To Turn Undergrads On To Sex-Ed: Phallic Name Tags And Orgasm Trivia

How do you get busy undergrads to focus on their sexual health? Try penis name tags.

That was among the many strategies deployed this week at a sex-themed trivia night organized by the Boston University Health and Wellness Office.

Diners who went to the Sunset Cantina just for the Mexican food on a recent evening were in for a surprise. Amidst the usual busy hum of this popular night spot, the thunderstorm of phrases like “female orgasm” and “pus-like discharge” booming continually across the restaurant may have shocked some into choking on their tacos.

The Cantina played host to BU's sex-ed evening, "Sex at the Sunset": students sporting comical penis-shaped name tags were spread around the venue, talking excitedly and sipping drinks from pink, labia-inspired straws.

A team of peer-health educators, known as the BU Student Health Ambassadors (SHAs), partnered with Bedsider — a pro-sex health outreach organization that advocates for the responsible use of birth control — to bring this racy, but informative, event aimed at BU students as a casual and amusing opportunity to learn and talk about sex.

Meilyn Santamaria, a senior at BU majoring in health sciences and one of the SHAs, helped organize the event and was also the mastermind behind the mood enhancing playlist -- hot, throwback tunes like “Sexual Healing” and “Like a Virgin” were thumping all night.

Santamaria has learned a thing or two as a peer-health educator. For instance, she says, approaches to sex-ed like this light, fun-filled evening are important because they engage kids on a different level; and they sure beat those dry, awkward gym class lectures on hygiene.

“You actually get to interact with the material,” says Santamaria. “It’s exciting, it’s fun, it’s a safe environment that is a less intimidating way for people to learn this kind of important information about sex.”

The trivia questions blended saucy with scientific, public health with pop culture and were just as entertaining as they were educational. Still, questions like, “How long does the average female orgasm last?” are potentially blush-inducing (particularly when they're blasted over a loudspeaker in a highly populated, public space). “I’m kind of shocked by some of the questions,” said one undergraduate student at the event.  “I would never think that someone would say stuff like this in such a big room to so many people.”

Even if some were made slightly uncomfortable, the event was at full capacity, with about 80 students participating enthusiastically, cheering and applauding after answers were revealed. This type of reception to a sex-ed event is encouraging given the current statistics for young, sexually active Americans. According to the CDC, young people aged 15 to 24 make up 27 percent of the sexually active population, but account for fully half of the 20 million new sexually transmitted infections in the United States each year.

This approach to sexual health education embodies what may be a shift towards messages that are sex-positive and pleasure-centered. The idea here is to accept that young people are having sex; and the goal is to teach sexual health practices that will maximize safety — and fun.

Labia-shaped straw and other sex-ed swag. (Photo: Sascha Garrey)

It's a far cry from many of the scare-tactics used in more traditional sex-ed models, some of which promote abstinence-only when it comes to birth control. “I’m from a small rural farming community in Iowa and sex was just not talked about,” said a graduate student. “In sex-ed, we had to do really off-putting stuff like wearing a really heavy pregnancy belly and trying not to break our egg children that we were supposed to care for. It led me to believe as I grew up that sex was just something you can’t talk about. I think that if I had had this approach to sex ed in high-school, it would have changed my whole perspective.”

Sure, some of the "Sex at the Sunset" attendees were more about the free food than the educational elements. “It’s a lot of fun. But I’m probably not going to take anything away from this,” said one male sophomore. “I don’t think that knowing how long the average male penis is will really affect my life.”

Regardless, as the night progressed many of the table conversations turned almost uniformly to heartfelt and heated discussions on safe sex. Lines of dialogue such as, “Wow! I cannot believe that 70 percent of Americans already have herpes!” were heard. Particularly striking was a frank and thoughtful conversation buzzing from from a table of beer-drinking, baggy-pants-wearing college guys: “The average female orgasm is 28 seconds? How long would you say your climax is, man?” to which his backwards-capped buddy responded, “You know, dude, it really depends on how aroused I am. But I’ve never really thought about it until now.”

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Here’s a bit of a recent thread on QuitNet, an online social forum to help people quit smoking, tagged “Can’t STOP the Tears:”

Gidget74: “I am crying a lot for no reason.  I just think of it as another way for my body to purge the nicotine.”

divinem: “I shed an ocean of tears during my first year.  Let them wash away the pain deep inside.  Quitting takes us to new heights – and depths”

lynnTheSurvivor:  “Thank you ALL so much J!  Feeling better today J”

kickthehabit101: “Glad you are better…one thing about getting so far down…the only way to go st up!”

lynnTheSurvivor:  “I think the world of you!  Thanks hunny!”

That conversation may look like a run-of-the-mill online chat to you, but to Professor Damon Centola, a researcher at MIT’s Sloan School of Management, it is a new kind of laboratory — and an example of a potential goldmine of information on how to help people live healthier lives.

“Online health environments may provide a brand new opportunity for research on the social determinants of health,” he  said.

Centola published a paper in the American Heart Association’s journal Circulation  last month on how Facebook, Twitter and specialized social networks like QuitNet form a new frontier for researching health behavior. He analyzed the results of several studies examining the link between online influence and health behaviors, which suggest successes in behaviors like smoking cessation, exercise and medication compliance can be shaped by interactions over web-based social platforms.

It’s no shocker that social networks can influence behavior — everything from succeeding at Weight Watchers, for instance, to actually getting a mammogram after years of delays and canceled appointments.  What Centola is fired up about is the idea that online social forums are treasure troves for gleaning real-time behavioral data, the gold nuggets needed for realizing the gold standard approach to scientific research, the randomized control trial. “Large scale public health theories typically cannot be tested experimentally,” he says.

To do that, researchers would have to compare the outcomes of social interventions on entirepopulations; a daunting task.

Randomized control trials have traditionally been almost exclusively the domain of physical scientists.  Social scientists studying behavior, like Centola, have been stuck with the murkier method of the observational study.  Though they produce important associative pictures, like howtelevision habits of 20 plus hours a week are linked to significantly shriveled sperm counts,  observational studies can leave causal considerations shrouded in mystery.

Ambiguous results often mean unclear policy recommendations coming from behavioral scientists, but  Centola says that his method could change all of that He says the potential to use social media for the basis of such experiments is vast because, “hundreds of thousands, or in some cases, millions of people are participating in these online communities, making these sites active domains of public health.”

Is the idea that what happens on Facebook stays on Facebook really the case these days?  Centola suggests that some researchers consider the digital universe to be an entirely separate space from the “real world” where you actually have to interact with people face to face. “Online and offline behaviors are two different worlds of research right now,” he says. “The suggestion [in this study] is that these are all interacting problems.”

Centola argues that these online networks are not mere proxies of what happens in real-life, but they are actually interactive spaces embedded in the real-life, modern experience. “My goal is to connect these online health interactions with real offline health outcomes, such as changes in medication, blood pressure, and obesity,” he says.

But what about my grandma who has never even touched a computer, never mind tweeting about, say, osteoporosis prevention? There remain vast segments of the population who don’t access online interactive spaces.  Centola appreciates the problem of the “Digital Divide.”

“With the excitement over the Internet and a number of sources of big data, even in observational data, the representativeness of the population can get lost,” he says.

Centola explains that his online methods for data collection do not eclipse the standard practices of social science research.  Rather, he says, his methods should be considered complimentary to other modes of data-gathering.

So what does the future hold for using online networks to analyze health behavior?  Centola thinks his method holds a lot of promise for the future of public health intervention design, but the implications are only now beginning to be explored. “[The study is] meant to be thought provoking in terms of what the potential is in doing massive, significant research online on changes in health behavior.”

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Disease. That word carries so much weight, and as of this week, it also concerns weight: The American Medical Association decided to officially define obesity, a condition that affects over one third of American adults, as a disease.

The decision went against the recommendations of the AMA’s own Public Health Committee to do the opposite, and it means that obesity will now be joining alcoholism and drug addiction as a “condition” whose elevation to “disease” sparks controversy.

So will calling fat people diseased pave the way to a healthier society?  Members of the fat acceptance community — advocates for reducing the stigma of obesity– say that all depends on what you consider “health” to be in the first place.

“The AMA’s decision makes a body size into a health diagnosis,” says writer and fat-acceptance activist Ragen Chastain.  She is upset by the AMA’s decision and thinks that it is an affront to her movement’s mission.

“The goal is to create a world where fat people are treated with respect, free from bullying, oppression and stigma,” she says. “I think this will absolutely lead to greater stigma.”

The AMA argues the opposite: It cites the reduction of stigma as part of its reasoning for labeling obesity as a disease.

Some advocates of the AMA’s decision say that labeling obesity as a disease is the wake-up call that doctors need to start treating their fat patients using more serious weight-loss strategies, such as bariatric surgeries.

Some also speculate that obesity’s new, serious status will put pressure on insurance companies to start covering fat-fighting procedures and treatment as they would, say, smoking cessation.

Lesley Kinzel, a senior editor of Xo Jane and a longtime Boston-based fat-acceptance ativist, says she recognizes that, from a medical standpoint, it is good to address stigma attached to fat patients.

“They may have a point by asking doctors, ‘Hey, instead of looking at your fat patients as people with no willpower, let’s see them as having a disease we can treat.’”

However, she fears that “medicalizng” obesity will lead to overtreatment and the over-allocation of scarce insurance dollars to expensive medical interventions.

She has strong doubts that the AMA decision to define obesity as a disease will do anything but increase the stigmatization of fat people outside the doctor’s office.

“Culturally, disease has a stigma,” she says. “To call obese people diseased will not elevate that group in the social stratosphere.”

An article from Time Magazine explains that studies have shown that disease labels can actually help redirect pointing fingers away from moral weakness to more complex webs of causal factors outside of the indvidual’s control. However, it warns that even though the AMA has good intentions, its decision isn’t without its darker implications:

A recent review of studies on conditions like addictions and other psychological problems that can have genetic causes found that such classification generally does reduce the blame heaped on people with the disorders, both by themselves and society. But the labels also increased pessimism about recovery, probably because people assume that as diseases with biological and genetic bases, they are immutable. One study on alcoholism, for example, found that the more people bought into the idea that addiction was a “chronic relapsing disease” over which they were “powerless,” the worse their relapses were. Although the label didn’t increase relapse itself, it made it worse if it did occur — and the majority of people with alcoholism will relapse at least once.

The article also points out that classifiying obesity itself — rather than the chronic condtions that can stem from it — as the disease may miss the mark.

The AMA Council on Science and Public Health, which advised against considering obesity a disease, noted that it is more of a risk factor for other conditions — such as diabetes,heart disease and high blood pressure — than a disease in itself.

In other words, it has the same relationship to disease as heavy drinking does to alcoholism: It’s a risk factor, not a disorder. The committee also noted that there are no standard criteria for drawing a line between healthy and unhealthy weights. After a year of study, it argued:
Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state. Similarly, a sensitive and clinically practical diagnostic indicator of obesity remains elusive.

Kinzel warns that calling a body size a disease confuses the matter, because fatness isn’t necessarily a health concern.

“Being fat has radically different consequences for different people,” she said. “Some have dramatic health issues; some have zero because they’re fat. I have trouble saying that this is a uniform disease because it doesn’t affect people in the same way.”

Chastain offers her thoughts on how obesity should be considered:

“I think we need to take weight out of the health discussion altogether. Healthy habits are better determinants of health than body size. We need a system that leads to people actually liking their bodies, and therefore believing they are worthy of care. Any intervention that starts off with the idea that certain people’s bodies are wrong is automatically a poor public health intervention.”

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A whiff of sour air greets the newcomer who steps into Josephine Nakajubi's poky examination room. The silver tray across from the room’s maroon examination bed is sparsely equipped with metallic probe-like instruments and hand sanitizer. On the floor next to the tray is a large plastic container of acetic acid, the source of the room’s pungency. The acetic acid—also known as common table vinegar—is essential to Nakajubi's work. Her examination room is reserved explicitly for screening women for cervical cancer.

“What motivates me to come and work is because I want to help out people,” Nakajubi, a nurse, said. “I don’t want to see them suffering with advanced cancers. Why should they suffer, yet I can do something? I want to see people helped at an earlier stage.”

Nakajubi’s examination room is nestled along one of the sun-lit corridors of the Infectious Disease Institute (IDI), a not-for-profit organization within Uganda’s Makerere University that operates an HIV clinic at their Kampala headquarters. Using “visual inspection”—a screening that involves applying acetic acid to a cervix in order to highlight any potentially problematic lesions in the area—Nakajubi screens as many as 100 women in a month.

The women she sees, however, are rarely in the IDI clinic for the purpose of being screened for cervical cancer. Her patients are mostly HIV positive and have more often come to IDI for help in managing this disease. Nakajubi recruits her patients by chatting with them about her screening services while they wait for their other appointments, but, she admits, they are often not persuaded.

“It’s not easy to convince them,” she said. “I can talk to like 10 (women) and I can get like 2 out of 10 who have accepted to come for the procedure. If they don’t accept, it’s not easy. I have to keep on talking, talk every day, every day.”

Cervical cancer is caused by the human papillomavirus, or HPV, a sexually transmitted infection. There are over 100 different strains of HPV and only several of them (strains 16 and 18 are considered to be particularly high-risk) develop into gynecological cancers if left undetected. According to the Center for Disease Control, most sexually active women will contract HPV at some point in their lifetime, but in the majority of these cases the infection will clear up on its own. However, HIV positive women who contract the cancer-causing strains of HPV have a more elevated risk of developing cervical cancer than women without HIV who contract the same strains.

In Uganda, the prevalence of HIV had reached an all-time low in 2006 with an estimated 6.3 percent of the total population living with HIV. However, according to the UN’s AIDS report this number has risen by 2012 to 7.2 percent—1.4 million people in all, over half of whom are women.

Nakajubi explains that many of the women who come to her clinic are more comfortable with an HIV diagnosis than one for cancer. She says that although she tries to explain that she screens women for the purpose of trying to catch any potential problems early, talk of cancer tends to instill a lot of anxiety in many of her patients.

“Some of them fear the results,” she said. “They say, I’d rather remain HIV positive, I’m used to it, but now you want to tell me I also have the cancer? I will die very soon.”

In her experience, the women Nakajubi sees start to feel more comfortable with the idea of being screened for cervical cancer after she has spent time with them explaining the procedure. In her opinion, more health education, or, “sensitization” in her words, around screening and prevention could really help Uganda’s high rate of cervical cancer.

Nakajubi has considered giving talks at her church to raise awareness about the disease. It is the number one cause of female cancer deaths in Uganda, killing approximately 2,275 women in the country each year, according to the WHO’s 2012 GLOBOCAN report. But, she says, she is so busy at her clinic and she lacks the basic resources needed for an educational outreach, such as diagrams and informational pamphlets translated in local languages; she’s not sure how to start.

“We should not wait for people to come,” she said. “We should even start from the places where we stay and create awareness. But I don’t know how I can do it.”

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“When I get the results, I will feel normal,” said Irene Anek, a 30-year-old single mother of two who also takes care of her elderly mother and her deceased sister’s three children.

Two months ago, Anek went to a clinic in Kisenyi, a slum in Kampala, Uganda’s capital city where she works occasionally selling maize, sorghum and millet on the roadside. “There is a sore in my private parts,” she explained. “I’d been hearing from the TV, where they are teaching to go test for cervical cancer.”

At the clinic she received an HPV-DNA test, a screening technique now piloted at several venues throughout Uganda.

A Canadian research team is examining its feasibility as an early detection option for cervical cancer. The test involves the collection of a specimen by way of vaginal swab and is later analyzed for the presence of Human Papillomavirus (HPV), the sexually transmitted infection that, according to the World Health Organization (WHO), is the cause of 99 percent of cervical cancer cases globally, particularly the strains 16 and 18.

“They told me to wait for the results. Then they’ll call me,” said Anek. “I’ve waited for two months. I went [to the clinic] and they said you wait, you wait.”

The absence of her test results causes Anek a great deal of anxiety. She explained that it is not cervical cancer itself that she fears, but, rather, the practical considerations that come with potentially positive results. She is the sole income provider for her family, and she worries about the time, money and confusion that being thrust into the fragmented Ugandan health system often entails for cervical cancer patients.

Uganda has one of the highest incidence of cervical cancer in the world. Though the exact reason underpinning the problem is not known, the risk factors are well documented. According to a WHO report, population trends that appear to contribute to Uganda’s elevated cancer incidence include high birthrates (the average Ugandan woman has approximately seven children), early sexual debut among women (the average age for a woman’s first sexual encounter is 15), and the relatively high prevalence of HIV.

“Cervical cancer is a big problem for our country,” said Iddi Matovu, the cervical cancer focal person for PACE , the Ugandan affiliate of Population Services International, an NGO.

Two years ago, PACE received funding from the Bill and Melinda Gates Foundation for promoting cervical cancer prevention in Uganda. Together with the NGOs Marie Stopes and International Planned parenthood (two other benefactors of Gates funding), Matovu and his team at PACE have designed and implemented a cervical cancer screening program that operates out of a network of private clinics throughout the country. Matovu explained that a focus of their cervical cancer programming is to identify pre-cancerous lesions through screening and treat those with such lesions on-site with cryotherapy, a technique that uses cold gases to burn cervical tissue. Problems arise, he says, when women with more developed lesions or cancer are referred elsewhere for more complex treatment.

“Our women are predisposed (to cervical cancer),” said Matovu. “People here have very many kids and the prevalence of HIV is high. That combined with a poor health system compounds it all. As a country we don’t have an organized system to identify these lesions.”

The Ugandan government is aware of the burden from cervical cancer weighing on the nation’s women. The Ugandan Ministry of Health (MOH) has drafted a policy that addresses the nation’s staggering rates in 2010. However, financial constraints stand in the policy’s way of being fully realized.

“The political will is there,” said Dr. Gerald Mutungi, the director of the MOH’s Non-Communicable Diseases unit. “I get calls from members of Parliament asking to get cervical cancer [outreach] to their districts. But out of 10 requests we can afford two or three.”

The MOH’s cervical cancer prevention policy considers “capacity for referral and continued care for women with invasive cervical cancer requiring conventional radiotherapy” by 2015 a strategic objective and the “establishment of proper referral systems” a core intervention.

The policy suggests that the way forward is with the acquisition of seven new Cobalt-60 radiotherapy machines—there is currently only one radiotherapy machine for the entire country located at Mulago Hospital in Kampala—and the addition of at least 15 new radiation oncologists to Uganda’s medical labor force.

However, delays related to a lack of consistent financing compromises the feasibility of the policy’s 2105 target for full implementation. Though cervical cancer, and cancer in general, in Uganda is getting increasing attention, Mutungi explains that most of the country’s healthcare funding, especially the dollars that come from international sources, are reserved for high-profile infectious diseases and illnesses such as malaria and AIDS.

“We have funding for HIV, but there is none that is earmarked for cervical cancer,” said Mutungi. “The money gets lost in the other areas of the health sector.”

Anne Alepo, a nurse a at the main health center in Nakasongola, a rural district in central Uganda, was trained to perform cervical screens in 2010, when PATH, an international nonprofit organization, came to set up cervical cancer prevention programming. She says that the women in her district are less likely to travel on their own accord to her health center, the primary facility for cervical cancer screening and first-line treatment in the district. Of those women who do come to see her, though, many wait until they have painful symptoms whose treatment would require a referral elsewhere.

“When you go and check the person [who] has delayed [her visit] and the whole cervix is eaten up,” she said, “you can’t even treat from here. They have to go to Mulago. They just go, ‘Oh no, if I go to Mulago it will take like three, four days. Even if I don’t have any relative that will help me there, how will I reach there? No, let me just go back and die.’”

The location of Mulago Hospital serves as a barrier for many women who live in more rural districts or remote villages across the country. The hospital, for instance, is several hours drive from Nakasongola, making a visit for cancer treatment an issue for poorer women who don’t have the financial resources for transportation and the additional cost of staying in Kampala during their treatment. But Mulago, in partnership with the nearby Uganda Cancer Institute, is the only public hospital in Uganda that has the resources required for treatment of later stage cervical cancer cases.

“Mulago, where do I start?” said Dr. John Kamulegeya, a colleague of Alepo’s and the former manager of the cervical cancer-screening program delivered by PATH. “Nakasongola being a distant community, people fear Mulago.”

Kamulegeya conducted a study that assessed the attitudes and knowledge of cervical cancer among women living in Nakasongola. He says that before PATH came to his district most women knew about breast cancer, but few were aware of cervical cancer. “I think it’s because of it being in a private organ and I think there has been more sensitization of breast cancer than cervical cancer,” he said.

Kamulegeya is pleased with the growing awareness of cervical cancer in his community since PATH’s arrival: The women he sees are becoming less afraid to be checked. A major challenge in his practice, he says, comes when referring his cervical cancer patients to other hospitals. He explains to his patients that the earlier their symptoms are treated, the greater their chances of survival are. However, without a national referral system, he says, it’s very difficult to know the status of his patients once they have left Nakasongola.

“Most people think that cancers, when you get them, you’re done. Like once you’ve got them that it’s a death sentence, but that’s not the case for cervical cancer,” said Kamulegeya. “We send people, but it would be good to get feedback. But there is no way of getting the feedback that people we have sent have reached.”

For those women who actually make it to Mulago, a chronically understaffed gynecological oncology ward is often yet another barrier to their treatment.

Irene Anek finds herself at the Mulago ward after finally receiving a telephone call about her results: She tested positive for HPV. She was instructed to go to the hospital for a second test, this time a pelvic exam to check for cervical lesions and cancer. But after spending three hours on a bus and then several hours waiting in line to be seen at Mulago, all she was given was an appointment to come back on another day.

“For an appointment I have to travel. I have to look for ways of coming,” she said. “The number of people here are very many. You come in the morning, then you go very late, so also feeding yourself is difficult. I have now to be patient, to wait for the (test), for what they will tell me.”

The broken referral system has created a cynical attitude towards the benefits of cervical cancer prevention in Uganda among some healthcare experts in the country. Dr. Jackson Orem, the Director of the Uganda Cancer Institute, acknowledges the pessimism he encounters among his colleagues.

“Some people say that without a working system, to diagnose early would not help,” he said. “If a patient is found to have cancer, what are you going to do?”

Even so, Orem insists that preventive efforts such as regular and widespread cervical screens are the way forward with managing cervical cancer. There needs to be more financing and resources put into the development of a national healthcare system that is more responsive to the particular needs of cancer: prevention and early detection.

In “just taking it as one of 'those diseases,' that perspective is lacking. Cancer will fall by the way side. The louder diseases are the infectious diseases. They will take priority. When malaria, HIV, tuberculosis are put side by side with cervical cancer, cervical cancer won’t get the resources," Orem said. “We need to look at cancer as a special case."

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“We get overwhelmed as clinicians,” said Dr. Luutu Israel “seeing patients in endless lines.”

Dr. Luutu holds up a large scan in front of a woman sitting in a wheelchair across from him in his little office at the back of the radiotherapy department at Mulago Hospital—Uganda’s National Referral Hospital. In the background, lively African pop music reverberating from a car parked outside the packed clinic, creates a sonic tension with the series of piercing monotonous beeps that burst from the radiotherapy equipment hidden away several rooms over.

Floating his fingers around the sea of sporadic dark splotches scattered across the scan, Dr. Luutu, the acting head of the department, calmly explains this image to his patient as he maps out the results of her ongoing cancer treatment before wheeling her out of his office. His assistant simultaneously ushers in his next appointment.

Cancer is on the rise in Uganda. The UN’s International Agency for Cancer Research reports that as of 2008 there are approximately 27,100 new cancer diagnoses in the country each year. According to a study by the Department of Pathology at Uganda’s Makerere University using data from the Kampala Cancer Registry, incidence rates of prostate and breast cancer rose annually by 3.7 percent and 5.2 percent respectively between 1991 and 2010. Cervical cancer—the most frequent and lethal of all gynecological cancers in the country—is also on an upward trend with a predicted 34.2 percentage point increase in incidence over the same time period.

Like many of the other cases of cancers presenting in the country, it is estimated that 80 percent of all new cervical cancer diagnoses are presented at late stages. This means patients will require aggressive treatments such as chemotherapy and radiotherapy to improve the chances of their survival or quality of life.

As the country’s cancer burden grows, so does the burden on Mulago’s radiotherapy department. With some 2,000 new patients seen at his clinic—staffed by four doctors, only two of which are radiation oncology specialists, four nurses and nine technicians—each year, Dr. Luutu is faced with a consistently tense professional obligation: He is in charge of managing the only radiotherapy machine in all of Uganda.

For many patients who have come to the clinic, the radiotherapy machine symbolizes the final stages of their cancer treatment.

“The last machine, that’s what locally people call it,” Dr. Lutuu said.

Uganda’s sole radiotherapy machine sits in the middle of a cavernous room, lit only by a small table lamp. While the main waiting room outside of Dr. Luutu’s office is filled with benches teeming with people, only three patients at a time sit outside the heavy doors separating them from the dark, L-shaped corridor that leads to the machine. The patients who wait here clutch large translucent-blue plastic bags that they will use as make-shift canopies to lie on once it is their turn with the machine.

Donated to Mulgo Hospital in 1995 by the International Atomic Energy Agency, the weathered Cobalt-60 machine “is of dubious quality.” Cobalt, the machine’s power source, is ideally replaced every five years. However, the amount of cobalt needed to power the machine comes with a price tag of several hundreds of thousands of dollars and its heavy regulation due to its other application in nuclear bombs creates big barriers to its acquisition. Even more pressing to the Mulago clinic, though, is that cobalt is constantly decaying.

“Whether you are treating patients or not it decays,” said Dr. Luutu.

Patients from neighboring countries who travel to Uganda for cancer treatment increase the already weighty burden on the Mulago radiotherapy department. According to Dr. Luutu, his clinic sees patients from countries and regions like western Kenya, South Sudan, the Democratic Republic of Congo and Burundi where the national health systems lack the appropriate equipment. But Dr. Luutu is sympathetic.

“There’s no doubt about that. There is a lot of strain onto the machine because of our neighbors,” he said, “but you can never ever chase away a neighbor, and especially if one is sick, one cannot look at them suffering and say no. It’s ethically unacceptable.”

With one rapidly aging machine subject to frequent breakdowns and a seemingly never-ending patient load, Dr. Luutu had to come up with a simple solution to avoid patients waiting for up to nine months for radiotherapy cancer treatment.

“The way out of that,” he said, “[is] we improvise a means of work: 21 or 22 hours in a day so that our patients, their waiting time, is about two weeks from the time the patient sees the doctor to the time the patient starts treatment and we are very, very proud of that, extremely proud of that. That doesn’t happen in many places [in Africa] even where they’ve got six, seven, eight machines.”

Dr. Luutu says he takes his job as “a calling,” and he believes the way forward for Uganda’s emerging cancer issue is through early detection.

“If we get a new machine that can treat say like ten patients a day that would improve our cure probability,” he said. “But the best way to [approach] either cervical cancer or any cancer is prevention, which our people in the Western world have done very, very well. That would go a very long way in reducing the incidence of cervical cancer and others.”

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An overwrought look at what the Affordable Care Act amendments will mean for Massacusetts

“I didn’t need that fourth glass of wine,” Cassandra St. James grumbled to herself as she slammed off her wailing alarm. Her headache from last night’s binge was beyond splitting, making her simultaneously grouchy and grateful that, thanks to federal health reform, her health insurance plan was banned from putting annual limits on essential services –  lately, she’d been going through her prescription migraine pills like they were Skittles.

“Uggghh…I cannot face another day at work!”

Cassandra had been feeling the heat at her job lately, perhaps sparking this new interest in multiple glasses of wine per evening. Being a customer service representative at a Boston-based health insurance company during the advent of federal Health Reform was stressful to say the least. But tension at work wasn’t the only reason for Cassandra’s hangover.

Cassandra was engaged to a man she hardly knew, even though she was still heartbroken over the loss of her true love, Dr. Lance Jones. It’s been almost three years since the freak boating accident that took Dr. Jones’ life along the Cape, but his body was never found, leaving Cassandra without closure. Maybe that’s why she’d agreed to marry Chip Montebello.

To be sure, Chip had a good heart, but his health insurance situation left something to be desired. His decision to defy the state’s individual mandate left him with a greater tax burden and no health benefits.

What’s more she had financial woes coming at her in every direction. It didn’t help that the health insurance available to her through her employer was all but affordable, with over 9.5% of her income put towards her premium each month. In more desperate moods, Cassandra fantasized about having the freedom to buy insurance over the Health Connector, but that fantasy was too farfetched even for her. Massachusetts law prohibits anyone with insurance available to them through their job to seek coverage elsewhere, regardless of its affordability.

But it wouldn’t matter even if she could stray to the Connector. Ever since her so-called “big promotion” her salary was boosted to $45,960 and with her household size of one, that boost put Cassandra at 400% of the federal poverty line. With an income at that level, she wouldn’t even qualify for any of the state subsidies for purchasing insurance on the Connector, available only to those with incomes between 133 – 300% of the federal poverty line.

“And then there’s my mother,” Cassandra said under her breath as the phone rang.

“Hello?”

“Where’s my money?”

“Speak of the devil.”

“I said, WHERE IS MY MONEY?”

“Mother – it’s coming. I’ve had a lot on my mind. I — I forgot.”

“Life’s not a permanent vacation, Cassandra. Don’t tell me these convenient memory lapses of yours were plaguing you between July 1st and August 15th . I didn’t raise you to forget about the Health Connector enrollment period that’s been in place ever since Massachusetts health reform!”

“Mother – you know I get insurance through work. Besides, once Obamacare kicks off, the Health Connector will have an extended enrollment period from October 1st, to March 31st. So relax, okay?”

“You think you’re so smart, don’t you? Well, you better not get used to taking your sweet time deliberating about how you should enroll during that initial extended enrollment period. After March 31st, 2014, all future enrollment periods in the state will be from October 15th until December 7th. Now get me my money…or else!”

“You’ll get your money, mother!” said Cassandra between clenched teeth, and slammed down the phone.

Ever since her mother, Elaine St. James, blew out the 65th candle on her diabetic-friendly birthday cake earlier this year, she’d been cashing in on her Medicare benefits. Elaine burned through her prescription drug coverage privileges fast, hitting the coverage gap, or that infamous “donut hole”, within months of becoming eligible for Medicare. Subsumed by a gnawing filial guilt, Cassandra had been footing the bill for her mother’s pricy alpha-glucocide inhibitors ever since.

Cassandra popped one of her migraine pills as she ripped off yesterday’s date from her page-a-day calendar.

“October 1st, 2013?” gasped Cassandra. “It can’t be!”

Not only was this the official onset of Obamacare across the country, but it was also her wedding day.

“I’ve got to get to the church! I’m going to be late!” cried Cassandra as she grabbed her wedding dress, the one she had originally bought when she was going to be Mrs. Dr. Lance Jones…..

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

At the Church

With her dress half on and stocking runs too extensive to be passed off as high fashion, Cassandra bolted through the church doors. She raced down the aisle, past what resembled more of an angry mob than a wedding party and to the altar that, besides one highly peeved Father Mortlock, was unoccupied. Cassandra covered her mouth in disbelief, smearing her lipstick into a vibrant red halo circling her lips. Had she been stood up?

“Where’s Chip?!” Cassandra yelped at Father Mortlock, who was glaring at her as he tapped his watch.

“Mr. Montebello will be late,” scoffed Father Mortlock, rolling his eyes. “He’s taking advantage of the new seamless enrollment experience on the Health Connector that has come with today’s initiation of Obamacare. He wanted you to know that he’s opted out of health coverage for so long because he found the enrollment process so infuriating, but now that there’s a standardized, one-stop shop situation for everyone purchasing insurance on the Health Connector, Mr. Montebello will be able to apply for coverage and determine his eligibility for assistance in one sitting.”

As Father Mortlock finished, Cassandra felt a tap on her shoulder. It was Chip!

“Hey, babe, sorry I’m late. You look, uhhh, great?” he said through a grimace.

“Chip! Why on earth did you decide to look into getting health insurance on our wedding day?”

“Listen, with Obamacare coming to town today, I was getting anxious. I knew that opting out of health coverage this time around I would be breaking both state and federal individual mandates.Come tax time, I would be forced to pay the higher of the two penalties for my non-compliance so I wanted to enroll as soon as I could.”

Cassandra couldn’t believe this was the man she was about to marry, but she liked that he was thinking about the future.

“All right,” huffed Cassandra, “you’re here now. Let’s just get this over with. Father Mortlock, would you mind doing the honors? And make it snappy – my migraine medication hasn’t kicked in!”

“Fine by me,” said Father Mortlock, raising his bible. “I’ll get right to the good stuff. If anyone objects to this union, speak now or forever hold your pea-”

“I OBJECT!”

(Gasps from the audience.)

Cassandra’s heart almost stopped. That voice! She’d recognize it anywhere! But it couldn’t be….

“Dr. Lance Jones?! But how? You died three years ago!”

“Well, I’m back from the dead and I object to this union! Back away from the bride, Montebello.”

“Lance! Lance my darling!” Cassandra cried, running to him. “I don’t understand! Where have you been?”

“Let me explain, “declared Dr. Jones, pushing Cassandra aside dramatically. “Back in the early days of 2010, I was finally getting used to all of the changes with health reform in Massachusetts, when all of a sudden it was announced that Obamacare was to become the law across the country. This got my blood pressure surging. How could there be more changes to state health insurance laws when Obamacare was modeled after Massachusetts health reform? What would this mean for me, someone who provides health care and consumes health insurance?

“This sent me head-first off a proverbial cliff into an abyss of uncertainty, causing me severe professional and existential angst. So I did what any overwhelmed physician would do. I staged a boating accident, faked my own death and have been living on Nantucket for the past three years. At the time, this was the path with the greatest number of options for me.”

(More gasps from the audience)

“Greater options?” blurted Chip. “What do you think you are? The Mass Health Connector after Obamacare?”

“What are you talking about?” bellowed Dr. Jones.

“The PPACA requires that the Mass Health Connector add a fourth metallic “Platinum” tier to its product shelf – right now there are only three,” Chip quipped, growing increasingly agitated. “When you combine that with the new Co-op plan that’s coming to this state’s insurance market in 2014, we’ll be seeing plenty of new coverage options by January. But right now, Jones, it looks like your only option is to explain why you’ve chosen to come back from the dead today, or be prepared to feel the wrath of a Chip Montebello knuckle sandwich! ”

“I-i-it’s October 1st!” sputtered Dr. Jones. “Obamacare kicks in across the country and will be in even greater effect come January 1st, 2014! I’ve had nothing but time on Nantucket and I’ve been following the news in detail. Some project that with the increased number of federal dollars coming into the state to assist with the expansion of Medicaid, Massachusetts taxpayers may see some savings in the coming years. What’s more, increased federal funds are available to health care workers who experiment with innovative ways of providing comprehensive care at lower costs. I had to come back now so I could finally realize my dream of operating an Accountable Care Organization!”

(Still more gasps.)

“Wait a minute!” chimed in Cassandra. “You’re a pediatric surgeon. The money for innovations in health care delivery is only available through Medicare. Plus, Massachusetts was already giving these types of financial incentives before you…er, died.”

“Yes, but there are even more federal dollars available for health care innovators now that Obamacare’s the law of the land. But more importantly, I’ve seen the light!” exclaimed Dr. Jones throwing his hands into the air. “Providing coordinated care to the elderly is my calling!”

“Something fishy’s going on here,” said Cassandra to herself.

“Ya think?” croaked a rather caustic voice from the back of the church. It was Elaine! But, Cassandra knew her mother wasn’t at the church to wish her a happy wedding.

“Now Cassandra, I’ve had just about enough!” Elaine barked as she stormed down the aisle. “Someone with the kind of chronic conditions I have can’t wait forever to buy her medication. Where is my money?!”

“That voice!” beamed Dr. Jones. “It’s like a choir of laughing angels! Oh! I can’t hold it in any longer! I’ve come back because my heart belongs to your mother, Cassandra. I’m in love with Elaine St. James!”

(Yet more gasps.)

“I knew it!” spat Cassandra. “I could sense you had a wandering eye when we were together before your death…or whatever. But my mother?! Well, it all makes sense. You knew she was turning 65 this year! Now you’ve come back to start your ACO that will receive funding through Medicare as part of some sick ploy to seduce her! Well fine! Now you can cover her donut hole expenses!”

“It’s true. That’s why I have come back,” said Dr. Jones, staring, bewildered, out towards the sea of dropped jaws occupying the church pews. “But pay for Elaine’s pharmaceuticals? The coverage gap for some medications covered by Medicare has been shrinking since 2011.  By 2020, the donut hole could be but a distant memory and seniors won’t see any change in their pharmaceutical coverage once they hit that level of spending.”

“What?” screeched Cassandra. “Mother! You’ve had pharmaceutical coverage all along? You’ve betrayed me! All that money I’ve been dolling out to you! For what?”

“Fine,” growled Elaine, brow furrowed and lips clenched. “You’ve caught me. But I can explain. I’ve been trying to get out of this good-for-nothing town for 65 years. Ever since I was a tot I’ve known I have what it takes to be famous. A Hollywood contract is my ticket out of here! But the only thing between me and world fame is….my teeth! Look at them!”

Elaine’s unveiling of her ghastly grin was met with a chorus of horrified screams.

“All right, all right,” Elaine began. “So I scammed my own daughter. How else was I going to come up with money for dental insurance? I knew it was my big chance when the Health Connector announced that for the first time ever, they’d be offering stand alone dental insurance plans as per new Obamacare regulations.”

“Well this is just great!” screeched Cassandra, throwing off her veil and crumpling to the floor. “What a wonderful life I’ve got! My fiancé would rather shop for health insurance than show up to our wedding on time, the love of my life, whose alleged death I’ve been mourning over for the past three years, has been hiding from the world on Nantucket, all the while pining for my two-faced mother who has been actively ripping me off! With you lot in my life, I ought to seek professional help! I would get myself a psychiatrist, but my employer covers less than 60% of my health benefits, and I just can’t afford that! Hey, Obamacare! You think you’re so great, but can you help me now?!!”

“Actually, yes it can.”

“Father Mortlock?” whimpered Cassandra. “How – how do you know?”

“Well,” said Father Mortlock, “I actually took an interest in this federal health reform business when the Church community was in a huff about the contraceptive mandate. From what I know about the law, come January 2014, if the insurance your employer offers isn’t affordable to you, you’ll be allowed to purchase coverage on the Health Connector. Affordability is determined using a federal measure, so if your employer’s insurance premiums are greater than 9.5% of your income, or if it covers less than 60% of the cost of the benefits on your insurance policy, then your insurance is considered to be unaffordable and you are free to wander the tiers of the Health Connector in search of coverage.”

“That’s good to hear, Father,” sighed Cassandra, “but my income is 400% of the federal poverty line. I won’t be eligible for government subsidies, so even insurance on the state exchange would be a financial strain for me.”

“Don’t you jump to conclusions like that in my church!” Father Mortlock scolded. “It just so happens that Obamacare shifts the income bracket for subsidy eligibility from 300% of the federal poverty line to 400%. You might want to follow the lead of Mr. Montebello and check out the new streamlined enrollment on the Health Connector.”

“Hallelujah!” cheered Cassandra, jumping to her feet. “Mother! You can have Lance. The two of you deserve each other. Chip – I never loved you. Besides, I don’t think I can be with a man who hasn’t seen the value in having health insurance until now. Goodbye, Father Mortlock, and hello, therapy!”

THE END

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A story broke Monday that Anthony Stokes – a teenager in Georgia, given six months to live on account of his dire heart condition — was denied a place on a heart transplant list due to his history of “non-compliance,” that is, not following medical orders. (Anthony’s family said the real reason they believe their child was denied a spot was due to “low grades and trouble with the law” according to anABC news report.)

Either way, though it was announced today by Stokes’ family that their son will now be placed on the transplant list, this controversy raises important questions: should bad behavior block a patient’s acces to the list?

While it may seem harsh to deny a child a spot on the heart transplant list because of past transgressions, George Annas, Chair of the Department of Health Law and Bioethics at Boston University, says a patient’s ability to follow post-transplant medical advice is an important screening criterion.

“There are not enough hearts for everyone,” he says.  “When someone gets a heart transplant that means there is someone who does not get one.  The last thing you want to do is give an organ to someone who doesn’t want one or who’s not likely to use it well.  If you’re certain that a person (receiving a transplant) will not comply, then you’re essentially wasting an organ.”

But how can anyone – including expert transplant surgeons — be certain of someone’s future behavior?  This, says Annas, is what makes the issue so controversial: it’s hard to be sure.

“Requiring a transplant to survive is a life changing experience,” says Annas.  “(A patient’s) past behavior may not be as predictive as one thinks as post-transplant behavior.  There is no blood-test to determine this.”

Indeed, when it comes to assessing the probability of someone’s future behavior, there is no scientific test that can be used to asses this.  In the absence of objective medical criteria, the decision to deny someone a spot on a transplant list on grounds for “non-compliance” can seem arbitrary.

“It’s actually unusual for transplant surgeons to use this criteria,” he says, “because it appears to invite all sorts of social worth determinations which wind up looking like discrimination against poor people or racial minorities.”

According to Annas, most people in need of a heart transplant are denied this opportunity because the list of people in need is much, much longer than the supply of organs available.  Because of this chronic mismatch, the issue of who gets on organ transplant lists is consistently controversial.

“This is the major place in medicine where we have to do rationing because of the limits in the numbers of organs available.   It forces us to confront the issue on how to do this fairly.”

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Food used to be a simple pleasure. But lately, it seems there are a million things to worry about when it comes to food. Even buying a plain-old bunch of carrots can induce anxiety:  Are they local?  Are they organic?  How much vitamin A do I need anyway?  Wouldn’t I rather spend my money on that giant bag of Doritos?

It’s certainly not new for food to be on everyone’s minds – it is a basic human need, after all.  But it seems that food occupies the cultural consciousness in new ways and more intensely than ever before.

Food-related headlines are a contemporary norm.  Consider the recent move to label obesity as a disease, or the super-sized soda ban in New York City.

Celebrity chefs are front-page news (think butter-worshipping Paula Deen’s owning up to her use of a racial slur.  We’re nuts about it!  But why is a famous donut advocate eliciting such widespread outrage)?

Public health officials are even more amped up in their stances on the future of nutrition.  A recent BMJ article laments the widespread failures of nutrition policy and urges policy makers to approach nutrition interventions with “brutal pragmatism”.

And then there’s the “personal is political” stance taking over many modern American kitchens. These are the raw-whole-natural-organic-local-fair-trade types who oppose the mainstream industrialization of food and food distribution.  One example: the recent viral postpublished by BuzzFeed that lists some of the alarming health horrors linked to chemicals in everyday favorites like Froot Loops and milk.

At the other end of the buffet table, there are those who view technical interventions, like food additives and various processing techniques as promising for the future. These folks sometimes view the “wholesome foodies” as food-hysteric, ignorant to the realities of science.  For instance, in response to the BuzzFeed list, one chemist wrote a blog post refuting the list point by point using his expertise as a scientist.  His post proved popular with the “science friendly” crowd, generating ample comments in support of his stance on food.

Somewhere along the great food wars spectrum falls an article recently published by The Atlanticthat criticizes foodies for getting in the way of the junk-food industry’s power to abate the obesity epidemic.

Why the crescendo of food-related debates?  What are we really fighting about? Dr. Sean Cash of Tufts Friedman School of Nutrition Science and Policy says it’s complicated.

“Food is something we all have an opinion on.  We all eat.  We’re all experts on it,” he says.

Cash agrees that food is on almost everyone’s mind in a different way than it was even 20 years ago.  He explains that half a century ago, simply being able to get enough food was a huge concern for the average American, but today, it’s far less of an issue for many.

“We spend half as much now on food as a percentage of our total income than we did in our grandparents’ generation,” he says.  “In 1950, 20% of income [was] devoted to food, now it’s around 10%.”

As food became less of a stressful uncertainty, it moved beyond simply being important in the domain of nutrition. Since World War II, as average household income rose and, for the most part, the real price of food declined, time and dollars were freed up for the average American.  This, Cash said, opened the door to a more cultural perception of what we eat: food as entertainment. Now, for instance, we can spend hours preparing a marinara sauce not because we have to, but because we want to.

It’s not uncommon for food writing to grace modern best-sellers lists – think the Omnivores Dilemma by Michael Pollan or Eating Animals by Jonathan Safran Foer – or for food films to make considerable profits – Food Inc. and Supersize Me are among the best-selling documentaries of all time.  The surging popularity of the Food Network over the past two decades is also a notable indication of just how much spare time many are allotting to the modern culinary craze. Cash says the idea of food as something worthy of so much precious leisure time to is a contemporary phenomenon.

“A middle class mom and dad going to the local store after the kids are in bed to attend a class on knife-use is not imaginable 20 years ago,” he says.  “We’re entertaining ourselves arguing about food.”

But the ability to spend spare time exploring new epicurean intrigues like canning for pleasure or concocting your own sour-dough starter is not a privilege accessible to the average American.  For many under serious economic constraints, this type of endeavor may not be a priority, or even an option.

“Trying to reconnect with food takes a lot of time and energy and the new foodie movement embraces this,” Cash says, “but when we focus in on that we see that issues around providing food are still very real for folks here and internationally.  There is record enrollment in SNAP and food stamps are up.  There is sometimes a lack of empathy on the part of foodies about the realities of other people in society.”

Cash thinks the tendency to lump anything and everything that concerns grub under one umbrella labeled “food” is problematic.  He explains that standardizing anything that concerns food into one camp can sometimes reduce the perception of a particular food debate as having clear-cut supporters and opponents.

“People only see two poles, but it’s more complicated than that,” he says.  “The issue is the word “food” is too simple. Food is everything.”

Dr. Cash says the fact that various food advocates come from many different knowledge bases — combined with the increased media attention on their divergent stances –contributes to the increased clamor around food.

“In the media, we just say that someone is an expert in “food” but then that encompasses such a huge portion of human endeavor,” he says.  “How often do we see an agronomist or soil scientist in the news giving an opinion?  On the same day, we have stories in our media about Monsanto winning the Food Prize that show up simultaneously with coverage of the top local breweries.”

As fragmented and confusing as they are, Dr. Cash is pleased that food debates are so hot right now.

“Now is a critical time,” he says. “We have the public’s ear to send messages that might resonate in a way they never have. It may be that this won’t be the case in five years.”

He points out that there actually have been some small victories for public health — such as near-universal bans on trans-fats and the increasing presence of whole grains in peoples’ diets — won without resorting to extreme policy measures.

“If we’re looking for big changes over night, that to me is fantasy,” he says.  “Don’t pooh-pooh the small changes.”

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