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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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No HIV-Positive MSM in Screening

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                    [post_content] => Djamil Bangoura, president of Association Prudence, Senegal’s largest LGBT health and human rights advocacy group, lists HIV prevention and treatment for men who have sex with men (MSM) as one of the organization’s most urgent priorities. Even though systematic homophobia in Senegal limits the organization's ability to improve health outcomes for the LGBT community, Prudence organizes HIV testing for MSM by using its network of 500 members.

“We need to be careful, but not so careful that we can’t take action on the ground,” Bangoura said. “We’re careful, but we take actions for key populations. We target the community in which we are a part of, the LGBT population.”

Prudence connects key populations to LGBT-friendly health services for testing and helps to refer HIV-positive MSM for treatment.

“We’re here as an organization to sensitize and to organize testing zones, and if we test one of our brothers who is positive, we try to counsel him so that he knows it’s not the end of the world,” Bangoura said. “He can live like everybody.”

Amadou, a member of Prudence, took part in a recent HIV testing and sensitization campaign with key populations in Dakar. Prudence frequently hosts these screenings for the LGBT community.

“By the grace of God, we had zero cases, and that’s a victory for us as the LGBT community to know that people took precaution against this disease,” Amadou said.

Although he explains that no men tested positive for HIV during this one screening, the HIV prevalence is 44% among Senegalese MSM 25-years and younger and 38% among MSM 25-years and older.
“We’re here as an organization to sensitize and to organize testing zones, and if we test one of our brothers who is positive, we try to counsel him so that he knows it’s not the end of the world,” Bangoura said. “He can live like everybody.”  
The Joint United Nations Programme on HIV/AIDS (UNAIDS) Key Populations Atlas, a new visualization tool, allows users to navigate country-specific data on populations particularly vulnerable to HIV. These key populations include sex workers, people who inject drugs, transgender people, prisoners, and MSM. UNAIDS maps eight indicators of key population health in countries where data sources are available. These indicators estimate HIV prevalence, population size estimate, condom use, HIV testing rates, ART coverage, denied health services, a measure of fear of seeking health services, and health laws. msm_senegal_chart_sm Because UNAIDS estimates the HIV prevalence at 0.5% in the Senegalese general population, these data reveal disparities in HIV rates in the country. “We went to battle,” Amadou said. “We fight, but I don’t think from now until 2020 we’ll have what we want. We hope with all our heart, but we can say that we’re truly vulnerable.” The UNAIDS Key Populations Atlas indicates 72.6% of Senegalese MSM use condoms and 41.9% are tested for HIV. Notably, the average HIV prevalence among MSM was 18.5% in 2013 and 41.9% in 2014 and 2015, though it ranges depending on age. Bangoura worries for MSM who are not tested for HIV and for those who are not included in UNAIDS estimates. He knows the stories of men who flee Senegal seeking refuge abroad in countries like Morocco and Mauritania. “We realized there have been a lot of loss of life,” Bangoura said. “There are a lot of displacements.” This is part four in a Public Health Post series about LGBT health in Senegal. Click here to read parts one, two, and three. The informants’ names are changed to protect their safety. Interviews were conducted in French and translated to English. Featured Image: An HIV/AIDS message on the exterior wall around a hospital in the Casamance regional capital of Ziguinchor, Senegal. © 2006 Sara A. Holtz, Courtesy of Photoshare [post_title] => No HIV-Positive MSM in Screening [post_excerpt] => In part four of PHP's series on LGBT health in Senegal, Association Prudence connects key populations to LGBT-friendly health services for testing and helps to refer HIV-positive MSM for treatment. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => high-prevalence-no-hiv-positive-msm-screening [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:38:15 [post_modified_gmt] => 2017-08-27 03:38:15 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=739 [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 )

In part four of PHP’s series on LGBT health in Senegal, Association Prudence connects key populations to LGBT-friendly health services for testing and helps to refer HIV-positive MSM for treatment.

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You Are Where You Live

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                    [post_content] => “You are where you live.”  This variation on the old saying is meant to highlight that where you spend your daily life influences your opportunities for healthy living. In light of the many environmental issues surrounding the Flint Water Crisis, and as the world of public health wades deeper into the waters of geographical inquiry, this concept bears extra weight.

Indeed, my involvement in the Flint Water Crisis began because of a lack of analytical and spatial sense about ‘YAWYL’ on the part of state-level officials. As I’ve noted elsewhere, some officials’ eyes were blind to the blood lead issue because of their use of an inappropriate unit of analysis, which led to a partial occlusion of the problem. Our team’s ability to discern the need for better analysis helped bring the state to its knee—though we should have never had to intervene.

A firm grounding in geographical concepts is particularly important for understanding not only what happened in Flint, but specifically where it happened and why it happened there.

In Flint, health disparities exist at multiple geographic levels—not only when compared to other regions, but also when comparing one neighborhood to another—and inquiry must therefore be nested within these contexts. Flint is not unusual in this regard. But like other cities with internal health equity issues, Flint is often maligned in the media because of the many social causes and manifestations of these disparities. Many people are unable to see why things are as they are, and instead focus on the outcomes as the core problem.

We have established that [ictt-tweet-inline]City of Flint residents were disproportionately affected by lead leaching into their drinking water[/ictt-tweet-inline]. But their challenges are much broader than lead in water and include all aspects of daily life.

City residents face the decision of sending their children to a struggling public school system or taking extra effort to send them out of district. When compared to the surrounding county, residents in the city have heightened exposure to crime and blight, and diminished opportunities for finding healthy foods or other retail goods. Flint residents also pay higher water rates (in fact, the highest in the country), higher property taxes, and receive poorer public services in return. These problems did not happen overnight; their causes date back decades.

In geographic research, such variables can be pulled together to contextualize what has been referred to as ‘deprivation amplification,’ or the negatively synergistic burden experienced by living in such environments. The role of GIS is essential, because it allows the user to understand spatial clustering and distribution of phenomena above and beyond census estimates of socioeconomic characteristics.
...the state’s actions over the past few decades are akin to a conversation like the following: “Give me your wallet…great, now buy us lunch. What do you mean you can’t afford it? Let’s go to a payday loan facility so you can afford it.”  
Subsequent work done by the Hurley/MSU collaborative team along these lines has recently shown that residence time of water in pipes, house age, and neighborhood housing condition are all strongly correlated to those sites where blood lead levels were highest in the immediate aftermath of the water source switch. It implicates a declining infrastructure in the public health problem. That is, [ictt-tweet-inline]the problem is one of neglect by a departing population and a tendency to abandon our cities[/ictt-tweet-inline]. It also reflects on the state of Michigan’s anti-urban bias over many decades.  Following annexation attempts by central cities in the 1960s and 1970s, the suburb-friendly state legislature passed laws establishing the right of suburbs to remain separate. More recently, the state has greatly reduced revenue sharing to core areas, and established a draconian emergency manager law that removes democratic control from local governments, allows the state to unilaterally cut expenses, and which has a stipulation preventing the public from conducting a referendum on the law. To paraphrase our State Senator Jim Ananich at a recent Save MI City event sponsored by the Michigan Municipal League, the state’s actions over the past few decades are akin to a conversation like the following: “Give me your wallet…great, now buy us lunch. What do you mean you can’t afford it?  Let’s go to a payday loan facility so you can afford it.” Such thinking lacks any form of logic, effectively blaming and then punishing the victim for an undeserved assignment of culpability. In this context, it is important for public health and healthcare providers to understand not only the singular context of lead-in-water, but the myriad determinants that roll together to affect health. All of these elements require an appreciation of the influence not only of the existing built environment on health, but of the structural forces that dictate how our cities will rise or fall. [ictt-tweet-inline]Flint must be viewed in the context in which it was placed: one in which the state set it up to fail[/ictt-tweet-inline]. Culpability should not be misdirected—decades of state policies created the conditions by which such a catastrophe would happen. Image: Michael Kappel, Flint MI Childrens Museum 366, used under CC BY/cropped from original  [post_title] => You Are Where You Live [post_excerpt] => Geographical concepts are important for understanding not only what happened in Flint, but specifically where it happened and why it happened there. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => you-are-where-you-live [to_ping] => [pinged] => [post_modified] => 2017-08-26 23:35:13 [post_modified_gmt] => 2017-08-27 03:35:13 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=732 [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 )

Geographical concepts are important for understanding not only what happened in Flint, but specifically where it happened and why it happened there.

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Campaigns Offer a Healthy Way Out for Senegalese MSM   

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                    [post_content] => For Senegalese men who have sex with men (MSM), discovering LGBT-friendly health providers is as challenging as finding housing, securing employment, and coming out. One non-governmental organization is making it easier for vulnerable Senegalese to access health care. The organization – referred to here as NGO – engages key populations facing discrimination because of their social status and operates in two of Dakar’s neighborhoods.

The NGO partners with the National Network of Key Population Associations to assist Senegalese MSM via three education campaigns. Two campaigns emphasize sexual and reproductive health and harm reduction by partnering MSM with 13 local clinics. A third campaign, implemented in 2016, aims to reduce provider discrimination against LGBT Senegalese.

“We think that it’s a problem of stigma because he who is stigmatized, who is discriminated, he lives in hiding,” said an NGO representative managing the campaigns. “There are those who are watching his every move, so he’s scared to go to the hospital. He’s scared to go to the clinic.”

In 2015, Amadou joined Association Prudence, Senegal’s largest LGBT health and human rights advocacy group. He realizes how [ictt-tweet-inline]homophobia among health providers is a barrier to MSM accessing health care[/ictt-tweet-inline].

“They don’t have the understanding to accept MSM or lesbians to treat us,” Amadou said. “In Senegal, people say that MSM are troublemakers, so they don’t touch us. They don’t see us. They don’t greet us. It wouldn’t be normal for them to treat us.”

Issa recently joined Prudence. He hides his sexuality from his father and also refuses to disclose his sexual orientation to health providers. Outing himself to friends, family, or health providers could lead to violence against MSM.

“When gays have sexually transmitted infections, we’re scared to go to the hospital for treatment,” Issa said. “There are even some hospitals that turn away from gays. When I go to the doctor, I never tell him that I’m gay.”

A disproportionate number of Senegalese MSM suffer from HIV: the prevalence ranges between 38-44% in this key population, but affects less than 1% of the general population in Senegal. Prudence refers HIV-positive MSM to LGBT-friendly health providers, although LGBT-friendly health providers, too, have to closet themselves when delivering services to Senegalese MSM. Although LGBT-friendly health providers are few and far, Lamine used Prudence to find a safe clinic.

“I always want to know my health [status],” Lamine said. “Every three months, I go for testing to also control my health.”

Recently, Amadou represented Prudence at a community discussion in Dakar. The conference fostered a dialogue on HIV/AIDS prevention between key populations, politicians, and religious leaders.
“They don’t have the understanding to accept MSM or lesbians to treat us,” Amadou said. “In Senegal, people say that MSM are troublemakers, so they don’t touch us. They don’t see us. They don’t greet us. It wouldn’t be normal for them to treat us.”  
“They told us that it’s the LGBT community who is responsible for the AIDS virus spreading throughout Senegal,” Amadou said. “Can you believe that? As if it’s only us who have sexual relationships.” During the focus group discussions with community stakeholders, he underscored the LGBT community’s role in HIV prevention. Amadou sees how the partnership between Prudence, the NGO, and LGBT-friendly health providers revolutionizes care for the vulnerable because it includes members of the Senegalese LGBT community in service delivery. “I know that not everybody is MSM, but the majority of people fighting this virus are MSM,” Amadou said. As a part of the third education campaign, the NGO plans to organize a community discussion similar to the conference Amadou attended with Prudence. “We’re organizing debates with the community that are composed of religious leaders and doctors,” the NGO representative said. “I think that it’s important because if these leaders are informed, then they’ll return and inform everyone else.” The education campaigns help foster a dialogue around the need for LGBT-friendly health providers by engaging MSM and community leaders in Senegal. “We try to work with these key populations so that they can live their sexual orientation without being an object of stigma, discrimination, and persecution because there are those who are persecuted,” the NGO representative said. Cheikh, another member of Prudence, was beaten by onlookers after attending a friend’s birthday party in Pikine. The police outed him to his family, and he fears seeking health services because of the stigma associated with identifying as MSM. “We need everything,” Cheikh said. “We need to live like everyone else. When everyone else is sick and they go to the hospital, they’re treated like Senegalese citizens. Here, we’re not.” Editor’s note – The NGO is unidentified and the informants’ names are changed to protect their safety.   Interviews were conducted in French and translated to English. This is part three in a series about LGBT health in Senegal. Click here for parts onetwo and four. Image: HPIM1525 by Xavier Damman, used under CC BY/cropped from original [post_title] => Campaigns Offer a Healthy Way Out for Senegalese MSM    [post_excerpt] => In part three of PHP's series on LGBT health in Senegal, an NGO assists Senegalese MSM via three education campaigns that emphasize sexual and reproductive health and harm reduction. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => campaigns-offer-healthy-way-msm [to_ping] => [pinged] => [post_modified] => 2018-02-22 12:10:33 [post_modified_gmt] => 2018-02-22 17:10:33 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=736 [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 )

In part three of PHP’s series on LGBT health in Senegal, an NGO assists Senegalese MSM via three education campaigns that emphasize sexual and reproductive health and harm reduction.

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Viewpoint

The End of “The End of AIDS”

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                    [post_content] => In late 2014, the organizers of the International AIDS Conference (IAC), the world’s largest meeting on any global health topic, met with a small group of scientists, activists, and policymakers to begin assembling that meetings’ return to South Africa. The last IAC in South Africa was held fourteen years earlier at a very different time in the AIDS response.

In 2000, the IAC arrived in Durban accompanied by a train of anger and controversy. Nearly two decades into the global pandemic, there were only ad hoc efforts by world governments to address the explosion of HIV infections and deaths in the developing world. In South Africa, President Thabo Mbeki’s misinformed, anti-science public health policies created a blockade against life-saving HIV treatment. His administration’s misguided attempts to attribute the role inequality and poverty play in fueling the epidemic cost thousands of lives before the conference arrived (and, by some estimates, hundreds of thousands more before those policies were rescinded).

The advocates and researchers gathered at the 2000 AIDS Conference were outraged by what they perceived as indifference to catastrophe. The conference became a lens through which the world saw the stark inequality in fighting HIV. Public demonstrations and pleas for change dominated. Though it is hard to pinpoint one moment, Nelson Mandela’s personal, human appeal to delegates at the closing ceremony exemplified how the world shifted – from shock and inaction to moral responsibility and ownership. In the months following the conference, the world began building a massive public health infrastructure to stop AIDS. Today, it is the largest public health response to a global pandemic in history.
The debate in Johannesburg in 2014 was not about the scientific reality of ending AIDS or the mathematical models showing the within-arms-reach-of-target possibilities. All were in agreement that these are very real scenarios. The argument was about our inability to address two persistent challenges to the “end of AIDS” goal.  
But for many in that meeting in Johannesburg in 2014, progress since AIDS 2000 felt mixed. A debate about the theme and direction of AIDS 2016 spiraled into a larger conversation about the separation between global advocacy and lived reality. The Conference’s South African hosts and partners made clear that language about “the end of AIDS” was unacceptable, an insult to the efforts involved in mounting the world’s largest AIDS response. The oversimplification of an enormous goal, some felt, was setting unrealistic expectations around how soon the world could move beyond AIDS (and setting up blame for not achieving it). This was not simply a matter of semantics. For many years, the “end of AIDS” was a rallying cry for global advocates eager to summarize the rapid rate of scientific breakthrough in fighting AIDS and the tremendously successful effort to rapidly scale up HIV treatment. In as little as ten years, scientists discovered the power of voluntary medical male circumcision to reduce HIV infection, the role viral suppression plays in preventing HIV transmission, and the utility of some forms of HIV treatment as both a therapeutic and prophylactic intervention. The pace of discovery was so rapid and the promise so extreme that the Economist touted the possibility of ending AIDS on its front cover in June 2011. The debate in Johannesburg in 2014 was not about the scientific reality of ending AIDS or the mathematical models showing the within-arms-reach-of-target possibilities. All were in agreement that these are very real scenarios. [ictt-tweet-inline]The argument was about our inability to address two persistent challenges to the “end of AIDS” goal[/ictt-tweet-inline]. The first is the significant lag between scientific discovery and on-the-ground implementation. Realizing the gains of new science has always been a gradual process, but that has felt particularly pronounced for HIV, as in the case of voluntary medical male circumcision. Similarly, it has been four years since the FDA approved Truvada as pre-exposure prophylaxis to reduce the risk of sexually-acquired HIV infection and yet only 20 countries have begun to implement it. The second is the persistent role stigma, discrimination, and inequality play in fueling HIV transmission everywhere. Travel bans, HIV criminalization, marginalization of key populations, and gender inequality continue to determine vulnerability to HIV. [ictt-tweet-inline]HIV has always fed off of our discomfort talking about sex or respecting diversity, and it continues to do so[/ictt-tweet-inline]. Now, more than five months after the conference, it is easy to see how important the debate on “the end of AIDS” was to the content and impact of AIDS 2016.  In the end, we chose a theme that described a more immediate agenda for many around the table – Access, Equity, Rights Now. This infused much of the conversation that followed, including a pragmatic reassessment of our progress on HIV prevention and treatment as well as a hopefulness that we haven’t lost the fire and spirit that carried us this far. A conference won’t end an epidemic, but it can be an important tool for critically reassessing if our goals are aligned with our actions. As we look to AIDS 2018 in Amsterdam, we begin that process again. Featured Image: UNIS ViennaWorld AIDS Day 2014, UNODC marked World Aids Day by projecting giant AIDS Ribbon on UN building, used under CC BY NC-ND 2.0 [post_title] => The End of “The End of AIDS” [post_excerpt] => Two persistent challenges remain to the “end of AIDS” goal. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => end-end-aids [to_ping] => [pinged] => [post_modified] => 2017-11-29 14:00:13 [post_modified_gmt] => 2017-11-29 19:00:13 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=678 [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 )

Two persistent challenges remain to the “end of AIDS” goal.

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ACA Politics: Lessons from Kentucky

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                    [post_content] => I’m the former Governor of Kentucky, the state that most aggressively embraced and succeeded in implementing the Affordable Care Act as a core part of a holistic strategy to improve its collective health. It’s also the state that for the past year has been watching my Republican successor starting to dismantle that strategy for no reason other than he can. So I have a message for Republicans in Washington who are giddy about the prospect—after years and years of trying—of finally repealing the ACA, the transformative program most closely affiliated with the eight-year administration of President Barack Obama: [ictt-tweet-inline]Step back and think about the people you’re elected to represent[/ictt-tweet-inline].

See, with all the ideological chest-thumping and rabid partisan rhetoric, with all the crowing about the political coup of gaining control of the White House and both chambers of Congress and what it will allow the GOP to do … not enough attention is being paid to the people who have the most to lose with this decision: the over 20 million Americans who currently have health coverage only because the ACA took an innovative approach to one of the most stubborn and damaging challenges in modern era—the lack of access to affordable health care.

What comes next for these Americans?

Unfortunately, no one knows and too few leaders seem to care.

Most of the “repeal and replace” talk—including from Kentucky’s own GOP delegation—over the years and even now continues to center on the “repeal,” with little serious consideration being dedicated to the far more complex problem of the “replace.” With decisions rooted firmly in ideology and political gain, the impact on actual families has been almost an afterthought.

The same reckless disregard has been true in Kentucky.
These people would get up every morning, go to work and roll the dice, hoping and praying that they didn’t get sick. They chose between food and medicine. They ignored checkups that would catch serious conditions early. They put off doctor’s appointments, hoping a lump or a pain turned out to be nothing. And they lived every day knowing that bankruptcy was just one bad diagnosis away.  
  I embraced the ACA for one simple reason: Kentucky’s collective health had long been terrible, and what we’d been doing for generations wasn’t working. In almost every measure of health there was, Kentucky ranked near the bottom or at the bottom and had for a long time. The suffering was deep. Kentuckians were sicker than most. We died too early. And our families were going bankrupt paying to treat diseases and chronic conditions. Our poor health also had devastating consequences for our state as a whole, as there was and remains a direct line between poor health and almost every challenge Kentucky faces—whether that’s poverty, unemployment, lags in education attainment, substance abuse or crime. Now, one of the biggest reasons for our poor health was lack of access. Before we expanded Medicaid eligibility and created our own state-based Health Benefit Exchange, an estimated 640,000 people in Kentucky were uninsured. That was almost one in six Kentuckians – putting both their health and financial security in jeopardy. These people would get up every morning, go to work and roll the dice, hoping and praying that they didn’t get sick. They chose between food and medicine. They ignored checkups that would catch serious conditions early. They put off doctor’s appointments, hoping a lump or a pain turned out to be nothing. And they lived every day knowing that bankruptcy was just one bad diagnosis away. Look, some politicians believe that these people are not deserving of health care because they’re poor, or because they work for an employer that doesn’t provide health care or it’s priced out of reach. They talk about them as if they are from some distant planet. But they’re not. They’re our friends and neighbors. Our former classmates and hunting buddies. We sit in the pews with them on Sunday and in the high school bleachers with them on Friday night. The Affordable Care Act gave us an opportunity to address this big problem in an aggressive way. And so—after consulting independent analysts who told me that yes, Kentucky would come out financially ahead if we did so—I moved forward. The result was phenomenal. In early 2016, a Gallup-Healthways survey measured Kentucky’s uninsured rate at 7.5 percent, down from more than 20 percent before the ACA. And even though better health outcomes tend to lag a few years behind health policy changes, a study by researchers at Harvard’s School of Public Health published in JAMA Internal Medicine in August 2016 found that already, low-income Kentuckians reported being in better health and were more likely to have a doctor, to have their chronic disease or condition treated and to have been screened for things like high blood sugar and high cholesterol, which are important in treating heart disease and diabetes. As for the effect on taxpayers and the state as a whole, a study in 2015 conducted by Deloitte Consulting and the University of Louisville Urban Studies Institute using hard data from our first year of expanded Medicaid, found that expansion generated 12,000 new jobs and $1.3 billion in new revenues for providers (increasing to almost $3 billion in the first 18 months of expansion).  It also projected a $300 million positive impact on the state’s 2016-18 annual budget and the creation of 40,000 new jobs and a $30 billion overall economic impact through 2021. There is a mountain of evidence demonstrating the success of the ACA in Kentucky. But that didn’t stop our newly elected governor, Matt Bevin, from claiming both that the ACA was not financially sustainable and that it wasn’t having an impact on health. He has no evidence, just ideology. In fact, he refuses to address all the evidence staring him in the face. Instead, he just says that low-income Kentuckians need to have “more skin in the game” and insists that making care harder to access will somehow make Kentuckians healthier. Recently he dismantled Kentucky’s exchange, called “kynect,” and moved to the federal insurance portal, needlessly complicating the process and destroying what was hailed as the nation’s most successful and simple exchange. Many advocates predict that enrollment numbers will drop. He also has applied for a Section 1115 waiver to administer Medicaid expansion, with the primary goal of saving money. By his projections, the waiver would save money, but only by cutting 88,000 people from eligibility rolls; eliminating vital benefits like dental, vision, and medical transportation; and imposing onerous administrative barriers like work requirements for eligibility, monthly premiums that increase the longer one is poor, lockout periods for not enrolling on time, and retroactive fines for emergency room visits later determined to be non-emergent. Medical professionals have warned that these steps will reduce enrollment and access and hurt care. Families and their advocates across the state used public comment periods to voice their outrage and anxiety. But the criticism has only strengthened the governor’s resolve. Even though parts of the waiver application run contrary to the goals of Medicaid and the waiver program (which should make the application impossible for the federal government to approve), Gov. Bevin has threatened repeatedly to get rid of expansion altogether if his waiver isn’t approved as written. That would strip health coverage from 400,000 vulnerable Kentuckians with a stroke of a pen. Again, it seems that ideology is more important than the fate of actual families. I fear the same result in Washington on a national scale. This isn’t about President Obama but about American families. And while there are some issues with the ACA that need to be addressed, there is also undeniable proof that it has strengthened this nation at its core. That’s why I urge our leaders to take a deep breath, let the reckless partisan fervor subside and ask themselves: What will happen to the 20-plus million Americans who have been put on the path toward hope and better health? Featured Image: Kentucky Democratic Party, Governor Steve Beshear, used under CC BY-NC 2.0 [post_title] => ACA Politics: Lessons from Kentucky [post_excerpt] => Steven Beshear, former Governor of Kentucky, the state that most aggressively embraced and succeeded in implementing the Affordable Care Act as a core part of a holistic strategy to improve its collective health, suggests putting partisan fervor aside. 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Steven Beshear, former Governor of Kentucky, the state that most aggressively embraced and succeeded in implementing the Affordable Care Act as a core part of a holistic strategy to improve its collective health, suggests putting partisan fervor aside.

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Viewpoint

Why Porn is a Public Health Issue

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                    [post_content] => It was not that long ago that domestic violence (DV) was seen as a private family issue, rather than a public health problem of enormous magnitude that has myriad effects on the social, psychological, economic and, of course, collective health of society at large. Thanks in large part to the feminist movement, which worked to build public awareness about the multiple harms of DV, health professionals drawn from a number of areas of specialization now understand DV as an issue that requires both prevention and intervention.

We have now reached a similar tipping point with pornography.  As the evidence on the harms of pornography piles up, it has become clear that [ictt-tweet-inline]we can no longer sit back and allow the porn industry to hijack the sexual and emotional well-being of our culture[/ictt-tweet-inline]. Extensive scientific research reveals that exposure to porn threatens the social, emotional and physical health of individuals, families and communities. These impacts highlight the degree to which [ictt-tweet-inline]porn is a public health crisis that undermines women and children's human rights[/ictt-tweet-inline], rather than being a private matter. But just as the tobacco industry argued for decades that there was no proof of a connection between smoking and lung cancer, so too has the porn industry, with the help of a well-oiled public relations machine, denied the existence of empirical research on the impact of its products.

Using a wide range of methodologies, researchers from a number of disciplines have shown that viewing pornography is associated with damaging outcomes. In a study of U.S. college men, researchers found that 83 percent reported seeing mainstream pornography, and that those who did were more likely to say they would commit rape or sexual assault (if they knew they wouldn’t be caught) than men who hadn’t seen porn in the past 12 months. The same study found that porn consumers were less likely to intervene if they observed a sexual assault taking place. A recent meta-analysis of 22 studies between 1978 and 2014 from seven different countries concluded that pornography consumption is associated with an increased likelihood of committing acts of verbal or physical sexual aggression, regardless of age. A 2010 meta-analysis of several studies found “an overall significant positive association between pornography use and attitudes supporting violence against women.”

 
In one of the most respected and highly cited studies on the content of pornography, Bridges and her team found that the majority of scenes from 50 of the top-rented porn movies contained both physical and verbal abuse targeted against the female performers.  
  This is no surprise given the violent and degrading nature of mainstream online pornography. In one of the most respected and highly cited studies on the content of pornography, Bridges and her team found that the majority of scenes from 50 of the top-rented porn movies contained both physical and verbal abuse targeted against the female performers. Physical aggression, which included spanking, open-hand slapping, and gagging, occurred in over 88% of scenes, while expressions of verbal aggression—calling the woman names such as “bitch” or “slut”—were found in 48% of the scenes. The researchers concluded that 90% of scenes contained at least one aggressive act if both physical and verbal aggression were combined. As Carin Götblad, Police Commissioner of Stockholm County, said about preventing DV, "there are no simple overall solutions.... what is needed is long-term, differentiated and sustained cooperation throughout society: efforts with a clear public health perspective." Culture Reframed (full disclosure: the author is the founder and President of the organization) is pioneering such a strategy to address porn as the public health crisis of the digital age. Tasked with building the public’s capacity to deal with online porn, our multi-disciplinary team of expert consultants is developing educational programs for parents, youth, and a range of professionals. These programs will create a robust set of health objectives that adhere to best practice in health promotion and violence prevention, and that align with the U.S. national health priorities and the U.S. national health policy, Healthy People 2020. These objectives serve to guide the development of our curriculum, evaluation, implementation, and long-term strategic plans. As with DV, the problem of pornography requires a creative and collective effort by building coalitions and partnerships, which Dr. Nidal Karim, a behavioral scientist with the Centers for Disease Control calls "the cornerstone of success." At Culture Reframed we recognize that organizing against a predatory misogynist industry demands that we work with multiple partners that include sex educators, parents, youth groups, health professionals, and anti-violence experts, to shift the culture from one that sees pornography consumption as a private issue to one that values and promotes a sexuality rooted in gender equality, dignity, autonomy, and consent. Featured image: laurenAmsterdam, The Netherlands. 2007, used under CC BY 2.0 [post_title] => Why Porn is a Public Health Issue [post_excerpt] => It was not that long ago that domestic violence was seen as a private family issue, rather than a public health problem of enormous magnitude. Gail Dines argues we have now reached a similar tipping point with pornography. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pornography-public-health-issue [to_ping] => [pinged] => [post_modified] => 2017-12-07 14:15:04 [post_modified_gmt] => 2017-12-07 19:15:04 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_viewpoint&p=635 [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 )

It was not that long ago that domestic violence was seen as a private family issue, rather than a public health problem of enormous magnitude. Gail Dines argues we have now reached a similar tipping point with pornography.

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