Standing Up to Sterilization, Eugenics, and the Abuse of Women

“Keep your hands off my uterus!” That’s an often-repeated placard and plea at women’s marches I’ve attended over the past forty years. In the U.S. and abroad, it’s a common, continuing refrain because government sanctioning of abuse of women’s bodies has been occurring since well before the Second Wave women’s movement exposed it in the 1970s.

I worked in the women’s health movement then alongside Our Bodies, Ourselves and other national organizations. One of the myriad issues we dealt with was the sterilization of poor, black and brown women.  We helped raise awareness of the medical abuse of Puerto Rican women that resulted in a third of women of reproductive age being sterilized for decades at clinics often funded by the U.S. government. In the 1960s women in Puerto Rico were also the subjects of birth control pill trials, without their consent. Those who became pregnant on placebos were offered no help, financial or otherwise, and were forced to carry resulting pregnancies to term.  

Another frequent abuse women of color faced was the lack of real informed consent. It can hardly be considered consent when you are asked to sign a paper in English and your only language is Spanish, or you are asked by the nice doctor if you’d like to stop having babies after you’ve just endured a long, arduous labor.

There is a long, ugly history of abusing and using women’s bodies by way of coercion and for experimentation. Dr. J. Marion Sims, know as the father of gynecology, practiced medicine in Alabama from 1835 to 1849. During that time, he conducted hideous experiments, without any anesthesia, on enslaved women he had purchased in the 1840s. At an annual convention of the American Public Health Association in the late 1970s his portrait was still on display – until enraged women demanded that it be taken down and never shown again.

Affluent white women were often subjected to having their ovaries removed in the second half of the 19th century if they were deemed to be overly sexual. This practice coincided with the belief that if women used their minds too eagerly, their uteruses would atrophy, denying them the God-given role of child bearers.

Medical abuse was further embraced in the early 20th century when eugenics was popular, with the growth of programs that coerced women to be sterilized if they did not willingly consent. As Alexandra Stern, author of Eugenic Nation, points out, sterilization was viewed as part of a “necessary public health intervention aimed at protecting society from deleterious genes…” This mindset prevailed late into the century. My friend’s daughter, who was mentally impaired, was subjected to sterilization in the 1970s as part of her care plan.

Some states, like California, passed laws that resulted in thousands of residents being sterilized for decades (including some men). Even as late as 2010 the California Department of Corrections and Rehabilitation had sterilized 150 women in four years. Richard Nixon, a Californian, significantly increased Medicaid funding for sterilization of poor Americans with an emphasis on people of color.

Let us remember, medical historians remind us, that eugenics policies in the U.S. aimed at those considered too mentally defective to reproduce, are credited with becoming models for Nazi Germany.

One of the saddest stories of a black woman being sterilized during her childbearing years is that of civil rights activist, Fannie Lou Hamer. She had a hysterectomy without her consent in 1961 while undergoing minor surgery for removal of a benign tumor. She spoke about her experience as a Black woman who had been subjected to what was known as a “Mississippi appendectomy,” when women were taken to local clinics and sterilized.

Now comes Dawn Wooten, a courageous nurse, who revealed that women in an ICE detention center in Georgia, run by a private prison company, had an outside doctor perform hysterectomies on them when they complained about non-threatening reproductive health issues. Many of the women who experienced major surgery awoke to find that they had had their reproductive organs all or partially removed without their prior knowledge or consent. Most were still of childbearing age and most had no idea why they had undergone the procedure.

Pauline Binam, 30, was one of them. She was being quickly deported by ICE to Cameroon, which she left at age two. Binam, now 30, was on the tarmac when members of Congress including Rep. Shirley Jackson Lee intervened to keep her in the U.S.  Binam's lawyer has said her client thought she was getting a routine procedure last year, but "when she woke up from surgery, the doctor informed her that he had to remove one of her fallopian tubes."

Imagine how hard it will be to find records of the 17 surgeries that have now been reported.  Think about how many abused women will be rushed onto airplanes and deported so they can’t bear witness. Then try to understand what it feels like to have undergone surgery that renders you unable to have a child because you are young, poor, and unwanted.

It boggles the mind, and makes you want to weep.

                                                                        # # #

Elayne Clift writes about women’s health from Saxtons River, Vt.  www.elayne-clift.com

“Keep your hands off my uterus!” That’s an often-repeated placard and plea at women’s marches I’ve attended over the past forty years. In the U.S. and abroad, it’s a common, continuing refrain because government sanctioning of abuse of women’s bodies has been occurring since well before the Second Wave women’s movement exposed it in the 1970s.

I worked in the women’s health movement then alongside Our Bodies, Ourselves and other national organizations. One of the myriad issues we dealt with was the sterilization of poor, black and brown women.  We helped raise awareness of the medical abuse of Puerto Rican women that resulted in a third of women of reproductive age being sterilized for decades at clinics often funded by the U.S. government. In the 1960s women in Puerto Rico were also the subjects of birth control pill trials, without their consent. Those who became pregnant on placebos were offered no help, financial or otherwise, and were forced to carry resulting pregnancies to term.  

Another frequent abuse women of color faced was the lack of real informed consent. It can hardly be considered consent when you are asked to sign a paper in English and your only language is Spanish, or you are asked by the nice doctor if you’d like to stop having babies after you’ve just endured a long, arduous labor.

There is a long, ugly history of abusing and using women’s bodies by way of coercion and for experimentation. Dr. J. Marion Sims, know as the father of gynecology, practiced medicine in Alabama from 1835 to 1849. During that time, he conducted hideous experiments, without any anesthesia, on enslaved women he had purchased in the 1840s. At an annual convention of the American Public Health Association in the late 1970s his portrait was still on display – until enraged women demanded that it be taken down and never shown again.

Affluent white women were often subjected to having their ovaries removed in the second half of the 19th century if they were deemed to be overly sexual. This practice coincided with the belief that if women used their minds too eagerly, their uteruses would atrophy, denying them the God-given role of child bearers.

Medical abuse was further embraced in the early 20th century when eugenics was popular, with the growth of programs that coerced women to be sterilized if they did not willingly consent. As Alexandra Stern, author of Eugenic Nation, points out, sterilization was viewed as part of a “necessary public health intervention aimed at protecting society from deleterious genes…” This mindset prevailed late into the century. My friend’s daughter, who was mentally impaired, was subjected to sterilization in the 1970s as part of her care plan.

Some states, like California, passed laws that resulted in thousands of residents being sterilized for decades (including some men). Even as late as 2010 the California Department of Corrections and Rehabilitation had sterilized 150 women in four years. Richard Nixon, a Californian, significantly increased Medicaid funding for sterilization of poor Americans with an emphasis on people of color.

Let us remember, medical historians remind us, that eugenics policies in the U.S. aimed at those considered too mentally defective to reproduce, are credited with becoming models for Nazi Germany.

One of the saddest stories of a black woman being sterilized during her childbearing years is that of civil rights activist, Fannie Lou Hamer. She had a hysterectomy without her consent in 1961 while undergoing minor surgery for removal of a benign tumor. She spoke about her experience as a Black woman who had been subjected to what was known as a “Mississippi appendectomy,” when women were taken to local clinics and sterilized.

Now comes Dawn Wooten, a courageous nurse, who revealed that women in an ICE detention center in Georgia, run by a private prison company, had an outside doctor perform hysterectomies on them when they complained about non-threatening reproductive health issues. Many of the women who experienced major surgery awoke to find that they had had their reproductive organs all or partially removed without their prior knowledge or consent. Most were still of childbearing age and most had no idea why they had undergone the procedure.

Pauline Binam, 30, was one of them. She was being quickly deported by ICE to Cameroon, which she left at age two. Binam, now 30, was on the tarmac when members of Congress including Rep. Shirley Jackson Lee intervened to keep her in the U.S.  Binam's lawyer has said her client thought she was getting a routine procedure last year, but "when she woke up from surgery, the doctor informed her that he had to remove one of her fallopian tubes."

Imagine how hard it will be to find records of the 17 surgeries that have now been reported.  Think about how many abused women will be rushed onto airplanes and deported so they can’t bear witness. Then try to understand what it feels like to have undergone surgery that renders you unable to have a child because you are young, poor, and unwanted.

It boggles the mind, and makes you want to weep.

                                                                        # # #

Elayne Clift writes about women’s health from Saxtons River, Vt. 

Mothers, Children and a Menacing Virus

During the years when I worked internationally on MCH – Maternal and Child Health – our mission was to save the lives of mothers and children in the so-called developing world through several primary health care practices. The “twin engines” driving child survival were immunization and diarrheal disease control. Family planning was the start point for women’s health.

Today, MCH takes on new meaning: Maternal and Child Hell. Its driving engines are lack of childcare and mothers driven out of the workforce because of it.

The crisis in childcare is not new, but it is exacerbated by the pandemic. Even affluent families who can afford reliable childcare are feeling the effect.

The Child Care Is Essential Act introduced in the Senate in June would help, if Mitch McConnell and Republicans weren’t in the majority. Covid-driven, it provides for $50 billion in appropriations for a Child Care Stabilization Fund to award grants to childcare providers during the public health crisis. Without that Act many facilities will close.

If corporations, universities, and other workplaces don’t offer onsite daycare, who will fill the gap?  It’s a difficult question for people who work freelance or who are unemployed but looking for work, and of course for undocumented workers. 

According to the Department of Labor, 30 million people lost their jobs since Covid-19 appeared. For working moms, already struggling with the work/home balance, this could have long-term negative consequences, including lost opportunities, less upward mobility in the workplace, lower incomes (impacting Social Security and pensions), and difficulty getting back into the job market. 

A recent Wall Street Journal article highlighting how women’s careers could be derailed because of the pandemic noted that “juggling work and family life has never been easy.” For mothers, the pandemic makes coping especially exhausting as traditional gender roles and pay disparities re-emerge as issues. Without childcare, working moms are forfeiting or delaying careers because they are still prime caretakers of families and children.

As Joan Williams, head of the Center for Worklife Law at the University of California Hastings Center said in the WSJ article, “Opening economics without childcare is a recipe for a generational wipeout of mother’s careers.”

Women who try to maintain careers or jobs often face situations like a woman in San Diego did when she was fired because the firm said her young children were interrupting Zoom meetings.  She sued. At Florida State University things didn’t go that far. Following an email to all employees that the university would “return to normal policy and [would] no longer allow employees to care for children while working remotely,” the hue and cry forced FSU to back down and issue an apology.

Last March 2,000 mothers working for Amazon organized an advocacy campaign urging the company to provide a backup child care benefit as other big corporations, like Apple and other corporate giants do.  They are not the only ones to organize like this. In most cases the results are not yet clear.

What’s clear is that the child care system in this country is broken and has been ever since women became educated, rejected confining their role to marriage and motherhood, and joined the ranks of working women at all levels of a society that has never caught up with that sociological change. Nor has it realized its obligation and co-responsibility for raising children while committing to work/home balance for the good of American families.

There is an economic gain to seeing the light, however.  Child care allows parents to work and their working contributes to economic growth. According to the Center for American Progress, American businesses lose more than $12 billion annually because of challenges workers face in seeking childcare and the cost of lost earnings, productivity, and revenue due to the childcare crisis totals an estimated $57 billion each year.

Along with businesses and other employers, states clearly have a role to play in establishing family friendly benefits for every family, but especially for low income families and families of color. Federal action is also needed, and that action is supported by voters across the political landscape.

With half of Americans living in so-called “child care deserts,” long term policy changes are imperative. In addition to including families at all levels of society in the national conversation, government must move beyond relying on disparate organizations to plug the holes. There needs to be a substantial shift in corporate culture such that universal childcare is the norm. Without that the very nature of “family” will be made to shift in the direction of the affluent, as so much of American policy has done already. We need to understand and act on the relationships, or “intersectionality,” of race, gender, and economics, which are all part of the fabric of social justice.

Surely the time to value our children enough that we ensure their safety and healthy development is now. The time to recognize the contributions women make to the workplace and the economy as well as the family is also now. In short, the time to leave the desert is now.

                                                                         # # #

Diminished, Dismissed, Misdiagnosed: When Doctors Don't Trust Women

Rana Mungin was 30-years old when she died of Covid-19 in March. A black teacher in Brooklyn with asthma and hypertension, she was twice diagnosed with having a panic attack in an ER, despite a fever and shortness of breath.

That reaction and lack of appropriate response by doctors was not a fluke. It happens frequently if you are female, especially if you’re a black woman, as several recent books about women’s health care reveal. That’s not news to women’s healthcare advocates, but perhaps now healthcare providers who may not have considered inherent problems involving diagnosing and treating women will be more enlightened.

Possibly the most important book on this issue is Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick by Maya Dusenbery. Adding to the impressive and important literature of women’s health, Dusenbery addresses two of the biggest impediments to women getting good care, the “knowledge gap” and the “trust gap.”

 The knowledge gap refers to the fact that many doctors don’t know enough about women’s bodies, their symptoms, or the diseases that affect them disproportionately. The trust gap speaks to the stereotyping of women as unreliable reporters at best, and hysterical at worst. These gaps are apt to occur more often with black women. Dusenbery’s central and necessarily repeated mantra is that women are either not trusted when they report symptoms or they are labeled crazy, malingering, or opioid- addicted.

“This book is not about a few sexist bad apples within the medical profession,” Dusenbery says in her introduction. “It is about how all health care providers, like all of us, have unconscious biases by virtue of living in a culture that holds certain stereotypes about women.”

These biases are revealed over and over again as women share their first-person horror stories of trivialization, misdiagnosis, not being believed and more, whether they suffer chronic pain, autoimmune diseases, reproductive problems, heart attacks or other life-threatening emergencies. 

Here’s one example. “I was asking for help. But my doctor said, ‘I don’t think you’re at the point where medication is an option, and it can be addictive. Keep exercising and doing yoga and maybe consider meditating. Try to get more sleep. If your symptoms persist, come back in a few months.”

Here’s another. A black woman I know was found to have multiple cysts in her body. She had gained weight and stopped menstruating. What did the doctor tell her? “You have a demanding job and a young child. I think it’s stress.” That opinion was rendered with no diagnostic workup, no referral to an endocrinologist, no curiosity or concern about what systemic problem might be causing the troubling symptoms.

Dusenbery backs up her conclusions with copious references to research studies, women’s personal stories, and other books in the women’s health canon, as she exposes “bad medicine and lazy science” in compelling and convincing ways.

“Doctors think that men have heart attacks and women have stress” speaks to the frequency with which women are told their symptoms are due to stress, a theme played over and over again in the stories women share. “It’s hard work behaving as a credible patient,” as one woman said, underscoring how often pain is deemed to be “all in your head.” 

A chapter in Dusenbery’s book called “This is Not Normal” reveals how often women must insist on having diagnostic workups. “Young women aren’t the only group of patients who frequently find their symptoms dismissed as ‘normal’ by healthcare providers. The tendency to normalize symptoms associated with women’s reproductive functions finds echoes in the way elderly patients, trans patients, and overweight patients are often treated.”

 “The Career Women’s Disease” points to the modern version of age-old myths suggesting that motherhood and work are incompatible. One 20th century “expert” on endometriosis notoriously stated that the painful condition was on the rise because of “delayed and infrequent childbearing.” The 19th century version of this myth was that if a woman exercised her brain her uterus would atrophy.

Autoimmune diseases are especially challenging for physicians who receive about five hours of lectures on this difficult topic during their entire medical education. Research has shown that women with these diseases, like with many others, see about five physicians over a period of seven years before receiving a correct diagnosis.

The frustration of not being believed or properly diagnosed is intense.  As Dusenbery puts it, “The long, frustrating search for a diagnosis is such a common theme running through the stories of women patients that many feel immense relief to finally get a diagnosis, any diagnosis. Being sick without knowing why is very stressful; being sick and told ‘nothing’s wrong,’ is more stressful still.” 

Delayed, downplayed, poorly diagnosed illnesses are not simply a medical issue. In this time of “intersectionality,” it’s important to realize that race, class, age, gender and more come into play. As one analyst put it, “if you’re not wealthy, not white, and not heterosexual, you may be receiving less than optimal care.”

That’s why Rana Mungin’s story is so sad, and why Dusenbery’s message, echoing that of other healthcare advocates, is so important. “Listen to women. Trust us when we say we’re sick. Start there, and you’ll find we have a a lot of knowledge to share.”  Books like Doing Harm go a long way in arming women for the task.

                                                            # # #

Elayne Clift has been a women’s healthcare educator and advocate for over three decades. She lives in Saxtons River, Vt.  

Imagining a New Normal

What will it be like, I wonder, when this terrible pandemic ends? Sure, we will never take toilet paper, pasta, or flour for granted again. We may feel less guilty about binge watching TV. Maybe we’ll even say “I love you” more often. But how will we be changed personally, professionally, culturally?  What lifestyle changes will we choose to make? What will “community” look like? Where will we work and how will we play?

No one knows for sure how we will be irrevocably altered by what has happened, but sociologists, psychologists, writers, and homespun “experts” are beginning to suggest answers to those questions, and to speculate on, or idealize, a remodeled future. Some of these people were invited to weigh in on a “new normal” in a recent article in Politico.

Communications professor Deborah Tannen thinks that having been so vulnerable to calamity will change us forever such that we will become compulsive hand washers who distance ourselves from others. Some analysts counter with the idea that we’ll be drawn together in real and virtual communities that we may not have considered joining or building before we experienced the loneliness of isolation. I agree with their assessment. I think we’ll become closer to family and friends, some of whom we’ve already re-connected with as a result of the pandemic.

Peter Coleman, a psychology professor, suggests that the shock of Covid-19 could put an end to the “escalating political and cultural polarization we’ve been trapped in, and could help us to change course toward greater national solidarity and functionality.” Sociologist Eric Klineberg adds that market-based models for social organization will fail. “When this ends,” he posits, “we will reorient our politics and make substantial new investments in public goods, especially for health and public services.” Given the blatant flaws in our health care system that have been exposed during the current crisis Americans will surely demand urgently needed healthcare reform, whether we call it Medicare for All or universal health care.

The digital lifestyle will likely take on new meaning and new tasks, as Sherry Turkle of MIT says. Whether it’s watching a performance, taking yoga or meditation classes, communicating with legislators, staying connected to long-distance friends and family, or telecommuting to work there are measurable benefits (and some drawbacks) that accompany such a change. One of the benefits is a cleaner environment, as demonstrated by the unpolluted air over cities like Beijing and Sao Paulo, Venetian canals no longer smelling like sewers, rivers running clean again, and the earth’s surface quieting down, which all attest to the benefits of living less frenetic lives and appreciating nature’s healing gifts.  

Two things that will make a comeback in the new normal are a renewed respect for science, and the realization that good governance along with ethical institutions are essential to a functioning democracy, writer Michiko Kakutani suggests. Applying lessons learned from the Trump administration’s failures, he believes people will realize that “government institutions need to be staffed with experts, and decisions need to be made through a reasoned policy process predicated on evidence-based science and geopolitical knowledge.  … We need to remember that public trust is crucial to governance, and that trust depends on telling the truth.”

Consistent with the urgency of good governance in this country is the recognition that we live in a globalized world.  Participation in international organizations, cooperation with other nations, and empathy for multitudes of people who live in conditions we cannot imagine, whether in shanty towns, refugee camps, detention centers, or on the streets has become essential. We can no longer avert our eyes when it comes to human frailty and suffering. 

In the U.S. we also can no longer live with the stark divide between an insanely wealthy one percent world while the 99 percent struggle to survive. As one pundit put it, change is inevitable and social justice actions will make the Occupy Wall Street movement look like child’s play.

There is another change that hasn’t received sufficient attention: More women are likely to be in leadership positions given their proven expertise in handling the pandemic and modeling leadership at all levels. Whether mayors, governors, community organizers, or prime ministers, women have proven their political and practical skills.

For example, New Zealand’s prime minister Jacinda Ardern’s early actions, including shutting down tourism and imposing an immediate month-long lockdown, limited the spread of Covid-19 and the death toll dramatically. So did the actions of Tsai Ing-wen, Taiwan’s president, who ordered all planes arriving from Wuhan to be inspected as soon as the outbreak there was identified.  She also opened an epidemic command center and ramped up production of personal protective equipment resulting in a stunningly low number of Covid-19 cases and deaths. These two examples help illustrate that women have proven their decision-making and managerial skills, especially in a crisis.

Julio Gambuto, writing for Cognoscenti, noted that “this is our chance to define a new version of normal, to only bring back what works for us, what makes our lives richer, what makes us truly proud. …We can do it in our communities, in what organizations we support, what truths we tell. We can do it nationally by considering “to whom we give power.”

We need only look to New Zealand and Taiwan for models.

                                                            # # #

Elayne Clift writes from Saxtons River, Vt. www.elayne-clift.com

Can a Pandemic Restore Humanity?

When Albert Camus published his allegorical story The Plague in 1947 about a deadly plague sweeping the French city of Oran in 1849, he raised a number of questions about the nature of the human condition. “I have no idea what's awaiting me, or what will happen when this all ends,” one of his characters says. Later Camus reflects that “a loveless world is a dead world, and always there comes an hour …when all one craves for is a loved face, the warmth and wonder of a loving heart.”

As we share the experience of a dystopian world of rapidly spreading disease, political despair and economic disaster, Camus’s words have renewed meaning. They help us remember what is truly important in a world in which we find ourselves increasingly isolated from each other, not only now in an abundance of caution, but because of growing isolation derived from social media in a computer age which fosters disconnection from each other.

That kind of solitude has meant a notable decline in courtesy, responsiveness, and compassion such that we no longer feel it necessary to respond to each other, to check on each other, to truly care about others. Our communities are now virtual to a large extent and loneliness has crept into the lives of many, especially those with limited mobility or age-related restrictions.

We have for too long been disinterested in others and disconnected from each other. Basic responsiveness and reciprocity have all but disappeared.  Now we find ourselves living on a planet spiraling out of control, its inhabitants pleading for a return to safety, and a return to communal well-being. It’s almost as if a higher order – some may call it God – is begging us to return to our fundamental humanity before it’s too late.

The earth itself seems to weep for what we’ve lost by casting upon us catastrophic floods, fires, and famine as we struggle to survive and now to cling to hope.

Of course, there are those among us who bear witness and who offer heart-based action. We donate money, share information, and volunteer while learning to grasp the lessons of isolation, among which are knowing how much we need each other for comfort and survival, practically and emotionally. We recognize our shared fragility and reach out to each other with virtual hugs.

In contrast there will always be those people who don’t look beyond themselves and who ignore and exploit others while remaining complacent, and even finding perverse pleasure in their ignorance and selfishness. We may never be able to expect more of them. As a Facebook post admonished, “Next time you want to judge boat people, refugees, migrants fleeing war-torn lands, remember that we fought over toilet paper.”

But the vast majority of us realize the urgency of compassionate, face-to-face interactive community. We often mourn the downside of computer-driven solitude and work-from-home opportunities, even though now our solitude and work are relieved by computer connection. Perhaps above all, we understand more than ever what can happen when our political leadership fails us and what we can do for each other in the face of such failure.

Still we carry on, and hopefully grow from the current experience of this shared, separative crisis. We offer virtual hugs and comfort, not in fear and despair so much as with the knowledge that our aloneness is no longer sufficient once we reach a new normal. We understand that we must actively and visibly renew our obligation to, and affection for one another. Perhaps  in that renewed knowing we can dare to steward ourselves toward a new world in which we shepherd each other back to a place where we can once again wrap our arms around each other in the knowledge that together, we can, as Winston Churchill once said, “brace ourselves … [and be able once again] to say, This was [our] finest hour.”

A despairing F. Scott Fitzgerald, quarantined in 1920 as a result of the Spanish flu, was able to write to a friend, “I weep for the damned eventualities this future brings. … And yet, … I focus on a single strain of light, calling me forth to believe in a better tomorrow.”

Even more inspiring is a poem by Lynn Ungar, a San Francisco poet, called Pandemic, circulating online, in which she writes, “Know that you are connected in ways that are terrifying and beautiful. Know that our lives are in one another’s hands. Reach out your hearts. Reach out your words. Reach out the tendrils of compassion that move, invisibly, where we cannot touch.  Promise this world your love – for better for for worse, in sickness and health, so long as we all shall live.”

Amen.

                                                            # # #

Elayne Clift writes from Saxtons River. Vt.  www.elayne-clift.com

The Challenging Failures of a Broken Health Care System

If there’s one issue on which there is consensus in this drawn out, drama-laden pre-election time it’s that our healthcare system is seriously broken.  Whether voters are for an incremental approach to reform, a course correction for the Affordable Care Act, or behind a magic bullet Medicare For All plan, they agree that the situation is a mess on many levels, often resulting in catastrophic outcomes or financial ruin.

We all have illuminating stories to tell. Mine is specific to the high cost of healthcare and a suspicion that Medicare is being seriously ripped off.

Not long ago I visited a specialist’s office to relieve a blocked ear that resulted from flying with a cold. A physician’s assistant looked in my ear, declared me free of fluid or infection, and bizarrely suggested I have an MRI to rule out a brain tumor. She then prescribed steroids.  I ignored her advice, tore up the prescription, and three days later my ear popped itself open. 

For that short visit I was billed $38. Medicare paid the remaining $305.

Astounded by a charge of $343 for a brief office visit with a PA, not the doctor I’d booked the appointment for, I called the billing office where I was seen to query the bill. I asked specifically who decided the billing codes, what the criteria were for coding, and why I was billed the same rate for a PA as for the MD I didn’t see. No one could answer my questions. I then called the physician’s office, which referred me back to the billing office.

I wrote to the billing office and soon received a troubling response from the Director of Customer Services, which I felt compelled to answer. My letter speaks for itself.

“Thank you for your response which attempted to explain your cost policies,” I wrote. “I do not wish to beat a dead horse, but I must reply for reasons which are obvious.

“You stated that ‘when it comes to pricing, rates are set by a board of directors annually.’ I fail to see how a hospital board can arbitrarily set prices, or codes, for services covered by Medicare, a federal program that establishes reimbursement standards for anyone whose primary insurer is Medicare.

“You also refer to ‘complexity levels based on the nature of your condition, paperwork, examination and counseling time.’ To be clear, my visit was hardly highly complex.  I had a blocked ear, not a perplexing condition. My visit required no paperwork beyond a chart note and a brief examination which simply involved looking in my ear. No sophisticated equipment or counseling was necessary. 

“You also stated that costs included “caregiver’s time, space where services were provided, equipment, supplies and medications used.” Let me be clear: No equipment, supplies or medications were used. My visit was a half-hour or less.  Am I to believe that my cost included a fee for using an examining room?  What’s next? An elevator fee? Restroom fee? Assessment for corridor or cafeteria space?

“You stated that yours is a ‘charitable healthcare organization’ that cares for people regardless of their ability to pay.  While that is admirable, I do not expect to be assessed a charitable giving fee.  I will decide, not your institution, how much and to whom my philanthropy goes!

“Equally, I do not expect to involuntarily subsidize ‘physician training’, ‘conduct of medical research,’ or ‘specialized services using the newest technology.’  If I wanted to support those goals, I would do so in the form of a dedicated donation. I am astounded that patients are unknowingly assessed fees for these things.

“How interesting that in listing your goals you state that you want to ‘have fair patient prices that enable [you] to advance health through research, education, clinical practice and community partnerships.’  Note the rank order of priorities in that list, and the absence of ‘quality patient care’ as the first priority.

“My experience doesn’t meet all the standards of Medicare fraud and/or abuse as articulated by the federal government and healthcare watchdog groups, but it comes very close to two of them: “Charging excessively for services or supplies” and “upcoding” or incorrect billing.

“I’m sad to say that I don’t expect this letter to change anything with respect to billing at your facility, but I do hope you and your colleagues will reflect seriously about the issues it raises -- and that you will be “fair and balanced” as well as transparent, when addressing costs incurred by Medicare and the seniors served by that program.  It is telling that I received a 10% cut in my Social Security this year due to the increased costs of providing Medicare.  No surprise there now that I’ve seen your billing criteria.”

According to www.CMS.gov ,  a government agency dealing with healthcare fraud and abuse, “No precise measure of healthcare fraud exists, but  those who exploit Federal healthcare programs can cost taxpayers billions of dollars.” CMS defines abuse as “practices that may directly or indirectly result in unnecessary costs to the Medicare program.” Examples of abuse include “charging excessively for services or supplies and misusing codes, or “upcoding.”

                                                            # # #

Environmental Disasters Loom Large But Remain Unnoticed

These are hard and exhausting times. Impeachment issues and the president’s continual bombardment of lies and insults that call for correction are wearing us out, remaining front and center both in the media and our minds. As a result of our fatigue and alarm, and because media is abrogating its duty to report essential news outside of Trump’s tantrums, it’s not surprising that disastrous decisions by the president, and their consequences, have gone unnoticed. None of the actions and policy changes of the current administration is more urgently in need of increased awareness, and resistance, than those that relate to environmental degradation and destruction posing serious threats to our health and safety.

Among the most egregious decisions of the Trump administration is the recent “Strengthening Transparency in Regulatory Science” proposal promulgated by the Environmental Protection Agency (EPA). This terribly dangerous idea would require scientists to disclose all their raw data, including confidential medical records, before the EPA would consider academic studies as valid. Scientific and medical research would be severely limited leading to Draconian public health regulations as well as environmental crises. EPA officials call the plan a step toward transparency, but it is clearly designed to limit important scientific information that should drive policy related to clean air and water, among other health-related environmental impacts.

As a presidential candidate, Donald Trump pledged to roll back government regulations as part of his pro-business “America First Energy Plan.” Once in the White House he immediately signed executive orders approving two controversial oil pipelines and a federal review of the Clean Water Rule and Clean Power Plan. Shortly thereafter, the Clean Water Rule was repealed.

The administration is allowing drilling in national parks and other treasured venues and opening up more federal land for energy development while the Department of the Interior plans to allow drilling in nearly all U.S. waters, opening up the largest expansion of offshore oil and gas leasing ever proposed. This year the administration completed plans for allowing the entire coastal plain of the Arctic National Wildlife Refuge to be made available for oil and gas drilling as well.

You have only to look at who Mr. Trump turned to or appointed to head key agencies that deal with energy and environmental policy. For example, three of four members of a transition team mandated to come up with proposals guiding Native American policies had links to the oil industry and his first head of the EPA, Scott Pruitt, challenged EPA regulations in court more than a dozen times. Pruitt also hired a disgraced banker with no experience with environmental issues to head the Superfund program, responsible for cleaning up the nation’s most contaminated land.

Other departmental gems include Andrew Wheeler, who replaced Pruitt. He was a coal industry lobbyist and a critic of limits on greenhouse gas emissions. Then there’s Rick Perry who was tasked with developing more efficient energy sources and improving energy education. At Interior, Ryan Zinke who didn’t last long. He was followed by an attorney and oil industry lobbyist who put his personal energy into deregulation and increased fossil fuel sales on public lands. At the National Oceanic and Atmospheric Administration (NOAA), a scientific agency that warns of dangerous weather, monitors atmospheric changes, oceans, and more, Trump’s guy was a lawyer and businessman who had advocated against NOAA.

In August, Mr. Trump instructed Sonny Perdue, Agricultural Secretary, to exempt Alaska’s Tongass National Forest, the world’s largest intact temperate rain forest, from logging restrictions and mining projects. The president had already told the Department of the Interior to review more than two dozen monuments with a view to reducing the size of Bears Ears National Monument and other sacred land.

National Geographic has been tracking how the administration’s decisions influence air, water, and wildlife. Here are just some of the ways environmental policies have changed since Trump became president. The U.S. has pulled out of the Paris Climate Agreement, loosened regulations on toxic air pollution, rolled back the Clean Power Act, revoked flood standards accounting for sea-level rise, green-lighted seismic air guns for oil and gas drilling that disorient marine mammals and kill plankton, and altered the Endangered Species Act.

A recent New York Times analysis counts more than 80 environmental rules and regulations “on the way out under Mr. Trump.” So far 53 rollbacks have been completed and 32 are in progress. The Trump strategy, the Times points out, relies on a “one-two punch” in which rules are first delayed, then overridden by final substantive rules. It packs a big punch any way you look at it.

Not long ago I visited Walden Pond in Concord, Massachusetts where the philosopher, writer and transcendentalist Henry David Thoreau lived for two years in a solitary cabin in the mid-19th century. Often credited with starting the environmental movement, he articulated a philosophy based on environmental and social responsibility, resource efficiency, and living simply. He believed fervently that we must keep the wild intact. “What is the use of a house if you haven’t got a tolerable planet to put it on?” he asked.

It’s a question we should all contemplate in the runup to November 2020.

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Elayne Clift writes about women, health, politics and social issues from Saxtons River, Vt. www.elayne-clift.com

Girls and Young Women Will Suffer Most from Anti-abortion Madness

Reading Facebook posts these days has become an exercise in masochism for many of us. Daily horrific posts reveal various forms of violence against the least powerful among us.

Among the victims of such violence are young women and “emerging adult” females. A recent post referenced an eleven-year old girl in Ohio pregnant by rape. Given Ohio’s newly proposed anti-abortion legislation, she could be forced to carry the fetus to term. That’s nothing short of state-sanctioned child abuse. State after state, the same kind of cruelty could be repeated.

We have heard little about the full impact of Draconian measures aimed at overturning Roe v. Wade on women’s mental and physical health, but of this you can be sure: The impact will be more drastic the younger the girl or woman subjected to such measures.

It should be noted that research reveals having a safe, legal abortion does not pose mental health problems for women. According to Lucy Leriche, Vice President of Public Policy, Planned Parenthood of Northern New England, “over 95 percent of women who have had an abortion report feeling relief that outweighs any negative emotion they might have, even years later.”

In contrast, a statement last month by the Activism Caucus of the Association for Women in Psychology (AWP) makes clear the psychological damage that will be inflicted on girls (and women) from restrictions on their reproductive rights, none more so than the hideous laws Alabama and other states want to impose.

“Growing girls learn that in crucial, life-altering ways, the government has more control over their bodies than they do. This is important for many reasons, one of which is that a sense of control has been shown repeatedly in psychological research to be important to mental health and well-being,” write psychologists Paula J. Caplan and Joan Chrisler on behalf of the AWP. “Rape and incest are examples of extreme loss of control, and at least in some cases, making the decision to have an abortion after rape and incest are important parts of healing, which the Alabama law prohibits.”

Like domestic abuse and sexual assault, current proposed and passed laws are about power and control, and men’s fear of losing that power and control. The laws aim to remove any sense of agency from women, over their bodies and their lives. In their worst form, they are a manifestation of terrorism in which a women’s body is owned by the state, as it was in the chilling novel, The Handmaids Tale. Laws that attempt to incarcerate a woman for crossing state lines to have an abortion, laws that can send her or her physician to jail for life, laws that in the extreme could result in executing a woman for having an abortion reveal the pure evil underpinning these laws.

Let’s remember that the same men (and yes, some women) who want to torture girls and women in these ways are the same men (and women) who legislate against ensuring the health, safety, education, and well-being of the babies born of this unspeakable coercion, and who rabidly support capital punishment.

Even if these reactionary attempts to challenge women reproductive and human rights were to fail, “the blaming and shaming of girls and women who choose to use birth control measures or who choose to have abortions causes fear, self-doubt, low self-confidence, feelings of being unsafe, and beliefs that others consider [women and girls] unable to make major, or ethical decisions,” the AWP points out.

The truly heartbreaking thing is that once shamed, fearful, self-doubting, and depressed, it is almost impossible to regain a sense of personhood or control over one’s life. That kind of despair, in which it seems impossible to envision a way out, especially prevalent in the young, can easily lead to self-destructive behavior, including suicide.

Some years ago, when I worked in Romania on reproductive rights, I saw the damage done to girls, women, and children during the time of the dictator Ceausescu. His regime required all girls graduating from high school to undergo a pelvic exam to determine if she was pregnant. Every working woman was also subjected to monthly pelvic exams in their workplaces. These cruel practices were enforced to ensure that all pregnancies were carried to term. I saw the results of that grotesque policy in the Casa Copii – orphanages where unwanted babies were dumped. Many of the children were visibly impaired, physically and mentally. Others suffered in ways that can only be imagined. Very few of them, I’m certain, had any vision of a happy future. It was worse than Dickensian and it broke my heart.

What is happening in this country now is not far removed from the tragedies that have occurred because of pronatalist policies elsewhere. The lack of humanity, morality, and ethics inherent in such policies is stunning. It leaves one speechless. Incredulous. Furious. Grieving.

But it must not leave us silent.

We must march in unity, speak out vociferously, resist mightily, vote, and support the #SexStrike movement together. Most of all, we must refuse to sacrifice our young and our females on the alters of misogyny and in the chambers of violence. Our survival as sentient beings depends upon it.

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Elayne Clift writes about women, health and social justice issues from Saxtons River, Vt. www.elayne-clift.com

Think the FDA is Looking Out for You? Think Again!

Back in the 1970s, when I sat on the FDA Consumer Consortium, an eclectic advocacy group comprised of organizations concerned with the health and well-being of various constituencies, I quickly learned that the FDA approval process needed watching. That was never truer than now.

Recently, as reported by the New York Times, the Food and Drug Administration went public with the fact that it couldn’t guarantee the long-term safety and efficacy – FDA’s twin mission – of a particular medical device, vaginal mesh products, that have been on the market for decades. Women were not surprised. Many of them remembered what Thalidomide and DES had done to them or their mothers, and many had experienced the failures and problems associated with breast implants.

Despite well-documented breast implant problems, an implant linked to a rare cancer is still being sold in the U.S., even though it’s banned in many other countries, because the FDA says there isn’t enough data to justify banning them. The vaginal mesh products in question, which support pelvic organs, have long been tied to life-altering injuries, according to the Times report. Eighty deaths were reported as of last year as a result of mesh complications, and over the past decade several companies have paid out $8 billion to resolve over 100,000 patient claims. Here’s what’s really shocking: Most of these medical devices were approved with almost no clinical data to support their safety.

As the Times story noted, “When trouble arises, devise makers equivocate, regulators dither, and patients seeking redress are forced into lengthy, expensive court battles.” That means that faulty or dangerous products can be on the market for years.

Vaginal mesh products were finally removed from the market in April, but the FDA has said it will not ban the breast implant linked to cancer and other forms of “breast-implant illness” because FDA regulators claim there is insufficient evidence of harm to justify pulling the product.

It’s not only women who are affected by poor FDA oversight or sheer negligence. Metal hips, implantable defibrillators, and artificial heart valves have also proven disastrous in some instances. “There have also been staples that misfired, temperature control machines that spray bacteria into open chest cavities, and robotic surgeons that slap, burn and main patients,” according to the Times story.

In every one of these cases, dubious regulatory approvals, poor post-market surveillance, and inadequate responses from regulators have caused irreversible, and avoidable, harm.

According to the International Consortium of Investigative Journalists, nearly two million injuries and over 80,000 deaths have been linked to faulty medical devices, many approved with little or no clinical testing. The FDA has continued to promised “transformative” changes to medical device regulation, but it’s ideas for improved regulation have yet to be realized, while regulation of the device approval process has generally accelerated. The head of the FDA office responsible for device regulation, Dr. Jeffrey Shuren, a former venture capitalist, is fine with that. He’s on record saying the benefits of getting innovative products to the marketplace quickly is worth the increased risks.

The FDA’s history hardly encourages hope that its regulation and oversight will improve any time soon. Its numerous scandals include a 2016 insider trading prosecution and a 2009 politicized medical device approval. A 2013 ProPublica investigation found the agency had overlooked fraudulent research and allowed potentially unsafe drugs to remain on the market.

How can such corruption be explained? First, follow the money. According to a 2018 report in Science Magazine, 40 physician advisors out of 107 who voted on FDA committees received more than $10,000 in post hoc earnings or research support from drug manufacturers whose products were approved by panels on which the physicians served. Almost half of the 40 physicians who were rewarded for their vote got more than $100,000, and six received more than $1 million.

As a blogger on http://globalnaticorruptionblog.com noted in 2017, “Corruption blooms where transparency and accountability are lacking.”

Because of that, “Instead of a regulator and a regulated industry, we now have a partnership,” Dr. Michael Carome, director of the health research group at Public Citizen, told ProPublica last year. “That relationship has tilted the FDA away from a public health perspective to an industry friendly perspective.”

So what can be done about a growing list of FDA disasters? Most advocates agree approval standards must be tightened so that loopholes can be closed, most importantly those that allow medical devices to hit the market in the absence of human testing. Post-market surveillance also needs to be fixed. It’s unbelievable that medical devices can be on the market before enough rigorous testing has occurred by manufacturers who argue that further testing of products occurs once they are being used. Finally, the revolving door that allows manufacturers and Big Pharma folks, who fund much of FDA’s mission, to work for the industry, then for the FDA, and back with industry again must be disallowed.

No patient should have to worry about medical devices, procedures or drugs being dangerously flawed or life-threatening. For those who have died when they are, the least the FDA can do is to correct course on their behalf, quickly and completely.

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Elayne Clift writes about women, health, and social justice issues from Saxtons River, Vt.

America's Shameful Maternal Mortality Rate

This being the month to celebrate mothers, it seems timely and important to ask, why is maternal morality so high in this country?

According to a recent report by the Commonwealth Fund, American women have the highest risk of dying from pregnancy complications than in any other high-income country. Their report shows that we have 14 deaths per 100,000 births; the Centers for Disease Control puts it even higher at 18 per 100,000 births. Compare that to Sweden’s 4 per 100,000 or the UK rate of 9 per 100,000 and we are not so “developed” as we think.

Maternal mortality is “a death that occurs during pregnancy or within a year postpartum from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiological effects of pregnancy.” In the U.S. it has risen to the level of social crisis from a public health perspective. Our maternal mortality rates have more than doubled in the last twenty years, with African American women suffering at the alarming rate of 40 deaths per 100,000. Some experts say it’s getting deadly to give birth here.

Several factors are at play, but one big problem relates to our high C-section rate. A third of American mothers are now delivering by Cesarean section, an increase of more than 500 percent since the 1970s. That’s an astounding figure even if surgery can be necessary sometimes. But what doctors, and moms who elect to have a section, often forget is that we’re talking about major surgery, not something as simple as a tooth extraction.

As the World Health Organization notes, C-sections are effective in saving maternal and infant lives, “but only when they are required for medically indicated reasons.” C-section rates higher than 10 percent, the organization says, are not associated with reductions in maternal and newborn deaths.

“We’ve designed the birth environment to resemble an Intensive Care Unit. Ninety-nine percent of American women deliver in environments that resemble ICUs, surrounded by surgeons,” Dr. Neel Shah, a professor at Harvard Medical School, told a New York Times reporter.

Midwives, who’ve been delivering babies for millennia, have known for a long time that woman-centered childbirth is basically a natural process that, with appropriate support, ends well; it is not routinely a medical emergency. Women who elect to have midwife-assisted deliveries, a practice that has grown since the 1970s thanks to women’s health advocates, know this too.

The midwifery model espouses a holistic approach to childbirth that includes affirmation and comfort as a woman experiences one of the most significant lifetime events. Midwives are highly trained professionals who call in a physician if the situation warrants, and research shows they have better outcomes than physician-directed births. In addition to skills and techniques that can avert an intervention, midwives have an abundance of patience. They understand that birth cannot be rushed, and they know that less medicalization is appropriate in normal births rather than more.

In most countries, mothers deliver their babies with midwives, who provide a relaxed but watchful environment. In this country, as research by Dr. Shah noted, a surgical delivery has less to do with health issues or particular physicians than with the hospital in which a mom delivers. “Your biggest risk factor is which door you walk into,” he says. That’s particularly true in urban cities and teaching hospitals. It’s also why women are now alert to “buyer beware birthing environments.”

Birthing centers like the one at South Shore Hospital in Weymouth, Massachusetts are breaking new ground in woman-centered childbirth. A team of experts there committed to reducing the C-section rate have developed a model to reduce Cesarean sections in collaboration with Dr. Shah and others at physician-writer Atul Gawande’s Boston Ariadne Labs. Recently they made national news when the team delivered twins naturally, one of whom (at least) would have been deemed a section in most other delivery suites.

In 2017 the House of Representatives introduced the Preventing Maternal Deaths Act which directs the Department of Health and Human Services to offer a range of ways to reduce the maternal mortality rate, including Maternal Mortality Review Committees, at the state level. It also provides for public disclosure of information in state reports. Passed by the Senate, Donald Trump signed the bill into law in December 2018.

In the U.S., the C-section rate continues to vary from seven to 70 percent, while the CDC estimates that 60 percent of maternal deaths in the U.S. are preventable. Those are shocking numbers, especially in a so-called developed country that reveres motherhood, at least rhetorically.

The lives of childbearing women in this country depend on the success – and implementation – of established and proposed legislation, especially to address structural inequities that put black, indigenous and rural families at disproportionate risk, making policy changes relating to Medicaid imperative. Several Democratic legislators have introduced such legislation.

For it to make its way through the labyrinth of public policy, people who care about moms, wives, and other American women, urgently need to advocate on their behalf.

What better time to start than on Mother’s Day?

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Elayne Clift writes about women, health, and social justice issues from Saxtons River, Vt. (www.elayne-clift.com

Women Beware! Birth Control, Abortion, and Your Healthcare Are at Risk

You’re a middle-class mom with two kids, a mortgage, a fragile marriage, and an elderly parent to care for when you find yourself pregnant. You’re a sexually active college student and because of a condom failure you’re pregnant. You’re pregnant with a wanted child when you learn your fetus has a serious anomaly and probably can’t survive outside the womb. You are a rural woman with limited income who gets routine healthcare at a Planned Parenthood now threatened with closure.

Variations on stories like these abound. For all kinds of women, and their advocates, they are terrifying, as federal and state legislators continue gunning for Planned Parenthood and vehemently resisting female autonomy, privacy, and decision-making.    

As a recent New York Times piece by the editorial board stated, “In its continuing assault on reproductive rights, the Trump Administration has issued potentially devastating changes to the nation’s nearly 50-year-old family planning program, Title X, which allows millions of women each year to afford contraception, cancer screenings, and other critical health services.”

To be clear, health clinics like Planned Parenthood have been barred from using federal funds for abortions, but they have been able to to offer non-federally funded abortions and other family planning services under one roof. Now the Department of Health and Human Services wants to make clinics that provide abortions navigate ridiculous regulations if they want to receive Title X funds. I mean ridiculous regs, like having separate entrances for abortion patients, or establishing an electronic health records system separate from their regular system. Providers will also be prohibited from making abortion referrals, or providing information that adheres to standards for “informed consent.”

In addition to threats at the federal level, more and more states are attempting to pass ridiculous anti-abortion laws, like requiring wider hallways or revamping janitor’s closets.

More Draconian is the unethical “domestic gag rule” that allows so-called “pro-life” staffers in Title X facilities to say a particular procedure doesn’t exist or to lie to patients about false risks of abortion.

As Dr. Leana Wen, the new president of Planned Parenthood, told The New York Times, “There will be many providers that will face an impossible decision: to participate in Title X and be forced to compromise their medical ethics, or to stop participating in that program,” a step that would lead to overwhelming demand for reproductive health care but not much in the way of supply to respond.

Since Roe v. Wade was decided in 1973, states have been constructing a maze of abortion laws that codify, regulate and limit whether, when and under want circumstances a woman can have an abortion, as the Guttmacher Institute points out. Major provisions to states laws, some on the books, other in litigation or defeated, include requiring that abortions be performed in a hospital or set gestational limits on abortion.

One example is the attempt to ban abortions when a faint heartbeat is detected, which can occur as early as six weeks, before a woman may know she is pregnant. Another is state restrictions on coverage of abortion in private insurance plans, and states allowing individual health care providers to refuse to participate in abortions. Some states mandate that a woman have counseling, including information on purported links between abortion and breast cancer, the ability of a fetus to feel pain, or long-term mental health consequences for the woman.

The Trump administration clearly wants to evict Planned Parenthood from the federal family planning program. It also hopes to ban abortion referrals. At the state level, early abortion bans called “heartbeat bills” are being proposed in several states. So far, five of them have advanced this legislation but every “heartbeat bill” passed to date has been overturned in state or federal court. With Judges Gorsuch and Kavanaugh on the Supreme Court, who know what will happen?

Five states have already passed preemptive “trigger laws” which would immediately ban abortion outright if Roe v. Wade is overturned.

Several abortion cases are currently in federal appeals courts or pending litigation in various states. Lawsuits are challenging such issues as required waiting periods, required ultrasounds, 15-week bans, admitting privileges, abortions for minors, and Medicaid coverage.

The situation, not only for women seeking their constitutional right to abortion, but for women – and men - seeking appropriate, quality, accessible, affordable reproductive health care ranging from preventive screening and contraception to treatment of sexually transmitted diseases, grows ever more dire as the Trump administration, and state legislators attempt to control what should be women’s private, personal decisions.

The irony is that rules rooted in anti-abortion (and anti-sex education) feelings threaten access to contraception, which prevents unwanted or unintended pregnancy and consequently increases health care costs in a nation where the cost of care is already skyrocketing.  Can anyone explain why that makes sense? 

More importantly, perhaps, can anyone fathom what would happen without Planned Parenthood?

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Elayne Clift writes about women, health, and social issues from Saxtons River, Vt.

www.elayne-clift.com

Let's Be Clear About Third Trimester Abortion

As a longtime women’s health educator and advocate, I was apoplectic when I read a recent commentary in my local newspaper by a “chaplain serving an elderly population” who is also “treasurer of the Republican Party” in my state and a “county party chair.”

The op.ed. proffered so many spurious and false assertions, often stated by others with far-right political views, that my hair was nearly on fire. Given where we are in this country regarding abortion, I felt compelled to address one of the egregiously uninformed views of the author, which I did in a Letter to the Editor.  It seems to me now important to share what I wrote for a wider audience, in the hope of reaching others inclined to make uninformed claims about a vital issue that affects so many lives and the culture in which we live. 

This is the claim that blew me away. It relates to a bill in my state proposing a law like ones in some other states protecting a woman’s right to abortion moving forward. “The bill goes far beyond Roe [v. Wade], guaranteeing unrestricted abortion through all nine months of pregnancy…” the author wrote. It’s a misleading claim that calls for revisiting the facts regarding the inaccurate use of the term “late term abortion.”

The first thing to note here is that abortion after fetal viability is a rare occurrence and usually involves a medical crisis. According to the US Centers for Disease Control and Prevention, abortions after 21 weeks make up less than 1.3% of all abortions in the United States. Abortions that occur beyond 24 weeks make up less than 1% of all procedures. Exceptionally rare cases that happen after 24 weeks are often because a fetus has a condition that cannot be treated and and that renders the fetus unable to survive, regardless of gestational age or trimester.

Secondly, the 14th amendment of the Constitution, which guarantees due process and equal protection under the law, was vital to the 1973 Supreme Court decision in Roe v. Wade. The 14th amendment also protects the right to privacy and the Court held that a woman's right to an abortion fell within that statute. By a 7–2 majority the Court ruled that unduly restrictive state regulation of abortion is unconstitutional. Importantly, the Court also determined the point of fetal viability as the “capability of meaningful life outside the mother's womb,” hence the 24- week marker. The Court’s decision gave women a right to abortion during the entirety of the pregnancy, however, while defining different levels of state interest for regulating abortion in the second and third trimesters.

It’s important to know that, as the Guttmacher Institute points out, if a physician determines that the child is “non-viable” and/or the abortion is necessary for the physical or mental health of the mother, a woman can have an abortion from the moment of conception until the child’s birth. State laws restricting third trimester abortions are unconstitutional under the precedent of Doe v. Bolton, a case in which the Supreme Court overturned a Georgia law. (Numerous states have laws that ban or restrict abortions in the third trimester. Because these statutes remain in place or haven’t been contested in federal court, they may imply that they are allowed by federal law. But because federal law trumps state law, no restrictions can be enacted that do not also allow the doctor to determine if abortion is necessary for the health of the mother.)

Here’s another fact: Overturning Roe and Doe won’t end all third-trimester abortions. When the Supreme Court throws the abortion issue back to individual states, third-trimester abortions will still be protected in states that reiterate prior standards for “viability” or “health.”

But here’s the most important thing for everyone to know. No woman decides to have an abortion after 24 weeks recklessly or without a great deal of anguish. Perhaps she does it because of a serious illness she has, like decompensating heart disease. Maybe her baby has a delayed diagnosis of anencephaly, which means the fetus forms without a complete brain or skull. There are a multitude of medical crises that can precipitate a third trimester abortion. But the decision is never taken lightly. In most cases, there is deep grieving and a profound sense of loss, brought about because of medical necessity and the wish that a much loved and wanted baby not suffer.

That’s why people like the man who wrote the troubling commentary – claiming that he “doesn’t oppose or seek to diminish women’s rights” and that he “supports [women’s] right to their own body and right to choose” -- people who misunderstand not just the right to abortion but the reasons women choose it, at any stage of pregnancy, must move beyond facile arguments, misstatements of fact, and feeble justifications. They must somehow begin to recognize that for many women, the choices they face are devastating and immensely complicated.  

Most urgently, they must find it in themselves to be compassionate and to resist judging those whose experiences and viewpoints differ from theirs. 

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Elayne Clift writes about women, health, politics, and social issues from Saxtons River, Vt. www.elayne-clift.com

Women vs. Fetus: Is Social Control Out of Control?

Not long ago, a woman in late pregnancy suffering severe depression tried to commit suicide. She survived but her baby died. She was charged with murder. A pregnant woman who lost her unborn child in a car accident in New York state was charged with manslaughter. So was a woman in Indiana who gave birth to a stillborn baby.

Even in cases where a fetus hasn’t died, pregnant women have been charged with crimes in various states – for miscarrying, falling down the stairs, failing a drug test, or taking legal drugs during pregnancy, often prescribed by doctors.

These examples, reported in a recent New York Times series exploring “legislative intrusions into the womb,” reveal a paternalism that is not new, but is alarming, and growing in the Trump era. They are also reminiscent of other frightening autocratic and dictatorial eras. Hitler, for example, “recruited” German women to produce Aryan children. Under the Romanian dictator Ceaușescu, assassinated in 1989, women were subjected to monthly pelvic exams in their workplaces while high school girls were routinely digitally raped by male doctors to ensure that all pregnancies were carried to term. In The Handmaid’s Tale, resurrected in the face of Trumpian resistance to reproductive freedom, forced insemination of those selected to be Mothers is assisted by designated Wives.

If all of this is disgusting to imagine it should be because it derives from a vile act of social control. Such control, still relatively rare but growing, is already occurring in America.

Here’s just one example.  Politicians in Ohio recently considered a bill that could have allowed abortions to be punishable with life sentences or the death penalty. The proposed law, would have extended the definition of a person in Ohio's criminal code to include the "unborn human." That meant that a fetus, from conception to birth, would be considered a person, leaving people who perform abortions or women who have them vulnerable to severe criminal penalties.

According to the ACLU, at least 38 states have fetal homicide laws, most of which relate to fetuses killed by violent acts against pregnant women. So-called pro-life advocates use laws like the Fetal Protection Act, the Preborn Victims of Violence Act and the Unborn Victim of Violence Act to argue that fetuses are persons, or “a child in uterus,” and need to be protected in all circumstances.

The ACLU argues that “a pregnant woman and her fetus should never be regarded as separate, independent, and even adversarial, entities. Yet that is precisely what some anti-choice organizations, legal theorists, legislators, prosecutors, doctors and courts have attempted to do in the past decade.”

Legislation designed to protect fetuses can take different forms, the ACLU points out. All of them endanger reproductive rights. States may amend existing homicide statutes to include fetuses as victims, they can pass statutes defining a fetus as a person, or establish a new crime category called “feticide” or fetal homicide. They can also permit civil suits against anyone who causes the death of a fetus, or enact new statutes to penalize injury to a pregnant woman that causes fetal death or injury. This law is aimed primarily at practitioners, which flies in the face of the constitutional right to choose, established by Roe v. Wade, which calls for abortion to be exempt from punishment when performed by “health care workers with the consent of the woman or in medical emergencies, and self-abortions.”

Clearly, fetal protection legislation fosters the policing of pregnancy, just as it did in Romania. It makes it more likely that practitioners will become overzealous, thereby complicating routine healthcare decisions. In Florida, for example, a woman was told by her doctor that he would send law enforcement to her home if she didn’t get to the hospital immediately for a C-section. A New Jersey mother lost custody of her newborn after refusing a surgical delivery.

All of this raises the larger, deeply troubling issue of social control, which usually comes at the expense of women. Writing in The Atlantic’s latest issue, editor Peter Beinart sounds this alarm: “Authoritarian nationalism is rising in a diverse set of countries [for various reasons, but] right-wing autocrats taking power across the world share one big thing, which often goes unrecognized in the U.S.: They all want to subordinate women.”

The question is why, and Valerie M. Hudson, a political scientist at Texas A&M, has this answer: “It’s vital to remember that for most of human history, leaders and their male subjects forged a social contract: ‘Men agreed to be ruled by other men in return for all men ruling over women.’ This political hierarchy appeared natural—as natural as adults ruling children—because it mirrored the hierarchy of the home. Thus, for millennia, men, and many women, have associated male dominance with political legitimacy. Women’s empowerment ruptures this order.”

In other words, keeping women “barefoot and pregnant” is essential to patriarchy. Autonomous women liberated from childbearing, empowered with reproductive choice, unleashed into the marketplace, the academy, and government threaten male power. That reality has played out in various forms throughout history.

Seeing it happen in the 21st century is unacceptable.

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Elayne Clift writes about women, politics and social issues from Saxtons River, Vt. www.elayne-clift.com

Keeping a Finger on the Pulse of America's Dangerous Epidemics

Advocates for sensible gun legislation had it right when they framed the epic number of individual and mass shootings in this country as public health issue. Public health professionals and organizations like the American Public Health Association and the American Medical Association have continued to push for addressing gun violence as a growing epidemic, and so they should.

According to the Brady Campaign, 318 people in America are shot daily in murders, assaults, suicides, suicide attempts, unintentional shootings, and police intervention. Every day 96 of them die from guns. No wonder. In this country, 1.7 million children live in a home with an unlocked, loaded gun and millions of guns are sold every year in “no questions asked” transactions.

Part of the gun violence epidemic we face resides in the growing, almost contagious episodes of police brutality and unnecessary use of weapons, primarily against people of color.  This year over 430 people have been shot and killed by police and the year is barely half over. Last year’s total number was 987. Some of the names we remember are Michael Brown, Trayvon Martin, Eric Garner and Tamir Rice. Among those whose names we may not recall are Danny Ray Thomas, an unarmed black man clearly suffering from a mental health crisis, who was killed by a Texas police officer, and more recently, Stephon Clark, another unarmed black man who was shot eight times, six of them in the back, by Sacramento police while simply holding a cellphone in his grandparents’ backyard.

We are clearly facing a growing number of public health crises involving guns, but gun violence, no matter who commits it, isn’t only contributing to a crisis that involves instant death or disability.  It is also leading to an epidemic of crises in mental health among survivors and victims’ families. Where is the discussion of that issue?  It’s telling that a search for information on this invisible crisis led me to myriad articles ruminating on the idea that gun violence is perpetrated by people with mental health problems, but not one link deliberating on the mental health toll gun violence takes on survivors or family members appeared.

Yet, just think what it must have done to Tamir Rice’s mother to learn that her child, simply playing with a toy, had been shot to death by police.  Or to Stephon Clark’s grandparents as they saw their grandchild gunned down in their backyard. Or to Eric Garner’s family, not only left to deal with economic worries, but with the lifelong sorrow of a husband and father being choked to death by police. Think about what Michael Brown’s family, Trayvon Martin’s family, Sandra Bland’s family and the multitudes of other family members of the unknown victims of violence– spouses, children, siblings – will have to live with for the rest of their lives. It is possible that there are worse things than death, like living with despair, and dread.

There is another epidemic of violence that needs attention as we appear to descend into a dark place while struggling with a new, unfamiliar reality grounded in our current political environment. America has always had an incipient underbelly, but unlike those who survived the fascism of Europe preceding and during WWII, Americans have been fortunate (until now) to avoid the punishing life of autocracy and dictatorship.

Now come Donald Trump et.al., and along with his followers, a dramatic increase in hate crimes not unlike the ones seen in many countries during the 1930s and 1940s and emerging once more. America has seen a growing number of hate crimes in recent years but they are proliferating even more as racists and white supremacy groups feel emboldened to openly spew their contempt for others. That contempt is aimed first at Jews, and then at Muslims, according to the FBI. Hate crimes are also on the rise as perpetrators target the LGBTQ community.

According to the Southern Poverty Law Center, the number of hate groups has increased along with the growing number of hate-filled violent acts.  These crimes range from vandalism in synagogues and cemeteries to graffiti messages and Swastikas on buildings, to threats to religiously affiliated schools. Many hate crimes are perpetrated against individuals. In 2014 a man killed three people at two Jewish centers near Kansas City, and recently a Muslim man was beaten in the Bronx by attackers calling him a terrorist. In another incident in New York, a man shoved a Mexican immigrant onto the subway tracks after dragging him off a train. He narrowly escaped death.

All the growing violence we’re witnessing, whether manifesting as verbal abuse or escalating to hate crimes and murder, even at the hands of police, can appropriately be seen as epidemic. And epidemics, seen through the public health lens, call for controls and eradication. None of us can be inoculated against the diseases of hatred in our zones of relative comfort and safety, because “no man [sic] is an island.”  As another famous quote reminds us, “Together we stand. Divided we fall.” 

The pain of a potential fall looms large, and it is likely to be more than any of us could bear.

Back to Barefoot and Pregnant Politics

In the late 1970s as I was beginning my career in women’s health, one of the first feminist icons I met of was a flamboyant, passionate, and deeply committed woman named Perdita Huston.  She had made her mark internationally working as a journalist and a Peace Corp professional, but what put her on the feminist map was her 1979 book Third World Women Speak Out. 

 

Huston’s book was remarkable because she was the first person to give women in the developing world a chance to tell their own stories. She gave them voice, and with that voice what they proclaimed most loudly was that they wanted fewer children, and they wanted those children to be educated.

It was a radical moment with far-reaching ramifications because it coincided with the early days of family planning becoming a goal of international funding agencies like the U.S. Agency for International Development (USAID). With the help of the Women in Development movement, spawned in large part by the Women’s Movement at large, donor organizations had begun to realize that family planning was key to a country’s economic and social development and that women’s reproductive health was an issue that mattered.

Subsequent years revealed that family planning was, indeed, a wise investment. Countries like Egypt and Bangladesh showed that once women controlled their fertility, families, communities, and countries benefited, whether by increasing educational opportunities for girls, widening agricultural opportunities for women, or bringing women into decision-making at some levels of society.

None of this happened quickly or easily; there are always naysayers and development “specialists” willing to argue against innovation (and empowering women), no matter how simple and effective an intervention may be. But gradually the world saw how important family planning was to the healthy development of nations, let alone women and their families.

Now fast forward to Trumpian times, in which the president has reinstated Ronald Reagan’s Mexico City Policy of 1984 – revoked by Bill Clinton, restored by George W. Bush, and revoked by Barack Obama - in which nongovernmental organizations are forbidden to receive U.S. federal funding if they perform or promote abortion in other countries. 

Trump goes even further. His administration, including the Departments of Health and Human Services, Treasury and Labor, wants to make it easier for employers to deny contraceptive coverage to their employees if the employer has “a religious or moral objection” to doing so. The administration also wants to make it harder for women denied birth control coverage to get no-cost contraception directly from insurance companies, as they have been doing.

In an attempt to rush this through, the administration made the absurd claim that taking time to seek public comment would be “contrary to the public interest,” and went so far as to say that coverage of contraception could lead to “risky sexual behavior,” a nod to those who believe women’s sexuality is evil.  Not only is that one huge misogynistic insult to women; what is riskier than setting women up for unwanted pregnancies while trying to eliminate safe abortion and shut down Planned Parenthood?

 These actions are a setback of huge proportion. They affect not just American women, but women around the world.  In Madagascar, for example, the change in policy is forcing dramatic cutbacks by the largest provider of long term contraception in the country, Marie Stopes International (MSI), which receives millions of dollars from USAID for its work there. Ironically, abortion is illegal in that country, but MSI cannot receive American aid because it will not renounce abortion as part of reproductive health services in other parts of the world.

Hundreds of women and girls flock to remote MSI clinics where they receive everything from malaria prevention to HIV treatment to contraceptives. It’s a scene repeated all over the developing world no matter who is providing services. What is to become of all those women?

The policy, already making its way to the courts, is clearly aimed at mollifying organizations like March for Life and Real Alternatives, anti-abortion groups that don’t qualify for religious exemptions but claim to hold strong moral convictions unrelated to a particular religion.

In his long string of lies, Trump and his administration have claimed, absent of any evidence, that its new rules won’t have an effect on “over 99.9 percent of the 165 million women in the United States,” while simultaneously arguing that low-income women will still be able to get subsidized or free contraception through community and government health programs. All this while the administration plans to substantially cut government spending on such programs.

The President’s attack on birth control, safe and accessible abortion, and the Affordable Care Act is low on intelligence and high on lies. It is spiteful, vindictive, woman-hating, and downright mean. It will hurt millions of women and their families. There are only two ways to describe it: utterly inhumane and grossly misogynistic. Everyone should be resisting mightily.

America's Rural Health Care Crisis Grows

Not long ago I received a call from my doctor’s receptionist. My long-time primary care physician and partner in healthcare decision-making was retiring her practice, she said, along with two other doctors in our small town. Together they would be leaving 4,000 patients to find care in a community where most physicians are not taking new patients because they are already overwhelmed by their caseload.

I felt especially troubled by the news since I don’t go to just any doctor, even if one is available. As a proactive health consumer, I research providers carefully because I want to work with someone with proven competence, a compassionate heart, and a philosophy of primary health care that supports my own. Finding a doc like that is not easy. It’s especially challenging when there are too few physicians available.

I also realized that I had become part of the troubling landscape of rural health care. I was suddenly caught up in a picture represented by facts and statistics like these: Disparities in access to healthcare for people who live in rural areas of America continue to widen. Recruiting physicians willing to work in isolated areas has also become more difficult, and is not helped by Donald Trump’s plans with respect to work visas and travel bans. Rural hospitals are closing at an alarming rate. In the past six years, 80 of them have closed and if the rate of closures holds, 25 percent of rural hospitals are predicted to close in less than a decade.

The number of doctors per 100,000 residents is 40 in rural areas compared to 53 in urban environments. That’s not counting specialists, where the comparison is 30 to 263. More than half of our counties have no practicing psychiatrist, psychologist or social worker while opioid-related addictions and overdoses are disproportionately higher in rural areas.

In addition, America’s rural population is older, makes less money, smokes more, is generally less healthy, and uses Medicaid more frequently.  Diabetes and coronary heart disease are more prevalent in rural areas and the death rates for rural white women have increased as much as 30 percent in recent years, reversing previous trends.

Studies published in the British Medical Journal recently revealed a severe lack of resources at rural hospitals, sparse staffing and limited access to specialist consultations and diagnostic tools. An attempt to reduce emergency department admissions for cost-cutting is also putting patients at risk.

The situation is complex and challenging due to economic factors, social differences, educational shortcomings, lack of understanding and political will among legislators, and the isolation of living in remote areas, according to the National Rural Health Association.

Some health care analysts and managers advocate for increased use of technology to help solve the growing problems in rural health care delivery, arguing that while technology won’t solve all the problems, it can make a discernable difference. For example, the Institute of Medicine believes that telemedicine can allow rural hospitals to “cut down on the time it takes rural patients to receive care, particularly specialty care.”

That’s all well and good, perhaps, when it comes to hospitals reducing costs and meeting their other needs. But where does it leave me, and other rural patients, when we’re sitting in our johnnies waiting to (literally) see our doctors?  Where is the comforting face-to-face communication and the physical observation so vital to a clinician’s assessment of a patient’s condition and emotional state? Where is the Q&A necessary for shared decision-making? I once left a practice because my doctor, who had previously looked me in the eye when we talked, listened carefully to what I said, and talked to me like a peer, suddenly couldn’t get his face out of his computer screen long enough to greet me when I entered the room.

As I search for a new doctor – the right doctor – in the coming days, I recognize that like many others, I have a big challenge ahead. For me that challenge goes beyond numbers - something the profession includes in discussions of “accessibility.” It involves trust, proven skills, two-way communication - often around intimate issues or possible critical life decisions - and mutual respect.

Such a partnership for health is not easy to find no matter where one lives. In rural America, it is becoming even more difficult. Patience and perseverance in selecting, hopefully, from a crop of good new physicians, may be just what the doctor – and this community -need to order.

Getting Real About Guns

Post Orlando, let’s get real. The latest massacre in America, and its worst to date, was not about ISIS. It was not about Muslims or Islam. It was not about mental illness.

It was about guns and how easy they are to obtain in this country. It was about our incredible inability to effect legislation that would do something about what is now recognized as a national embarrassment as well as a continuing national tragedy, one that is finally acknowledged to be a major public health issue.

The shocking numbers support that claim. Last year 469 people died as a result of 371 mass shootings. So far this year at least 288 people have died in 182 mass shootings. Since Orlando, more than 125 people have been killed by guns, 269 were injured, and five mass shootings have occurred. We don’t even hear about most of these events, or the fact that nearly 10,000 American children are killed or hurt by guns every year.  Nationally, guns kill twice as many children and young people as cancer and 15 times more than infection according to the New England Journal of Medicine. Let that sink in.

Here’s another startling statistic. In 2010 there were 3.6 gun murders per 100,000 Americans.  In Canada and Portugal there were 0.5. Many other countries ranked even lower than that, including Australia at 0.2.  (Does anyone seriously think they have fewer mentally ill people per capita than we do?)

Lat month a story in Seven Days revealed that a reporter bought an AR-15 semiautomatic rifle in South Burlington, Vt. for $500 cash with “no paperwork and no background check. [The seller] had no idea who I was or what my intentions were,” Paul Heintz wrote. “Nine minutes after I met the man, I drove away with the sort of weapon used 39 hours earlier to slaughter 49 people in Orlando.” A woman in Philadelphia reported a similar experience, beating Heintz’s time by two minutes.

Sadly, my home state of Vermont has the nation’s most permissive gun laws, so what took place when Heintz bought his gun, the same kind that killed all those children and their teachers in Newtown, Ct., was legal. The same kind of gun, by the way, also killed the people in Aurora and the people in San Bernardino.

What will it take to end the madness? One answer comes from a grassroots movement in Vermont, where gun laws have been nearly nonexistent and its politicians have waffled over the issue for years.

Gun Sense Vermont (GSV), an example for others, has been effectively moving reluctant politicians and prospective candidates toward action. Since startup three years ago, GSV’s track record is impressive. It first began a conversation about guns in the Statehouse. Then last year state senators received 1400 letters from constituents along with 12,000 petition signatures calling for action, all from Vermonters. Two Senate committees seriously considered gun-related issues and gun-owning groups announced a plan to lead a Vermont version of the suicide-prevention New Hampshire Gun Shop Project. The Vermont Senate Judiciary Committee voted unanimously to send a bill to the full Senate making it a state-level violation for felons to have guns, and to require court records of dangerous individuals be submitted to the National Instant Background Check System. And the governor signed into law a bill to prevent gun violence.

“Gun Sense Vermont is a growing, bipartisan, grassroots organization that focuses on closing gaps in Vermont’s gun laws that make it too easy for guns to fall into the wrong hands,” says Ann Braden, founder of GSV. “We come from all walks of life and 160 Vermont towns and every voting district. We are united in our call for common sense action that protects the rights of individuals as well as those of our communities.”

After Orlando, Vice President Joe Biden sent a letter to people who signed a petition calling on the government to ban AR-15-type assault weapons from civilian ownership. In it he addressed the thriving gun culture in this country that allows gun violence to continue.  “The President and I agree with you,” he wrote. “Assault weapons and high-capacity magazines should be banned from civilian ownership. … These weapons have been used to commit horrific acts. They’ve been called ‘the perfect killing machines.’”

Then he explained that the 1994 bill that banned assault weapons expired two years ago and was never renewed. How can that be, we might ask. The answer, in two words, is Republican Congress.

The vice president discussed other legal measures that could be taken which were debated and defeated in the Senate last month, a shameful event that resulted in a sit-in by House Democrats demanding action.

Faith leaders, law enforcement officials, businesses, public health experts, the majority of gun owners, and some legislators are calling for legislation that will help put an end to death by gun violence in this country. All over America millions of people are marching, pleading, praying, weeping for gun control. But pleading and prayers won’t do it. Neither will stigmatizing the mentally ill or spewing rampant Islamophobia or fear-mongering about ISIS.

Voting will help do it. That’s why this year is so important.  If we want to confront the gun culture that is ripping our nation apart, now is the time, once and for all, to get real about guns.