CHMP

Jen Busse, RN, MPH, is an intern at the CHMP, and currently pursuing an MS in nursing as a Family Practice Nurse Practitioner at Columbia University.

Made in India at Roosevelt House

Those who watched Made in India at CHMP’s Film and New Media Series event with their own preconceived notions regarding reproductive tourism were left with more questions than answers.  With the film, filmmakers Rebecca Haimowitz & Vaishali Sinha, expertly create a nuanced view that thoughtfully represents perspectives of both infertile couples and the reproductive tourism industry without vilifying either side.  In fact, the moviegoer finds themselves sympathetic to both sides in this story.  The film leaves one questioning the currently unregulated world of international surrogacy; its need for parameters to protect families seeking a surrogate mother, as well as for the surrogates, themselves.

Made in India is a documentary that transports the viewer into the world of surrogate “outsourcing” to India.  We are taken on the journey of a blue-collar American couple in their quest to have a biological child.  The viewer watches them struggle to articulate their case to an often-skeptical public in America.  We witness a strong bond between the would-be parents, as they trudge through hormone treatments, make the long trip back and forth to Mumbai, and finally, are nearly unable to take their children home with them.  We watch the trials of the surrogate, who later finds out she is pregnant with twins.  She struggles through relationships with her family and friends, and then sufferes a placental abruption, a medical emergency, early in her third trimester.

Following the film was a panel discussion moderated by CHMP’s Barbara Glickstein with the filmmakers and two experts in the field: Dr. Carole Vance and Daisy Deomampo.  The panel and audience discussed how the surrogate, who at first the audience believes is powerless, actually has a strong ability to negotiate her interests with respect to her husband, the medical tourism company, and the couple she provided a surrogacy for.  However, when it comes to the initial contract she had entered into, there existed no legal enforcement mechanism.

The film, however, does not portray the worst-case scenario in these situations, as Dr. Vance pointed out.  The filmmakers noted that a pregnancy is not guaranteed in these contracts and loss of a pregnancy is common.  The film chooses not to take the easy way out and does not latch on to an extreme of cases.  Consequently, it does not romanticize or disparage, but portrays the agency of the film’s subjects.  It paints a complex picture that is international surrogacy.  While the case shown in the film is not the worst, one is left to wonder what happens in such cases.  Rather than condemning the practice of reproductive tourism, the filmmakers highlighted the need for regulation of the industry.  The need for regulation is especially true, as shown in the final 5 minutes of the film, because this particular company has plans to expand to other developing countries.

While the biological parents and United States Department of State ultimately negotiate a way for the twins to leave India, the viewer is left with concern that this may not be the case in other situations.  Fear also remains of an industry unregulated, and therefore unable to protect the basic human rights of the surrogates, for whom offering surrogacy is an increasingly appealing way to provide for their families–especially when they are left with few other options.  Perhaps most importantly, the film raises the point of how policies, globally, will be required to keep up with growing and evolving international industry and technology.

Vaishali Sinha

Barbara Glickstein

Panel

Panel

Roosevelt House

Daisy Deomampo

February 20th-26th is National Eating Disorders Awareness Week.  Eating disorders are a sensitive topic, making it too easily and too often skipped in conversations about health and wellness.  Overlooked are discussions with young about body image, among whom this crisis runs rampant.  The media still swoons, after many years, over the “perfect” size 0 body.  So I’d like to ask: Where are the role models for young women?  Why is this destructive media attention to unattainable thinness allowed to continue when there are 10 million females and 1 million males suffering from disordered eating in the United States—an illness related to the highest mortality rate of any mental health disorder?

As a nurse and a nurse practitioner student, it has become my role as a provider to intervene when I see a child nearing the clinical label of “overweight”.  I must speak to the family about healthy food choices and exercise, but is a fine line I walk when approaching my patients and their families.  I think, “Could I create an eating disorder in this young person?  How can I best be sensitive to their needs?”  Similarly, when I see a young girl, painfully underweight with little self-confidence, how can I also approach her with the same sensitivity?  How can I effectively battle the images young people are assaulted with daily in movies, TV, and magazines in the exam room?

From my own experience as a Division I collegiate cross country and track and field athlete, I know the physical and emotional toll body image issues took on my teammates and myself.  The secrecy of this unspoken “thing” was apparent in our nightly rituals, as we distance runners sat in the dining hall together, after two or more hours of grueling practice, eating little and comparing meal choices, silently, to those of our teammates.  We had severely low BMIs and most of us no longer got our period–both indications of malnutrition and unhealthy bodyweight.

I know we weren’t the only ones coping.  I watched female gymnasts, field hockey and basketball players, as well as my friends in the dorm struggle, too.  But where were our coaches, health care providers and teachers?  Where were our positive role models?  No one talked about it.  Through our misery, we continually received reinforcement that our emaciated bodies were “beautiful” and “healthy” via images of the professional athletes we aspired to be like, and through media portrayal of the “ideal” woman.  So, the bones we were seeing in the mirror were beautiful?

Women in college are not the only ones at risk.   In 2009, Ralph Lauren made national news for firing a size 4 model for being “too fat” after they had severely altered her image in their campaign (see above).  This is where the National Organization for Women and the National Eating Disorders Association come in with their “Let’s Talk about it Campaign”.  Visitors to the site are encouraged to speak out against media representation of unrealistic bodies bombarding the eyes and minds of us all.  On the website, you can share your story and feelings or be inspired by videos of others who have struggled with their own self-image and come out stronger on the other side.

Do you have your own story of a struggle with body image?

Through my work at Planned Parenthood and in community health nursing, I have heard more than my share of terrible stories about abused women becoming pregnant.  By their own accounts, many, many young, pregnant women have told me similar stories of partner abuse: a pressure to get pregnant.

For health care professionals in the community setting, this is not an unusual story.  These women’s stories are now being corroborated by a report to be released today by the federally funded National Domestic Violence Hotline.  The group found that 1 in 4 women, of the 3,000 women questioned who had called the hotline, reported being pressured or forced into having unprotected sex.

The horror doesn’t end there.  According to an article in the New York Times, the director of health at the Family Violence Prevention Fund, Lisa James, recounted stories discovered by the study.  This included men refusing to wear condoms or flushing their partner’s birth control pills down the toilet.  Many women also reported being forced to conceal taking their own birth control pills.

All of this comes on the coattails of the highly controversial new bill about to be considered by South Dakota’s GOP-dominated House of Representatives regarding “justifiable homicide” of abortion providers based on “resisting an attempt to harm an unborn child”.  South Dakota’s proposed bill, in a state where it is almost impossible for a woman to safely terminate a pregnancy, is just one of the many new assaults on a woman’s right to choose featured in the news recently.

We cannot discount the link between interpersonal violence and unwanted pregnancy.  Proposed new legislation, such as that in South Dakota, seeks to conceivably protect an abuser attempting to keep his partner pregnant.  According to the New York Times, Ms. James, of the Family Violence Prevention Fund, believes not enough people are asking questions about interpersonal violence and abuse of women with unwanted pregnancies.  Is it just because we don’t want to hear their answers?

The FDA released a report Wednesday regarding recent findings of a link between persons with breast implants and anaplastic large cell lymphoma (ALCL), a rare form of cancer involving the immune system.   The FDA stresses that too few cases (37 identified cases since 1997) of ALCL have been recognized among those with breast implants for them to make a causal link between the two.

A registry of breast implant recipients has been proposed by the FDA and the American Society of Plastic Surgeons in order to identify people with breast implants who go on to develop ALCL.  Clinicians can report confirmed cases to the FDA safety information program, MedWatch.  Physician and FDA scientist, Binita Ashar took part in a Q&A on the FDA website regarding the issue.  He noted ALCL has been identified in those with both silicone and saline-filled implants.

The FDA identified this potential connection through their own surveillance, not from agreed upon post-approval studies by makers of breast implants that have enrolled very few women.  At the present time the FDA is not suggesting people remove their implants, but it is important to understand this recently identified potential risk.

The FDA states the information they will have to share about this link will be solely based upon the number of reports the registry receives.  It will be interesting to see if the increased attention to this issue increases monitoring, and thus case-finding, among breast implant recipients.  However, considering the 5-10 million people worldwide with breast implants and 37 confirmed cases of ALCL among them, is this just another media-hyped story adding to cancer-hysteria?

The repeal of the Affordable Care Act is up for a vote today in the House, and Republicans seem to be dead-set on doing away with the current legislation.  They claim the law would cost the country 650,000 jobs.  This is a shaky claim, especially with the mounting counter-evidence supported by economists.

The Congressional Budget Office says that initially, the law could lead to some employers not hiring as many low-wage workers, but they point out this will also slow the increase in health care costs, leaving those employers with more capital to expand their businesses.  The budget office also claims that 30 million people would gain coverage with the Affordable Care Act, again creating jobs.

White House officials advocate this law has the potential to create over 300,000 jobs by containing costs of employee health benefits, as well.  Importantly, when Massachusetts instated a health insurance mandate, there was an increase in health insurance coverage, as well as an increase in health care utilization, which resulted in the creation of jobs.  It is hoped that this would be a similar trend with the Affordable Care Act.

The Department of Health and Human Services released a report yesterday showing 129 million Americans under age 65 have some pre-existing medical condition that could lead them to be denied health care coverage without protections that would be afforded to them by the new health law.  This is another argument for health care reform and job creation.

What are your thoughts about health care reform and its potential repeal by the House?

CHMP intern, Jen Busse, has had her second blog post of a series added to the American Journal of Nursing blog, “Off the Charts”.  The article discusses the importance of the nurse mentor-protégé relationship, and how it will become increasingly important with the advent of health care reform and the Institute of Medicine and Robert Wood Johnson Foundation Report on the Future of Nursing.  She also discusses the significance of CHMP directors Diana Mason and Barbara Glickstein in her personal and professional development as a new nurse.  Read the article here on AJN’s blog.

No scientific evidence supporting physical harm exists stating emergency contraception (EC), also referred to as Plan B, should not be available to women under the age of 17.  If you are a female and think your birth control failed, unlike women over the age of 17, you must find a health care provider and get a prescription to buy EC. Not an easy task for most young women who know that you must take Plan B within 72 hours of sexual intercourse in order for it to be effective; actually, the sooner, the better.

Barriers exist for women over the age of 17 too.  Many FDA regulations for EC were made in the name of politics – not because science dictated these actions. The Center for Reproductive Rights (CRR) is doing something about this – it’s bringing the FDA to court.

One complaint in this suit by CRR also addresses access – emergency contraception, a non-prescription item, is not displayed on a shelf but stored behind a pharmacy counter and must be asked for by the purchaser.  Remember when condoms were stored out of sight so you had to ask out loud for them? Another unheard of requirement when making a drug purchase: the person buying EC must present a government issued ID. Another few minutes at the counter showing a photo ID in a crowded pharmacy may increase anxiety in someone already worried his or her birth control method had failed.  These two obstacles were already raised and litigated against the FDA, and resulted in a judge demanding the FDA reconsider these regulations.  So far, nothing has changed.

CRR discusses how these practices set a precedent:

“No drug besides Plan B is subject to a two-tiered prescription/over-the-counter structure based on age. And no other over-the-counter drug requires production of identification for purchase. The testimony of FDA employees and officials makes clear that the FDA’s decisions regarding emergency contraception were made on the basis of politics, rather than on considerations of the drug’s safety and efficacy. This influence appears to have come from as far up as the White House.”

To make matters worse, some Walgreens pharmacies in Texas and Mississippi are refusing to sell Plan B to men. Earlier in the year the ACLU was made aware of this problem, which resulted in Walgreens administering a bulletin clarifying the law about emergency contraception to all of its pharmacists.  Reports that men who arrive without a female over the age of 17 (or under 17 years of age with a prescription and valid ID) continue to be turned away.  According to FDA policy, men and women over age 17 may purchase EC without proof of whom the pill will be for.  However, this policy has not been enforced.

The bottom line really is: Will the FDA, an organization founded on scientific principles and clinical data, uphold its commitment to, as they say, “helping the public get the accurate, science-based information they need to use medicines”?  Or, will they support political decisions as opposed to clinical evidence to create policies?

There is further information about this on the CRR’s website here.

Jen Busse, RN, MPH is an intern at CHMP and is currently pursuing her MSN as a Family Nurse Practitioner at Columbia University School of Nursing.

Congratulations to CHMP Intern Jen Busse, for her first published post on the American Journal of Nursing’s  Off The Charts “An NP Prepares: When ‘Normal’ Is Better Than ‘Fine’”

Jen Busse, RN, MPH, who is currently working as a nurse while studying at Columbia University College of Nursing to be a family nurse practitioner.

CHMP is grateful for all the feedback to last week’s events when CHMP Visiting Scholars, Fiona Gold and Juanita Maginley, the Street Nurses, were in NYC from Vancouver, BC.  Alison Bulman, senior editorial coordinator at the American Journal of Nursing, writes about her reaction to learning about their work and watching the documentary film,  Bevel UP directed by the noted filmmaker Nettie Wild and co-produced by the National Film Board of Canada and the BCCDC outreach nurses themselves. Read her post “Harm Reduction or Stigmatization: What’s Your Approach to Drug Addicted Patients?” in Off The Charts, the award-winning blog of the American Journal of Nursing (AJN).

"Bevel Up: Drugs, Users, and Outreach Nursing"

On Tuesday, October 26^th, and Thursday, October 28^th, The Center for Health Media and Policy hosted two events with Vancouver Street Nurses, Fiona Gold and Jaunita Maginley.  Both evenings began with a screening of their educational documentary entitled, “Bevel Up: Drugs, Users, and Outreach Nursing”, and was followed by a question and answer session with Ms. Gold and Ms. Maginley.  Below are some interesting questions and comments raised during the question and answer sessions after screenings.

From the October 26^th Event at Hunter College, moderated by Dr. Jessie Daniels (CHMP Senior Fellow and Associate Professor of Urban Public Health at Hunter College), and the October 28^th event at New York Academy of Medicine’s Ninth International Conference on Urban Health:

In the film, a Street Nurse asks Becky to step outside of the van to inject her heroin.  Why is this?

From Ms. Gold and Ms. Maginley: The supervised injection site in Vancouver is new and still highly contested, so it was important to the Street Nurses that they not undermine the work being done there by allowing supervised injection in the Street Nurses’ Van.  Ms. Maginley said, “Good care and smart politics go hand in hand,” and Ms. Gold said, “We don’t want to seem like renegade nurses.”

With the complexity of care involved with Street Nursing, how has the program been organized to handle this?

From Ms. Gold and Ms. Maginley:  Key to keep in mind is the saying that came from the HIV/AIDS movement, “Don’t make plans about us, without us” (Ms. Maginley).   Listening to the needs of the people being served is the most important factor in providing good care.  This allows the program to better connect people to housing, clinics, detoxification programs and mental health services.

What have you seen come out of widespread distribution of the film?

From Ms. Gold and Ms. Maginley: The film has been even more than just an instructional tool, but also a way to create dialogue about difficult questions regarding needs of an area where those who are watching it are.  Masha Golovanevskaya from the Open Society Foundations New York was present, and was asked to share her experiences of working with nurses and public health organizations in Russia and the Ukraine.   She said “Bevel Up” has been included as part of a harm reduction curriculum in many harm reduction programs throughout the Ukraine and Russia.  Not only has it helped to promote effective harm reduction strategies, but it has also helped empower nurses to help those suffering from addiction.

Comments on Frankfurt’s success with their supervised injection sites

From Ms. Gold and Ms. Maginley: Ms. Gold had recently visited a supervised injection site in Frankfurt, and spoke about the “continuum of care” those living with addiction are able to receive there.  In the same building, in addition to supervised injection rooms, there is housing available, a needle exchange program, as well as a detoxification program¹.

There was also discussion on applications of harm reduction to the U.S., including California’s Proposition 19 (decriminalization of marijuana)

From Ms. Gold and Ms. Maginley: In 2001 Portugal abolished all criminal penalties for possession of drugs including marijuana, cocaine, heroin and methamphetamine.  The new policy has shown significant successes in public health².

Notes:

¹The Frankfurt program has been found to significantly reduce the number of homeless drug users, incidents of drug-related crime and violence, and drug-related deaths (source: Kemmesies, U.E. (1999). The open drug scene and the safe injection room offers in Frankfurt and Main 1995. Final report. Hamburg, Germany: European Cities on Drug Policy.)

²A report on the new policy 5 years later showed positive results, as the deaths from overdoses went from 400 to 290 annually since 2000, and the number of new HIV cases caused by dirty needles to inject heroin went from 1,400 in 2000 to 400 in 2006.

Jen Busse, RN, MPH is an intern for CHMP and is currently working toward her MSN as a family nurse practitioner