So, originally this week I was going to write about some of the developmental delays I've been seeing this past week in clinic. But after multiple Supreme Court rulings on the contraceptive mandate, I decided I really can't stay quiet about this.
For those of you who haven't heard of these rulings, allow me to summarize them for you.
First, we have Burwell vs. Hobby Lobby. Hobby Lobby is an arts and crafts store owned by the Green family, who are devout Christians. Their argument was that their corporation remains a family owned business, and they should be able to run that corporation in line with their religious beliefs. The particular argument was that the contraceptive mandate of the ACA (the section that required insurers to cover at no additional cost all 20 FDA approved contraceptives) violated their religious beliefs because 4 of the contraceptives covered (two forms of IUDs and two forms of 'emergency contraception') are abortifacients, that is, they have an action that may prevent implantation and thus result in 'abortion' of a fertilized egg.
A linked case, Conestoga vs. Burwell, had a similar argument. The Hahn family is the sole owner of the company and also believe that these four contraceptives are abortifacients.
In these cases, the Supreme Court voted 5-4 in favor of the companies. It should be noted that all three female justices voted against this decision.
Wheaton College vs. Burwell was not decided this week, but was allowed to abstain from the contraceptive mandate until they can gather arguments to go in front of the Supreme Court in the future.
I see multiple issues with these decisions, but for now am only going to focus on the medical aspect: Whether these contraceptives are abortifacients or not.
Before we get into how these contraceptives work, here's a crash course on what needs to happen for pregnancy.
First, there needs to be a viable egg. Each month, roughly, an egg is released from the ovary following a hormonal signal called the LH surge. This is referred to as ovulation. The egg then travels down the Fallopian tube towards the uterus (you can view of diagram of this here, if you're more of a visual person). Somewhere in this Fallopian tube, it is met by the sperm released after sex. The sperm fight to be the first inside the egg, and the now fertilized egg (soon to be an embryo) travels down to the uterus, where it implants in the rich lining and starts to form an actual baby. Progesterone, another hormone, is produced by the ovary following ovulation to promote the growth of the lining of the uterus until the placenta (the direct connection between baby and mama) forms and can produce this hormone on its own.
You'll note that I said the sperm meet the egg in the Fallopian tube. Sperm can live inside the female body for up to 5 days after sex. The egg can only survive without being fertilized for 24 hours or so after ovulation. So the most fertile time for women is actually having sex prior to ovulation so that the sperm can already be present when the egg is released.
When the embryo does not implant, there is obviously no development of a placenta, so after a period of time (usually 2 weeks), the ovary stops producing progesterone, and the uterine lining sheds, resulting in a period. Birth control pills work by supplying the body with a continuous dose of progesterone (and some estrogen, yet another hormone), so the body thinks its pregnant and doesn't release another egg. Thus, when you are on the placebo pill week, you have your period because you are not producing progesterone.
Onto the 'emergency contraceptives'. Plan B, Plan B One-Step, and Next Choice are levonorgestrel, a progesterone-like hormone. Thus, it acts like progesterone by preventing ovulation. As already described, progesterone is necessary to keep the uterine lining intact for the developing embryo. So, if this pill was taken after ovulation, the ovary would continue to produce progesterone, allowing the implantation of the embryo into the uterine lining. This is taken after sex, so it wouldn't prevent the sperm from getting into the Fallopian tube in the first place (as daily birth control pills might). The only way it would prevent pregnancy is if it prevents ovulation. So, not an abortifacient.
Now, an aside, taking the pill after ovulation doesn't mean you'll get pregnant. Everything else has to go right for that to happen. Successful implantation is estimated to occur in 15-30% of natural cycles. Many miscarriages are not realized because the body simply rejects the embryo before the woman knows she's pregnant. Most of the time, this is because there is some major genetic issue--an extra set of chromosomes, or something of that nature. Trust me, after studying genetics and embryology, I was amazed that this process worked at all.
There are some studies showing that there may be some changes in the uterine lining following administration of loveonorgestrel, but as far as I can tell, these studies were all done in the 80s, and much more recent studies have shown that there is little to no effect on the lining. Medications have also changed a great deal in that time.
Ella, ulipristal acetate, is another pill form of emergency contraception. It acts as a mixed progesterone receptor agonist and antagonist, which means it sometimes acts like progesterone and sometimes blocks the action of progesterone. Its effect is determined by the timing of the cycle. It can prevent the LH surge if given early enough, but can also block the effect of the LH surge (ovulation) if given after this hormonal signal. Essentially, it directly delays ovulation, ideally long enough so that the sperm are no longer viable. If given after ovulation, though, it diminishes the ability for the ovary to produce progresterone, thus affecting the uterine lining. Because of this action, I can see its potential for 'abortion', by preventing implantation. Ella is a relatively new contraceptive medication, so there are relatively few studies out there--it was difficult for me to pin down its exact mechanism of action.
Intrauterine Devices (IUDs) are implants placed by an OB/GYN or another clinician trained in the insertion that are used for long-term contraception. Historically, they were thought to have effects primarily in the post-fertilization phase of pregnancy, but other evidence now suggests otherwise.
There are two types available on the market today. First is the copper IUD. This one has been around forever. There is no hormonal effect to this contraceptive, and it is cited as an effective emergency contraception. It seems the effect is primarily toxic to the sperm as they move through the uterus, but it also produces an inflammatory response in the uterus which may affect implantation. So, potentially disrupts implantation.
The second type of IUD is the hormonal IUD, such as Mirena or Skylar. It is a small plastic device that contains progesterone, which acts in much the same way that the progesterone pills function. They are effective for about 3-5 years after insertion and prevent 99% of pregnancies. In theory, these can cause a foreign body reaction in the uterus that prevents implantation, but women can still get pregnant using this device, and it's not very effective as an emergency contraception, so it doesn't seem that this is an active issue. Therefore, I say it's not an abortifacient.
Conclusions: Hobby Lobby may have had a case. As I mentioned, I disagree with the decision on multiple fronts, and this was only the start of it. At minimum, they should not be permitted to object to Plan B and hormonal IUDs on the basis of them being abortifacients, because the science indicates that they are not, and thus it is a flawed argument. Ella and other similar oral emergency contraceptives need to be studied more before we determine for certain whether they result in decreased implantation of a viable embryo. Copper IUDs likely produce an environment that is hostile to life in general in the uterus, and thus potentially disrupt implantation.
There is some disagreement about the term 'abortifacient' as well, since by definition an abortion is the termination of a pregnancy, and a pregnancy can only occur if there is implantation of the embryo, but I chose not to get into this discussion for now.
Thoughts? Questions? Concerns? Feel free to comment or use the contact me form located at the top of the blog. See you next week!
Sunday, July 6, 2014
Sunday, June 29, 2014
Growing Big: When Health and Self Esteem Collide
When I was growing up, I was big. I'm not sure where exactly I fell in relation to other kids my age, because I rarely went to the doctor. That's what happens when you don't play sports and move every couple years, and thus don't have a good relationship with a doctor. But, I was definitely bigger than most kids. And I got teased for it. Throughout high school, I wore a giant, baggy jacket, because I was so ashamed about my body. As a sophomore in high school, I was asked by another student if I was pregnant. One of my friends desperately wanted me to go to the homecoming dance as a freshman so that I could have a Cinderella moment.
Point being, I know what it's like to have a low self-esteem.
But, as a doctor, I also know the harms of childhood obesity. I've talked about it before. So, I want young girls to get healthy and be at a healthy weight.
Problem is, weight is a very sensitive subject for adolescent girls. I saw a girl in clinic who completely shut down on me, to the point where we got a social worker to come talk to her, because I mentioned she was heavier than was healthy. It's not an easy subject to discuss, and I hate bringing it up, but I do it because it's in their best interest.
Well, a recent study has come out that may affect how I bring up the topic. This study took a group of girls and asked if someone had ever called them 'too fat'. They specifically asked about family members, teachers, and peers. Girls who were labeled as such at age 10 were significantly more likely to be obese at age 19 than those who were not, independent of what weight they started at.
Makes you wonder about all that media that girls consume now, doesn't it? How they are comparing themselves to the size 0 models in magazines, or worse, real women who are photoshopped to be unrealistic in proportions. Or how Ursula and the Queen of Hearts underwent a makeover to make them skinnier.
Yes, obesity is a problem.
But you know what? I was at my healthiest weight when I felt great about myself. It took me a long time to get there--years of affirmation by someone I loved. But I became happier with myself, accepting of myself, and started to walk around with confidence. And those extra pounds melted off.
So maybe the focus should be on body image, and not weight. After all, there is also such a thing as being too skinny.
Point being, I know what it's like to have a low self-esteem.
But, as a doctor, I also know the harms of childhood obesity. I've talked about it before. So, I want young girls to get healthy and be at a healthy weight.
Problem is, weight is a very sensitive subject for adolescent girls. I saw a girl in clinic who completely shut down on me, to the point where we got a social worker to come talk to her, because I mentioned she was heavier than was healthy. It's not an easy subject to discuss, and I hate bringing it up, but I do it because it's in their best interest.
Well, a recent study has come out that may affect how I bring up the topic. This study took a group of girls and asked if someone had ever called them 'too fat'. They specifically asked about family members, teachers, and peers. Girls who were labeled as such at age 10 were significantly more likely to be obese at age 19 than those who were not, independent of what weight they started at.
Makes you wonder about all that media that girls consume now, doesn't it? How they are comparing themselves to the size 0 models in magazines, or worse, real women who are photoshopped to be unrealistic in proportions. Or how Ursula and the Queen of Hearts underwent a makeover to make them skinnier.
Yes, obesity is a problem.
But you know what? I was at my healthiest weight when I felt great about myself. It took me a long time to get there--years of affirmation by someone I loved. But I became happier with myself, accepting of myself, and started to walk around with confidence. And those extra pounds melted off.
So maybe the focus should be on body image, and not weight. After all, there is also such a thing as being too skinny.
Sunday, June 22, 2014
The Elusive Good Night's Sleep
I know, I haven't posted the past 2 weeks. This is what happens when you have to move and lack internet for a week.
Sleep is a very important part of our lives. After all, we spent roughly 1/3 of our lives sleeping. There are several theories on why, exactly, we need sleep. My favorite is the converting of short-term memory to long-term memory. Essentially, if you don't get enough sleep, you won't learn anything new. But for now, I'm going to focus on how much we need and how to get that sleep. In fact, this was the focus of a recently published article that has caught the attention of many news sites.
It's more than just memory, though. Getting less sleep than you need can result in poor academic performance. According to a small study by the American Academy of Sleep Medicine, this effect is as much as binge drinking or smoking marijuana, independent of other risk factors such as psychiatric disorders.
Sleep has also been linked to weight, particularly in adults. A recent study published in Pediatrics shows that getting less than the recommended amount of sleep in infancy and childhood is linked to obesity by age 7. Indeed, even how much a parent sleeps can affect how much the child sleeps, and thus his or her risk of obesity later in life.
Finally, sleep is the time when many hormones are released. For children, the most important of these is growth hormone. That's right--if children don't get enough sleep, they might not grow properly. As an aside, the unbalance of hormones is likely part of the reason why lack of sleep can lead to obesity--the body produces hormones to increase alertness, which promote deposition of fat for future use.
So clearly sleep is important. But how much do we need?
The amount of sleep we need is entirely based on age. Infants sleep most of the day, while adults only need 8 hours or so. Infants also don't sleep at 'normal' times, because they are accustomed to being in the womb and rocked to sleep while mom was awake and walking, and awake when mom was resting. When adults don't get enough sleep, they tend to develop quick tempers and have low energy. When children don't get enough sleep, though, they tend to become hyperactive. Many parents have experienced this with infants that cry more when they aren't put to bed on time.
By two months of age or so, the circadian rhythm starts to develop. This is our body's innate way of telling time, and is based on light clues. In a completely cut-off environment, a normal circadian rhythm lasts about 25 hours. Of course, we don't live in a world where the day is 25 hours long, so this is where the light cues come in.
One of the first things we, as pediatricians, do when we hear a child is not getting enough sleep is to ask about sleep hygiene. Where do you sleep? What time do you go to bed? What time do you get up? What else is in your room?
Lack of light triggers the release of melatonin, a hormone that helps us feel sleepy and fall asleep. If your room is filled with light, even lights from computers, iPads, televisions, etc, you could inhibit your release of melatonin and have a harder time falling asleep. So, one of the first things we recommend is to get those computers and televisions and whatnot out of the bedroom. Even if you don't use them right before bed, the lights that stay on can influence your melatonin production. You can also condition yourself unintentionally into not associating the bedroom with sleep, but rather with activity.
Getting up and going to bed at the same time every day, even on weekends, can also help your body just get used to going to sleep at the same time. I realize this isn't ideal for adults, but there's no reason kids shouldn't have a consistent bedtime.
Finally, as we get older (by early elementary school), our sleep cycles become more consistent and average out to 90 minutes each. Waking in the middle of a sleep cycle can be very disorienting, and can make you feel tired all day. So, bedtime and alarms should be planned so there is a multiple of 90 minutes in the sleep time. In other words, you should try to ensure you are getting 6 hours, 7.5 hours, 9 hours, or 10.5 hours of sleep (depending on age, with younger kids needing more sleep), rather than 8, 10, or 6.5 hours.
This is only an introduction, and I'm sure I'll talk about it more in the weeks to come, but to not bore you too much, I'll leave it there for now.
Have additional questions? Leave them in the comments!
Sleep is a very important part of our lives. After all, we spent roughly 1/3 of our lives sleeping. There are several theories on why, exactly, we need sleep. My favorite is the converting of short-term memory to long-term memory. Essentially, if you don't get enough sleep, you won't learn anything new. But for now, I'm going to focus on how much we need and how to get that sleep. In fact, this was the focus of a recently published article that has caught the attention of many news sites.
It's more than just memory, though. Getting less sleep than you need can result in poor academic performance. According to a small study by the American Academy of Sleep Medicine, this effect is as much as binge drinking or smoking marijuana, independent of other risk factors such as psychiatric disorders.
Sleep has also been linked to weight, particularly in adults. A recent study published in Pediatrics shows that getting less than the recommended amount of sleep in infancy and childhood is linked to obesity by age 7. Indeed, even how much a parent sleeps can affect how much the child sleeps, and thus his or her risk of obesity later in life.
Finally, sleep is the time when many hormones are released. For children, the most important of these is growth hormone. That's right--if children don't get enough sleep, they might not grow properly. As an aside, the unbalance of hormones is likely part of the reason why lack of sleep can lead to obesity--the body produces hormones to increase alertness, which promote deposition of fat for future use.
So clearly sleep is important. But how much do we need?
The amount of sleep we need is entirely based on age. Infants sleep most of the day, while adults only need 8 hours or so. Infants also don't sleep at 'normal' times, because they are accustomed to being in the womb and rocked to sleep while mom was awake and walking, and awake when mom was resting. When adults don't get enough sleep, they tend to develop quick tempers and have low energy. When children don't get enough sleep, though, they tend to become hyperactive. Many parents have experienced this with infants that cry more when they aren't put to bed on time.
By two months of age or so, the circadian rhythm starts to develop. This is our body's innate way of telling time, and is based on light clues. In a completely cut-off environment, a normal circadian rhythm lasts about 25 hours. Of course, we don't live in a world where the day is 25 hours long, so this is where the light cues come in.
One of the first things we, as pediatricians, do when we hear a child is not getting enough sleep is to ask about sleep hygiene. Where do you sleep? What time do you go to bed? What time do you get up? What else is in your room?
Lack of light triggers the release of melatonin, a hormone that helps us feel sleepy and fall asleep. If your room is filled with light, even lights from computers, iPads, televisions, etc, you could inhibit your release of melatonin and have a harder time falling asleep. So, one of the first things we recommend is to get those computers and televisions and whatnot out of the bedroom. Even if you don't use them right before bed, the lights that stay on can influence your melatonin production. You can also condition yourself unintentionally into not associating the bedroom with sleep, but rather with activity.
Getting up and going to bed at the same time every day, even on weekends, can also help your body just get used to going to sleep at the same time. I realize this isn't ideal for adults, but there's no reason kids shouldn't have a consistent bedtime.
Finally, as we get older (by early elementary school), our sleep cycles become more consistent and average out to 90 minutes each. Waking in the middle of a sleep cycle can be very disorienting, and can make you feel tired all day. So, bedtime and alarms should be planned so there is a multiple of 90 minutes in the sleep time. In other words, you should try to ensure you are getting 6 hours, 7.5 hours, 9 hours, or 10.5 hours of sleep (depending on age, with younger kids needing more sleep), rather than 8, 10, or 6.5 hours.
This is only an introduction, and I'm sure I'll talk about it more in the weeks to come, but to not bore you too much, I'll leave it there for now.
Have additional questions? Leave them in the comments!
Sunday, June 1, 2014
Yes, All Women...
This happened after I posted my blog post last week, and rather than take it down and post this one to make it timely, I decided to wait a week and see what sort of clarity that brought to the situation.
On May 23, 2014, there was a shooting near the UCSB campus in California. Elliot Rodger was identified as the shooter, and he killed his three roommates, two young women in a sorority, and a bystander before taking his own life. Thirteen other people were also injured. Prior to his killing spree, he posted a Manifesto and YouTube video explaining that he was doing this because he had been shunned by women. Because he did not feel he had gotten the attention he deserved, as a male, from women his age. How he hated other men for getting that attention.
Evidently, there was a cry of support for Rodger's actions on some social media sites, some even stating that more young women needed to die because feminism was destroying society. In response, Twitter started trending #YesAllWomen, essentially an outcry against rape culture and victim blaming. This hashtag trended for at least 4 days, and has sparked plenty of discussion since. If you haven't read any of the tweets yet, I encourage you to stop and do so now.
As a young woman, I've experienced this rape culture myself. During my first year of medical school, I went to a bar with some girlfriends. It was crowded, and we easily got separated. A guy came up to me and asked if I wanted to dance. I turned him down, and went to seek out my friends. He came up to me about 5 minutes later asking if I was here with someone. I gestured to my friends and moved away. Still a third time, when I was dancing, he came up and started dancing with me. My friends quickly moved me to the inside of our dance circle. Thankfully, that was the end of it.
A friend and I were walking to a bar with her boyfriend. We had to walk through a less than desirable part of town. Down the block, on the opposite side of the street, a lone man was standing, watching us. We continued on our path and actively had to block my friend's boyfriend from crossing the street near the man: he had not noticed the man standing there.
In my town, we get an e-mail whenever there is a report of violence near the University campus or involving University students. Nine times out of ten, probably more, the victim is female. For instance: "The victim was walking [after dark] when an unidentified male approached her from behind, putting an arm around her neck and fondling her breast and genitalia with the other hand." "The victim reported she was sexually assaulted after being forced into the bathroom of the apartment where she was attending a party."
Young girls are taught to never go out alone, to always order their own drinks and not leave them unattended, to dress conservatively so as to not draw attention to themselves. We're taught to use the line 'I have a boyfriend,' or give out a fake number when we're not interested in a guy, because 'no' isn't good enough. It's the reason I'm not okay with going out by myself at night, but my male friends don't think twice about it. It's the reason my dad gave me pepper spray when I was in high school.
How prevalent rape is in our society is debatable, because many believe that it is grossly underreported. However, the CDC cites that roughly 1 in 5 women report being sexually assaulted sometime in their life. In a surprising statistic that I will expound more on at a later time, over 50% of the time, the perpetrator is an intimate partner. Men are not victimless either, as 1 in 71 men also report being sexually assaulted during their lifetime.
The lesson? A girl is not 'asking for it' by wearing a low-cut or high riding dress. She's not asking for it by having a bit too much to drink. She has the right to walk down the street, day or night, without getting catcalls or being fondled, or worse, raped. We need to have real punishments for those who violate the personal boundaries of others. We need to empower those who are victims and allow them to tell their stories without feeling shame. Men and women alike need to take these lessons to heart, as women can be just as bad as the men in perpetuating the victim-blaming.
Most social media campaigns do little to change the status quo, but I have a feeling that the popularity and insight this one has produced will change something, even if it's just getting a few men more interested in the lives of their female friends and family members.
This is not about blaming men. This is about getting the good ones to help us fight back enough that women don't need to feel this way anymore.
On May 23, 2014, there was a shooting near the UCSB campus in California. Elliot Rodger was identified as the shooter, and he killed his three roommates, two young women in a sorority, and a bystander before taking his own life. Thirteen other people were also injured. Prior to his killing spree, he posted a Manifesto and YouTube video explaining that he was doing this because he had been shunned by women. Because he did not feel he had gotten the attention he deserved, as a male, from women his age. How he hated other men for getting that attention.
Evidently, there was a cry of support for Rodger's actions on some social media sites, some even stating that more young women needed to die because feminism was destroying society. In response, Twitter started trending #YesAllWomen, essentially an outcry against rape culture and victim blaming. This hashtag trended for at least 4 days, and has sparked plenty of discussion since. If you haven't read any of the tweets yet, I encourage you to stop and do so now.
As a young woman, I've experienced this rape culture myself. During my first year of medical school, I went to a bar with some girlfriends. It was crowded, and we easily got separated. A guy came up to me and asked if I wanted to dance. I turned him down, and went to seek out my friends. He came up to me about 5 minutes later asking if I was here with someone. I gestured to my friends and moved away. Still a third time, when I was dancing, he came up and started dancing with me. My friends quickly moved me to the inside of our dance circle. Thankfully, that was the end of it.
A friend and I were walking to a bar with her boyfriend. We had to walk through a less than desirable part of town. Down the block, on the opposite side of the street, a lone man was standing, watching us. We continued on our path and actively had to block my friend's boyfriend from crossing the street near the man: he had not noticed the man standing there.
In my town, we get an e-mail whenever there is a report of violence near the University campus or involving University students. Nine times out of ten, probably more, the victim is female. For instance: "The victim was walking [after dark] when an unidentified male approached her from behind, putting an arm around her neck and fondling her breast and genitalia with the other hand." "The victim reported she was sexually assaulted after being forced into the bathroom of the apartment where she was attending a party."
Young girls are taught to never go out alone, to always order their own drinks and not leave them unattended, to dress conservatively so as to not draw attention to themselves. We're taught to use the line 'I have a boyfriend,' or give out a fake number when we're not interested in a guy, because 'no' isn't good enough. It's the reason I'm not okay with going out by myself at night, but my male friends don't think twice about it. It's the reason my dad gave me pepper spray when I was in high school.
How prevalent rape is in our society is debatable, because many believe that it is grossly underreported. However, the CDC cites that roughly 1 in 5 women report being sexually assaulted sometime in their life. In a surprising statistic that I will expound more on at a later time, over 50% of the time, the perpetrator is an intimate partner. Men are not victimless either, as 1 in 71 men also report being sexually assaulted during their lifetime.
The lesson? A girl is not 'asking for it' by wearing a low-cut or high riding dress. She's not asking for it by having a bit too much to drink. She has the right to walk down the street, day or night, without getting catcalls or being fondled, or worse, raped. We need to have real punishments for those who violate the personal boundaries of others. We need to empower those who are victims and allow them to tell their stories without feeling shame. Men and women alike need to take these lessons to heart, as women can be just as bad as the men in perpetuating the victim-blaming.
Most social media campaigns do little to change the status quo, but I have a feeling that the popularity and insight this one has produced will change something, even if it's just getting a few men more interested in the lives of their female friends and family members.
This is not about blaming men. This is about getting the good ones to help us fight back enough that women don't need to feel this way anymore.
Sunday, May 25, 2014
Race and Medicine
I'm taking a bit of a different turn this week, spurred on by an article I read recently, and some discussions we've had among our classmates. There are two prongs to this discussion: first, the concept of race or ethnicity in health, and second, the role of the medical provider in ethnic communities.
One of my classmates was African. As in, she immigrated from Central Africa (I, sadly, forget the exact country) to the US, and much of her family still lives there. During the first two years of medical school, when we were learning about various diseases that can afflict people, she became irritated with the idea that race and certain diseases had a correlation. She felt that we should be race blind, because it's impossible to tell someone's background by just looking at them.
In some ways, I see her point. Race is a human construct. It is more useful to define people by culture than by race, as there is more genetic variation within a given 'race' than between them. And with how open we've come to interracial couples, it really is hard to determine someone's race by simply looking at them.
But, at the same time, there is a correlation in several diseases, and race or ethnicity can help us narrow the list of diseases a patient is likely to have. For instance, individuals descended from Africans are more likely to have sickle-cell disease. Why? Because malaria is very prevalent in Africa, and there is an evolutionary advantage to having sickle cell trait, as it protects you from dying from malaria. But, when two people with sickle cell trait have a child together, there is a 1 in 4 chance of their child having sickle cell anemia, a disease that can cause loss of limbs and intense pain. If you are descended from an Ashkenazi Jew (Jews who lived in northern and central Europe), you are far more likely to have a number of diseases, including Tay-Sachs (a disease that causes multiple problems with the brain) and breast cancer, just to name a few. This is because the Jewish population of Europe had a great deal of intermarriage, partly due to religion and partly due to various anti-semitic pressures in the area. Even Caucasians are not immune to this racial bias, as Cystic Fibrosis is 4-5 times more common in Caucasians than in African Americans, and is even more rare in Asians.
All these are genetic diseases. What about those that aren't genetic? According to the CDC, non-Hispanic black patients are 50% more likely to die of cardiovascular disease than their non-Hispanic white counterparts. Adult diabetes is much more common in Hispanic and Native American populations than it is among white and Asian populations. A good portion of this is due to socioeconomic pressures; you're more likely to develop diabetes if you live in a low-income neighborhood than if you live in an affluent neighborhood, likely due to the access to fresh and healthy foods. Some of it is due to healthcare access: either these individuals cannot afford proper healthcare, they don't have access to the proper healthcare, or they choose not to seek healthcare due to cultural norms.
In this sense, I think ethnicity is a very important part of medicine.
Recently, I have heard discussions over medical school admissions and what role race should play in these decisions.
See, in many cases, patients reportedly like doctors of the same race as them. Thus, black patients prefer black doctors, Hispanic patients prefer Hispanic doctors, etc. There are many reasons for this; there is a certain distrust of the US medical system, and specifically white physicians, among black patients, thanks to experiments such as the Tuskegee Syphilis Experiment, there are subtle differences in culture, such as how patients perceive and express pain, etc. Even my own classmates have noticed that when they speak to Hispanic patients in Spanish, even if the entire interview is not conducted in Spanish, the patient tends to open up more and express their concerns more. Whether this actually helps in all cases is debatable.
So, the goal among many medical schools is to train a more diverse student body, to train more black and Hispanic physicians, rather than white and Asian or Indian physicians, in order to better meet the needs of these underserved populations. The degree to which race plays a role in medical school admissions is uncertain, based on what I've heard from friends on admissions committees. But there is no doubt that it does play some role. Some argue that this tactic is necessary in order to develop more mentors in underrepresented minorities, so that more of these individuals will enter medicine in the future. Others argue that it's a poor way judge a person's experiences, in that an African American from a well-off family will have a much different experience than a white person from a poor family, but the African American will naturally be judged to have better experiences thanks to the color of his skin. In essence, it's attempting to combat racism with racism, and is not the best way to go about things.
I'm not sure what the answer is from that front, but I do have no doubt that some people are inherently more comfortable with people from similar cultural backgrounds. Whether we should select medical school candidates based on that trait--I don't know, but I don't have a better solution for the fact that African Americans, Hispanics, and Native Americans are less likely to make it to the level of med school than a white or Asian person.
Racism, even 'benign' racism such as that we use in medicine, is still prevalent in our society today. It's not going to be an easy fix to change that, but I think we're trying. Hopefully within the next generation, this won't need to be a topic of discussion any longer.
One of my classmates was African. As in, she immigrated from Central Africa (I, sadly, forget the exact country) to the US, and much of her family still lives there. During the first two years of medical school, when we were learning about various diseases that can afflict people, she became irritated with the idea that race and certain diseases had a correlation. She felt that we should be race blind, because it's impossible to tell someone's background by just looking at them.
In some ways, I see her point. Race is a human construct. It is more useful to define people by culture than by race, as there is more genetic variation within a given 'race' than between them. And with how open we've come to interracial couples, it really is hard to determine someone's race by simply looking at them.
But, at the same time, there is a correlation in several diseases, and race or ethnicity can help us narrow the list of diseases a patient is likely to have. For instance, individuals descended from Africans are more likely to have sickle-cell disease. Why? Because malaria is very prevalent in Africa, and there is an evolutionary advantage to having sickle cell trait, as it protects you from dying from malaria. But, when two people with sickle cell trait have a child together, there is a 1 in 4 chance of their child having sickle cell anemia, a disease that can cause loss of limbs and intense pain. If you are descended from an Ashkenazi Jew (Jews who lived in northern and central Europe), you are far more likely to have a number of diseases, including Tay-Sachs (a disease that causes multiple problems with the brain) and breast cancer, just to name a few. This is because the Jewish population of Europe had a great deal of intermarriage, partly due to religion and partly due to various anti-semitic pressures in the area. Even Caucasians are not immune to this racial bias, as Cystic Fibrosis is 4-5 times more common in Caucasians than in African Americans, and is even more rare in Asians.
All these are genetic diseases. What about those that aren't genetic? According to the CDC, non-Hispanic black patients are 50% more likely to die of cardiovascular disease than their non-Hispanic white counterparts. Adult diabetes is much more common in Hispanic and Native American populations than it is among white and Asian populations. A good portion of this is due to socioeconomic pressures; you're more likely to develop diabetes if you live in a low-income neighborhood than if you live in an affluent neighborhood, likely due to the access to fresh and healthy foods. Some of it is due to healthcare access: either these individuals cannot afford proper healthcare, they don't have access to the proper healthcare, or they choose not to seek healthcare due to cultural norms.
In this sense, I think ethnicity is a very important part of medicine.
Recently, I have heard discussions over medical school admissions and what role race should play in these decisions.
See, in many cases, patients reportedly like doctors of the same race as them. Thus, black patients prefer black doctors, Hispanic patients prefer Hispanic doctors, etc. There are many reasons for this; there is a certain distrust of the US medical system, and specifically white physicians, among black patients, thanks to experiments such as the Tuskegee Syphilis Experiment, there are subtle differences in culture, such as how patients perceive and express pain, etc. Even my own classmates have noticed that when they speak to Hispanic patients in Spanish, even if the entire interview is not conducted in Spanish, the patient tends to open up more and express their concerns more. Whether this actually helps in all cases is debatable.
So, the goal among many medical schools is to train a more diverse student body, to train more black and Hispanic physicians, rather than white and Asian or Indian physicians, in order to better meet the needs of these underserved populations. The degree to which race plays a role in medical school admissions is uncertain, based on what I've heard from friends on admissions committees. But there is no doubt that it does play some role. Some argue that this tactic is necessary in order to develop more mentors in underrepresented minorities, so that more of these individuals will enter medicine in the future. Others argue that it's a poor way judge a person's experiences, in that an African American from a well-off family will have a much different experience than a white person from a poor family, but the African American will naturally be judged to have better experiences thanks to the color of his skin. In essence, it's attempting to combat racism with racism, and is not the best way to go about things.
I'm not sure what the answer is from that front, but I do have no doubt that some people are inherently more comfortable with people from similar cultural backgrounds. Whether we should select medical school candidates based on that trait--I don't know, but I don't have a better solution for the fact that African Americans, Hispanics, and Native Americans are less likely to make it to the level of med school than a white or Asian person.
Racism, even 'benign' racism such as that we use in medicine, is still prevalent in our society today. It's not going to be an easy fix to change that, but I think we're trying. Hopefully within the next generation, this won't need to be a topic of discussion any longer.
Sunday, May 18, 2014
Differences in Expectations: A Tale of Two Countries
As I mentioned a few weeks ago, I spent a few weeks studying in another country. It was actually my last two official weeks of medical school, and I went and spent time at the Hospital Nacional de Niños in San José, Costa Rica. My first day on the rotation, we sat down with our supervising physician and talked about the similarities and differences in health care in Costa Rica and in the US. He had experienced both systems, having done his fellowship training in the US before returning to Costa Rica to practice. Since I was privy to this discussion (and since I'm graduating today and have a lot of other things on my mind), I thought I might share some of the points with you.
First and foremost, medical education. I told you all about the system in the US back in my first post. So, how does it differ? As in most foreign countries (many European countries included), students enter medical school right after high school. Depending on whether they go to a public or private school, the schooling lasts for 5-6 years. The first two are spent in the classroom, and they spend the next four doing various clinical activities. The final year is referred to as their internship, and is similar to our first year of residency, except they aren't specializing. They spend 3 months each in Internal Medicine (Adults), Surgery, OB-GYN, and Pediatrics. After this schooling, they can choose to work as a general practitioner, or they can elect to do a residency. The residency could be in either Costa Rica or the states, though it is more difficult for them to get into residency in the states due to the licensing requirements. Competition for the residency slots is tough, and really the best and brightest are the ones who end up doing residency.
So, similar, but different.
Where things get really interesting is how the health system is set up. They have health care for every citizen. It's funded by a 10% tax on the citizen's paycheck--the employee pays 5% and the employer pays another 5%. The government matches this 5% contribution, so, in essence, 15% of each citizen's paycheck, regardless of what they make, goes into the Seguro Social. These public hospitals are set up all over the country. Primary care offices are the first line to the citizens, and in theory, the Primary Care offices know everything about the patients in their neighborhood. Then, there are the hospitals: primary, secondary for more advanced or specialty care, and tertiary. The Hospital Nacional de Niños is the only tertiary children's hospital in the country; the secondary hospitals have pediatric floors and some specialists, but the complex kids all get referred.
Under this system, everyone gets the healthcare they need. They may have to wait for it if there are more urgent cases to be seen, but everyone eventually gets what they need. A truly social system. Of course, they've also developed a private system on top of the public system, where you can go and get things done faster if you have the money for it. And, because they increased the government funding to healthcare, they elected to abolish their military, relying on international courts to resolve disputes with neighbors.
It was a little amusing to talk about the health systems to the students and residents, because everyone seems to be so astounded that the US, a first world country with a better standard of living than Costa Rica, doesn't provide healthcare to everyone. We are, of course, in the process of changing that now, but it's still in infancy.
A few more interesting tidbits more specific to pediatrics. First, which astounded me, particularly after last week's post, was that parental refusal of vaccines is a justifiable reason to call social services. In other words, they've deemed vaccines so important that they will overrule parents in whether or not their child gets the vaccine. If we did that in the US, we wouldn't be seeing these outbreaks.
Second, their age range for pediatrics is very different. In the US, Pediatricians care for children from infancy up through college-aged, sometimes well into their 20s depending on their overall health. When I was working in our Pediatric Emergency Department (I am not currently in a stand-alone children's hospital, so our Peds ED was attached to the adult ED), we'd see patients all the way up to 26 or 28, depending on who was working. In the PICU, they took a harder cut-off at age 18.
But in Costa Rica, they start transitioning over to the adult physicians at age 13. Which does make some sense--adolescents are more like adults than they are like infants--but they still aren't small adults. I'm not sure where this age came from--whether it was due to a lack of pediatricians or a universally decided on age, but it's interesting none-the-less.
Then, of course, the mix of diseases is very different there. I spent a week working in the Pediatric Endocrine clinic, and saw a grand total of 2 kids with diabetes while I was there. Contrast to my month on Pediatric Endocrine here, where 2 full clinic days per week were dedicated to kids with diabetes (only one full day was dedicated to other endocrine disorders). And I saw a couple patients with Bartter syndrome, which is apparently most frequent in Costa Rica.
They also have stricter laws on abortions, though I didn't delve too much into that discussion, so I'm not entirely sure what those laws are. But I do know that it is not legal to have an abortion due to a prenatal diagnosis of Down Syndrome.
Overall, they seem to have a well run health system. They do most all the same things we do, with some minor differences in tests (hypoglycemic growth hormone stimulation test instead of arginine). They do not have the same number of nurses (1 nurse per 4-5 patients in the NICU), so their NICU was much louder than I was accustomed to. They have slightly different instrumentation and ways of sterilizing, but still maintain aseptic technique and clean religiously. Based on my perception, I wouldn't deem them a third-world country. Maybe a second-world country, because they aren't quite up to the first world yet. But they're getting there, and seem to have made great strides.
Plus, it's an absolutely beautiful country.
First and foremost, medical education. I told you all about the system in the US back in my first post. So, how does it differ? As in most foreign countries (many European countries included), students enter medical school right after high school. Depending on whether they go to a public or private school, the schooling lasts for 5-6 years. The first two are spent in the classroom, and they spend the next four doing various clinical activities. The final year is referred to as their internship, and is similar to our first year of residency, except they aren't specializing. They spend 3 months each in Internal Medicine (Adults), Surgery, OB-GYN, and Pediatrics. After this schooling, they can choose to work as a general practitioner, or they can elect to do a residency. The residency could be in either Costa Rica or the states, though it is more difficult for them to get into residency in the states due to the licensing requirements. Competition for the residency slots is tough, and really the best and brightest are the ones who end up doing residency.
So, similar, but different.
Where things get really interesting is how the health system is set up. They have health care for every citizen. It's funded by a 10% tax on the citizen's paycheck--the employee pays 5% and the employer pays another 5%. The government matches this 5% contribution, so, in essence, 15% of each citizen's paycheck, regardless of what they make, goes into the Seguro Social. These public hospitals are set up all over the country. Primary care offices are the first line to the citizens, and in theory, the Primary Care offices know everything about the patients in their neighborhood. Then, there are the hospitals: primary, secondary for more advanced or specialty care, and tertiary. The Hospital Nacional de Niños is the only tertiary children's hospital in the country; the secondary hospitals have pediatric floors and some specialists, but the complex kids all get referred.
Under this system, everyone gets the healthcare they need. They may have to wait for it if there are more urgent cases to be seen, but everyone eventually gets what they need. A truly social system. Of course, they've also developed a private system on top of the public system, where you can go and get things done faster if you have the money for it. And, because they increased the government funding to healthcare, they elected to abolish their military, relying on international courts to resolve disputes with neighbors.
It was a little amusing to talk about the health systems to the students and residents, because everyone seems to be so astounded that the US, a first world country with a better standard of living than Costa Rica, doesn't provide healthcare to everyone. We are, of course, in the process of changing that now, but it's still in infancy.
A few more interesting tidbits more specific to pediatrics. First, which astounded me, particularly after last week's post, was that parental refusal of vaccines is a justifiable reason to call social services. In other words, they've deemed vaccines so important that they will overrule parents in whether or not their child gets the vaccine. If we did that in the US, we wouldn't be seeing these outbreaks.
Second, their age range for pediatrics is very different. In the US, Pediatricians care for children from infancy up through college-aged, sometimes well into their 20s depending on their overall health. When I was working in our Pediatric Emergency Department (I am not currently in a stand-alone children's hospital, so our Peds ED was attached to the adult ED), we'd see patients all the way up to 26 or 28, depending on who was working. In the PICU, they took a harder cut-off at age 18.
But in Costa Rica, they start transitioning over to the adult physicians at age 13. Which does make some sense--adolescents are more like adults than they are like infants--but they still aren't small adults. I'm not sure where this age came from--whether it was due to a lack of pediatricians or a universally decided on age, but it's interesting none-the-less.
Then, of course, the mix of diseases is very different there. I spent a week working in the Pediatric Endocrine clinic, and saw a grand total of 2 kids with diabetes while I was there. Contrast to my month on Pediatric Endocrine here, where 2 full clinic days per week were dedicated to kids with diabetes (only one full day was dedicated to other endocrine disorders). And I saw a couple patients with Bartter syndrome, which is apparently most frequent in Costa Rica.
They also have stricter laws on abortions, though I didn't delve too much into that discussion, so I'm not entirely sure what those laws are. But I do know that it is not legal to have an abortion due to a prenatal diagnosis of Down Syndrome.
Overall, they seem to have a well run health system. They do most all the same things we do, with some minor differences in tests (hypoglycemic growth hormone stimulation test instead of arginine). They do not have the same number of nurses (1 nurse per 4-5 patients in the NICU), so their NICU was much louder than I was accustomed to. They have slightly different instrumentation and ways of sterilizing, but still maintain aseptic technique and clean religiously. Based on my perception, I wouldn't deem them a third-world country. Maybe a second-world country, because they aren't quite up to the first world yet. But they're getting there, and seem to have made great strides.
Plus, it's an absolutely beautiful country.
Sunday, May 11, 2014
Vaccines: Building Our Immunity One Shot at a Time
I hope I'm not just preaching to the choir with this post, but I feel like I can't have a blog written from the Pediatrician's perspective and NOT talk about vaccines. It's too big a part of our practice.
Vaccines truly form one of the cornerstones of a pediatric practice. They are among the few interventions that are cost-saving. One of the others is providing clean drinking water. In the US, we have a schedule of vaccines for all children, and will provide them to everyone because they are cost-saving. These include Hepatitis A and B, Diptheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Polio, and Chicken Pox. It is because of these vaccinations that polio no longer exists in the Western Hemisphere (the reason it has not been eradicated in the Eastern Hemisphere is because there is resistance to vaccination efforts), and partly the reason smallpox only exists in labs.
And yet, despite all the data showing that vaccines work, there is a huge anti-vaccine movement in industrialized nations. Organizations such as the Vaccine Liberation and the Think Twice Global Vaccine Institute advocate to parents not to get their children vaccinated.
Don't get me wrong. I'm all about informed consent and vaccine safety. I think all vaccines should be rigorously tested before they are given to millions of children. I think vaccine reactions should continue to be monitored, and that vaccines aren't necessarily a one-size fits all thing. There are some children who can't get vaccines, either because they are allergic to something in the vaccine itself, or because they do not have a strong enough immune system to make the vaccine effective (or worse, they could contract the disease if a live vaccine is used). But, considering that, all children who are able to get vaccines should, in order to protect those who can't. When the healthy population doesn't get vaccinated, they serve as possible source of infection to those children.
Let's look a little more in depth into their arguments.
First, the supposed link with autism. While this could be a blog post in and of itself, let's run through a quick history of this argument. Back in 1998, Andrew Wakefield, a surgeon from the UK, published a paper in Lancet, a well renowned medical journal, claiming that MMR vaccines had a link to autism. Around this same time, the FDA published guidelines requesting the removal of mercury based products from foods. Thiomersal, a mercury-based solvent and preservative, was being used at that time in several vaccines, and the CDC and AAP requested vaccine manufacturers to remove it. Note that these two episodes were linked in time, but not by anything else. In the ensuing decade, thousands of studies have been done. None have been able to replicate Wakefield's results, and none have shown harm to thiomersal, though it is no longer used in vaccines. In 2004, the Lancet partially retracted Wakefield's paper, after Brian Deer (a reporter in London) demonstrated that there were conflicts of interest that were not disclosed. Then in 2009, Deer determined that Wakefield had actually falsified much of his data. In 2010, the Lancet fully retracted the paper, and Wakefield was banned from practicing medicine by the General Medical Council in the UK.
Moral of the story: vaccines do not cause autism. There has not been a single study that shows that it does. The vaccine schedule is set up in a way that children are going to have developmental changes shortly after administration of the vaccines. That's what happens when kids get older.
Vaccine Liberation makes the claim that cleanliness can prevent all diseases, and 'proves' this with graphs showing that the death rate of several vaccine-preventable diseases and several where there is no vaccine available. The primary problem with these graphs is that they only look at death rates. Death isn't what we're concerned about in most cases. Polio, for instance, causes paralysis. We can prevent death through a variety of interventions, including the ventilator. It's the paralysis that we want to prevent. Mumps? It rarely causes a complication resulting in death; we give the vaccine to prevent inflammation of the testicles or ovaries, which can result in infertility. It also just doesn't sound like a fun illness to have. Complications from measles are more common, but it's especially bad to be pregnant and exposed to measles (same with chicken pox; most complications are in pregnant women). The graphs don't take into account any of these complications; they just look at the death rate.
Think Twice claims "Recently vaccinated children do carry the disease germ and are able to spread it to other children. Many so-called epidemics are initiated and spread in this manner, even though the unvaccinated are blamed." It is true that some vaccines are live vaccines, meaning that the virus was altered to cause an immune response, but not disease, and the virus itself is still functional. These vaccines tend to be more effective than other vaccines, because they act more like a disease-causing virus than the segments that are used in the inactivated or subunit vaccines. These include the varicella (chicken pox), oral polio, and MMR vaccines.
However, the idea that children can spread disease after getting these vaccines, especially that this accounts for most of the cases of these diseases, is incorrect. Most measles cases are imported, meaning that they were brought back from people traveling overseas, usually to Asia. These were most commonly unvaccinated people who contracted the illness, though some vaccinated people remain susceptible. Of course, the recent outbreaks of measles may change that assumption in the near future.
This post is already getting long, so I'll end it here, but if you know of any other arguments against vaccines, please feel free to bring them to my attention and I will do my due diligence in examining the data. But in the meantime, please vaccinate your children. For the good of society, and for their own health.
Need more evidence that parents not vaccinating their children is causing harm? Check out this map. It shows the vaccine-preventable diseases Measles, Mumps, Rubella, Polio, and Whooping Cough (Pertussis) on a world map where all the epidemics are occurring, along with how many cases are in each epidemic.
Vaccines truly form one of the cornerstones of a pediatric practice. They are among the few interventions that are cost-saving. One of the others is providing clean drinking water. In the US, we have a schedule of vaccines for all children, and will provide them to everyone because they are cost-saving. These include Hepatitis A and B, Diptheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Polio, and Chicken Pox. It is because of these vaccinations that polio no longer exists in the Western Hemisphere (the reason it has not been eradicated in the Eastern Hemisphere is because there is resistance to vaccination efforts), and partly the reason smallpox only exists in labs.
And yet, despite all the data showing that vaccines work, there is a huge anti-vaccine movement in industrialized nations. Organizations such as the Vaccine Liberation and the Think Twice Global Vaccine Institute advocate to parents not to get their children vaccinated.
Don't get me wrong. I'm all about informed consent and vaccine safety. I think all vaccines should be rigorously tested before they are given to millions of children. I think vaccine reactions should continue to be monitored, and that vaccines aren't necessarily a one-size fits all thing. There are some children who can't get vaccines, either because they are allergic to something in the vaccine itself, or because they do not have a strong enough immune system to make the vaccine effective (or worse, they could contract the disease if a live vaccine is used). But, considering that, all children who are able to get vaccines should, in order to protect those who can't. When the healthy population doesn't get vaccinated, they serve as possible source of infection to those children.
Let's look a little more in depth into their arguments.
First, the supposed link with autism. While this could be a blog post in and of itself, let's run through a quick history of this argument. Back in 1998, Andrew Wakefield, a surgeon from the UK, published a paper in Lancet, a well renowned medical journal, claiming that MMR vaccines had a link to autism. Around this same time, the FDA published guidelines requesting the removal of mercury based products from foods. Thiomersal, a mercury-based solvent and preservative, was being used at that time in several vaccines, and the CDC and AAP requested vaccine manufacturers to remove it. Note that these two episodes were linked in time, but not by anything else. In the ensuing decade, thousands of studies have been done. None have been able to replicate Wakefield's results, and none have shown harm to thiomersal, though it is no longer used in vaccines. In 2004, the Lancet partially retracted Wakefield's paper, after Brian Deer (a reporter in London) demonstrated that there were conflicts of interest that were not disclosed. Then in 2009, Deer determined that Wakefield had actually falsified much of his data. In 2010, the Lancet fully retracted the paper, and Wakefield was banned from practicing medicine by the General Medical Council in the UK.
Moral of the story: vaccines do not cause autism. There has not been a single study that shows that it does. The vaccine schedule is set up in a way that children are going to have developmental changes shortly after administration of the vaccines. That's what happens when kids get older.
Vaccine Liberation makes the claim that cleanliness can prevent all diseases, and 'proves' this with graphs showing that the death rate of several vaccine-preventable diseases and several where there is no vaccine available. The primary problem with these graphs is that they only look at death rates. Death isn't what we're concerned about in most cases. Polio, for instance, causes paralysis. We can prevent death through a variety of interventions, including the ventilator. It's the paralysis that we want to prevent. Mumps? It rarely causes a complication resulting in death; we give the vaccine to prevent inflammation of the testicles or ovaries, which can result in infertility. It also just doesn't sound like a fun illness to have. Complications from measles are more common, but it's especially bad to be pregnant and exposed to measles (same with chicken pox; most complications are in pregnant women). The graphs don't take into account any of these complications; they just look at the death rate.
Think Twice claims "Recently vaccinated children do carry the disease germ and are able to spread it to other children. Many so-called epidemics are initiated and spread in this manner, even though the unvaccinated are blamed." It is true that some vaccines are live vaccines, meaning that the virus was altered to cause an immune response, but not disease, and the virus itself is still functional. These vaccines tend to be more effective than other vaccines, because they act more like a disease-causing virus than the segments that are used in the inactivated or subunit vaccines. These include the varicella (chicken pox), oral polio, and MMR vaccines.
However, the idea that children can spread disease after getting these vaccines, especially that this accounts for most of the cases of these diseases, is incorrect. Most measles cases are imported, meaning that they were brought back from people traveling overseas, usually to Asia. These were most commonly unvaccinated people who contracted the illness, though some vaccinated people remain susceptible. Of course, the recent outbreaks of measles may change that assumption in the near future.
This post is already getting long, so I'll end it here, but if you know of any other arguments against vaccines, please feel free to bring them to my attention and I will do my due diligence in examining the data. But in the meantime, please vaccinate your children. For the good of society, and for their own health.
Need more evidence that parents not vaccinating their children is causing harm? Check out this map. It shows the vaccine-preventable diseases Measles, Mumps, Rubella, Polio, and Whooping Cough (Pertussis) on a world map where all the epidemics are occurring, along with how many cases are in each epidemic.
Subscribe to:
Posts (Atom)