Health (373)
It's not every day that an American physician gets asked to function as an international pharmaceutical supplier, but for some, it's becoming a regular occurrence.
A doctor I know told of a patient getting ready for a trip to Istanbul, where he would connect with Iranian friends. The patient asked for a prescription for a diabetes medication, "The most you can write for," he said. The doctor was puzzled: his patient did not carry a diabetes diagnosis. "It's for my mother," came the response. "It's getting very difficult to find this medicine in Iran, and she's going to run out soon."
Healthcare professionals report acquaintances, family of family, and others recently approaching and asking for all sorts of medical supplies, ranging from anti-maceration medications for the bedridden, to insulin pumps.
Reading the news in the comfort of my home, I've come across more troubling stories -- patients dying from shortages of needed medication, or waiting years for organ transplants only to find themselves without the medication needed to prevent rejection of the donor organ.
Why are the people of Iran in the midst of a medicine shortage?
In 2010, then-Secretary of State Hillary Clinton stated that the United States had begun discussions with allies regarding methods of "pressure and sanctions" to counter Iran's nuclear program, emphasizing that the goal was to stop the Islamic regime without harming innocent civilians. Specifically, she said the U.S. government's aim was "to pressure the Iranian government ... without contributing to the suffering of ordinary [Iranians]."
More recently, David Cohen, Undersecretary for Terrorism and Financial Intelligence at the U.S. Treasury Department, made similar comments, saying that "we have no quarrel with the people of Iran" and that "the ultimate objective is to try and slow down the development of Iran's nuclear program ... not to make food and medicine scarce."
In clinical medicine, design and implementation of interventions, ostensibly in the service of improving care, is a common undertaking; when we see that an intervention is not achieving its stated goals, or in fact harming patients, substantial corrective action is indicated, even if it means abandonment of the intervention altogether.
In this vein, how do the intended effects of sanctions imposed on Iran by the U.S. government and others compare with the actual effects?
Several prominent health professionals within Iran have called attention to the plight of vulnerable patients as a result of the sanctions. Ahmad Ghavidel, head of the Iranian Hemophilia Society, a nongovernmental organization that assists some 8000 patients, characterized the situation as "a blatant hostage-taking of the most vulnerable people." Fatemeh Hashemi, of the Charity Foundation for Special Diseases, has publicly voiced concerns about impaired access to life-saving treatments for patients with multiple sclerosis, cancer, end-stage renal disease and other illnesses, as a result of the sanctions.
Many diseases such as hemophilia require advanced medicines that are simply not available in Iran for a variety of reasons including patent laws and access to specialized raw materials and technology for manufacture — such medications and materials have to be imported, mainly from Western nations.
While the U.S. government states that there are exemptions for food, medicine and remittances, the timely receipt of the right quantity of medicines is not as simple as submitting a request to the Treasury Department. A Wilson Center report found that it is the sanctions affecting the majority of large Iranian banks (and the international and US-based banking institutions that would do business with them) that have most affected the availability of medicines for purchase and use.
"Iran's own mismanagement of the situation has aggravated the problem, but it is not the root cause of it," the authors stressed. "While the list of issues leading to the supply crunch is long and complicated, at the heart of it all are the obstacles that sanctions have created in denying Iran the necessary banking operations and limiting its access to hard currency." Simply put, "the pronounced role of sanctions in creating shortages of life-saving medical supplies and drugs in Iran may have been unintentional, but it is also irrefutable."
The report goes on to say that the main beneficiaries of the sanctions have been Iranian government-owned businesses, which often get preferential access to currency, as well as smugglers and black market dealers who are buying up medicines and selling them (or knockoffs of them) to civilians with high markups.
Others are now beginning speaking out. Ahmad Shaheed, the United Nations special rapporteur for human rights in Iran, who has been vilified by the Iranian government for his investigations, feels that sanctions could "absolutely" worsen the human rights situation in Iran. In a situation where shortages of medical supplies are created, he said, "the most vulnerable people suffer immediately, and over the long term there is wider suffering caused."
Maziar Shirazi is an Iranian-American family physician completing his residency training in Philadelphia. When he is not working, he freelances and plays capoeira.
Mary Bowman is a 24-year-old fast food employee who lives in Suitland, Md. For the last three years, she has been expressing herself, and revealing snippets of her life through poetry. She recently recited a poem in which she describes her mother as a dandelion in the midst of roses.
"Ignorant of her purpose she uprooted her soul and unknowingly left herself for dead to dandelions," said Bowman at an HIV/AIDS event at Howard University on April 11, the day after the first National Youth HIV and AIDS Awareness Day. "All the while dying on the inside, AIDS didn't kill my mother. It put her at rest," Bowman told the crowd.
Her mother died when she was three.
"It's definitely a part of my life, it's as second nature as having an arm," said Bowman about being born HIV positive. She didn't know she had the disease until she was in the fourth grade and she shared her status with her entire class. To tell her story and to help others tell theirs, Bowman created a nonprofit organization called Purpose Over Entertainment or P.O.E.T., which helps to inform others how she and those like her live with the disease.
Bowman joins 76,400 young people nationwide who are living with HIV, according to Advocates for Youth, a Washington, D.C.-based nonprofit that aims to help and inform young people about their sexual health. The organization used April 10, 2013, as the first Youth AIDS Day, in the hope of bringing attention and awareness to the importance of getting tested, and to also bring attention to the fact that one in four new HIV infections in the United States is among youth between the ages of 13 and 24. There are 1,000 new HIV cases diagnosed among young people each month.
Discovered in the 1980s, Human Immunodeficiency Virus or HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). AIDS weakens the body's immune system so it loses the ability to fight off infection and illnesses. When it was first discovered, many people thought it was a death sentence. However advocates contend that new medications have made living with HIV far more manageable.
"Diabetes is harder to manage as a patient, and the medical outcomes are worst," said Justin Goforth, 47, a registered nurse and director of community relations at Whitman-Walker Health, a nonprofit community health center in the District with special expertise in HIV/AIDS care and care for the Gay, Lesbian, Bisexual and Transgender community. Goforth handed out flyers and pamphlets that showcased the clinic at a table at a Howard University symposium on increasing the numbers of minorities in health professions on April 10. He said young people stopped to chat about the clinic's work.
Dawn Wilson, a graduate student at Howard University, was waiting for the results of her HIV test at the April 11 AIDS awareness event at Howard, which was hosted by Metro TeenAIDS (MTA) in Southeast, a community health organization dedicated to supporting young people in the fight against the disease.
"I'm not nervous at all," said Wilson, 25, a Silver Spring, Md., resident. "This isn't my first time. I know my status and I do what I have to do." Besides visiting Howard to offer free HIV tests, MTA took its RealTalk bus into Wards 7 and 8 to offer these tests. About 60 people received HIV tests, said Dwayne Lawson-Brown, a community outreach coordinator for MTA.
"In the District, we have a special understanding of how HIV/AIDS can destroy lives," said Adam Tenner, MTA executive director. "We won't stop until we have created the first AIDS-free generation."
Advocates for Youth, which provided the majority of the literature for the National Youth HIV and AIDS Awareness Day, insists that although 50 percent of young people say they want more information about HIV, only 22.6 percent of sexually active high school students have been tested.
Goforth understands the impact that HIV can have on loved ones.
His 23-year-old adopted son, who came out as a homosexual to his biological family at 16, has lived under the cloud and shame of having the disease for several years.
"He would take his medications in private, closing his door," said Goforth, 47. "He's an example of what we see, young, gay black men who are disowned by their families, sofa surfing, and who have to deal with both being gay and their HIV status." He said that churches need to provide some leadership as HIV and AIDS enters its fourth decade.
"I'm always shocked how after all this time, attitudes toward HIV haven't changed all that much," said Goforth, who has had HIV since 1992. He said people can live with the disease, take their medications without dramatically changing their lives.
"People still ask me if they could get it though saliva or from kissing. We have to change people's minds on what HIV is, and we have to continue to encourage young people, all people to get tested," he added.
With the higher numbers of adult deaths, infant mortality rates and other health-related issues plaguing minorities, it becomes even more vital to increase the participation of health care professionals with diverse backgrounds in the industry, which will greatly improve the health outcomes in these communities.
These were the conclusions by several speakers at an all-day health care symposium hosted by Howard University in Northwest on April 10.
In the early 1990s, millions of dollars were used to address HIV/AIDS, making it less threatening today, said Dr. Louis Sullivan, former U.S. Secretary of Health and Human Services, who delivered a keynote address on preparing minorities for subjects in Science, Technology, Engineering and Mathematics (STEM).
"We need to address health disparities with the same vigor and resources as they were for AIDS," said Sullivan, chief executive of Alexandria, Va.-based Sullivan Alliance to Transform the Health Professions, which works toward diversifying the health workforce. The Sullivan Alliance was created to act on recommendations included in the 2004 Sullivan Commission (Missing Persons: Minorities in the Health Professions).
One in three Americans belongs to a racial or ethnic minority group, with African Americans, Hispanic Americans, and American Indians making up more than 30 percent of the population, according to studies cited by the alliance. For those under age 20, the percentage is 43 percent. The U.S. Census Bureau predicts that by 2042, there will be no majority population in the United States. Yet, today only 12.3 percent of physicians, 7 percent of dentists, 10 percent of pharmacists, and 11 percent of registered nurses belong to a racial or ethnic minority group.
These numbers compel advocates like Sullivan to work to close the health disparities gap.
He cited instances of unconscious bias in treatment. In the 2011 book, "Seeing Patients: Unconscious Bias in Health Care," by Augustus White and David Chanoff, ethnic minorities are undertreated for acute cardiac symptoms as they receive less bypass surgery and are less likely to receive pain medications in emergency rooms.
"Urgent attention is needed for disparities in preventive services and access to care," Sullivan said, adding that attention was needed for residents in inner cities and rural areas; more attention to diabetes management and cancer screening. Data has shown that health disparities can be eliminated with more minorities in the workforce as patients feel more comfortable visiting providers who look like them.
"African Americans play a significant role in dental care for blacks," said Dr. Jeanne Sinkford, associate executive director at the American Dental Education Association (ADEA), who cited ADEA findings that 61.8 percent of African Americans visit black dentists as opposed to 27 percent who visit white dentists.
However, the American Association of Medical Colleges stated that in 2008, there were almost 30,000 African-American physicians or 6.3 percent in comparison to more than 350,000 white physicians or 75 percent; and more than 60,000 Asian-American physicians or 12.8 percent. Black physicians are still underrepresented because the African-American population is 12.6 percent, as of the 2010 U.S. Census.
Opening up health care professions to more minorities begins with children in the kindergarten to 12th grades looking at STEM as viable career options, said Dr. Leo Rouse, dean at Howard's School of Dentistry who joined Sullivan on a panel before an audience of more than 100 people at the Blackburn Center. Kurt Schmoke, vice president and general counsel at Howard, also joined in the discussion which was moderated by WUSA TV9 anchor JC Hayward. The panelists focused on preparing minorities for STEM subjects, which eventually lead to careers in medicine and health care.
STEM degrees include mathematics; natural sciences; engineering and engineering technologies; health professions and related clinical sciences; and computer and information sciences.
"The STEM pipeline is about leadership, understanding the significance of diversity and industry and developing a cohort of men and women," said Rouse. "But we always question who's in the pipeline. How can we get our community engaged in STEM and where are the African-American men?"
Dr. Antoine Garibaldi, a Howard alumnus and president of the University of Detroit Mercy, sought to address black males in the health care pipeline.
"The trend is clear. African-American students are scoring below the basics," said Garibaldi, quoting numbers from the National Assessment of Educational Progress, the largest national sample and continuous subject-area assessment of American students in grades 4, 8 and 12. African Americans scored the lowest among all racial and ethnic groups on the standardized ACT in 2009, 2010 and 2011, and average SAT scores for the same time were more than 200 points below the national average.
Alexis Webber, a pre-med student at Howard's College of Nursing and Allied Health Sciences, appeared overwhelmed.
"I thought it was eye-opening," said Webber, 22, a St. Louis, Mo., native. "For me, as a student I had no idea so many teachers who weren't pushing black students who want to go to college were African American themselves." She referenced a study by Garibaldi on New Orleans Public Schools in the late 1980s. Not much has changed since then.
For solutions, speakers suggested more mentoring as a tool to increase participation in the health care pipeline; the possibility of scholarships with service requirements for loan repayment; and an increase in online resources across health professions, among other strategies.
"By providing more Americans with access to quality care, (the health reform law) was a major step toward equalizing health care across communities," said Jannette L. Dates, dean emerita of Howard's School of Communications and chair of the symposium planning committee. "Key to our mission of eliminating health disparities is increasing the number of minority health professionals who understand the communities' needs."
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