Most people are familiar with some form of triage: When you go to an emergency room, you first sit down with a triage nurse who records your symptoms, takes your vital signs and assesses the urgency of your medical need.

As of Thursday, that’s happening over the phone for 911 callers in Washington, D.C., where triage nurses now sit alongside 911 dispatchers to help field calls.

Why are they there? D.C. has the highest rate of 911 calls in the U.S., and 1 in 4 of those calls is not an actual emergency — instead, it’s a twisted ankle, or a cough or a rash. The new triage program aims to improve those numbers by diverting needs that aren’t urgent to medical care that doesn’t involve an ambulance or an emergency room.

During a practice session, trainee Ogechi Ukachu, a registered nurse who has previously worked in an ER, clicks through a series of questions.

“Are you having any difficulty breathing or catching your breath?” she asks the training exercise’s pretend caller, who has complained of a sore throat. “Do you hear any weird sounds when you’re breathing — like whistling?” No, and no, the caller tells her.

It’s not an emergency, Ukachu determines, so instead of having the dispatcher send an ambulance, Ukachu gets to work finding the caller an appointment with a primary care provider who can see the patient that day.

On her computer, based on the information the caller has provided, Ukachu can see whether the patient already has a relationship with a doctor or clinic, or, if not, which community health clinic is closest. She can also see nearby clinics’ schedules for the day, so can make the patient an appointment.

The triage nurses can even coordinate free Lyft rides for people who are on Medicaid — including a stop at a pharmacy if needed.

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Dr. Robert Holman, medical director of the D.C. Fire and EMS Department, got the idea for the program two years ago, when he realized the city’s system was getting backlogged with nonemergency calls.

Claire Harbage/NPR

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Claire Harbage/NPR

The “ride” part of the new triage service is critical, proponents say, because that’s the real emergency for many of the inappropriate calls to 911. Some callers simply have a hard time getting to the doctor in parts of the district where clinics can be miles away, and public transportation may not be readily accessible.

It has taken two years to pull off this plan. City health agencies, 22 primary care clinics, contractors and unions were all involved, under the coordination of the D.C. Fire and EMS Department.

“We’re very excited,” says Dr. Robert Holman, the department’s medical director, “and of course we all have butterflies in our stomach.”

Holman says he hit upon the idea soon after taking his job two years ago. He was looking at the city’s emergency call data and noticed that more than a hundred calls every day were for basic medical issues.

“I simply asked a question,” he says. ” ‘Wouldn’t this be simply better evaluated using a triage nurse?’ “

Other cities across the U.S., such as Louisville, Reno and the Dallas-Fort Worth area, have tried similar initiatives, Holman says. But D.C.’s program is distinct in its broad reach, and in the way it’s embedded within the 911 dispatch system.

The hope is that the triage line will save the city and insurers money — ambulances and ERs are the most expensive way to deliver care. Wait times for ambulances should go down, as should ER overcrowding.

And the patients will benefit, too, Holman believes. One example might be someone like a patient he encountered in his previous job at a walk-in health clinic; she’d come to the clinic looking for antibiotics for an infection.

“She mentioned that she’d had a bladder infection quite recently that was treated easily in an emergency department nearby,” he recalls.

Instead of just giving her the antibiotics, Holman also checked the patient’s vital signs and talked to her. Her blood glucose levels were really high. She was depressed and had stopped taking her diabetes medication, she told him.

“We could actually offer her treatment for her behavioral health problem as well as treatment of her diabetes,” he says, “in addition to [treating] her bladder infection.”

This is part of Holman’s message to city residents: Helping callers get a primary care visit, if they need one, is a service the triage nurse can provide.

“The mapping of our low-acuity callers exactly maps to where our community health centers are in Washington,” he says.

However, D.C. has a somewhat rocky history when it comes to its emergency services. In a few high-profile cases in the past, patients have died while waiting for emergency care. Some 911 callers who are advised their case isn’t an emergency may feel they’re being denied something crucial.

To address these fears in advance, Holman and his colleagues have crisscrossed the district, going to community meetings and neighborhood associations talking to residents.

Lois Wiley, a longtime resident of the LeDroit Park neighborhood, is skeptical of the triage plan and lets Holman know that at a public meeting.

“Suppose,” she says, “I say I don’t want to talk to the nurse, I want to go to the hospital?”

Holman tells her the city’s response will be based on the severity of the problem. “If you call with a sore throat,” he says, “we are not taking you to the emergency department.”

“Oh, yes you are,” Wiley says under her breath.

In the face of that sort of skepticism, Washington officials are prepared to carefully monitor how well the pilot project is working.

According to the city’s plan, every caller who gets sent to a clinic instead of the ER will be surveyed the next day about their experience. And data analysts will be checking ambulance response time, ER use, primary care use and 911 call volume.

Other cities grappling with the same difficult issues will be closely watching, too.

This story is part of NPR’s reporting partnership with local member stations and Kaiser Health News.

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States are continuing to do battle with budget-busting prices of prescription drugs. But a recent federal court decision could limit the tools available to them — underscoring the challenge states face as, in the absence of federal action, they attempt on their own to take on the powerful drug industry.

The 2-to-1 ruling Friday by the U.S. Fourth Circuit Court of Appeals invalidated a Maryland law meant to limit “price-gouging” by generic drug manufacturers, inspired by cases such as that of former Turing Pharmaceutical CEO Martin Shkreli, who raised one generic drug’s price 5,000 percent after buying the company.

The law, which had been hailed as a model for other states, is one of a number of state initiatives designed to combat rapidly rising drug prices. It gave the state attorney general power to intervene if a generic or off-patent drug’s price increased by 50 percent or more in a single year.

If dissatisfied with the company’s justification, the attorney general could file suit in state court. Manufacturers could face a fine of $10,000 and potentially have to reverse the price hike. The generics industry was fiercely critical of the law.

“We are evaluating all options with regard to next steps,” Maryland Attorney General Brian Frosh said, in a written statement. His office would not elaborate further.

The state could appeal to have the case heard “en banc,” meaning by the full Fourth Circuit, as opposed to just the three judges.

Such appeals aren’t commonly granted, but this law could be a strong candidate, suggests Dr. Aaron Kesselheim, an associate professor at Harvard Medical School who researches drug-price regulation.

The Friday ruling looms large as other state legislatures grapple with ever-climbing drug prices.

Similar price-gouging legislation has been introduced in at least 13 states this year, though none of those measures became law, according to the National Conference of State Legislatures. Three other bills failed to gain passage.

The NCSL also cited the law in a March advisory for states seeking new approaches to regulating drug prices.

The appeals court’s finding could have a chilling effect on such efforts, especially as more state legislatures wrap up business for 2018.

“A negative court ruling will put a damper or a pause on state activities,” says Richard Cauchi, NCSL’s health program director. “Unless this topic is your number one priority of the year, your legislators are juggling multiple bills, multiple strategies. When bill three gets in trouble, they move to bill four.”

The appeals court held that Maryland’s law overstepped limits on how states can regulate commerce — specifically, a constitutional ban on states controlling business that takes place outside their borders. The majority ruling argues that since most manufacturers of generic drugs and medication wholesalers engage in trade outside Maryland, the state cannot control what prices they charge.

In a dissenting opinion, the panel’s third judge argued Maryland can regulate the drug prices charged within the state since it only is meant to affect medications being sold to its own residents.

Kesselheim, in an article published last month in the medical journal JAMA, argued a similar point.

Regardless, striking down a law on constitutional grounds can be particularly discouraging, says Rachel Sachs, an associate law professor at Washington University in St. Louis, who researches drug regulations.

“If it had been a rejection on vagueness grounds, that’s something you can cure with a more specific statute,” she says. “But the fact that they said this is unconstitutional poses real concern for other states.”

That’s important. While the federal government has talked a big game on bringing down drug prices, it’s done little. Instead, states have taken the lead — spurred by the budget squeeze pricey prescriptions impose on their Medicaid programs and on benefits packages for state employees.

But states have far fewer tools at their disposal than does Congress. Most state laws so far only tackle pieces of the problem — targeting a specific drug or particular practice, specialists in health law say.

“We’ll get more broad and better evolution on this issue if the federal government decides to take it seriously — which it hasn’t so far,” Kesselheim says.

In the meantime, Maryland’s law is only one of a bevy of approaches.

Other states have focused on price transparency laws. In California, drug companies must disclose in advance if a price might increase by more than a set percent, and the companies must justify that increase.

Drugmakers have sued to block the California law.

New York has limited what the state will pay for medications, establishing a process to review if expensive drugs are priced out of step with their medical value.

Since 2017, a number of states have passed laws regulating pharmaceutical benefits managers — the contractors who negotiate discounted drug coverage for insurance plans, but who rarely reveal what level of discount they actually pass on to consumers.

Health policy specialists expect that activity to continue, especially as drug prices show little sign of letting up.

“The states are going to keep trying and experimenting,” Sachs says. “This is a problem that isn’t going away.”

Even efforts such as Maryland’s — which targeted price gouging — will likely remain at the forefront.

“I don’t think this is the end of states trying to do something on price gouging,” says Ellen Albritton, a senior policy analyst at the consumer advocacy group Families USA, who consults with states on drug pricing policy. “It’s such an issue that offends people’s sensibilities. It’s crazy [that] people can do this.”

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As a bill that would legalize recreational marijuana works its way through the Canadian Parliament, the government is gearing up to track cannabis consumption more closely than it has before. Statistics Canada has begun to do city-scale drug screening by monitoring what Canadians flush down the toilet.

Six cities have agreed to contribute samples from the place where all drains congregate — their wastewater treatment plants. Toronto, Montreal, Edmonton, Alberta; Vancouver and Surrey in British Columbia; and Halifax, Nova Scotia, will participate. All told, the network would capture data on drug use from about a quarter of Canada’s total 36 million inhabitants.

Prime Minister Justin Trudeau had aimed to legalize marijuana by July, but the draft legislation still has a ways to go. After the Canadian Senate passed it on March 22, five committees are now considering changes.

Regardless of what happens with marijuana legislation in Ottawa, Statistics Canada has already begun testing sewage for signs of drugs. Canada joins several countries in Europe that sample wastewater for drugs annually. New Zealand has been collecting data from sewage since last year, and Australia tests nearly half of its population’s wastewater for substance use.

Statistics Canada’s main goal is to get an unbiased read of how legalization affects cannabis use. “There are things like surveys and whatnot where people report frequency of use, but the consumption numbers weren’t quite as reliable as we would like them to be,” says Anthony Peluso, an assistant director of Statistics Canada. Eventually the testing may be expanded to 25 cities, he says.

Ideally, Statistics Canada would like to estimate how much cannabis Canadians consume, in total, through the sewage measurements. It might be possible then to subtract legal sales and arrive at the amount of cannabis sold illegally, Peluso says.

But the route from a wastewater treatment plant to that kind of calculation gets really murky really fast. For starters, Peluso says, Statistics Canada has to consider some basic questions that get quite complex on a national scale: “The suburban users, are they peeing in the city but consuming in the suburbs?”

Researchers say it’s relatively straightforward to detect marijuana traces, such as tetrahydrocannabinol, the main psychoactive ingredient in marijuana. Tests pick it up even in dilute wastewater. But there’s something more difficult: using the THC concentration in sewage to extrapolate back to the amount of pot consumed.

Budding wastewater testing

According to Italian researchers who tested sewage for cocaine in 2004, to was the first time anyone had used wastewater to estimate illicit drug use. Toxicologist Ettore Zuccato, at the Mario Negri Institute in Milan, led the experiments; the results were published in the journal Environmental Health in 2005.

Zuccato had studied pharmaceuticals in wastewater previously, so recreational compounds were a logical next step.”Cocaine was just a starting point, because cocaine was widely used by the population,” Zuccato says.

Cocaine users only expel a tiny fraction of the drug in its original form, so Zuccato and his team also tested for chemicals produced when the body processes cocaine, or metabolites. That way, the experiments also separated cocaine that was snorted from cocaine dumped down the drain for disposal.

From the cocaine metabolites floating down the river Po, Zuccato’s initial study estimated that Italians in the area were using a total of about four kilograms of cocaine per day. Assuming that 15-34 year olds were responsible for the use, the researchers estimated around 30 doses (a dose being four “lines,” or 25 milligrams) per day for every 1,000 young adults. That figure was higher than national surveys had previously reported.

For Zuccato, the cocaine experiments were a gateway project. The next year, he and his colleagues published a study in Analytical Chemistry that detailed concentrations of opioid metabolites, amphetamines, and cannabinoids from marijuana.

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A sample of wastewater collected over 24 hours from a Washington city’s wastewater after defrosting and just before chemical analysis. Solids in the sample can be seen settled at the bottom of the container.

Dan Burgard

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Dan Burgard

A Cannabinoid Comparison

Soon, scientists around the world were reporting results from testing a few water treatment plants at a time. Use of MDMA, or Ecstasy, peaked on weekends, people in larger cities excreted more evidence of cocaine and smaller cities’ sewage often reflected more opioid use.

But the sampling protocols were a bit of a patchwork, so it was difficult to compare drug use in Milan with that of Antwerp, Belgium. In 2010, Sewage Analysis Core Group Europe, or SCORE for short, started to standardize this testing.

Pretty quickly, SCORE agreed on how to measure evidence of cocaine, MDMA, methamphetamine and amphetamine. They also settled on standard estimates of total drug use from the wastewater concentration of these drugs and their metabolites.

By comparing results, scientists could see, for instance, that major cities in the Netherlands consistently top the list for MDMA use.

Other drugs gave researchers more trouble. Metabolites of heroin and marijuana would sometimes degrade in wastewater before tests could pick them up. So SCORE hasn’t always included data on opioids and cannabinoids in its yearly reports — mainly because there’s been some disagreement about how to analyze these compounds, Zuccato says.

Mysterious marijuana mathematics

Dan Burgard, a chemist at the University of Puget Sound in Tacoma, Wash., has thought a lot about how to wring marijuana data out of sewage.

When Washington state voted to legalize recreational marijuana in 2014, the National Institutes of Health funded Burgard to monitor cannabis use by analyzing wastewater from two treatment plants in a western Washington city (he hasn’t officially released results, or the name of the city yet).

Like Statistics Canada, Burgard wanted to measure marijuana use, and also compare legal cannabis sales with illicit use to get an idea of underground sales.

Sampling and testing cannabis metabolites went smoothly, thanks to sensitive lab equipment and consistent habits in Washington. “It turns out, in the Pacific Northwest, we don’t need to concentrate the wastewater for cannabis metabolites, we have enough of them in there,” Burgard says.

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In Viviane Yargeau’s lab at McGill University in Montreal, wastewater samples pass through cartridges that retain drug traces for chemical analysis. Based on her previous work measuring drug use from sewage, Statistics Canada has tapped Yargeau’s group to run the country’s pilot testing.

Viviane Yargeau

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Viviane Yargeau

But estimating total marijuana use was harder. He struggled with a number he calls the excretion factor: the relationship between how much cannabis someone consumes and how much THC they excrete.

Researchers have studied this consumption-excretion relationship for marijuana, Burgard says, but, it’s not always clear how closely laboratory test results would correspond to real-life use. In some experiments, participants receive intravenous injections of THC, and that’s quite different from the smoking, eating or vaping that most people partake in. “I’m not sure the last time you hung out with stoners, but nobody seems to be injecting pot these days,” he says.

Forensic toxicologist Eugene Schwilke, who has studied cannabinoid excretion, agrees that pinning down this kind of relationship to one number is tough.

With all drugs, there are lots of variables that affect the consumption-excretion ratio — tolerance to the drug and how a substance is administered, for instance. “There’s also biological and metabolic differences between individuals within the population and so you can’t assume any one thing,” he says.

Marijuana is particularly tricky, he says, because the compound measured to detect cannabis use — THC-COOH— sticks around in fat, not water, and it leaves the body slowly, over days rather than hours. And while cocaine and MDMA have a couple of well-established modes of administration, there’s a bit more variance in how people use marijuana.

Also, given that wastewater testing primarily samples liquids, not solids, it only provides a small window into all the cannabinoids that exit when you use cannabis. The majority of the chemical evidence of marijuana consumption appears in poop, Schwilke says, especially if partaking involves edible, rather than inhaled, forms of cannabis.

But even if wastewater tests did include more solids, current protocols test specifically for the compounds that show up in pee, not the separate chemical that you’d find in poo.

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As she leaves a 12-hour-day on the labor and delivery shift, Dr. Katie Merriam turns off her pager.

“I don’t know what I’d do without it, you know? It’s another limb. I always know where it is,” she says, laughing.

The third-year resident in obstetrics and gynecology at the Carolinas Medical Center hospital in Charlotte, N.C., works in a medical specialty dominated by women, treating women. Merriam says she feels a special connection to her patients.

“You just, you can feel what they feel and understand why they feel certain ways. I do feel a special bond,” she says.

Nationally, 82 percent of doctors matching into OB-GYN residency programs are women. Many OB-GYN patients say they prefer female doctors. Merriam’s residency class is a bit of an anomaly — half of its members are men. Though it’s nice to work with so many women, Merriam says, she and some of her female colleagues also like the perspective that men bring to the work environment.

“No one could really pinpoint about what balance they bring, but there’s something nice about having them,” she says.

It’s important to have men in the field, she says, if only to continue to give patients options in their choice of providers. But most of her friends and other women she talks to, she says, want female doctors.

Blake Butterworth, a fourth-year obstetrics and gynecology resident at the Medical University of South Carolina in Charleston, says he doesn’t take it personally when he hears that sort of thing from a patient.

“I don’t get discouraged; I don’t get offended,” Butterworth says. “I gladly hand that patient off.”

He’s one of only two male residents in the program of 24 at MUSC and says he finds it rewarding when he can win a new patient’s confidence.

“I have patients that clearly express disdain to have to see a guy,” he says. “Then I develop rapport with her. And she says, ‘I expected you to be X-Y-Z, and you were better than that.’ “

Butterworth says he chose obstetrics and gynecology because it lets him develop long-term relationships with patients — providing routine OB-GYN care and more complicated surgeries if need be.

“Once you really get into it, and get involved in it, I don’t think that bias [that the field is best left to women] holds true,” he says.

Butterworth believes it is incumbent on male OB-GYNs to talk to male medical students about the benefits of having men in the field. Students need to know it’s OK to have an interest in the field, he says, and that they will find work.

In fact, says Dr. Ashlyn Savage, an associate professor of obstetrics and gynecology at MUSC, it may be the opposite.

“In an effort to really diversify the applicant pool, we will apply in some cases different screening standards to decide who we are going to interview,” Savage says. “For example, we might consider an applicant with a slightly lower board score — just to enhance how many men we are interviewing and considering.”

It has been a challenge to find male OB-GYNs for the program, she says. The gender that at one time dominated the field is now at some schools considered a diversity hire. But Savage questions whether balancing the number of men and women in the specialty is as important as racial or ethnic diversity.

“The interesting thing to me is the primary motivation to [seek a diverse candidate pool] is so that patients have the opportunity to seek out physicians who might … feel like themselves,” she says. “In this particular case … all of the patients for OB-GYNs are women.”

Among practicing OB-GYNs in the U.S., a little fewer than half are men, according to the American Congress of Obstetricians and Gynecologists. But ACOG predicts that 10 years from now, two-thirds of the doctors in that specialty will be female.

Still, male doctors hold a lot of the key positions in OB-GYN professional organizations.

“Leadership tends to be held by people who are older,” Savage says. “And we are still in a scenario where [more of] our older faculty tend to be men.”

A study published last fall found that women are underrepresented in leadership roles in medical school departments of obstetrics and gynecology all around the country. That ratio was most lopsided in men’s favor in the South.

It’s perhaps only a matter of time before that, too, changes. Savage says she just learned that her program’s incoming class of OB-GYN residents next year will be all female.

This story is part of NPR’s reporting partnership with WFAE andKaiser Health News.

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Last December, Deb Wiese bought hearing aids for her parents, one for each of them. She ordered them online from a big-box retailer and paid $719 for the pair. But her parents, in their 80s and retired from farming in central Minnesota, couldn’t figure out how to adjust the volume or change the batteries. They soon set them aside.

“Technology is not only unfamiliar, but unwelcome” to her parents, Wiese says. “I don’t know what the answer is for people like that.”

A bill introduced by Sen. Elizabeth Warren (D-Mass.) and Sen. Rand Paul (R-Ky.) in March could make it easier for her parents and millions like them to get assistance. It would allow Medicare to pay audiologists to teach beneficiaries how to adjust to and use their hearing aids effectively in different settings such as a crowded room, for example.

Under current law, Medicare generally reimburses audiologists for diagnosing hearing loss in older adults but not for providing assistance to fit, adjust and learn to make the most of hearing aids.

Not being able to afford hearing aid services is one of many challenges older adults who are hard of hearing face. Even if they can afford hearing aids, Medicare doesn’t usually cover the services to fit and service them so many people go without.

The proposed bill comes on the heels of an effort to increase the chances that people who need hearing aids get them. A law signed last summer by President Donald Trump directs the Food and Drug Administration to establish and regulate a new category of hearing aid to be sold over the counter for people with mild to moderate hearing loss.People will be able to buy products off the shelf without consulting an audiologist or hearing aid dispenser, and standards for online sales will be tightened. The agency has three years to develop safety and other consumer protection standards.

The National Academies of Sciences, Engineering and Medicine recommended that the FDA take that step in a 2016 report.

Although it should improve access, the new law doesn’t address one of the biggest barriers faced by the nearly 50 million people with age-related hearing loss: insurance coverage.

Neither traditional Medicare nor most private insurers typically cover hearing aids. (Some Medicare Advantage plans provide some coverage, and some insurers may offer a discount if members use certain suppliers.)

“Cost has for many years been the Number 1 problem in the calls, emails and letters we get,” says Barbara Kelley, executive director and CEO of the Hearing Loss Association of America, a patient advocacy group. “People say, ‘I need hearing aids and I can’t afford them.’ It’s really heartbreaking.”

Only 10 to 20 percent of people with hearing loss have ever used hearing aids, according to studies. In addition to cost, lack of access to care and the stigma associated with wearing a hearing aid discourages people, Kelley says.

But losing the ability to hear well doesn’t just mean people have to turn the volume way up on their favorite TV shows. Hearing loss is associated with depression, social isolation and an increased risk for cognitive decline and dementia in older adults.

Hearing aid prices vary widely, ranging from an average $900 to $3,100 apiece, according to a survey of hearing care professionals by the Hearing Review, a trade magazine. On the high end, devices may be Bluetooth-enabled to stream wirelessly from people’s cellphones to their hearing aids, among other perks.

But not everyone needs or wants that much help. “Some people are very mildly impaired,” says Kim Cavitt, a billing and reimbursement consultant and former president of the Academy of Doctors of Audiology who supports over-the-counter sales. “They don’t have a $3,000 problem, they have a $300 problem.”

Experts say they hope the over-the-counter hearing aid law will spur competition and product innovation and bring down prices.

One of the reasons hearing aid prices are often high is because the devices are typically bundled with a service package to fit, troubleshoot and maintain them.

Disentangling the service from the devices would benefit consumers, says Nicholas Reed, a faculty member at the Cochlear Center for Hearing and Public Health at Johns Hopkins Bloomberg School of Public Health who has studied over-the-counter hearing devices that provide results comparable to hearing aids.

People may still need some help using their hearing aids. In addition to basic hearing-aid fitting and maintenance, hearing care professionals can help people learn strategies to hear better, Reed says. For example, people learn to sit with their back to a wall at a restaurant to eliminate the sound behind them so they can focus on listening to the person in front of them.

“The over-the-counter law will lower the cost and make hearing aids more accessible,” Reed says. “But if the services aren’t covered, people, especially older adults with health literacy issues, will stop using them.”

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When Josephine Majani came to, she was on a hard hallway floor in the Bungoma District Hospital in Bungoma, Kenya.

Majani heard nurses yelling: “I saw them carry the baby away. They screamed at me, ‘Why have you delivered on the floor? Who is going to clean up all this blood? Get up. Get your things and go back to the delivery room.’ I was helpless.”

Majani has no memory of being slapped, she says, but when she regained consciousness her cheeks stung. She did as she was told. She struggled to her feet and followed nurses back to the room to deliver the placenta.

This was in August 2013. Eight years earlier, she had safely delivered a girl at home. Then four years before, she gave birth to a boy at a hospital.

“It was good, clean care. I had assistance. It was a good experience,” she says of that delivery.

Her third baby had been overdue — so three days before his birth, she went to the hospital. She was given medication to induce labor. As her labor progressed, she found herself on her own.

“There were no attendants, no one to assist me,” she says. “I called for help, and no one ever came. I got out of bed to find someone to help me. I was in the hall, and I fell on the floor. I was unconscious.”

That’s when the baby came.

This extreme lack of attention is not unusual in hospitals in poor countries, says Martin Onyango, the senior Africa legal advisor for the Center for Reproductive Rights based in Nairobi.

“This is a systemic problem in Kenya,” he says. Onyango is Majani’s attorney in a landmark case against the hospital.

What was unusual was that a hospital intern captured it all on video: the mother and newborn on the floor, the slaps, the verbal abuse, the public humiliation.

The video fell into the hands of a Kenyan journalist. It ran on television programming nationally in Kenya — and went viral not long after the incident.

“We got to know of Josephine’s case because we saw it on TV,” Onyango says. More than four years later, in February, the court issued a landmark ruling awarding Majani $25,000 (2.5 million Kenyan shillings) in damages, requiring that hospital staff formally apologize to her and setting a precedent that demands women be given quality care and treated with dignity during childbirth.

“The court ruled that nothing excuses behavior that is so degrading to a woman, a human being,” Onyango says.

Dr. Sanghvi Harshad is chief medical officer of Jhpiego, a group that works in 40 countries to improve health care for women and families.

“What happened to this lady is unfortunately all too common,” says Harshad, a Kenyan who formerly headed up the University of Nairobi Hospital. “I recently visited a hospital in western Kenya. They are equipped for 10 to 15 births a month. But they’re doing almost 300 births a month. You can imagine the overcrowding, the shortage of supplies.”

Such conditions can be fatal. A report released by the Kenya government in February found that of 484 maternal deaths in Kenyan hospitals studied in 2014, 90 percent were the result of substandard care.

According to statistics reported by the CIA, Kenya has the 19th highest rate of maternal mortality among 184 countries studied — with 510 deaths per 100,000 births. Finland, Poland, Iceland and Greece are the safest countries to give birth in, with 3 deaths per 100,000 births. The United States ranks 138th with 14 maternal deaths per 100,000 births.

But Peter Johnson, senior director for nursing and midwifery at Jhpiego, says most people go into health care, nursing or midwifery because they sincerely want to help people in need. He has seen people he calls heroes and saints delivering maternity care under the most difficult circumstances.

“Nobody wants to be mean. They want to make a difference,” Johnson says. “But these folks can work under horrendous conditions. I’ve been in labor wards in India where I’ve watched midwives kick rats out of the way to get to the woman.”

Midwives in poor countries are not always trained as thoroughly as they are in the developed world, Harshad says. And often, because they are usually women in places with great gender inequality, they are not respected. Add to that overcrowded conditions and lack of supplies and resources, and nurses and midwives can feel enormous pressure to move women along during labor.

“Providers can be in a state of panic,” Harshad says. “Under those conditions, mothers will get pushed, slapped, verbally abused, partly because of the provider’s panic.”

When nurses and midwives see the abuse in their training, they copy the behavior, and the cycle of abuse continues, he says. “We need to fix how people are being trained.”

Harshad looks to a program he worked on in Afghanistan as a model for how to develop a system of maternity care.

“Midwifery schools were wiped out. We needed to completely revamp them,” he says. “We wanted to empower midwives to be full professionals. We taught them computer skills. We taught them English so they could read the medical literature. It has paid off tremendously. They are extremely competent.”

Another program in Mozambique has encouraged mothers to ask for a companion— a husband, mother, sister or friend — to accompany them in the hospital through labor and delivery. Such so-called companionship programs have been shown to improve the quality of care in hospitals, according to a February World Health Organization report, Intrapartum Care for a Positive Childbirth Experience.

“Fifteen years ago, the level of companionship was essentially zero,” Harshad says. “As of a year ago, 58 percent of mothers in Mozambique now have a companion.”

And in Kenya, a program of anonymously surveying mothers about their hospital maternity care is beginning to pay off. Harshad explains:

“Everyone, even poor people, have cell phones in Kenya. We told mothers they would receive a text message survey when they got home. We asked: Was it clean? Were they treated with kindness? Were they scolded? We showed the results to the hospital. And they took action. If we told them that 26 percent of patients said they did not receive privacy, they took action. It’s hard, because of overcrowding, but they started putting up curtains.”

The Center for Reproductive Health, along with Jhpiego, are part of an international movement to improve the birth experience most recently exemplified by the WHO recommendations on childbirth, Harshad says.

“Those guidelines are unique,” he says. “They focused not just on hard science, but on what women themselves want in their childbirth experience.”

Women all over the world have struggled to have their voices heard regarding labor and delivery, and even wealthy countries can fall short, says Johnson:

“I’ve worked in the city of Baltimore as a midwife for many years. I’ve seen some of the same phenomena — people living under chronic stress; nurses, midwives and physicians working under difficult circumstances; a feeling of bad chemistry, bad communication; women being induced before they’re ready; withholding water if they’re thirsty, or food if they’re hungry; not letting them out of bed to walk around so they can be more comfortable. These are things that we’re promoting globally, but we don’t always promote it here in the U.S.”

Maternity care may be changing at a glacial pace, but Majani is proud that her horrendous experience has helped move the needle toward better care.

“I just know this is going to be a lesson to all the clinical attendants who perform their work in maternal health care,” she says. “They are going to serve the people equally. They are going to be loving and perform their work with kindness.”

Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester, and co-author of A Change of Heart.

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Our tummies are teeming with trillions of bacteria — tiny microbes that help with little things, like digesting food, and big things, like warding off disease.

Those same microbes may have another purpose: waging war against worms.

Researchers at Washington University in St. Louis made the discovery after studying the microbiomes of individuals from Liberia and Indonesia. They found that the guts of individuals infected with parasites share common microbes — even if they live in completely different geographic locations. Similarly, healthy individuals whose bodies can clear out parasites without treatment seem to share a common gut bacteria.

This suggests the gut microbiome can be altered to protect people from becoming infected with parasitic worms, says Makedonka Mitreva, the lead researcher on the study and a specialist in infectious diseases and the microbiome.

“It may be wishful thinking, but maybe we could implement a control strategy after deworming where we strengthen or alter the microbiomes of individuals who are prone to infection,” Mitreva says.

Nearly 25 percent of the world’s population is currently infected with parasitic worms like hookworm, whipworm or roundworm, according to the World Health Organization. The worms are a disease of the developing world, for the most part. They spread when an infected individual defecates outside, leaving behind stool that’s contaminated with eggs. When the eggs hatch, wriggling microscopic worms can latch on to the ankles or bare feet of individuals who walk by.

Once on board, the worms burrow into skin and travel to the gut to feed on blood or other tissues. Symptoms can vary, depending on the number of worms inside a person. In cases of severe infection, people can experience anemia, nutritional deficiencies and impaired growth.

Despite decades of deworming efforts to rid the world of worms, people in developing countries get reinfected often, according to Mitreva.

“Even if the [drug] therapy works and the infection is cleared, the exposure to contaminated soil is so pervasive that new infections are extremely common,” she says.

Mitreva and her team recently analyzed hundreds of fecal samples from infected and uninfected people in Indonesia and Liberia. Samples were obtained once from some individuals, but other participants were followed long-term to see how their microbiome changed over time with or without drug treatment.

Participants’ fecal samples were first tested for the presence of parasites. Then they were studied for their microbes.

Twelve strains of bacteria were significantly associated with parasitic infection in both countries. These included Olsenella, a bacterium that has been shown to reduce gut inflammation when administered as a probiotic. It is also associated with lean versus obese individuals.

In worm-free individuals, the researchers identified a high presence of Lachnospiracae. The same genus was found in individuals that had parasites and were able to clear the infection naturally. Lachnospiracae has been associated with modulating gut inflammation during infections and has also been linked to obesity and protection from cancer.

What does it all mean?

“When the body is infected with worms, it tries to do worm expulsion with an inflammatory reaction,” Mitreva says. “Worms have to fight back to remain in the gut; that’s why worms are known to secrete anti-inflammatory molecules to reduce inflammation.”

Mitreva adds, “Our interpretation is that parasites need a healthy environment for long-term survival. Good bacteria may facilitate parasitic survival, so a bacterium like Olsenella that decreases gut inflammation is helpful.”

P’ng Loke, a parasitologist at New York University who was not involved in the study, says it’s especially interesting that the research found that Lachnospiracae is associated with individuals who can clear our worms naturally.

But that’s just it; it’s just an association, Loke says. The researchers now need to demonstrate that these bacteria actually hurt or help worms.

“Whether the bacterial associations that are identified really do directly affect worm colonization efficiency hasn’t been demonstrated yet,” he says.

Mitreva agrees that more work is needed, but she’s not giving up. In the future, she hopes to use fermented foods to plant worm-defending microbes inside of individuals to build their defense against worms.

That may be easier said than done.

“I don’t think anyone knows how to really alter the microbiome at the moment. That’s probably the ‘dream’ rather than a near-term possibility,” Loke says.

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