR had gone so far as to organize a 1938 National Health Conference to confer with his Technical Committee on Medical Care to examine a “program of medical care…to serve the entire population.”(62) The proposals would appear in the Senate’s Wagner bill of 1939. But FDR’s unwillingness to expend political capital in the lead up to a possible war, coupled with strong AMA opposition, collapsed the effort. The AMA would be there as well in 1943 to help defeat the Wagner-Murray-Dingell bill seeking universal coverage, and FDR’s “economic bill of rights” with health care services in 1944, and Truman’s “single system “ efforts a few years later.(63)

By the time Truman made his push, America was deeply entrenched in the “Cold War” and the Iron Curtain was about to be drawn. The IWO was on a 1947 list of “subversive organizations” prepared by US Attorney General Tom Clark.(64) Senator Joe McCarthy from Wisconsin had launched “McCarthyism” in a speech in 1950, and the search for American Communists was on. In that same year, the New York superintendent of insurance declared the IWO to be “a recruiting and propaganda unit for the Communist Party”. In June, 1953, Julius Rosenberg and his wife Ethel went to the electric chair convicted of espionage. They never proved Julius to be a Communist, but he did acknowledge having an insurance policy with the IWU, which was felt to be incriminating. With fear all around, membership in the IWU rapidly declined, and in 1953, the IWO was liquidated.(65)

As for Margaret Sanger, she lived to fight another day, in part due to skillful maneuvering in 1942. After accommodating to “medicalization” and benefitting from the subsequent AMA endorsement of contraception in 1937, she felt the winds of change and renamed her Birth Control Federation of America as the Planned Parenthood Federation of America.(66) This literary power shift dropped the notion of “birth control” with its implications of struggle and replaced it with the more congenial “family planning”.

Sanger was an adept politician and fund raiser. She received extensive funding from the Rockefeller’s, but always anonymously, so as to protect the career trajectory of Nelson Rockefeller who feared public support of Sanger could lead to formal opposition to his future campaigns by the Catholic Church.(67)

The Church’s advances in the immediate post-World War II period had convinced the hierarchy that bigger was better than smaller. Their numbers were on the steep incline as soldiers returned from the war, and the Church was committed to keeping it that way. The bishops believed that family planning was mission critical and should be a Church-down affair. They would need to be well organized and would need to include Catholic doctors like my father.(68)

As the Church stayed true to it’s roots, Sanger responded in kind. She leaned back on her clinical interests and brought together philanthropist Katharine McCormick and biologist Gregory Pincus. He would use the money he received from McCormick wisely linking up with his old fiend John Rock at the Free Hospital for Women in Boston, to create the first U.S. birth control pill, Envoid (a combination of mestranol and norethynodrel), developed and distributed by G. D. Searle & Company, after its FDA approval on June 10, 1957.(69)

The Church could see this coming for a while. Way back in 1930, a Catholic doctor from the Netherlands, John Smulders, had developed the first calendarized scheme designed to avoid pregnancy.(70) His work took advantage of early discoveries in 1920 by Austrian gynecologist Theodoor van deVelde and Japanese gynecologist Kyusaku Ogino, who independently proved that ovulation occurs about 14 days before menstruation.(71) Ten years later, Smulders published his “rhythm method” which drew wide usage in Europe. In the U.S. however, it remained highly controversial, even after Leo Latz published his book, The Rhythm of Sterility and Fertility in Women, describing the method in 1932, and John Rock opened his Rhythm Clinic in Boston to teach Catholic parents the technique.(72)

The American Catholic Church and its’ leadership could easily predict the next step. As the science of maternal health and its’ natural rhythms were increasingly exposed to examination, it was only a matter of time before pharmaceutical companies and their allied physicians would figure out how to manipulate and destroy this miraculous system. Clearly, God’s rights to decide when and where to deliver His children was under attack, and the Church must defend, defend, defend. As Pope Pius XI had said in his famous Encyclical, Casti Connubi, on December 31, 1930: “…every attempt of either husband or wife in the performance of the conjugal act or in the development of its natural consequences which aims at depriving it of its inherent force and hinders the procreation of new life is immoral; and that no ‘indication’ or need can convert an act which is intrinsically immoral into a moral and lawful one.”(73)

But what to do now with science on the rise? The Church faced a choice. Embrace the new “Rhythm Method” which at least emphasized restraint and periodic abstinence, and might dampen the march toward use of horrid preventatives, paganism, and sins of the flesh; or stand strong and face the possibility of being overrun by modernity. In the end, the bishops sided with this new semi-natural method. But a vocal minority labored on, and not in silence. As late as 1948, popular preacher and radio broadcaster, Father Hugh Calkins had this to say, “Catholic couples have gone hog-wild in the abusive employment of rhythm…A method meant to be a temporary solution of a critical problem has become a way of life, a very selfish, luxury-loving, materialistic way of life. But heaven, not security, is the goal set for the babies God sends…Every couple should have the children God wants them to have.”(74)

Margaret Sanger would live and work for another decade, as founder of the International Planned Parenthood Foundation. By the time she died on September 6, 1966 at the age of 86, her Planned Parenthood Federation of America was the largest government provider of reproductive health services.(75)”

Excerpted from Unholy Alliances, (copyright/Mike Magee©2015)

For Health Commentary, I’m Mike Magee.

References:
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33. Starr P. The Social Transformation of Health Care. New York: Basic Books. 182. p.53.

34. Foote, Edward Bliss (1863). Medical Common Sense; Applied to the Causes, Prevention, and Cure of Chronic Diseases and Unhappiness in Marriage. New York. p. 380. Accessed 10/16/14.
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38. Paul CJ, Schwartz ML. Obscenity in the mails: A comment on some problems of federal censorship. University of Pennsylvania Law Review. Vol. 106(2), December, 1957.

39. Aine Collier (2007). The Humble Little Condom: A History. Buffalo, N.Y: Prometheus Books. pp.223-225.

40. Aine Collier (2007). The Humble Little Condom: A History. Buffalo, N.Y: Prometheus Books. pp.236-238.

41. Engelman PC. The History of the Birth Control Movement in America. Santa Barbara, CA: Praeger. 2011.p.169

42. “The Accident of Birth”, Fortune, February 1938, 85.

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45. Margaret Sanger: Biographical Note. Five Colleges Archives and Manuscript Collections. Accessed 10/16/14. http://asteria.fivecolleges.edu/findaids/sophiasmith/mnsss43_bioghist.html

46. “Disorder in court as Sanger is fined. Justices order room cleared when socialists and anarchists hoot verdict.” New York Times. Sept. 11, 1915. Accessed 10/16/14 http://query.nytimes.com/mem/archive-free/pdf?_r=1&res=9C05E5D91138E633A25752C1A96F9C946496D6CF&oref=slogin

Tempkin E. Contraceptive Equity. Am J Public Health. 2007 October; 97(10): 1737-1745. Accessed 10/16/14.
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47. IMargaret Sanger: Biographical Note. Five colleges Archives and Manuscript Collections. Accessed 10/16/14. http://asteria.fivecolleges.edu/findaids/sophiasmith/mnsss43_bioghist.html

48. “Family Limitation”: A Book That Shaped America. Margaret Sanger Papers project – Research Annex. July 16, 2012. Accessed 10/16/14. http://sangerpapers.wordpress.com/2012/07/16/family-limitation-a-book-that-shaped-america/

49. Hurt A. The Absolute Mistress of Her Body: A century after Sanger, women’s reproductive health still inflames passions. The New Physician. december, 2006. American Medical Student Association. Accessed 10/16/14. http://www.amsa.org/AMSA/Homepage/Publications/TheNewPhysician/2006/tnp327.aspx

50. Tempkin E. Contraceptive Equity. Am J Public Health. 2007 October; 97(10): 1737-1745. Accessed 10/16/14.
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51. Tempkin E. Contraceptive Equity. Am J Public Health. 2007 October; 97(10): 1737-1745. Accessed 10/16/14.
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52. Moran Hajo, C. January 2, 1943 First Legal Birth Control Clinic Opens In The US. Margaret Sanger Papers Project – Research Annex. April 9, 2014. Accessed 10/16/14. https://sangerpapers.wordpress.com/author/cathymoranhajo/

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54. The Margaret Sanger Papers Project: Sanger and the Medicalization of Birth Control. NYU. Accessed 10/16/14. http://www.nyu.edu/projects/sanger/research/topicguide2009.php

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57. Tempkin E. Contraceptive Equity. Am J Public Health. 2007 October; 97(10): 1737-1745. Accessed 10/16/14.
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58. Henry F. Pringle, “What Do the Women of America Think About Birth Control?” Ladies’ Home Journal, March 1938, 14–15, 94–95, 97.

59. American Birth Control League for the Year 1937, pp. 29–30; Hannah M. Stone, “The Vaginal Diaphragm,” Journal of Contraception 3, no. 6–7 (1938): 123.

60. Robert L. Dickinson and Woodbridge E. Morris, Techniques of Conception Control, Baltimore, Md: Williams and Wilkins Co, 1941, p7.

61. Tempkin E. Contraceptive Equity. Am J Public Health. 2007 October; 97(10): 1737-1745. Accessed 10/16/14.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994190/#!po=2.27273

62. A National Health Program: Report of the Technical Committee on Medical Care 1938, Washington, DC: GPO, 1939, p.3; John E. Middleton, “A New Deal for Health,” New Order, August 1938, p.10.

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64. “Report on Examination of the International Workers Order, Inc, by the Insurance Department of the State of New York,” 1950, pp. 143–144, in box 24, Kheel Center for Labor-Management Documentation and Archives, Cornell University Library.; Tempkin E. Contraceptive Equity. Am J Public Health. 2007 October; 97(10): 1737-1745. Accessed 10/16/14.
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65. Sabin, AJ. In Calmer Times: The Supreme Court and Red Monday. Philadelphia: University of Pennsylvania Press. 1999. pp. 212–215.

66. “The Report of the Committee on Contraception of the American Medical Association,” Journal of Contraception 2, no. 6–7, 1937, p.123.

67. Taylor, J. The Rockefeller’s Support of Planned Parenthood. “Our Cause”: Sanger and the Rockefellers. Life Issues. 2001. Accessed 10/16/14. http://www.lifeissues.net/writers/tay/tay_04robthecrad.html

68. Tentler LW. Catholics and Contraception. Ithaca, NY: Cornell University Press. 2004, p.3

69. Margaret Sanger and the Pill. Margaret Sanger Papers Project – Research Annex. November 21, 2012. Accessed 10/16/14. http://sangerpapers.wordpress.com/2012/11/21/margaret-sanger-and-the-pill/

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71. Rhythm Method: Highlights of the Percy Skuy History of Contraception Gallery. Case Western Reserve University. Accessed 10/16/14. http://www.case.edu/affil/skuyhistcontraception/online-2012/Rhythm-method.html

72. Latz LJ. The Rhythm of Sterility and Fertility in Women. Chicago: Latz Foundation. 1939.

73. Pope Pius XI. Casti Connubii. December 31, 1930. Accessed 10/16/14. http://www.vatican.va/holy_father/pius_xi/encyclicals/documents/hf_p-xi_enc_31121930_casti-connubii_en.html

74.Tentler LW. Catholics and Contraception. Ithaca, NY: Cornell University Press. 2004, p.180.

75. “Margaret Sanger is dead at 82; Led campaign for birth control.” New York Times. Sept. 7, 1966. Accessed 10/16/14. http://www.nytimes.com/learning/general/onthisday/bday/0914.html

The Zuckerberg’s Shine a Light on Miscarriage: What Each of Us Can Do.

Posted on | August 8, 2015 | No Comments

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Mike Magee

This past week, Mark Zuckerberg of Facebook fame announced that he and his wife, Priscilla, are expecting a baby. At the same time, he shared this: “We’ve been trying to have a child for a couple of years and have had three miscarriages along the way.”

In doing so, he connected with millions of other parents who have experienced the loss of a child, and the often silent and life-changing aftermath of the experience. What makes the experience doubly painful for so many is the inability of family and friends to properly support couples going through the experience.

Pregnancy can be an exciting and happy time for potential parents. But when something goes wrong and miscarriage is a result, recovery can be difficult. It’s not so much the physical problems as the emotional ones. With about 1 million known miscarriages out of 6 million U.S. pregnancies each year, a startling number of expectant parents are left devastated – without knowing who to turn to or what to think. Even though most miscarriages occur before 13 weeks of pregnancy, it’s normal for the parents to have already established a deep connection to the unborn child. Friends and family members might not be able to fully understand this, so the pain and grief can be very isolating.

The March of Dimes offers this to grieving parents, “It can take a few weeks to a month or more to physically recover from a miscarriage…It may take longer to recover emotionally. You may have strong feelings of grief about the death of your baby. Grief is all the feelings you have when someone close to you dies. You may feel sad, angry, confused or alone. At times, your feelings may seem more than you can handle. You may have trouble concentrating. You may feel guilty about things that happened in your pregnancy. It’s OK for you to take time to grieve, ask your friends for support, and find special ways to remember your baby.”

On top of this, studies have found that women often blame themselves for the failed pregnancy in the immediate months after it occurs. And yet,  in the vast majority of cases, there’s nothing the parents could have done to prevent a miscarriage.

Still, out of 1 million miscarriages, approximately 15% of women suffer clinical depression and 45% experience increased anxiety. Concerns, in the form of questions, include:  Why did the pregnancy fail?  Is it likely to happen again?  How long will I grieve? Are my feelings, and those of my partner, normal?  If not, how do I get help in recovery?  To answer these questions, ACOG advises follow-up visits with a doctor and, at times, referral to a counselor.

In many cases, the grief dissipates within four months, and acceptance soon follows. But it’s important for patients to take as much time as they need to heal emotionally — even though a woman’s body may be ready to conceive again in just a month or two.

If there is any good news here, it’s that “Miscarriage is usually a one-time occurrence. Most women who miscarry go on to have a healthy pregnancy after miscarriage. Less than 5 percent of women have two consecutive miscarriages, and only 1 percent have three or more consecutive miscarriages.”

Many emotions are triggered when a baby is lost through miscarriage, and a culture of silence and misunderstanding can sometimes surround such an event.  Family and friends should educate and prepare themselves. Sometimes it’s hard to know what to say or what to do. In the past, the March of Dimes offered this advice, “While it is very difficult to find the words that might help the grieving family, it is comforting to tell them ‘I’m so sorry for your loss’ or to admit ‘I don’t know what to say.’  Letting a family know ‘I’m here for you’ or ‘I’m praying for you’ is also a help. Even tears are comforting.  Do not make comments like ‘you’ll get over it in time’ or ‘you can always have another baby.’  The parents need to grieve this loss.  Try to be sensitive to their deep loss and the fact that, while time may ease the grief, they will never get over it.”

The Zuckerberg’s sharing this week helps bring transparency to an issue that deserves our support. What can each of us do? Be available, and be ready to listen.  Help with errands and meals.  Acknowledge the baby existed and share the grief.  If parents wish, tell others for them.  And be aware that certain times – such as the baby’s due date or pregnancy loss date, will be sensitive times, marked by sadness and extra need for kindness and support.  Finally, if depression or anxiety visibly persists beyond several months, encourage additional counseling and support.

Around one million American women and their partners suffer a lost pregnancy each year. It’s regrettable that most cases are not preventable. But it’s unconscionable to allow these parents to suffer in isolation and silence, and without adequate support.

For HealthCommentary, I’m Mike Magee.

50Th Anniversary of OAA: Why Feeding Seniors Still Makes Financial Sense.

Posted on | July 31, 2015 | No Comments

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Mike Magee

By now, most of my readers have heard that this is the 50th anniversary of Medicare and Medicaid. But some of you may be unaware that it is also the 50th anniversary of the Older Americans Act. The what?
The Older Americans Act of 1965 was signed by LBJ. Its’ goal was to secure an adequate safety net for older Americans by providing protections for equal opportunity, sufficient income in retirement, the best health services independent of economic status; adequate housing; long term care; civic, cultural, educational and recreational inclusion; self-determination; and appropriate protection against abuse.
Programmatically, this translated into nutrition and community-based services, elder rights programs, the National Family Caregiver Support Program, and health prevention strategies on a local level. In short it acknowledged for the first time that health was profoundly political. The law for the first time defined health as a collection of resources unequally distributed in society. Health’s “social determinants” such as housing, income, and employment, were critical to the accomplishment of individual, family, and community well being and were themselves politically determined. Health was recognized at the time by many throughout the world as a fundamental right; yet it was irreparably intertwined with our economic, social, and political systems.

This important law, targeted at those over 60, spoke to the interconnectedness of health.
As described in this week’s NEJM:

1. “ Nearly 13 million people receive regular OAA services, including meals, caregiver support, personal care, and transportation assistance. “

2. “Currently, more than 40% of OAA funding goes to nutrition services (Meals on Wheels), primarily meals delivered to homes or community centers. In 2014, nearly 140 million home-delivered meals and 90 million congregate meals were served.”

3. “The remaining 60% of OAA funding is spent on health-related services, including home and adult day care, support, and elder-abuse protection.”

4. “Programs are administered by the federal Administration for Community Living and local Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs).”

5. “Recipients of daily meals also reported decreased isolation and worry about living at home. Moreover, 1 year of home delivered meals costs nearly the same as one emergency department visit and less than a 1-week nursing home stay.”

And yet few would be surprised that the funding of OAA is under constant attack. Eight years ago I stated that, “There is a growing political disconnect between those who make health policy and those most affected by health policy. While the former continue to reinforce silos and the status quo, the latter seek broad, fundamental and comprehensive reform. Such reform might include expansion of insurance coverage, realignment of financial incentives toward prevention, increased reimbursement of physicians and nurses for team coordination that includes home health managers, support for early diagnosis and screening, and expansion of education and behavioral modification for individuals and families.”

Properly feeding our elders remains a logical and defensible starting point.

For Health Commentary, I’m Mike Magee.

Retail Medical Clinics – The Disruptive Impact of Walmart

Posted on | July 24, 2015 | 1 Comment

Mike Magee

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Mike Magee

This week’s NEJM article on the expansion of retail clinics in the U.S. begins:

“ In a tumultuous era of change propelled by public health policies and private entrepreneurial activity, the spread of retail clinics offering basic primary care, walk-in visits, extended hours, and lower prices than a doctor’s office or emergency department is unsettling the medical profession, especially family physicians and pediatricians. Most U.S. retail clinics are owned and operated by vast corporate enterprises and staffed by advanced practice nurses and physician assistants. Although relatively few assessments have been conducted of the quality of care in such clinics, some peer-reviewed studies indicate that they deliver their circumscribed set of services at least as well as physicians’ offices do.”

The article is written by the legendary Health Policy guru, John Inglehart, who goes on to lay out the numbers surrounding the new corporate face of the retail clinic business, including the latest CVS and Walgreen figures. He also reveals that Walmart is now jumping in with both feet. As he says, “Within the past year, the corporate giant Walmart announced a new health clinic strategy. Until recently, Walmart had leased space in its superstores to a clinic operator (usually a health system), but it is letting many of these leases expire. In those clinics, nurse practitioners have delivered primary care, and Walmart has contracted with a separate company (QuadMed) to arrange for community-based physicians to provide clinic oversight consistent with state regulations. But recognizing a rapidly evolving health care landscape, Walmart has announced a new model, the “Walmart Care Clinic…”

What Inglehart does not catalogue is the vast number of American corporations that sponsor their own on-site employee health clinics. He does suggest, however, that part of Walmart’s rationale and business model includes providing care to Walmart employees. Employees pay only $4 for basic services, while outside customers pay $40 per visit. It was just a year ago that this massive corporation was being slammed in the media for its low wage scale and poor health benefits. Herein lies an in-house solution at least to the health coverage issue, which by the way, could also be a profit center with customers, and potentially a lower cost solution for other corporations who have been funding their own in-house health centers.

In 2012, I wrote that “retail pharmacy clinics deliver a good product, that ‘virtual minute clinics’ as extension arms of the retail based sites might come to your home in the future, that home care for older chronically ill patients could easily be mixed with well-care like sports physicals or strep cultures for grandchildren at home, that home health care companies should consider themselves to be ‘comprehensive virtual clinical practice’ not a pay for hire service, and that the competition (doctors’ offices and hospitals), provided uneven service if you were able to get an appointment for standard care issues.”

At that time, Christine Cassel from the American Board of Internal Medicine and Thomas Bodenheimer of UCSF had penned articles on the same topic in JAMA and the New England Journal of Medicine respectively. Dr. Bodenheimer opined on how to improve access to primary care, while Dr. Cassel reflected on the expanded use of retail clinics in pharmacy settings to address the need for improved access to care.

Dr. Bodenheimer noted that current wait times in Massachusetts for a primary care appointment were 36 days for family medicine and 48 days for internal medicine. In their words, “The reason for the access problem is an imbalance between demand for care and capacity to provide care…. One answer is for physicians to share care with an empowered health care team….In most primary care practices, non-clinician team members – registered nurses(RN’s), medical assistants, health educators, and others – are not empowered to share the care…The most significant barrier is the discomfort that many physicians feel about giving up decisions regarding preventive and chronic care, which, though seemingly routine, are often complicated by patients’ various coexistent conditions, preferences and goals…Creating teams to share the care is not an end in itself. The purpose of this practice change is to address the national demand-capacity imbalance while enhancing quality and reducing clinician stress and burnout.”

Dr. Cassel’s comments were considerably more direct. She wrote, “Easy access to medical clinics in retail settings is gaining momentum in the United States…For a working person with a sudden onset of febrile illness, the retail clinic provides a solution: the person can be seen quickly the day the problem arises and most often is able to receive a simple and straightforward evaluation and treatment or recommendation to seek specialist care if indicated…the visit would be less than $100 and the pricing would be transparent. In contrast, the same minor problem could cost hundreds of dollars for an emergency department visit…The retail clinic phenomenon could be transformative for a vast number of patients in the United States.”

What was missing three years ago was adequate informational connectivity and flow between retail clinic caregivers and primary care and hospital networks, and expanded ubiquitous presence of retail clinics nationwide.

Walmart might change that.

For Health Commenatary, I’m Mike Magee.

The President Drives the 2015 White House Conference on Aging.

Posted on | July 15, 2015 | 2 Comments

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Mike Magee

If summertime is normally marked by a sleepy Washington news cycle, than 2015 will stand out for many years as a distinct anomaly. Between marriage equality, the trade agreement, the survival of the Affordable Care Act, and now the Iran agreement, it would be very easy to miss other notable events that have occurred.

One such event was the just completed 2015 White House Conference on Aging. By all accounts, the participants saw it as a major success. In addressing the gathering, President Obama set the context in noting that this year marks the 80th anniversary of the passage of Social Security and the 50th anniversary of the passage of Medicare.

Seemingly, everyone was there from Diane Nyad to Ruth Bader Ginsburg, also known, according to the President as “the Notorious R.B.G.”. That label, which drew laughter and applause, was representative of a growing respect and strong embrace of aging Americans who remain active, engaged, and contributory members in a dynamic American society.

The President took the opportunity to speak about the future of Social Security and Medicare. He said that the critics who said that the two programs were “in crisis”, were wrong. Specifically, he said, “Medicare and Social Security are not in crisis, nor have they kept us from cutting our deficits by two-thirds since I took office.  Both programs are facing challenges because of the demographic trends I just talked about.  And for Medicare, that means we’ve got to keep slowing the growth of health care costs, and keep building on the progress we’ve already made in the past few years.”

Speaking quite directly to health providers of all shapes and sizes in the audience, the President tied Medicare and Social Security to his controversial, and increasingly popular, signature health legislation. In his words, “Since I signed the Affordable Care Act — also known as Obamacare — (applause) — since we signed the ACA into law, we’ve extended the life of the Medicare Trust Fund by 13 years.  We’re moving Medicare towards payment models that require quality of care instead of quantity of care as the measure of what you get paid, creating a different set of incentives.  And that’s something that will keep older Americans healthy and Medicare healthy as well.”

As for specifics derived in part from the ACA, he listed these:

1. “We’ve extended the life of the Medicare Trust Fund by 13 years.”

2. “…we’re moving Medicare towards payment models that require quality of care instead of quantity of care as the measure of what you get paid, creating a different set of incentives.”

3. “… this law has saved over 9 million people on Medicare currently more than $15 billion on their prescriptions… Built into the Affordable Care Act, 9 million seniors have gotten significant discounts on their prescription drugs.”

4. “It’s also given nearly 40 million people on Medicare free preventive health services.  And we’ve expanded the options for home- and community-based services offered by Medicaid, which means that more older Americans are able to make the same choice that my grandmother did and live independently.”

In laying out the challenges ahead, and next steps, the President sounded anything but the lame duck. Here are a few of the priorities on his “To-Do” list:

1. Clean up the nation’s retirement plans. The President wants a system that would automatically establish IRA’s for all new workers when they begin employment. He also wants to shed light on the financial industry’s “hidden fees” which explain why so many Americans retirement investments funds never to seem to grow.

2. He wants to reauthorize the Older Americans Act which coordinates aging organizations nationwide and a range of services including nutrition, job training, senior centers, caregiver support, transportation, health promotion, and benefits enrollment. It’s reauthorization ran out in 2011.

3. He wants to push harder for workplace flexibility and family leave provisions especially for family members who are serving as family caregivers.

4. He wants to expand nutritional assistance for seniors living independently.

5. He wants to update nursing home safety and quality measures, and expand prosecution for elder abuse.

In taking the time in a summer schedule that has been jammed with monumental legislative events, the President is acknowledging the critical importance and the realities of aging demographics and aging influence. The recent Gallup-Healthways Well-Being Index noted as much, reporting that those over 55 score higher that those under 55 in the survey, but those over 75 eclipse everyone.

Others have noted why this is likely the case listing contributors like “productive engagement, social connection, healthy diet, exercise/physical fitness, adequate sleep, financial management, spiritual well-being”.

For the President, he emphasized the government’s role, and in the process, his own contributions. As he put it, “So one of the best measures of a country is how it treats its older citizens.  And by that measure, the United States has a lot to be proud of.  Medicare, Medicaid, Social Security are some of our greatest triumphs as a nation.  When Social Security was signed into law, far too many seniors were living in poverty.  When Medicare was created, only a little more than half of all seniors had some form of insurance. Before Medicaid came along, families often had no help paying for nursing home costs. Today, the number of seniors in poverty has fallen dramatically.  Every American over 65 has access to affordable health care.  And, by the way, since the Affordable Care Act was signed into law, the uninsured rate for all Americans has fallen by about one-third.  (Applause.)  Just thought I’d mention that.  (Applause.)”

For Health Commentary, I’m Mike Magee.

Is “Amazing Grace” Mediated Through The Placebo Neurobiologic Effect?

Posted on | July 5, 2015 | 2 Comments

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Mike Magee

This week, Ted Kaptchuk and Franklin Miller published a seminal article in the New England Journal of Medicine titled, “Placebo Effects in Medicine”. I believe it will be remembered for many years, not for its scientific insights, which are considerable, but for its’ theologic, sociologic, and historical revelations, buried deep in its straight forward prose.

You see, the authors’ insights happened to be published within days of President Obama’s Eulogy for Reverend Clementa Pinckney in Charleston, South Carolina, a speech reflecting on the subject of grace – Amazing Grace. And in many ways, I believe Kaptchuk and Miller were covering the same ground as our President. I say this because health, the capacity to reach full human potential, requires a bias toward success, and a commitment to equal justice. And as our President said, “.. justice grows out of recognition of ourselves in each other; that my liberty depends on you being free, too… the path of grace involves an open mind. But more importantly, an open heart.”

In the battle for health, we expect and require that our physicians take on all comers, without bias; that they care for others as they would their own; that they touch and empathize, as they advise and council. Kaptchuk and Miller say, “..medicine’s goal is to heal, which can include cure, control of disease, and symptom relief or provision of comfort. When no cure is available — an inevitable occurrence at some points — medicine’s ultimate mission is to relieve unnecessary suffering. Supportive and attentive health care (preferably with effective medications, but even without) legitimately creates a ‘therapeutic bias’ in patients toward hope and an experience of relief and reprieve.”

The authors say we have minimized and undervalued the human physiology that underlies the placebo effect. They define it as the “improvements in patients’ symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions… This diverse collection of signs and behaviors includes identifiable health care paraphernalia and settings, emotional and cognitive engagement with clinicians, empathic and intimate witnessing, and the laying on of hands.”

They also say that, “Placebo effects rely on complex neurobiologic mechanisms involving neurotransmitters (e.g., endorphins, cannabinoids, and dopamine) and activation of specific, quantifiable, and relevant areas of the brain…”

They ask us to remember three things about the neurobiologic workings we label the “placebo effect”.

1. “ Placebos may provide relief, they rarely cure.”

2. “Placebo effects are not just about dummy pills: the effects of symbols and clinician interactions can dramatically enhance the effectiveness of pharmaceuticals.”

3. “The psychosocial factors that promote therapeutic placebo effects also have the potential to cause adverse consequences, known as nocebo effects. Not infrequently, patients perceive side effects of medications that are actually caused by anticipation of negative effects or heightened attentiveness to normal background discomforts of daily life in the context of a new therapeutic regimen.”

What if you had a doctor who you could say, “… lived by faith, a man who believed in things not seen, a man who believed there were better days ahead off in the distance, a man of service, who persevered knowing full-well he would not receive all those things he was promised, because he believed his efforts would deliver a better life for those who followed…”

What if you were cared for by a health professional of whom was said, “… his graciousness, his smile, his reassuring baritone, his deceptive sense of humor, all qualities that helped him wear so effortlessly a heavy burden of expectation.. wise beyond his years in his speech, in his conduct, in his love, faith and purity.. he never gave up. He stayed true to his convictions. He would not grow discouraged.”

What if you were cared for by a nurse of whom was said, “She conducted himself quietly and kindly and diligently. She encouraged progress not by pushing her ideas alone but by seeking out your ideas, partnering with you to make things happen. She was full of empathy and fellow feeling, able to walk in somebody else’s shoes and see through their eyes.” Suppose that person believed that “Our calling, is not just within the walls of the congregation but the life and community in which our congregation resides.”

What is the placebo effect really, but a bias toward success, toward trust, toward health, toward hope. What if it is grace – the kind of “Amazing Grace” our President highlighted – in action? What if the “nocebo effect” is the expression of an opposite physiologic effect, one fueled by hatred, fear, prejudice, hopelessness?

What should we do with this grace, this placebo effect? The President says that God has “given us the chance where we’ve been lost to find out best selves. We may not have earned this grace with our rancor and complacency and short-sightedness and fear of each other, but we got it all the same. He gave it to us anyway. He’s once more given us grace. But it is up to us now to make the most of it, to receive it with gratitude and to prove ourselves worthy of this gift.”

The medical authors this week emphasized that symbols can ignite both the “placebo effect” and the “nocebo effect”. On this issue, our President was clear.

“For too long, we were blind to the pain that the Confederate Flag stirred into many of our citizens. It’s true a flag did not cause these murders. But as people from all walks of life, Republicans and Democrats, now acknowledge, including Governor Haley, whose recent eloquence on the subject is worthy of praise as we all have to acknowledge, the flag has always represented more than just ancestral pride. For many, black and white, that flag was a reminder of systemic oppression and racial subjugation.”

“We see that now. Removing the flag from this state’s capital would not be an act of political correctness. It would not be an insult to the valor of Confederate soldiers. It would simply be acknowledgement that the cause for which they fought, the cause of slavery, was wrong. The imposition of Jim Crow after the Civil War, the resistance to civil rights for all people was wrong.”

“It would be one step in an honest accounting of America’s history, a modest but meaningful balm for so many unhealed wounds. It would be an expression of the amazing changes that have transformed this state and this country for the better because of the work of so many people of goodwill, people of all races, striving to form a more perfect union. By taking down that flag, we express God’s grace.”

This week’s medical authors say, “…placebo effects can help explain mechanistically how clinicians can be therapeutic agents in the ways they relate to their patients in connection with, and separate from, providing effective treatment interventions.”

But isn’t that the job of all of us? Shouldn’t each of us try to exercise our internal placebo workings, our “Amazing Grace”, by, as the President said, “recognizing our common humanity, by treating every child as important, regardless of the color of their skin or the station into which they were born and to do what’s necessary to make opportunity real for every American. By doing that, we express God’s grace.”

For Health Commentary, I’m Mike Magee.

AMA Relieved

Posted on | June 25, 2015 | 2 Comments

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Steven J. Stack, MD President

“The American Medical Association (AMA) is relieved that today’s Supreme Court decision will allow millions of patients to continue accessing the health care they need and deserve.

“Physicians know that the uninsured live sicker and die younger so the AMA has been a leading voice in support of expanding health insurance access to ensure patients can get the care they require.

“The subsidies upheld today help patients afford health insurance so they can see a doctor when they need one and not have to wait until a small health problem becomes a crisis. The subsidies provide patients with peace of mind that they will not risk bankruptcy should they become seriously ill or injured and experience catastrophic health care costs.

“With this case now behind us, we hope our country can move forward and continue strengthening our nation’s health care system.”

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