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From Policy to Practice: Body Autonomy and Breastfeeding in the Workplace

WHO Breastfeeding Campaign Poster

How do policies surrounding breastfeeding affect women in the workforce? It is not hard to imagine the difficulties – or rather, impossibility – of breastfeeding without the proper facilities, privacy, or policies in the workplace. According to the Centers for Disease Control and Prevention (CDC), 79% of women breastfeed after giving birth, however only 49% exclusively breastfeed 6 months later (2014).

The Affordable Care Act (ACA) and Family Medical Leave Act include policies that address breastfeeding access in the workplace. The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life. Breastfeeding has a strong correlation with the lifetime trajectory of individuals and populations, lowering the risk of childhood-related diseases and chronic diseases later in life. The Family Medical Leave Act indirectly supports breastfeeding by mandating unpaid time off for a short period of time postpartum. Yet, low-wage workers and unmarried women are less likely to be eligible for unpaid leave and more likely to be unable to survive on little to no income. The ACA includes a “Reasonable Break Time for Nursing Mothers” which states that workplaces are required to provide a private space (not a restroom) for women to take unpaid breaks to pump breast milk. While this amendment was created to assist women working for hourly wages, studies have shown that these women are least likely to have access to ACA accommodations.

Why is policy not translating into practice in both of these cases? Dr. Elizabeth Dalianis explored this issue for her doctorate in Public Health at Drexel University. She analyzed the relationship between state laws and enforcement of the above federal laws with breastfeeding practices among working women, with a particular focus on racial disparities in breastfeeding practices. She utilized the CDC survey on infant feeding, the first of its kind, and she stratified the data into three separate categories for analysis: states with regional law on breastfeeding in the workplace that include enforcement mechanisms (California, Minnesota, and Connecticut), states with regional law on breastfeeding with no enforcement mechanisms (n=28), and states which only have the ACA federal requirement (n=19). Across the board, longer duration of breastfeeding was associated with regional law on breastfeeding and active enforcement of these laws. In California, for example, the Labor Commissioner investigates complaints from workplaces that do not uphold the standards of the ACA and the state law. If the claims are proven true, there is a $100 fine assessed per infraction. This is not a perfect solution, however, because it places the burden and responsibility on women to self-report on their employers. For those states without any enforcement specified in the law, it was as if there was no law protecting the basic rights of breastfeeding women at all.

The lack of breastfeeding policy enforcement across the United States (in 47 out of the 50 states), according to Dr. Dalianis’s work, leads to a disparity in breastfeeding practices among working women, particularly for low-income and hourly wage-working women. Without the conditions necessary to breastfeed in the workplace, women are denied the choice to breastfeed their children. Body autonomy is an important aspect of any discourse on Women’s Health. Institutions continually under-prioritize women’s rights to body autonomy– by writing laws that are never enforced, or by creating laws that make it near impossible for women to access the health resources that they need. Many women across the United States are forced to choose between breastfeeding and their career, or between breastfeeding and their livelihood. Women with low-incomes do not even have the luxury of that difficult choice due to the institutional devaluation of women’s body autonomy.

While establishing women’s body autonomy is argument enough to support better enforcement of breastfeeding accessibility laws and policies in the workplace, in terms of public health, breastfeeding a baby provides numerous health benefits that last into adulthood. Thus, low-income women’s inability to choose to breastfeed their children can become a powerful form of structural violence that perpetuates social and health inequalities on the population level.

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Can human milk deactivate Zika virus?

On February 1, 2016 the WHO officially declared the Zika virus a Public Health Emergency of International Concern after microcephaly and other neurological disorders became associated with the latest outbreak of the virus. Fifty-three countries have reported an outbreak since 2015, and the CDC reports that there have been 4973 total cases in the United States.

While the virus itself gives cause for alarm, one of the major fears connected with Zika is its ties with microcephaly and other neurological disorders for infants in utero. Pregnant women with Zika have the chance of giving birth to babies with congenital Zika virus syndrome, which can cause anything from malformation of the head to seizures, to hearing and sight problems. 
 With all the health concerns connected to Zika, as well as the growing number of reported cases in the past year, scientists have been busy researching different aspects of the disease, especially in relation to mothers and infants.

A study recently published in Virus Research took a look into the the presence of Zika virus in human breast milk. 
 Previous studies established that Zika virus is present and active in the breast milk of mothers infected with the virus. Despite the revelation, this past June the WHO recommended that mothers continue breastfeeding. According to the WHO, breast milk’s numerous benefits outweigh the risk of passing Zika to the infant. Researchers from the Virus Research study, including Dr. Stephanie Pfänder, a group member of the Virology and Immunology Department of the University of Bern in Switzerland, wanted to dig deeper into the relationship between the breast milk and the Zika virus within it. To do this, they examined the stability of the Zika virus in breast milk to explain its stability over time and find ways to inactivate the virus to make breast milk even safer for infants.

The scientists infected breast milk from three healthy mothers with different strains of Zika. They then stored the breast milk for a period of several days at 4°C. Within one to three days, depending on the donor, the virus became inactivated and no longer able to infect the baby. Researchers hypothesized that fatty acids within the milk damage the viral envelope protecting the virus.

“During the storage process over several days, free fatty acids are released which act [as an] antiviral against the virus,” Dr. Pfänder said in an email. “With our storage, we mimic the release of free fatty acids artificially, however, the same process happens in the stomach of the infant where free fatty acids are being released upon milk digestion which could then act [as an] antiviral against the virus.”

Although the finding indicates that breast milk will deactivate Zika on its own, the researchers also wanted to determine a quick, relatively cheap method to ensure breast milk is safe. They found that pasteurizing the milk at 63°C for 30 minutes made the virus unable to infect the baby.

“We sometimes hear [from] the critics that our approach is quite artificial, as milk is not routinely stored at 4°C for longer time periods,” Dr. Pfänder said in an email. “We do not suggest that mothers should routinely store their milk samples before feeding the infants. However, if a mother has a suspected or confirmed infection with Zika we provide information of how stable the virus could be in the milk sample and how to inactivate it to prevent a possible transmission to the infant.”

The recent findings could prove very important as more of the world faces the threat of Zika, and could help prevent the spread of the virus.

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The Trump Administration’s Global Gag Order: What Lies Ahead for Abortion and Gender Equality

Trump and the Global Gag Rule

In Donald Trump’s presidential campaign, he promised to wage a war on abortion rights. He did indeed keep that promise; one of his first executive actions in office was reinstating the Global Gag Rule, which defunds international nongovernmental organizations (NGOs) that provide abortion services or even discuss abortion with their patients.

This rule has been through a kind of political rollercoaster since its inception in 1984. That year, the Reagan Administration implemented it at a population conference in Mexico City. Known as the Mexico City Policy, Reagan declared any NGO that includes abortion or abortion consultation among their family planning services ineligible for U.S. funding.

This policy is different from the Helms Amendment, which prohibits the use of U.S. aid directly for abortion services. The Gag Rule prohibits funding organizations that have anything to do with abortion–which includes a majority of family planning programs. As a result, it is not just abortion that will be affected but every aspect of sexual and reproductive health.

Republican administrations since Reagan have upheld the gag rule, while the Democratic administrations of Bill Clinton and Barack Obama have renounced it.  

But this time, Trump did not merely reinstate this policy. He intensified it by a factor of 15, according to Population Action International. Historically, the gag rule has applied to $575 million in family planning and reproductive health funding. Trump’s Global Gag Rule applies to all global health funding, which amounts to $9.5 billion. This cuts funding from the National Institutes of Health, Centers of Disease Control, the Food and Drug Administration and various agencies of the United Nations.

In the past, international NGOs could still receive funding from the United States Agency for International Development and the U.S. State Department under the Mexico City Policy. Not anymore. Trump offers no exceptions.

This extreme cut in U.S. funding could destabilize health organizations worldwide. HIV prevention and treatment, maternal health care and Zika prevention programs will suffer as a result.

Northwestern Professor Sarah Rodriguez, who is a medical historian specializing in women’s reproductive and sexual health, said other aspects of women’s health will be affected. “A NGO, for example, can provide services beyond those that pertain to pregnancy. It can be doing mammograms, cervical cancer screening, pap smears and more.”

The NGOs that received U.S. funding from the Obama Administration now have to face a choice: cut funding and limit the scope of their care, or receive funding but cut the abortion services they provide.

 

What It Means for Abortion

The Gag Rule aims to cut down abortion rates, but a 2011 study by Stanford researchers found that it actually results in the opposite. Examining the policy’s impact in 20 sub-Saharan African countries from 1994 to 2000, they found that the rate of abortions actually increased. Unsafe abortions, that is.

This correlation could be due to a number of reasons. The researchers suggested that NGOs contributing to contraceptive distribution lost the funding to do so, leading women to become pregnant without wanting to.

Out of desperation, women will still seek abortions, whether they are safe or not. Reducing the availability of abortion services will not change a woman’s desire to terminate her pregnancy. In fact, it makes sense that making abortion illegal–criminalizing it–forces women to turn to harmful practices. In Kenya, women will resort to drinking battery acid, using wire coat hangers and asking others to stomp on their stomachs until they are no longer pregnant.

One of the most frustrating global health issues is the high rate of unsafe abortions; they hugely contribute to the maternal mortality rate even though they are the only entirely preventable cause. 47,000 women die from childbirth-related causes every year, almost exclusively in developing countries.

There are areas in the world where abortion rates have sharply declined: rich countries where abortion is legal. This includes the United States. Since abortion was legalized in 1973, the number of total abortions performed every year has been on a steady decline.

The Gag Rule is a way to satisfy anti-abortion supporters in America, but it is those in remote rural areas of developing countries who suffer most. The policy limits the ability of organizations to increase birth control access, resulting in more unwanted pregnancies. Combined with a ban on abortion, women face horrifying realities.

 

Response and Reparation

“When the policy was first installed in 1984, only a handful of groups refused the money,” Rodriguez said. “By and large in the past, most groups continued to receive funding and chose to limit the kind of services they offered.”

Shortly after Trump put the gag rule in order, the International Planned Parenthood Federation (IPPF) confirmed that they will not abide by these conditions. Their U.S. funding will be cut off, meaning that the organization will lose about $100 million in the next four years for sexual and reproductive health services. When the Gag Rule was in effect under the Bush administration, IPPF said their partners in Nepal, Kenya and Ethiopia had to close clinics and offer fewer contraceptives.

The Netherlands openly opposes Trump’s decision. Lilianne Ploumen, the Dutch international development minister, said they plan to fund family planning programs with about $600 million over the next four years to help fill the financial gap Trump’s Gag Rule will cause. As many as 20 other nations indicated that they plan to do the same.

However, this additional funding may not have as much impact as it seems. Historically, aid from foreign governments tends to fail without serious political pressure from the countries that need it. And with Trump’s version of the gag rule, $600 million would only fill a small portion of a vast gap in funding. To weather the storm of this new administration, civic engagement and commitment to public health advocacy will be more important than ever before. 

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Global Health and Climate Change Agenda in Jeopardy

Less than a week following the inauguration of America’s 45th president, news outlets began pumping out stories about the chief executive’s silencing of two major governmental groups. The administration banned employees in the Environmental Protection Agency and the U.S. Department of Agriculture from publishing any social media posts, including tweets, or press releases about their recent scientific findings.

The ultimate purpose of this gag order has not been officially established. However, this action, and Trump’s previous statements about climate change being a “hoax” have concerned climate change activists, as well as global health organizations. As more and more research demonstrates that climate change impacts the health of individuals around the world, supporters of climate change action and global health advocates are uniting to address both problems. The Centers for Disease Control and Prevention (CDC) scheduled the Climate and Health Summit, a three-day conference in February to discuss the intersection of the two issues, but the new government’s transition is making officials reconsider.

During the week of January 23, the CDC announced to the media that it was indefinitely postponing the conference, originally planned for February 14-17. No public statement was given by the agency to explain the action. The Trump administration did not directly order the cancellation, but likely played a large role in the decision, according to other sponsors of the event. A co-sponsor of the event stated that organizers felt uncertain about the amount of support the administration would offer the event, given the president’s previous statements about climate change. Rather than potentially face conflict with the administration over the conference, the CDC decided to postpone holding the event until officials could discuss details with the new administration.

Friday, former vice president Al Gore announced in a release from the Climate Reality Project, that there would be a replacement for the conference. A number of organizations, including the American Public Health Association, the Climate Reality Project, Harvard Global Health Institute, and the University of Washington Center for Health and the Global Environment will sponsor the Climate and Health Meeting in Atlanta, Georgia. While the goals of the meeting are very similar to the summit, the timeline has been shortened to a single day.

As global temperatures continue to set records, the consequences of climate change are already affecting the health of individuals around the world, particularly in vulnerable regions. Increases in heat have been clearly tied to the increasing number of heat-related illnesses. However, climate change also impacts many intermediary factors that result in worsened health conditions. For example, changes in temperature have allowed mosquitoes to expand their habitats, putting more of the world at risk for diseases like dengue, malaria and Zika. Scientists have also linked global climate change with increased and worsened episodes of natural disasters like floods, droughts, and hurricanes. Not only do these disasters often result in direct death and injury, they place added burdens on countries whose health systems lack the resources to effectively deal with the aftermath.

While officials in the United States continue to debate the reality of global climate change, much of the rest of the world is taking steps to study and solve the complex health problems associated with a warming planet. In July, the WHO hosted its second annual conference on Health and Climate. Although there is a growing number of countries involved in these efforts, it will be key for the United States to join them to bring about effective and impactful changes.

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A Look at the Israeli Healthcare System

In the quest to create a healthcare system that provides universal health coverage to all Americans, it is important to evaluate other healthcare systems throughout the world. While conversations typically focus on the European Union’s health insurance programs, I believe that further investigation of the universal healthcare system in Israel is necessary.

Under collaborative supervision by the Israeli Ministry of Health and the Palestinian Authority, all citizens and residents of the state of Israel receive compulsory health insurance and medical services. This means that all people inhabiting the state of Israel, even those who accept Palestinian Authority citizenship and deny Israeli citizenship, receive health insurance regardless of religion, gender, race, or socioeconomic status. Not only do all people residing in Israel receive health insurance, patients have the freedom to choose from one of four competing health plans on the market, allowing them to select the program that best fits their medical needs.  Besides giving patients freedom of choice, the competition amongst the health insurance plans drives down costs. Further ensuring the success of the system, all persons are required by law to enroll in a health insurance plan.  Because it is illegal to be unenrolled in the health insurance program, high-income low-risk individuals subsidize low-income high-risk individuals.  In the United States, many opponents of the Affordable Care Act fear that the lack of competition on the market will cause prices to sky-rocket for patients. More so, they fear that high income low risk individuals will chose to pay the small fee associated with not enrolling in the health insurance, thus threatening the financial stability of the U.S. healthcare system. Israel’s healthcare system addresses these concerns, while still maintaining a system that reflects the fundamental ideals of the Affordable Care Act: providing healthcare for all people.

In addition to the distinctive structure of the Israeli healthcare system, Israel’s Magen David Adom and their method of caring for senior citizens make the healthcare system unique and particularly interesting in its own right. Magen David Adom (MDA) is the Israeli version of the Red Cross and acts as Israel’s emergency medical service providing first aid assistance by ambulance, a blood bank, and first aid and disaster relief courses. While the government mandates that this organization serves as the first responders in a medical emergency, they do not receive any government funding. Thus as Israel’s sole EMS system, they are entirely reliant on donors for funding as well as the 10,000 volunteers who make up their staff. These volunteers are trained through a 60-hour rigorous course and serve as assistant medics and dispatch center employees, among other roles. The donors and volunteers have created a qualified and effective emergency service system in Israel that successfully operates without government funding.

Another identifying aspect of the Israeli healthcare system is the way in which it cares for senior citizens. Since Israel is a developed country, characterized by a less intact community structure in which family members often live far way from the aging, the country’s health system is forced to handle disabled elderly citizens. Further complicating the issue, in Israeli culture, sending elderly persons to retirement homes is considered immoral and disrespectful. Hence, the majority of elderly people are taken cared for at home. Currently, community health organizations provide many necessary services for the elderly, including preserving at home independence, providing financial assistance for in-home caretakers, ensuring safety at home, and providing meals-on-wheels, medical equipment, and transportation.

However, the healthcare system is not without flaws and it presents a number of challenges to the public health status of the country.  Many politicians assert that the immense military spending budget has undermined the need for budget allocation to health care (Reeves & Stuckler, 2013). The inadequate funding has led to high copayments and a turn towards privatized medicine, placing low socioeconomic individuals at risk. Many Israelis also complain about the wait times to see specialized physicians and the fact that many life saving medications are not approved because of the cost-benefit ratio (“Overview of Israeli Healthcare System,” 2016).

Overall, however, the Israeli healthcare system is considered efficient because the health status levels of the population are relatively similar to that of other developed countries, even though a lower proportion of GDP is spent on health care. Israel’s healthcare expenditure comprises 7.5% of its Gross Domestic Product (GDP), which ranks 10.4 % lower than the United States’ share of GDP spent on healthcare, and 1.4 % lower than the OECD country average. (Chintz, 2014). While still considered a form of socialized medicine, the competition amongst healthcare insurance plans provides fair market pricing and physician choice for the patient.

This past summer I spent two months living in Tel Aviv and working in Israel’s health sector. I chatted with young professional Israelis who appreciated having the ability to chose their own health insurance plan. I met children who had been waiting over a year to see a specialized physician for their rare condition. I encountered economically disadvantaged patients receiving similar treatment as their economically advantaged counterparts. I worked alongside health care providers who were not only multi-lingual, but were able to provide culturally and religiously competent care to all patients they treated. As Israel is a mecca of religions, cultures, languages, and ethnicities, I personally witnessed a healthcare system which is responsive to the needs of the community. While of course no system is perfect, as American leaders work to create a healthcare system that provides quality, culturally competent, and affordable healthcare to all citizens, I believe that we could learn a thing or two from the Israeli healthcare system.

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