Viewpoint

Let’s Not Panic About the Vaccine Commission Just Yet

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                    [post_content] => Many people are concerned about President-elect Trump creating a commission "on vaccine safety and scientific integrity." As someone who spends a lot of time studying child vaccine policy (such as this article in the Millbank Quarterly and this blog post published by NACCHO), I wanted to provide some reasons why I do not think we should panic just yet:

1. Much of child vaccine policy is set at the state level. Want to mandate that children receive the chickenpox vaccine? State governments are responsible for these laws. Want the right to opt out of vaccines due to religious reasons? State governments are responsible for this, too. Want to make sure that every parent of a seventh-grader is informed about the HPV vaccine? You guessed it, state governments again. While creating such a commission (or publicizing the fact that there might be such a commission) could cast doubt on the safety of vaccines, the federal government cannot change these types of laws outright.

2. It's tough to change state child vaccine policies. Even when the now-discredited article claiming the MMR vaccine-autism link came out, there wasn't a bunch of legislation passed to remove vaccine requirements or allow more parents to opt out of vaccines for their kids. Notably, in 2003, Texas (more about Texas later) and Arkansas changed their laws to allow for philosophical exemptions to vaccination. To qualify for a philosophical exemption, parents simply say that they do not believe in vaccination, or question the safety of vaccines, and their child is able to attend school unvaccinated. To be fair, if a couple states do end up changing their laws to allow more philosophical exemptions, it could spell trouble at the local level.
While talk of vaccine safety commissions is concerning to those of us who believe that vaccines are both safe and effective, there is no reason for us to panic just yet.  
3. The feds have turned to panels of experts before to examine vaccine safety. They found no causal link between the MMR vaccine and autism. (Granted, the investigation may be more politically motivated this time). The report referenced above is written for an academic audience and, as such, they bury the lead: "The committee concludes that the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism." A listing of additional independent vaccine reports by the Institute of Medicine is available here. Let's save federal dollars and effort and put them toward other pressing health concerns. Speaking of which... 4. We should be focusing our media and personal attention on other health-related policy issues (ahem, ahem, the ACA). I'll let you know when I'm worried about the state of state vaccine policy, which has been going the other way recently (see for example, laws in Michigan in 2014, and California and Vermont in 2015 that aim to increase vaccination among children). Speaking of which, a Republican lawmaker in Texas has introduced a bill that would require parental education prior to opting out of vaccination. This comes two years after another Republican lawmaker tried to get rid of the philosophical exemption entirely. Without going into too much detail about state politics, it is worth noting that both Republicans (e.g., Michigan and Texas) and Democrats (e.g., California and Vermont) work to promote childhood immunization. 5. While I'm not concerned about the Trump administration changing mandate and exemption laws (recall, these are state-level policies), the administration can exert control in some troubling ways. For example, I would be concerned about the fate of the federal-level Vaccines for Children program. This program provides free vaccines to children whose families can’t afford them. But, it's likely that a repeal and replace of the Affordable Care Act will take precedence over cuts to programs like this (I hope). While talk of vaccine safety commissions is concerning to those of us who believe that vaccines are both safe and effective, there is no reason for us to panic just yet. Featured image: Quinn Dombrowski, Day 354: First Shot, used under CC BY-SA 2.0 license/cropped from the original [post_title] => Let's Not Panic About the Vaccine Commission Just Yet [post_excerpt] => While talk of vaccine safety commissions is concerning to those who believe that vaccines are both safe and effective, here are some reasons not to panic. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => lets-not-panic-vaccine-commission-just-yet [to_ping] => [pinged] => [post_modified] => 2017-08-23 17:44:46 [post_modified_gmt] => 2017-08-23 21:44:46 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=998 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

While talk of vaccine safety commissions is concerning to those who believe that vaccines are both safe and effective, here are some reasons not to panic.

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Viewpoint

Lessons from 1993

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                    [post_content] => President Trump. I am stunned to see these two words side by side on my computer screen. But here we are. Donald Trump's inauguration today opens a dramatic new chapter in the debate over health reform in the United States. I thought we were done fighting over the ACA's existence. In my office at home I have a sign that I kept from being outside the Supreme Court the day King v. Burwell was decided in June 2015. "The ACA is Here to Stay" it reads.

The pendulum on opinions about the law's future quickly shifted last November. After Hillary Clinton lost many people said it was a done deal that the ACA would be repealed. Without question it is still vulnerable, however, [ictt-tweet-inline]I am more optimistic about the ACA's fate than I have been at any time since the morning of November 9th[/ictt-tweet-inline]. Recent history makes it clear just how hard it is to pass major health reform legislation. Yes, the type of reform that Paul Ryan, Mitch McConnell, and Donald Trump are trying to enact is fundamentally different from what Bill Clinton and Barack Obama attempted and so the lessons do not apply exactly. But [ictt-tweet-inline]the current reform debate feels more like the failed effort in 1993/1994 than the successful one in 2009/2010[/ictt-tweet-inline].
I am more optimistic about the ACA's fate than I have been at any time since the morning of November 9th  

Health Reform is Inevitable?

When Democrats took control of all three branches of government in 1993 there was a widespread desire to pass comprehensive health reform. This was the moment. Health reform was inevitable. Yet while there was consensus on a desire to pass health reform, there was no consensus on what type of reform to pass. Democrats couldn't decide whether to push for a single payer system or something more moderate. They considered using reconciliation but Senator Byrd said no. Their lack of consensus created a vacuum that opponents used to own the messaging. As a result, the Clintons' reform went nowhere, dying without a vote on the floor of either chamber. Republicans right now agree they want reform. They believe it is OK to fight over the details because repeal is inevitable. But they are far from a consensus on what to replace the ACA with once it is repealed. They have tried to get around this by delaying the date that repeal would go into effect and focusing primarily on what they can remove through reconciliation. This process lowers the vote threshold in the Senate from 60 votes to 51. However, even this is a very tough bar to clear with almost no room for a single defection. A handful of Senators have recently made it clear that they believe it would be a mistake to repeal the law without replacing it, raising questions about whether reconciliation is even feasible. Some have argued that enough Democrats will vote with Republicans on a replacement bill in order to mitigate the damage done by repealing the law. However, that does not seem to be the case. Democrats seem to have learned from the successful efforts by Republicans in 1993 and 2009 by uniting against the party in charge. [caption id="attachment_986" align="alignright" width="338"] Image taken by author outside Supreme Court on June 25, 2015[/caption]

Letting Congress Lead

One way this moment feels very different from 1993 is that the policy agenda is not being driven by the White House. Trump is criticized for saying he will leave the policy details of health reform to Congress. To some extent this is out of necessity - I don't think he really understands the policy details. Even so, he is putting in place a health policy team of Tom Price and Seema Verma that do understand the ACA. I suspect we will see a lot more policy details from the Trump administration once Tom Price and Seema Verma are confirmed. But letting Congress lead the conversation is actually smart politics. One of the main lessons from 1993 was that Clinton should have more fully respected the role of Congress in shaping policy. Committee leadership in the House and Senate were not interested in rubber-stamping a White House bill. Some accused the Obama administration of over-learning this lesson and being too distant, but letting Congress drive the process was an important reason the ACA passed. [ictt-tweet-inline]Republicans in Congress do not seem to have learned a couple major lessons from 1993 and 2009[/ictt-tweet-inline]. Most importantly, the clock is ticking and compromise gets harder with time, not easier. The Trump administration will soon have to produce a budget. The midterm elections will come sooner than seems possible. Long delays in the legislative process give an opening to opponents to attack. [ictt-tweet-inline]It might already be too late for Republicans to come to a meaningful consensus[/ictt-tweet-inline]. House Democrats in 2009 made an unprecedented move by writing a single bill for all three major health reform committees. It's true that this bill was not introduced until July 2009 and so it might seem like Republicans still have many months to get to this point. But remember that leading Democrats had actually spent most of 2008 working through issues, before even knowing whether the next president would be Barack Obama or John McCain. Paul Ryan seemed to want to do the same thing last summer with "A Better Way," but there was reportedly enough infighting over this that the blueprints are not detailed enough to provide much of a road map. It is still far too early to know how this will play out. Republicans are under enormous pressure to do something. But they are finding that being in a position to deliver on threats is very different from being in the minority when you can promise just about anything knowing it won't happen. Donald Trump is the wild card in this process. Politics has never seen anyone quite like him and he has already shown he can change national (and international) dynamics with a Tweet. He has encouraged Congress to act quickly and to pass something that makes insurance available to everyone. I am not convinced either is possible. In fact, the two might be mutually exclusive. Featured Image: DVIDSHUB, Marines support 57th Presidential Inauguration, used under CC BY license, cropped from original. Audience members wave flags from the National Mall during the 57th Presidential Inauguration in Washington, Jan. 21, 2013. More than 700 thousand people made their way to the National Mall for the day's events. For centuries, Marines and other service members have supported the inaugural events. U.S. Marine Corps photo by Staff Sgt. Mark Fayloga. [post_title] => Lessons from 1993 [post_excerpt] => I am more optimistic about the ACA's fate than at any time since November 9th. The current fight feels more like 1993 when Clinton failed than 2009 when Obama succeeded. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => lessons-from-1993 [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:49:03 [post_modified_gmt] => 2017-08-27 03:49:03 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=982 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

I am more optimistic about the ACA’s fate than at any time since November 9th. The current fight feels more like 1993 when Clinton failed than 2009 when Obama succeeded.

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Viewpoint

Put People and Prevention Ahead of Politics

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                    [post_content] => We're pleased to publish the winning essay in PHP's first essay contest "Dear Paul Ryan..."   Congratulations and thank you to all the students who submitted essays! Here are links to our Tuesday and Wednesday finalists.

Dear Mr. Speaker,

You and the new administration could largely dismantle the ACA by eliminating the individual mandate and subsidies through budget reconciliation. However, that pesky saying comes to mind, “be careful what you wish for.” The uncertainty of delayed repeal without a clear plan for replacement could prematurely collapse the insurance exchanges and leave the Republican-controlled Congress in crisis. As you mention in “A Better Way,” “people must come first” and we need to work towards a system that provides “high-quality health care for all.” Health reform often focuses on the decision making of individuals – patients and their doctors – and rightfully so. We try to elicit efficient consumption of health care from patients by balancing “skin in the game” with the long-run costs of foregone care. However, we have known for decades that patients are not good at differentiating between medically effective and low-value care with more recent evidence that increased cost-sharing can actually reduce utilization of clinically important services. We develop new payment models to address the supplier side incentives to increase utilization and hope that these mechanisms combine to yield more efficient use of care. Though accountable care organizations have gained traction as a new form of managed care, promising signs of reductions in low-value care in Medicare have not translated over to a more diverse Medicaid population. We also peg Medicare reimbursements to 30-day readmission rates that may be a flawed measure of quality of care–but perhaps correctable. There isn’t a silver bullet that will ‘fix’ health care spending. Greater price transparency would be great for consumers – in theory – if savings were substantial (not so far) and records from an MRI or blood tests could be instantly transferred from the low-cost provider to your preferred physician (but their EHRs probably can’t talk to each other). So what should we do? I would argue that all of this is important work given that even a half or one percent change in total health care spending is still billions of dollars. That said, it is only window dressing. We need to focus on the underlying causes of poor health and to do this, we must focus on public health.
Health insurance, no matter how well designed, cannot improve population health and create massive reductions in health care spending.  
A healthy population is critical to unleashing our innovative capacity and creating robust economic growth. Health insurance, no matter how well designed, cannot improve population health and create massive reductions in health care spending. Racial disparities in health care are associated with over $200 billion per year in economic losses through lost productivity and premature death, not including another $35 billion per year in excess health care spending. And that ignores the psychological toll on millions of Americans and their families. These disparities have evolved from the social determinants of health, including education, income, housing, and neighborhoods, which play a huge role in determining health outcomes. The fact that two children born a few Metro stops apart can have an 8 year difference in life expectancy doesn’t resonate with the vision of equal opportunity and social mobility that America is supposed to represent. So again, what do we do? Public health is about much more than infectious disease–it is about identifying the root causes and improving health through any means necessary. For example, CDC developed a hard-hitting media campaign that encouraged 100,000 smokers to quit at a cost of less than $500 per quitter in just its first year [Disclosure: I am part of the evaluation team at RTI International for this campaign.] Twenty-four cities in Missouri banded together to rebuild their community by thinking holistically, the Columbia Gorge region of Oregon improved food security and gave its residents a voice in the structure of Medicaid spending, and so on. There are dozens of stories like this around the country but sadly not enough.
Make the Prevention and Public Health Fund, currently part of the ACA, permanent and fully funded through standalone legislation.  
If we want to truly make a difference, here is a simple way to start. Make the Prevention and Public Health Fund, currently part of the ACA, permanent and fully funded through standalone legislation. We spend 75 percent of our health care dollars on preventable disease but only three percent on prevention. If we want to make a dent in spending, we need to focus on prevention (not just preventive services) and really mean it–by taking it farther from the political arena. This is only a first step. Building a Culture of Health will require bold action on housing, education, and other social determinants of health. However, before we can go there, we all need to agree that health is a shared value and understand how the social determinants of health shape our lives – only then can we begin to reshape federal policy and the budget to address health care spending. We both want what is best for America – taking this small step forward together and making public health a non-partisan issue is a smart investment in our future. Featured Image: U.S. Department of AgricultureUSDA Photo by Lance Cheung. Students saw, touched and sometimes tasted produce that was new to them at Nottingham Elementary School in Arlington, VA, on Wednesday, October 12, 2011. Farmers from Bigg Riggs Farm in Hampshire County, WV, and Maple Avenue Market Farm in Vienna, VA were very popular with the students. Today's menu included roasted chicken, roasted butternut squash with dried cranberries, farm fresh mixed lettuce salad, turkey wraps, pita wedges, hot muffins, carrots, Asian pears and more. Used under CC BY 2.0 license/cropped from the original [post_title] => Put People and Prevention Ahead of Politics [post_excerpt] => We're pleased to publish the winning essay in PHP's first essay contest "Dear Paul Ryan..." Congratulations and thank you to all the students who submitted essays! [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => put-people-and-prevention-ahead-of-politics [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:44:18 [post_modified_gmt] => 2017-08-27 03:44:18 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=938 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

We’re pleased to publish the winning essay in PHP’s first essay contest “Dear Paul Ryan…” Congratulations and thank you to all the students who submitted essays!

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Making a Case for a Public Option

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                    [post_content] => We're pleased to publish the second of two finalists in PHP's first essay contest "Dear Paul Ryan..."  Read our other finalist here. The winning essay will be published tomorrow (Thursday, January 18, 2017).

Dear Mr. Speaker,

I believe in the ability of public health initiatives to improve the lives of individual Americans as well as the country as a whole. Public health focuses on population health and preventative measures that improve health. Historical public health movements have resulted in providing clean water, creating sewage systems, and improving unsafe housing conditions in order to prevent epidemics such as typhoid, yellow fever, and cholera. Individuals are not equipped to deal with these systemic issues, thus the government must step in to provide the needed interventions. I ask you to prioritize public health as the Speaker of the House in order to ensure better access to health care, lower health care costs, and to improve both health and economic outcomes. The United States spends the most on health care per capita in the world but Americans often have worse health outcomes than individuals in the other countries. In 2015, the United States spent 16.9% of its GDP on all health expenditures. Switzerland, the Organization for Economic Co-operation and Development (OECD) country that has the second highest percentage, spent only 11.5% of its GDP that year. This number may be justifiable if the United States had the best health outcomes, but unfortunately we do not. Life expectancy at birth in the United States ranks 26th out of 38 OECD countries and the infant mortality rate in the United States is higher than the OECD average. If we are spending more, we should be getting more.
Keeping the Patient Protection and Affordable Care Act (ACA) is the most pressing way at the moment our federal government can promote public health.  
Many poor health outcomes are a result of social determinants of health and people not receiving the care they need.  Low socioeconomic status often means higher disease rates and premature death due in part to inadequate access to health care. It is morally wrong to deny people equal access to living a quality life, and it is also bad for society. Sick people are not able to give back as much as healthy people. A recent NBER working paper shows that children who were eligible for Medicaid at an earlier age had lower mortality and disability rates as adults, earned more income, and reduced overall governmental spending because of increased tax contributions and decreased benefit payments. Health and productivity are intertwined, thus better health for individuals provides a more stable bottom line for America. Keeping the Patient Protection and Affordable Care Act (ACA) is the most pressing way at the moment our federal government can promote public health. The ACA has successfully achieved its goal of providing greater access to health insurance. Twenty million more Americans are now more likely to get the care they need without suffering dire financial consequences. I realize the ACA is incredibly unpopular with you, despite its successes, but I urge you to reconsider your position on repealing and delaying. A report by the Urban Institute lists the disastrous ramifications of partially repealing the ACA, stating that uninsurance rates and health care costs would be even higher than before the ACA.
It is morally wrong to deny people equal access to living a quality life, and it is also bad for society.  
If the individual mandate is eliminated, whether through a full repeal or a budget reconciliation bill, healthy people will be less likely to sign up for insurance and premiums would continue to rise. If subsidies are also reduced, people will be unable to afford insurance on the exchange, meaning that the ACA will be effectively destroyed. I would like to propose a different option. You’ve heard this before but I would like for you to consider it and its benefits: the government-run public insurance option. I ask you to reconsider because the ACA and the public option have more support than you may think and providing a public option will mean that more people can stay insured and receive the preventative care they need. Republicans are backpedaling on their desire to repeal the ACA in its entirety and polls show that more Americans want to expand or keep the law as is compared to repealing or limiting the reach of the law. Similarly, more Americans are in support of a public option plan than not, and the majority of physicians support having a public option. Repealing parts of the ACA has already been shown to be unpopular, and maybe even impossible. The newly elected Governor of Kentucky ran his campaign on the promise of undoing Medicaid expansion in the state. When he got into office, he was unable to take the insurance away from 425,000 individuals and switched his goal to reforming instead of repealing. I realize people do not expect Republicans to consider this proposal and therefore look for other, and I argue more complicated, ways to improve the ACA. But I think this is the right thing to do and it should be considered. A public option would address some of the problems of the ACA, including private insurers leaving the market place since it would serve as an option in marketplaces where there are no other options. Since the government does not need to make a profit, it should provide an insurance option that is lower-cost that provides higher quality. It could be budget neutral if it served as a place for people to pool their premiums. Also the government could set its payments to providers lower as it does for Medicare and Medicaid, thus lowering health care costs. Perhaps the best way to do this is through Medicaid managed-care plans as suggested recently by Michael Sparer in New England Journal of Medicine, but either way, there must be a government-run option in the ACA marketplace in order to improve the health care system in the United States. Featured Image: LaDawna Howard#protectthelaw Rally in support of the Affordable Care Act in front of the US Supreme Court in Washington DC, can be reused under CC BY 2.0 license [post_title] => Making a Case for a Public Option [post_excerpt] => The second of three essays chosen in PHP’s first essay contest “Dear Paul Ryan…” [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => making-a-case-for-a-public-option [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:46:39 [post_modified_gmt] => 2017-08-27 03:46:39 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=923 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The second of three essays chosen in PHP’s first essay contest “Dear Paul Ryan…”

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Viewpoint

US Public Health Emergencies: Maternal Mortality and Gun Violence

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                    [post_content] => We're pleased to publish the first of two finalists in PHP's first essay contest "Dear Paul Ryan..." Read our second finalist here. The winning essay will be published on Thursday, January 18, 2017.

Dear Mr. Speaker,

As a student of health policy, I urge you to make public health a chief priority as you consider new health reform legislation in 2017. Your own bill in 2009, The Patients' Choice Act, emphasized the importance of public health, with the first section devoted to “Preventing Disease and Promoting Healthy Lifestyles.” I strongly agree that to restrain health care costs and improve quality of life for Americans, "investments in public health and disease prevention" are of the utmost importance. As a country, the United States spends about three trillion dollars each year on health care. Discussion of this figure often concerns strategies to reduce health care expenditures, yet rarely addresses why the US has poorer health outcomes than other developed nations. Public health is intrinsically linked to individual health and health care, and as such must be prioritized in order to improve overall health and to reduce U.S. health care expenditures in the long run. Historically, national public health initiatives like mass vaccination campaigns and the enforcement of seat belt laws have saved the lives of millions of Americans. Of particular importance, the United States faces two public health emergencies that require the government's immediate attention: maternal mortality and gun violence.
...maternal mortality is one of the principal markers of a nation's health and the foremost indicator by which public health and human rights are assessed.  
Despite the fact that the United States spends more on health care than any other country, it ranks 50th in the world for maternal mortality. In 2013, the US pregnancy-related mortality ratio, or maternal mortality rate, was 17.3 deaths per 100,000 live births. Significant racial disparities in US maternal mortality rates exist; pregnancy-related mortality ratios were 12.1, 40.4, and 16.4 for white women, black women, and women of other races respectively. Examination of these differences is critical to understanding their cause and in devising maternal mortality prevention efforts. In conjunction with life expectancy and infant mortality, maternal mortality is one of the principal markers of a nation's health and the foremost indicator by which public health and human rights are assessed. The US must make maternal health a national priority, and can reduce the maternal mortality rate through comprehensive public health initiatives. According to the American Public Health Association (APHA), health risks for pregnant women are amplified by unmanaged chronic conditions such as diabetes, obesity, and hypertension. A successful way to improve maternal health and reduce maternal mortality is therefore to increase access to contraceptives, reproductive health services and family planning to ensure that pregnancies are intended and well planned. This strategy is also cost effective; for every dollar spent on family planning, a government can save up to 6 dollars in future expenditures. To prevent pregnancy-related complications and deaths, maternal mortality surveillance and identification must be strengthened. The federal government should mandate that all states adopt the US standard birth and death certificates, including five CDC-recommended checkboxes that indicate whether a woman was pregnant at the time of death or at any time during the year preceding death. Ideally, funding to state governments would increase with the goal of establishing maternal mortality review boards. As Speaker of the House, you have the power to support and pass legislation that will reduce maternal mortality by improving data collection and implementing performance measures, and by increasing funding and coordination of maternity care at the Department of Health and Human Services as recommended by the APHA.
The United States faces a second, more polarizing public health emergency: gun violence.  
The United States faces a second, more polarizing public health emergency: gun violence. According to the CDC, there were over 30,000 US firearm deaths in 2014. Americans are 10 times more likely to be killed by a gun than people of other developed countries. In comparing the US to 22 other high-income nations, our gun-related murder rate is 25 times higher. The American Medical Association, the largest association of physicians and medical students in the country, recently joined the American College of Physicians in calling U.S. gun violence a "public health crisis." The United States cannot wait for another mass shooting, or for another toddler to accidentally shoot and kill his sibling, before taking action. Gun control measures, including comprehensive background checks and waiting periods for all firearm purchases, must be implemented. To obtain an epidemiological analysis of gun violence and understand how to prevent gun injury and death, Congress must overturn the ban preventing the CDC from using federal dollars for gun violence research and from advocating gun control. That the foremost federal agency dedicated to improving the health of US citizens is hindered in investigating a gun violence epidemic unrivaled in any other developed country, because of NRA lobbying and a Republican-controlled Congress, is reprehensible. Though in the past you have fought against gun control agendas promoted by the Obama administration and lobbyist groups, and were given an "A+" rating by the NRA for the 2016 election, I strongly urge you to view gun violence as a public health issue rather than a political one as you move forward with health legislation in 2017. In conclusion, it is time for the country that calls itself the greatest on earth to have the greatest health care system, and a bipartisan public health focus is crucial if we are to make headway. It is your responsibility as a congressional leader and respected political figure to take direct political and legislative action to reduce the US maternal mortality and gun death rates. These two particular issues are by no means the only public health issues in the United States that need consideration and reform, but they demand immediate attention. Ignoring these exigent public health emergencies would be detrimental to the economy and to the American people. Featured image: Martin FreySculpture NON VIOLENCE, Knotted Gun, used under CC BY-NC-ND 2.0 license/cropped from original [post_title] => US Public Health Emergencies: Maternal Mortality and Gun Violence [post_excerpt] => The first of three essays chosen in PHP’s first essay contest “Dear Paul Ryan…” [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => u-s-public-health-emergencies-maternal-mortality-gun-violence [to_ping] => [pinged] => [post_modified] => 2018-06-07 07:24:02 [post_modified_gmt] => 2018-06-07 11:24:02 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=939 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The first of three essays chosen in PHP’s first essay contest “Dear Paul Ryan…”

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Reproductive Justice: What It Means and Why It Matters (Now, More Than Ever)

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                    [post_content] => “What is reproductive justice?”  This is almost always the first question we are asked when describing the Black Women’s Health Imperative’s work in reproductive justice and sexual health. Oftentimes, people think the term reproductive justice is synonymous with reproductive rights. However, the two are distinctly and philosophically different.

Reproductive rights are centered around the legal right to access reproductive health care services like abortion and birth control. The Supreme Court’s decision in Roe v. Wade represented a watershed moment that cemented a woman’s right to choose whether to have an abortion or not. But we are now facing a time when women’s reproductive rights are under coordinated, unrelenting and mainstream attacks, and we need to consider new and more nuanced ways of tackling these threats.

What good is a right if you cannot access the services that right has provided? This is why reproductive justice is critical. Reproductive justice links reproductive rights with the social, political and economic inequalities that affect a woman’s ability to access reproductive health care services. Core components of reproductive justice include equal access to safe abortion, affordable contraceptives and comprehensive sex education, as well as freedom from sexual violence.

[ictt-tweet-inline]It’s not enough that abortion is legal in your state. Access is key.[/ictt-tweet-inline] If you are working multiple jobs to pay household bills, how can you afford to take the time off to visit a clinic and make use of their abortion services? And if you live in a state that doesn’t have any clinics offering the reproductive services you need, such as birth control, how do you find the means to travel across state lines to access those services? These are questions more and more women are facing as policies that restrict or hinder access to reproductive health care surface. And it’s important to note that these policies are no longer constrained to traditionally marginalized communities.
As the attacks to reproductive rights and justice continue to grow, it’s more important than ever to build and strengthen a new generation of young Black women who will fight for unrestricted access to comprehensive reproductive health care.  
These questions frame the work that we do at the Black Women’s Health Imperative, the only national organization solely dedicated to improving the health and wellness of the nation’s 21 million Black women and girls — physically, emotionally and financially. One of our signature programs is My Sister’s Keeper (MSK), an advocacy and leadership-building initiative for young women attending Historically Black Colleges and Universities. The program is designed to strengthen, engage and mobilize young Black women around reproductive justice and sexual health, as well as sexual violence prevention. As the attacks to reproductive rights and justice continue to grow, it’s more important than ever to build and strengthen a new generation of young Black women who will fight for unrestricted access to comprehensive reproductive health care. To further our work in MSK and the fight for reproductive justice, we are taking steps to ensure policymakers adopt policies that grant and protect a woman’s right to make reproductive decisions that are best suited for her life. These policies include repealing the Hyde Amendment and other anti-abortion laws, like 20-week abortion bans, that essentially penalize low-income women and women of color and prevent them from accessing safe abortion care. We also support policies that ensure unrestricted access to contraceptive services such as the Affordable Care Act’s birth control coverage requirement, and we continue to call on policymakers to do the same. Everyone stands to benefit from understanding and joining the reproductive justice movement. We are at a moment in time where it would behoove traditional reproductive rights organizations to tap into the rich history, strength and resilience of this movement. By partnering, reproductive rights and reproductive justice organizations can collectively tackle some of the broadest threats to women’s reproductive health we have faced in a generation. Featured Image: LeslieOrgans, used under CC BY-NC-SA 2.0/cropped from the original [post_title] => Reproductive Justice: What It Means and Why It Matters (Now, More Than Ever) [post_excerpt] => People may think reproductive justice is synonymous with reproductive rights, but the two are distinctly and philosophically different. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => reproductive-justice [to_ping] => [pinged] => [post_modified] => 2017-08-22 18:05:59 [post_modified_gmt] => 2017-08-22 22:05:59 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=875 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

People may think reproductive justice is synonymous with reproductive rights, but the two are distinctly and philosophically different.

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Accelerating 21st Century Cures

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                    [post_content] => On December 13, 2016, President Barack Obama signed into law a 996-page piece of legislation that will accelerate the discovery, development, and delivery of life-saving and life-improving therapies. This new law, commonly referred to as 21st Century Cures, will have real and positive impact not just for the life sciences supercluster in Massachusetts, but also for patients around the world.

Medical breakthroughs come when life sciences companies license basic research from academic institutions, invest hundreds of millions of dollars in clinical research on safety and efficacy, work for years with the FDA to meet strict standards for regulatory approval and build the infrastructure to manufacture and distribute that breakthrough out to patients around the world. This is a process that takes too long and costs too much when patients are waiting.

Provisions in the 21st Century Cures Act will break down barriers to collaboration in research, provide funding for important research initiatives including the Cancer Moonshot and the Precision Medicine Initiative, and strengthen the FDA’s ability to engage with patients throughout the regulatory process.

The law will:

Provide the NIH with $4.8 billion in new funding that is fully offset. These dollars advance the Precision Medicine Initiative to drive research into the genetic, lifestyle and environmental variations of disease ($1.5 billion); bolster Vice President Biden’s "Cancer Moonshot” to speed research ($1.8 billion); and invest in the BRAIN initiative to improve our understanding of diseases like Alzheimer's. Dozens of Massachusetts’ research institutions and innovative companies are already engaged with these forward-thinking initiatives and this renewed commitment means they can continue the important research they’ve begun.

Provide the FDA with $500 million for regulatory modernization and give the agency the ability to recruit and retain the best and brightest scientists, doctors, and engineers. The FDA is currently limited in how quickly and efficiently it can review drug applications because of troubles staffing the agency. More resources for FDA means treatments can come to market faster.

Streamline regulations and provide more clarity and consistency for innovators developing health software and mobile medical apps, combination products, vaccines, and regenerative medicine therapies. Massachusetts is at the forefront of science and the growing field of digital health, and these regulatory improvements will allow our companies and institutions to keep pushing the boundaries of technology to improve human health.

Modernize clinical trials. The clinical trials process is the longest and most expensive piece of bringing a drug to market. Provisions in the law require FDA to issue guidance documents that would help companies use more nimble adaptive designs and new statistical modeling in order to make clinical trials more efficient and effective.

Put patients at the heart of the regulatory review process. The law requires the FDA to issue guidance regarding how to collect patient experience data and how it will be will use that data when evaluating the risks and benefits of a drug. These sections go a long way in clarifying and formalizing a trend of patients and patient organizations engaging in the drug discovery and development process, and ensure the FDA can take into account preferences, viewpoints and experiences from patients themselves. [Check out the work FDA did on a Voice of the Patient initiative.]

Science today is moving increasingly fast, powered by new technologies and the passionate participation of patients in the R&D process. Our policies and regulations have not had time to catch up. MassBio and its members were proud to support this carefully crafted, bipartisan bill, and we look forward to taking advantage of the opportunities it contains.

Read more about 21st Century Cures  |   Learn more about MassBio 
                    [post_title] => Accelerating 21st Century Cures
                    [post_excerpt] => Robert K. Coughlin of MassBio on why a new law, commonly referred to as 21st Century Cures, will have real and positive impact. 
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Robert K. Coughlin of MassBio on why a new law, commonly referred to as 21st Century Cures, will have real and positive impact.

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Happy Holidays from PHP!

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                    [post_content] => The last two months have been incredibly exciting for us. We quietly launched PHP on October 29th and have since published a new article every weekday. We are thrilled to have contributions from leading policymakers such as former Kentucky Governor Steve Beshear on the ACA's future and Massachusetts State Senator Jason Lewis on marijuana legalization. We have also featured important scholarship by senior researchers such as Gene Declercq on maternal mortality and Gail Dines on pornography, as well as junior scholars such as Rick Sadler on Flint and Dennis Wendt on Native American health. I have loved our profiles of cool people doing important work, such as Chrysula Winegar and Saran Verbiest.

I am most proud of our three fantastic graduate students serving as the first cohort of Public Health Post fellows. Working with Jonathan Gang, Nicholas Diamond, and Maggie Thomas has been one of the best parts of my PHP experience. I am also particularly grateful for Project Manager Melissa Davenport who skillfully makes everything run smoothly. Thank you Melissa!
We also can’t wait to determine the winners of our first student essay contest. Remember that the deadline for a submission is January 2nd.  
We are taking a break for the holidays but are excited about our plans for 2017. We have more profiles lined up with interesting people and will continue to highlight important public health issues, always with an eye to how we can advance the conversation. We also can't wait to determine the winners of our first student essay contest. Remember that the deadline for a submission is January 2nd. [ictt-tweet-inline]Students at any level and from any type of program are eligible[/ictt-tweet-inline]. Three finalists will have their posts published on PHP and the winner will receive $250. Full submission details are available here. Thank you for reading Public Health Post. Happy holidays and see you in 2017! [post_title] => Happy Holidays from PHP! [post_excerpt] => Thank you for reading Public Health Post. We're excited about our plans for 2017, we'll continue to highlight important public health issues, always with an eye to how we can advance the conversation. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => happy-holidays-php [to_ping] => [pinged] => [post_modified] => 2017-01-29 17:58:10 [post_modified_gmt] => 2017-01-29 22:58:10 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=837 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Thank you for reading Public Health Post. We’re excited about our plans for 2017, we’ll continue to highlight important public health issues, always with an eye to how we can advance the conversation.

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Understanding the US Maternal Mortality Problem

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                    [post_content] => The headlines have been frightening. “Maternal Mortality Rate in U.S. Rises, Defying Global Trend, Study Finds,”(New York Times) “Why U.S. Women Still Die During Childbirth” (Time) and “U.S. Death Rate in Pregnancy, Childbirth Raises ‘Great Concern’” (CBS News).  In the increasingly fact-free debate over policy is this just another example of fake news or hyperbolizing of a small finding into a major crisis? As one of the authors of the paper that prompted these articles, I can assure you the problem of maternal mortality is real. Unfortunately for those who like simple solutions, the nature of the problem is complex and resolving it involves the kind of public health prevention efforts that will likely be under attack in the near future. First, some background.

[ictt-tweet-inline]The U.S. has ranked behind most industrialized countries on maternal mortality for years,[/ictt-tweet-inline] but the U.S. stopped publishing an official maternal mortality ratio in 2007. It was this failure of the U.S. to publish a maternal mortality ratio that was the impetus for our study.

Was the reason no ratio had been published an attempt to hide the U.S.’ poor performance? That conspiracy theory might be attractive to those who distrust everything the government does – and there are apparently 62+ million of those folks around at the moment. Unfortunately for conspiracy buffs, the answer is pretty mundane and reflects not an attempt to hide facts, but rather to better identify maternal deaths.

The public image of maternal mortality is a death that occurs unexpectedly during labor, as in the death of a beloved character on Downton Abbey. In fact the official measure of maternal mortality involves a death in pregnancy, labor or up to 42 days after the pregnancy ends for a pregnancy related reason. It was the difficulty in identifying the cases during pregnancy and after the birth that had public health officials concerned and led to a reform. In a revision to the U.S. Standard Certificate of Death, states were requested to include a checkbox on death certificates that identified if a deceased female had been pregnant at the time of her death or up to a year after her death.

It was hoped this revision would accurately identify more maternal deaths, but states didn’t uniformly adopt the 2003 change.  A few added the checkbox each year and by 2007, 24 states and D.C. had the standard checkbox, 12 had their own version of the checkbox and 15 didn’t have it at all.  The result was the inability to come up with a national ratio since states with the checkbox were finding almost twice as many cases as those without and rather than publish an inaccurate national rate, the National Center for Health Statistics ceased publishing a rate in 2007. This meant that the U.S. couldn’t be compared to other countries on maternal mortality except for those using algorithms applied internationally.
...even the most conservative assumptions we used resulted in the U.S. ranking far behind the rest of the industrialized world...  
That’s where we came in. We took the data for each state and modeled the effect of adding the checkbox to a state’s reporting and estimated a national ratio of 23 per 100,000 births. That ratio would place the U.S. 30th among 31 countries in the Organization for Economic and Cooperative Development (only Mexico fared worse). Is our estimate a precise measure of maternal mortality in the U.S.? No, that’s why we call it an estimate. There is some evidence that the addition of the checkbox may have led to some overcounting and we’re exploring that issue, but even the most conservative assumptions we used resulted in the U.S. ranking far behind the rest of the industrialized world. There are three excuses regularly used for the poor performance of the U.S. in international comparisons. The first is that we are a more diverse population than European countries and, since non-whites have worse health outcomes, the problem is demographic, not a problem with the health system. Aside from the potential for implicit racism of that charge, that claim is undermined by the fact that the maternal mortality ratio is actually lower for Hispanic mothers in the U.S. than non-Hispanic whites.  Also, while maternal mortality for non-Hispanic black mothers is about 3 times higher than that for whites, comparing outcomes for only white mothers to other country’s overall rates, we find the U.S. still ranks near the bottom. Second, there’s a contention that the U.S. is simply doing a better job at identifying cases than other countries, but the countries we are compared to are also wealthy countries with excellent surveillance systems. Finally there is the tendency to blame mothers themselves. They’re having babies at older ages, are more likely to be obese and generally not as healthy. However, the point of an accessible, effective public health system is to take population differences into account and develop community prevention programs as well as gleaming hospitals. It will only be when we treat women’s health throughout the lifecourse as valuable in and of itself, rather than being important only as preparation for a healthy baby, will U.S. maternal mortality decline. Featured Image: Greg ScalesMother, used under CC BY 2.0 [post_title] => Understanding the US Maternal Mortality Problem [post_excerpt] => The U.S. has ranked behind most industrialized countries on maternal mortality for years, but stopped publishing an official maternal mortality ratio in 2007. It was this failure that was the impetus for our study. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => understanding-us-maternal-mortality-problem [to_ping] => [pinged] => [post_modified] => 2017-10-16 16:14:13 [post_modified_gmt] => 2017-10-16 20:14:13 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=808 [menu_order] => 0 [post_type] => bu_viewpoint [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The U.S. has ranked behind most industrialized countries on maternal mortality for years, but stopped publishing an official maternal mortality ratio in 2007. It was this failure that was the impetus for our study.

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Judge not.

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                    [post_content] => I was in a delivery room in rural Haiti and a mother of four young children was hemorrhaging on the bed in front of me. Her older sister, a mother of three well beyond her young years, had ensured that she arrived at this clinic supported by the NGO that I founded and currently run, Circle of Health International (COHI). This young mother, a few breaths from death, had used a stick to abort her seventh pregnancy. She did not want another child; her family could not afford another child. The Haitian midwives caring for her have a tough line to tow: they work in a maternity clinic supported mostly by anti-choice Christian churches in America. They encounter thousands of American tourists each year who come to pray over the women they care for, offering too much judgement and not enough autonomy. These smart, capable, professional midwives want to offer what is truly needed: family planning and a space where women can freely, without judgement, get the care that they are asking for: help in spacing and timing their pregnancies according to their own wants and needs.

My job as a public health professional, as a midwife, and as a human, is to do no harm to those that ask for health care. My job is to get every woman, every child, the care they need to determine their own destiny, their own path. [ictt-tweet-inline]My job is not to judge, but to support and provide quality, accessible healthcare to keep mothers and children safe[/ictt-tweet-inline]. Because a donor like COHI is on the scene at this maternity clinic, the Haitian midwives can offer oral contraception to the women who deliver here. But, they must do so quietly, so as not to upset the other donors who may not be in support of birth control. Abortions happen, not here at this clinic, but elsewhere in Haiti as they do everywhere. These kinds of abortions are dangerous and there is a tremendous stigma.

This is the messy daily reality of international reproductive health programming. It’s not neat and tidy and often smells badly. And it always, always, involves conversations and real time decisions about abortions.
US foreign policy’s toying with the reproductive fate of women and girls living outside of the US is not new to this century.  
As new Presidents do, [ictt-tweet-inline]Donald Trump is expected to take action by declaring his intentions for women’s reproductive health stance[/ictt-tweet-inline] immediately upon his arrival into the White House in January. This will have dire and immediate consequences for women worldwide. I believe that Trump will likely reinstate the Mexico City Policy — or as it’s known in the health community, the Global Gag Rule — a Reagan-era policy prohibiting groups receiving U.S. aid from providing abortions, or even counseling patients about the procedure. Doing so will force millions of women’s health clinics to close, thereby decreasing access to essential contraception and in turn leading to an increase in unsafe abortions around the world. U.S. foreign policy’s toying with the reproductive fate of women and girls living outside of the US is not new to this century. The allocation and deployment of US state sanctioned funds to pay for abortions has been illegal since the Helms amendment was enacted in 1973. Therefore, Non-Governmental Organizations that accept U.S. aid are required to use their own funds on abortion related services. President Ronald Reagan enacted the Mexico City Policy in 1984. It has since become a tradition for incoming presidents of opposing parties to declare their support or opposition to this policy as one of their first acts of office. President Bill Clinton revoked it right after taking office; President George W. Bush reinstated it shortly after his inauguration; and President Barack Obama once again revoked the policy as soon as he entered the White House. President Trump will likely revoke this policy in his first days in office, negatively impacting hundreds of millions of women around the world who didn’t have the opportunity to vote for him as they are not U.S. citizens, thereby reducing access to safe abortions and the family planning that helps in preventing them. A reduction of access to safe abortions can have serious health consequences, but one doesn’t have to outlaw abortions to limit one’s access to what women need to determine their own fate. What difference has the Global Gag rule made in the lives of real women around the world? [ictt-tweet-inline]Evidence shows that the impact of the Global Gag rule has limited access to contraception and thereby led to an increase in abortions[/ictt-tweet-inline]. One example of this evidence is in the 2011 study at Stanford University that compared pre- and post-Bush policy abortion rates in sub-Saharan Africa. The International Food Policy Research Institute released a study in 2015 that found that the Planned Parenthood Association of Ghana closed several sites that provided family planning as a result of the mandate of the Bush policy. In the aftermath, an increase in unwanted pregnancies in Ghana was observed — with one in five of those pregnancies ending in abortion. PAI provided a report that found that 22,000 women die and 8.4 million suffer serious illness or injury after undergoing an unsafe abortion. These deaths and injuries are preventable — all it takes is expanding access to family-planning services and ensuring that they are affordable. [ictt-tweet-inline]The U.S. is the biggest state donor in the world for women’s health in developing countries[/ictt-tweet-inline]. This puts the US in a powerful position to support the reduction in stigma around abortion around the world, should that be the position we decide to take. This can be carried out in many different ways, one of which being the protection of funding for family planning and the education of girls, both known to reduce the number of unplanned and unintended pregnancies. [ictt-tweet-inline]It seems likely that Trump will undo much of the advancements made to protect and promote women[/ictt-tweet-inline], girls, and their health. When Trump reinstates the Global Gag Rule millions of women’s lives will be in danger as they face a reality that does not provide the health care that they will need to chart their own reproductive course. Featured Image: A billboard shows family planning methods near the Plassac Health Clinic run by HAS (Hôpital Albert Schweitzer) in rural Haiti. © 2008 Margaret F. McCann, Courtesy of Photoshare. [post_title] => Judge not. [post_excerpt] => What difference has the Global Gag rule made in the lives of real women around the world? 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What difference has the Global Gag rule made in the lives of real women around the world?

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