CRISPR

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

In policy news, it is no secret that Senate Republican bill to repeal the Affordable Care Act was a failure. Their proposals included many measures that would curtail health care for women in the form of either provision of contraception, for health screening for condition such as sexually transmitted diseases, breast cancer or cervical cancer and access to prenatal and maternity care. The failure of this bill led many of us who care for women to breathe a sigh of relief. 

However there is a new threat to women's healthcare. The House Appropriations Committee is responsible for setting the federal governments spending priorities for the upcoming year. These budgetary items come in the form of bills. Most of the bills concern essential services such as the military but included with these budgetary plans are several add on provisions or riders which contain potential law related to women's healthcare and it's funding. For example, the bland and harmless sounding "Financial Services and General Government Bill" would prevent people from purchasing insurance through the Affordable Care Act exchange which includes comprehensive reproductive coverage. As another example, the "labor, health, and education" bill would eliminate funding for Title 10 family planning clinics which provide a low income women and men with cancer screenings birth control tests for sexy transmitted diseases. The Republican plan for this care is to reroute it to community health centers. However many question the ability of community health centers to meet this increased demand.

MATERNAL MORTALITY BY COUNTRY FROM THE CIA WORLD FACTBOOK VIA indexmundi.com

MATERNAL MORTALITY BY COUNTRY FROM THE CIA WORLD FACTBOOK VIA indexmundi.com

Representative Nita Lowey (Democrat from New York) is the top ranking Democrat on the House Appropriations Committee. She and several colleagues have offered alternative amendments to guarantee that women have access to these health services. They include provisions for birth control without co-pay, Title X family-planning funding, rescinding the Global Gag Rule, and re-instituting funding for the United Nations Population Fund. Without control of Congress these are likely doomed, but at least drafts are in place and the issues are on the table.

Last week, Senate leaders passed some bills that stand to help patients. The first is a bill that will help fund the FDA review of prescription drugs and medical devices.  The second bill, called the”Right to Try” Act, it will help the FDA to “…speed review generic drug applications”.

Even those of us who applauded the Affordable Care Act realize that it needs some more robust Federal funding for the the upcoming years. Republican Senator from Tennessee Lamar Alexander has “...organized bipartisan hearings next month" to help fund ACA a insurance marketplaces next year. Governors from both parties have urged the Trump administration to act continue to making ACA subsidy payments. President Trump has tried to characterize these federal contributions to defray the cost of healthcare as an insurance company "bailout". 

The expanded health care that the Affordable Care Act provided was beneficial in human and longer-term economic terms. However instituted immediately in the then insurance marketplace, it would have been financially unaffordable without federal subsidies. That is the reason why the federal government subsidies were designed in the first place. Consumers would contribute, States would contribute, and the federal government would contribute through the taxpayers, in what amounted to an elaborate cost sharing plan. The implicit and explicit philosophy was that the healthcare of the American people was a shared responsibility and a worthwhile financial investment for the future. 

As has been previously reported, Texas has a maternal mortality crisis. The maternal mortality rate is 35.8 deaths per 100,000 live births as of 2014 where is the rest of the nation sits at 23.8 deaths per 100,000 live births. Texas's rate is characteristic of a third world country Robinson United States of America which has state-of-the-art medical care. This issue has been on the table for several months now in a large study is underway to fully understand the reasons why. Meanwhile editorials in Texas newspapers abound to the effect that the crisis is no mystery. Various pieces of legislation large and small, State and federal, over the last decade have resulted in curtailment of access to women's healthcare, including reproductive health care, general women's healthcare, and prenatal care. Could there be a connection?

In the medical news, we begin with the opioid crisis. According to new research publishing the animals of internal medicine, approximately 2,000,000 Americans self report that they are addicted to opioids. There are likely many more. 11 million admit to misusing opioids. Opioid addiction is surprisingly dangerous and hard to treat as it becomes enmeshed with behavior and Biology. There are specialists who treat opioid addiction but they are few and far between even in sophisticated medical communities. Doctors who will treat pregnant women with opioid addiction correctly are even more scarce.

Do you think cultural factors matter in health? Do you think behavior is ”catchy” ? I just learned that pregnant women in Florida smoke at double the rate of women in the rest of the country. I think such outliers are very interesting and provide potentially informative subjects for study.

I am the sort of person who is very interested in maps and infographics. The idea of regional variations in health behaviors is fascinating to me and can be portrayed in maps. See todays' illustration lifter from indexmundi.com who lifted it from the CIA World Factbook   The case of Florida and smoking, the case of Texas and maternal mortality, and indeed the case of the entire south and rates of obesity should constitute low hanging fruit for any interested researcher. 

The FDA is taking a powerful step in the battle against smoking. We have had warning labels. We have had higher taxes on cigarettes. We have had educational campaigns. However now, the FDA will lower the amount of nicotine in tobacco products. There is good reason to believe that lower nicotine in cigarettes will lead to smokers quitting and enable them to quit more easily.

In the odd and frightening department we see the new research published in the Journal Cancer Epidemiology, which suggests that postmenopausal women with gum infections are more likely to get many common cancers than their peers. Ladies, use those electric toothbrushes, that thick floss, and those peroxide and fluoride mouthwashes. Check in with your dentist. More research is clearly necessary.

Mothers across the world are missing a great opportunity. This is breast-feeding. According to the World Health Organization and UNICEF, only 40% of babies were exclusively breast fed for six months, which is the undisputed recommendation. Rates in the United States are considerably lower with  25% of mothers exclusively breast-feeding for six months. The report included research on the key reason why mother stop breast-feeding. It is the need to return to work. Solving this problem would be a matter of addressing culture, policy pertaining to postpartum leave, paid postpartum leave, and breast-feeding in the workplace.

Breast-feeding has numerous benefits for babies, mothers, families, and society at large. A new study documents that breast feeding may be linked to a lower risk of breast cancer. This study was a meta-analysis of 18 prior studies. 13 of which showed that breast cancer risk dropped 2% for every five months a women breast-fed.

News continues to filter in regarding the use of CRISPR to edit genes in human embryos. At present CRISPR has been used to edit out the single gene mutation that causes hypertrophic cardiomyopathy. The most logical next candidates are other single gene mutations which cause disease. Examples of single gene diseases are cystic fibrosis, sickle cell disease, fragile X syndrome, muscular dystrophy, also known as Huntington's disease. Hope is on the horizon ! 

 

Stay tuned next week for more exciting news from the world of Obstetrics and Gynecology. 

Medical Monday: Delayed Edition

Deep in the backcountry of Montana I was able to almost forget about medical politics. However, now that I am back, the time has come to recap events of last week in both medicine and policy. 

Moderate Republicans had hoped to achieve passage of a rewrite of the Affordable Care Act by making scaling down their proposal, making the changes less extensive. However even this “ skinny ” rewrite failed to pass as three Republican Senators Collins of Maine, Murkowski of Arkansas, and John McCain of Arizona opposed the measure. If you ask me it is no coincidence that two of these maverick Republicans are women and the other, Senator McCain, is a cancer patient. Here are three people who understand what is at stake, i.e. health care for women and the seriously ill. 

Also during the week, 148 Democrats wrote to HHS ( Health and Human Services) Director Tom Price objecting to the decision to cut two years of funding from the TPPP (Teen Pregnancy Prevention Program). Again, if someone could explain to me why decisions of this magnitude can be made single handedly, I would be much obliged. 

Texas has passed a bill which requires women to obtain separate addition insurance coverage for non-emergency abortions. It seems to me that this could be a compromise solution in which everyone would get a chance to support what they espouse. Of all the health care controversies, it seems this one is the biggest, and thus the one to compromise on. 

On the other hand, insurance wold become useless as a tool to support the general health and prosperity of the population if we conceded to every anti-vaccine person who refused to pay for coverage which included vaccines, or a Jehovah’s Witness who refused to pay for insurance covering blood transfusions. You could imagine the list would go on, as there are folks who are anti-antibiotic, and anti-mammogram, and yes, those who are anti-birth control. And just as I would advocate compromising on abortion coverage, I would dig in just as firmly on the critical need for birth control coverage, which is I think essential to our stability and progress as a society, not to speak of essential to the health and well being of women and children. 

Here’s a brand new issue: Menstrual Leave. This is is policy which allows a worker to take a paid day off during her period. Such leaves are in place in several countries including Japan and Taiwan. However, many experts feel that this has the potential to retard women’s progress in the workplace. The notion that work performance suffers during menstruation is a fallacy, and this policy plays into it. If a women’s period is so heavy, painful or otherwise debilitating that she need stay home from work, then she should seek consultation with a Gynecologist. 

In medical news, it turns out that some perinatal exposures may last through several generations. A new study in mice has shown that exposure in pregnancy to environmental pollutants results in offspring with increased asthma risk for up to three generations. 

For your we-already knew-this report of the week, new research has demonstrated that a brief daily run helps protect bone mineral density in women. Indeed brief bursts of any high intensity exercise will do it, increasing bone by about 4 %, which may not sound like much but is considerable. 

In exhilarating and awe-inspiring news, we have CRISPR. If you do not know this acronym, you should. It stands for "clustered regularly interspaced short palindromic repeats”. Basically these are short segments of DNA which read the same way in one direction or the other. In nature, they are used as part of the immune system of various creatures. In technology, they are useful for editing genes. 

The MIT technology review has reported on original research at Oregon Health Sciences University where researchers have edited DNA in the viable human embryos as a way of preventing disease. It is interesting to note that while the federally funded National Institutes of Health does not support studies involving CRISPR in human embryos, the US National Academy of Sciences has “ opened the door to such research providing that the work would address serious inherited diseases.”

 

And with this momentous news we conclude this delayed edition of Medical Monday. See you next week.