Kaiser Health News
Epidemic: Bodies Remember What Was Done to Them
Tue, 10 Oct 2023 09:00:00 +0000
Global fears of overpopulation in the '60s and '70s helped fuel India's campaign to slow population growth. Health workers tasked to encourage family planning were dispatched throughout the country and millions of people were sterilized — some voluntarily, some for a monetary reward, and some through force.
This violent and coercive campaign — and the distrust it created — was a backdrop for the smallpox eradication campaign happening simultaneously in India. When smallpox eradication worker Chandrakant Pandav entered a community hoping to persuade people to accept the smallpox vaccine, he said, he was often met with hesitancy and resistance.
“People's bodies still remember what was done to them,” said medical historian Sanjoy Bhattacharya.
Episode 6 of “Eradicating Smallpox” shares Pandav's approach to mending damaged relationships.
To gain informed consent, he sat with people, sang folk songs, and patiently answered questions, working both to rebuild broken trust and slow the spread of smallpox.
To conclude the episode, host Céline Gounder speaks with the director of the global health program at the Council on Foreign Relations, Thomas Bollyky. He said public health resources might be better spent looking for ways to encourage cooperation in low-trust communities, rather than investing to rebuild trust.
The Host:
Céline Gounder
Senior fellow & editor-at-large for public health, KFF Health News
Céline is senior fellow and editor-at-large for public health with KFF Health News. She is an infectious diseases physician and epidemiologist. She was an assistant commissioner of health in New York City. Between 1998 and 2012, she studied tuberculosis and HIV in South Africa, Lesotho, Malawi, Ethiopia, and Brazil. Gounder also served on the Biden-Harris Transition COVID-19 Advisory Board.
In Conversation With Céline Gounder:
Thomas Bollyky
Director of the global health program at the Council on Foreign Relations
Voices From the Episode:
Chandrakant Pandav
Community medicine physician and former World Health Organization smallpox eradication worker in India
Gyan Prakash
Professor of history at Princeton University, specializing in the history of modern India
Sanjoy Bhattacharya
Medical historian and professor of medical and global health histories at the University of Leeds
Click to open the transcript
Transcript: Bodies Remember What Was Done to Them
Podcast Transcript Epidemic: “Eradicating Smallpox” Season 2, Episode 6: Bodies Remember What Was Done to Them Air date: Oct. 10, 2023
Editor's note: If you are able, we encourage you to listen to the audio of “Epidemic,” which includes emotion and emphasis not found in the transcript. This transcript, generated using transcription software, has been edited for style and clarity. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.
Céline Gounder: In the early 1970s, all around the world, worries about overpopulation were mounting.
Politicians warned about the dangers.
Richard Nixon: Our cities are gonna be choked with people. They're going to be choked with traffic. They're gonna be choked with crime. … And they will be impossible places in which to live.
Céline Gounder: And news outlets repeated the claims. A 1970 news analysis from The New York Times described “two avenues” to deal with the problem of overpopulation.
Voice actor reading from NYT article: “… one is persuasion of people to limit family size voluntarily, by contraception, sterilization or abortion. The other is compulsory, through such means as large‐scale injection of at least temporary infertility drugs into food or water.”
Céline Gounder: Popular books like “The Population Bomb” suggested an impending, apocalyptic future. Pulpy paperbacks were passed around — capturing people's imagination and stoking fears.
Two million copies of “The Population Bomb” were sold. And the author landed on late-night television, his dire predictions becoming entertainment for Americans sitting at home on their couches.
Meanwhile, on the other side of the globe, India — with its growing population — was in the crosshairs of the world's anxieties.
[Solemn music plays.]
Céline Gounder: In the early '50s, India had launched a family planning program.
Narrator of Indian Family Planning Film: There are 5 million more mouths to feed every year. … If our population continues to grow unchecked at the present alarming rate, we cannot solve our problems of food and shelter.
Céline Gounder: And that state-sponsored campaign got political and financial backing from international organizations like the World Bank and American foundations like Ford and Rockefeller.
Health workers were dispatched across India to get people to have fewer children.
Sometimes voluntarily.
Sometimes for a monetary reward.
Sometimes using force.
Violence and coercion created distrust.
In this episode, we'll explore how that distrust affected the public health campaign to stop smallpox.
And ask: What is the path to restoring trust?
I'm Dr. Céline Gounder and this is “Epidemic.”
[“Epidemic” theme music plays.]
Chandrakant Pandav: Ready? Good afternoon. My name is Dr. Chandrakant Pandav. This is a recording in my office at New Delhi.
Céline Gounder: Chandrakant Pandav's office is decorated with his academic degrees, lantern lights, and floral wallpaper. There are photos of Mahatma Gandhi, Mother Teresa, and various Hindu deities framed in gold.
And on his desk is a small saffron-white-and-green flag.
Chandrakant Pandav: Most important, I have India's flag always in front of me.
Céline Gounder: And what's the reason for that?
Chandrakant Pandav: Patriotism, mera desh mahaan.
Céline Gounder: Mera desh mahaan — “My great Nation”— he says in Hindi. Chandrakant was so eager to share his pride that at one point he picked up the flag and waved it around a bit.
He could barely contain his love for his country — and its culture.
He even got up out of his chair, turned on a song, and started dancing.
[Video of Chandrakant dancing to upbeat music playing.]
Céline Gounder: A twist of the hand here, a little shimmy there; he did a few hand mudras with a look of delight on his face.
I couldn't help but smile along with him.
[Dance video continues playing, Céline and Chandrakant laugh.]
Céline Gounder: But even with all that joy, when the music stopped and he shuffled back to his chair, you're reminded that Chandrakant is in his 70s, with more than 50 years of experience in public health.
[Video of Chandrakant dance video fades out.]
Céline Gounder: He was one of thousands of people asked to take part in the smallpox eradication program in the early and mid-'70s. He didn't hesitate when he got the call.
Chandrakant Pandav: I said, this is the time to serve my India. Because India has spent so much of money on my education and making me a doctor, so I came from this culture strong, strong ethical background that your life is not for yourself. Money is … doesn't matter. Serve the society.
Céline Gounder: Chandrakant led a team of smallpox eradication workers. He says nearly every person he talked to about taking the smallpox vaccine seemed to have the same worry, the same questions.
Chandrakant Pandav: “What is this vaccine? What is this you're doing us? Maybe it's a population control measure.” So the strongest question they had: “This is the government of India's new policy for sterilization?”
Céline Gounder: Sterilization. The government's decades-long family planning campaign was very much top of mind.
Decades later, when Chandrakant thinks about the program — and the unethical tactics India used — the pride melts off his face.
Chandrakant Pandav: It was a very aggressive strategy, unfortunately. I don't want to go into that period. It was very aggressive.
Céline Gounder: Chandrakant didn't want to talk about it. But you can't tell the story of smallpox eradication success without talking about the family planning policies that came first.
Without talking about the state-sponsored coercive tactics that were commonplace and accepted by many.
Without acknowledging the violence of forced sterilizations.
Public health doesn't happen in a vacuum.
And India's approach to family planning eroded trust in public health workers for years.
So — in this season all about smallpox — we're going to spend some time this episode diving into the details of the family planning program.
Gyan Prakash: My name is Gyan Prash and I'm professor of history at Princeton University.
Céline Gounder: Gyan has spent years studying India's family planning campaign and the various tactics the government used to sterilize millions of people.
The government would pay people to get sterilized, and after natural disasters, like a drought, when many were desperate, any amount of money could be a powerful motivator. Patients might receive fewer than 100 rupees as compensation — which translates to only a few days' wages, according to a 1986 article published in the journal “Studies in Family Planning.”
Gyan Prakash: It was a very small amount, but it mattered; it mattered to the poor. It was coercive, because it was between going hungry and, and not going hungry.
Céline Gounder: And if you chose not to get sterilized, Gyan says, the government found other ways to twist the screw. Families would receive food rations for up to only three children — any child beyond that would not be allotted food.
Gyan Prakash: Which punishes families which have more than three children.
Céline Gounder: At one point, the government began to prioritize men for sterilization.
Vasectomies were sometimes pushed on men, according to a 1972 report from The Associated Press.
Céline Gounder: Gyan says India's family planning campaign created an atmosphere of intimidation and harassment that was nearly impossible to escape.
Gyan Prakash: You know, sending district authorities, backed by police, to the countryside and hold sterilization camps. So, I mean, the entire state machinery was mobilized to get people to the sterilization table.
Céline Gounder: Some of the harshest treatment during the sterilization campaign was aimed at Muslims and Indigenous populations like Adivasi tribes living in remote and rural parts of the country. I spoke to Sanjoy Bhattacharya about this.
Sanjoy Bhattacharya: I'm a historian of medicine with a deep interest in health policy, national, international, and global. And I'm the head of the School of History at the University of Leeds, United Kingdom.
Céline Gounder: Sanjoy says marginalized communities were often scapegoated.
Sanjoy Bhattacharya: That global narrative of overpopulation took the shape of, oh, Muslims have more children than Hindus, therefore Muslims are the problem behind Indian overpopulation. So we need to control the Muslim birthrate. What sterilization did was to violently sterilize men from a certain community who were blamed for a population problem that was a general population problem.
Céline Gounder: Sanjoy says many Adivasi and Muslim communities, in particular, lost trust in the government. This distrust lingered and simmered for years.
Imagine for a moment that for decades government trucks have descended on your village unannounced. Tents were set up. Equipment was unloaded. Workers fanned out to talk to village leaders.
This is what it looks like when Indian health workers showed up to sterilize you and your people.
And then, in the early 1970s, more government trucks arrived, maybe with familiar faces at the wheel. Maybe it's some of the same public health workers.
They unload similar sharp-edged tools and set up their tents, but this time they promise it's not for sterilization, it's for a smallpox eradication program. You'd have a hard time trusting them.
Sanjoy Bhattacharya: And there are tales of how villages would empty when rumors would spread that these teams were coming ostensibly to vaccinate, but maybe really to sterilize. I mean, people's bodies still remember what was done to them.
Chandrakant Pandav: They were treated like animals. Coercion, coercion, coercion.
Céline Gounder: That's community medicine physician and longtime public health leader Chandrakant Pandav again. He says when he arrived in the northern region of the state of Bihar, he knew these communities had every reason to doubt his team.
So first he worked to earn people's trust.
Chandrakant Pandav: So when you sit with the leader of the village, along with the batch of people there, you talk to them, you explain to them.
Céline Gounder: And Chandrakant says it's helpful to think of yourself more as a guest than a guest of honor.
Chandrakant Pandav: You don't sit on a chair. Céline, I didn't sit on a chair. I sat next to them to make them feel that I'm part of that community.
Céline Gounder: It sounds like convincing the village leader was enough to convince the villagers.
Chandrakant Pandav: It is the first step.
Céline Gounder: Another important step, he says, was to learn the local traditions around smallpox. Locals in Bihar faced the disease for many years, and they'd developed their own ways of dealing with it.
They would tie the leaves of a neem tree outside the homes of infected people.
The neem tree is said to have medicinal properties. Displaying its leaves outside homes where an active infection was present alerted others to stay away — a strategy designed to slow disease spread.
It didn't stop the virus — it wasn't effective in the same way as vials of vaccine or the bifurcated needle — but the traditions needed to be honored.
So Chandrakant and the other public health workers adopted some of the local strategies.
Chandrakant Pandav: So it was a very good combination of ancient medicine, ancient practice, with modern approach. Very good combination.
Céline Gounder: Another tradition his team tapped into was folk songs. They frequently used drums, songs, and the public address systems to communicate with people about smallpox.
Music was an especially good match for Chandrakant's lively personality.
Remember all that joy for India I witnessed in his office in New Delhi — the flag? The dancing? Imagine that harnessed on behalf of his mission to wipe out smallpox.
In fact, he still remembers some of those folk songs nearly half a century later.
Chandrakant Pandav: Because it's part of me, every atom, every molecule residing [sings folk song in Hindi]. So, it became an important method of communication. I come back again and again, Céline, to the same point: Establish a rapport and instill a sense of faith, anything is possible.
Céline Gounder: Chandrakant was able to pave the way for acceptance of the smallpox vaccine and rebuild trust in public health. But he was one charismatic man. His approach, his compassion were admirable — and it worked, where he was, with the people in front of him.
But the Indian government broke trust with tens of millions of its citizens during the family planning campaign. It makes me wonder about what it might look like to repair trust at that level, across the public health system, across an entire country.
Maybe that would mean an apology. Maybe that would be some kind of reparation to victims for the damage done to their bodies.
My friend and colleague Tom Bollyky says there's no single silver bullet for rebuilding trust.
Tom Bollyky: That is too big of a mission for public health. We have enough challenges as it is. Instead of planning for how do we rebuild trust, we should be planning for dysfunction.
Céline Gounder: That's after the break.
[Music fades out.]
Céline Gounder: Distrust and mistrust in the government became something of a defining feature of the response to the covid pandemic here in the United States. And while that might have taken many Americans by surprise, it was totally predictable to Tom Bollyky. He's the director of the global health program at the Council on Foreign Relations. Bollyky says trust in the U.S. has been deteriorating since Watergate, and that decline accelerated around the 2008 financial crisis. Mistrust here divides along racial lines. It's lower among African Americans, for example. And most notably, mistrust tends to be partisan. But it didn't start that way during the covid pandemic.
Tom Bollyky: I think we all forget that there was, for a period of time, a surprising level of political consensus. Almost all states imposed protective policy mandates and most states imposed them at the same time. But as the fall stretched out, you saw some of those mandates and responses become more politicized.
And the moment I regret is, I think there was a moment, when the Biden administration came in and there was an attempt to reset and I … myself and many others really again focused on this message of following the science. But I do feel like perhaps we missed a opportunity to try to pull in some people across partisan lines at that moment.
Céline Gounder: So, as I'm hearing you describe this, restoring trust seems like a really massive undertaking.
I wonder whether you think that's even the right framework that we should be using to think about this challenge.
Tom Bollyky: Such a great question. No, I think it isn't. I think if we set an agenda for public health to rebuild the cohesiveness of our societies, to make us have a better relationship with our government, with each other, we will fail.
That is too big of a mission for public health. We have enough challenges as it is. Instead of planning for how do we rebuild trust, we should be planning for dysfunction. That's really what preparedness is about.
Céline Gounder: So what are some of the ways that public health officials can reach skeptical communities?
Tom Bollyky: Through kinship networks and, uh, local leaders has been important. In some other public health crises, like HIV, people have used soap operas.
Céline Gounder: I remember being in South Africa in the early 2000s. There was a soap opera called “Soul City.” We pulled a clip of it, and there's this one scene where a husband comes home to find his wife has placed a romantic gift by their bedside. He opens it up and sees condoms.
[Music]
“Soul City” clip: Woman: So that we can have safe sex. Man: Safe sex. Woman: I can't have sex with you while I'm anxious about getting sick. Or, would you prefer I use condoms maybe? Man: We don't need condoms. Woman: I do.
Tom Bollyky: I was in South Africa and the country was riveted. People really talked about it. It took, it took hold. Uh, they did a nice job of making it interesting, like weaving in the themes you wanted to weave in about people getting tested and talking to their partners and loved ones about their circumstances.
I know, Céline, you were very involved in the Ebola response, in 2013 through 2016. You know, there is high levels of mistrust in government in those post-conflict settings that were most affected in that epidemic.
Céline Gounder: People there don't trust government, they think that people who serve in government do so to enrich themselves and their family and friends.
When I was in Guinea during the Ebola epidemic, they said Ebola was a hoax, that it was just a way for government officials and international organizations to enrich themselves. And yet, we were able to make some inroads convincing people to comply with Ebola control measures, so hand-washing, testing, safe burials.
Much of that was done through imams and other religious and community leaders.
Tom Bollyky: Those are the types of strategies we should be deploying when the next health crisis emerges, but not simply waiting until that happens. We need to start to build the infrastructure, the relationships. Again, even if it isn't around fundamentally transforming, you know, communities, relationships with the government, or even how community members feel about, uh, one another, because interpersonal trust, social trust is a big part of this, too.
It's about building the connections, the networks, about starting to engage individuals in these programs or through those institutions so that when the crisis emerges, you're not building that from scratch.
Céline Gounder: Well, and to your point, as we prepare for the next pandemic, do you think we've learned those lessons about trust or are there things we're still getting wrong?
Tom Bollyky: I think there is a greater appreciation for trust as an important issue. You hear that messaging. What I worry about is we're not seeing it reflected yet in where the money is going. Where the money is going by and large is to developing vaccines faster, better vaccines in the future. But if really the lessons we're drawing from this crisis are that developing a vaccine instead of in 326 days in 250 days … if we really think that would have made a difference in this pandemic, we haven't been paying attention.
Céline Gounder: Next time on “Epidemic” …
Daniel Tarantola: They did not consider smallpox as the major issues among the many issues they were confronting. … No. 1 priority is food and food and food. And the second priority is food and food and food.
CREDITS
Céline Gounder: “Eradicating Smallpox,” our latest season of “Epidemic,” is a co-production of KFF Health News and Just Human Productions.
Additional support provided by the Sloan Foundation.
This episode was produced by Taylor Cook, Zach Dyer, Bram Sable-Smith, and me.
Saidu Tejan-Thomas Jr. was scriptwriter for the episode.
Swagata Yadavar was our translator and local reporting partner in India.
Our managing editor is Taunya English.
Oona Tempest is our graphics and photo editor.
The show was engineered by Justin Gerrish.
We had extra editing help from Simone Popperl.
Music in this episode is from the Blue Dot Sessions and Soundstripe.
This episode featured clips from National Education & Information Films Limited
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Follow KFF Health News on X (formerly known as Twitter), Instagram, and TikTok.
And find me on X @celinegounder. On our socials, there's more about the ideas we're exploring on our podcasts.
And subscribe to our newsletters at kffhealthnews.org so you'll never miss what's new and important in American health care, health policy, and public health news.
I'm Dr. Céline Gounder. Thanks for listening to “Epidemic.”
[“Epidemic” theme fades out.]
Credits
Taunya English
Managing editor
Taunya is senior editor for broadcast innovation with KFF Health News, where she leads enterprise audio projects.
Zach Dyer
Senior producer
Zach is senior producer for audio with KFF Health News, where he supervises all levels of podcast production.
Taylor Cook
Associate producer
Taylor is associate audio producer for Season 2 of Epidemic. She researches, writes, and fact-checks scripts for the podcast.
Oona Tempest
Photo editing, design, logo art
Oona is a digital producer and illustrator with KFF Health News. She researched, sourced, and curated the images for the season.
Additional Newsroom Support
Lydia Zuraw, digital producer Tarena Lofton, audience engagement producer Hannah Norman, visual producer and visual reporter Simone Popperl, broadcast editor Chaseedaw Giles, social media manager Mary Agnes Carey, partnerships editor Damon Darlin, executive editor Terry Byrne, copy chiefGabe Brison-Trezise, deputy copy chiefChris Lee, senior communications officer
Additional Reporting Support
Swagata Yadavar, translator and local reporting partner in IndiaRedwan Ahmed, translator and local reporting partner in Bangladesh
“Epidemic” is a co-production of KFF Health News and Just Human Productions.
To hear other KFF Health News podcasts, click here. Subscribe to “Epidemic” on Apple Podcasts, Spotify, Google, Pocket Casts, or wherever you listen to podcasts.
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Title: Epidemic: Bodies Remember What Was Done to Them
Sourced From: kffhealthnews.org/news/podcast/epidemic-season-2-episode-6-bodies-remember/
Published Date: Tue, 10 Oct 2023 09:00:00 +0000
Jazmin Orozco Rodriguez
Mon, 20 May 2024 09:00:00 +0000
About a year into the process of redetermining Medicaid eligibility after the covid-19 public health emergency, more than 20 million people have been kicked off the joint federal-state program for low-income families.
A chorus of stories recount the ways the unwinding has upended people's lives, but Native Americans are proving particularly vulnerable to losing coverage and face greater obstacles to reenrolling in Medicaid or finding other coverage.
“From my perspective, it did not work how it should,” said Kristin Melli, a pediatric nurse practitioner in rural Kalispell, Montana, who also provides telehealth services to tribal members on the Fort Peck Reservation.
The redetermination process has compounded long-existing problems people on the reservation face when seeking care, she said. She saw several patients who were still eligible for benefits disenrolled. And a rise in uninsured tribal members undercuts their health systems, threatening the already tenuous access to care in Native communities.
One teenager, Melli recalled, lost coverage while seeking lifesaving care. Routine lab work raised flags, and in follow-ups Melli discovered the girl had a condition that could have killed her if untreated. Melli did not disclose details, to protect the patient's privacy.
Melli said she spent weeks working with tribal nurses to coordinate lab monitoring and consultations with specialists for her patient. It wasn't until the teen went to a specialist that Melli received a call saying she had been dropped from Medicaid coverage.
The girl's parents told Melli they had reapplied to Medicaid a month earlier but hadn't heard back. Melli's patient eventually got the medication she needed with help from a pharmacist. The unwinding presented an unnecessary and burdensome obstacle to care.
Pat Flowers, Montana Democratic Senate minority leader, said during a political event in early April that 13,000 tribal members had been disenrolled in the state.
Native American and Alaska Native adults are enrolled in Medicaid at higher rates than their white counterparts, yet some tribal leaders still didn't know exactly how many of their members had been disenrolled as of a survey conducted in February and March. The Tribal Self-Governance Advisory Committee of the Indian Health Service conducted and published the survey. Respondents included tribal leaders from Alaska, Arizona, Idaho, Montana, and New Mexico, among other states.
Tribal leaders reported many challenges related to the redetermination, including a lack of timely information provided to tribal members, patients unaware of the process or their disenrollment, long processing times, lack of staffing at the tribal level, lack of communication from their states, concerns with obtaining accurate tribal data, and in cases in which states have shared data, difficulties interpreting it.
Research and policy experts initially feared that vulnerable populations, including rural Indigenous communities and families of color, would experience greater and unique obstacles to renewing their health coverage and would be disproportionately harmed.
“They have a lot at stake and a lot to lose in this process,” said Joan Alker, executive director of the Georgetown University Center for Children and Families and a research professor at the McCourt School of Public Policy. “I fear that that prediction is coming true.”
Cammie DuPuis-Pablo, tribal health communications director for the Confederated Salish and Kootenai Tribes in Montana, said the tribes don't have an exact number of their members disenrolled since the redetermination began, but know some who lost coverage as far back as July still haven't been reenrolled.
The tribes hosted their first outreach event in late April as part of their effort to help members through the process. The health care resource division is meeting people at home, making calls, and planning more events.
The tribes receive a list of members' Medicaid status each month, DuPuis-Pablo said, but a list of those no longer insured by Medicaid would be more helpful.
Because of those data deficits, it's unclear how many tribal members have been disenrolled.
“We are at the mercy of state Medicaid agencies on what they're willing to share,” said Yvonne Myers, consultant on the Affordable Care Act and Medicaid for Citizen Potawatomi Nation Health Services in Oklahoma.
In Alaska, tribal health leaders struck a data-sharing agreement with the state in July but didn't begin receiving information about their members' coverage for about a month — at which point more than 9,500 Alaskans had already been disenrolled for procedural reasons.
“We already lost those people,” said Gennifer Moreau-Johnson, senior policy adviser in the Department of Intergovernmental Affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization. “That's a real impact.”
Because federal regulations don't require states to track or report race and ethnicity data for people they disenroll, fewer than 10 states collect such information. While the data from these states does not show a higher rate of loss of coverage by race, a KFF report states that the data is limited and that a more accurate picture would require more demographic reporting from more states.
Tribal health leaders are concerned that a high number of disenrollments among their members is financially undercutting their health systems and ability to provide care.
“Just because they've fallen off Medicaid doesn't mean we stop serving them,” said Jim Roberts, senior executive liaison in the Department of Intergovernmental Affairs of the Alaska Native Tribal Health Consortium. “It means we're more reliant on other sources of funding to provide that care that are already underresourced.”
Three in 10 Native American and Alaska Native people younger than 65 rely on Medicaid, compared with 15% of their white counterparts. The Indian Health Service is responsible for providing care to approximately 2.6 million of the 9.7 million Native Americans and Alaska Natives in the U.S., but services vary across regions, clinics, and health centers. The agency itself has been chronically underfunded and unable to meet the needs of the population. For fiscal year 2024, Congress approved $6.96 billion for IHS, far less than the $51.4 billion tribal leaders called for.
Because of that historical deficit, tribal health systems lean on Medicaid reimbursement and other third-party payers, like Medicare, the Department of Veterans Affairs, and private insurance, to help fill the gap. Medicaid accounted for two-thirds of third-party IHS revenues as of 2021.
Some tribal health systems receive more federal funding through Medicaid than from IHS, Roberts said.
Tribal health leaders fear diminishing Medicaid dollars will exacerbate the long-standing health disparities — such as lower life expectancy, higher rates of chronic disease, and inferior access to care — that plague Native Americans.
The unwinding has become “all-consuming,” said Monique Martin, vice president of intergovernmental affairs for the Alaska Native Tribal Health Consortium.
“The state's really having that focus be right into the minutiae of administrative tasks, like: How do we send text messages to 7,000 people?” Martin said. “We would much rather be talking about: How do we address social determinants of health?”
Melli said she has stopped hearing of tribal members on the Fort Peck Reservation losing their Medicaid coverage, but she wonders if that means disenrolled people didn't seek help.
“Those are the ones that we really worry about,” she said, “all of these silent cases. … We only know about the ones we actually see.”
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By: Jazmin Orozco Rodriguez
Title: Medicaid Unwinding Deals Blow to Tenuous System of Care for Native Americans
Sourced From: kffhealthnews.org/news/article/medicaid-unwinding-endangers-native-american-health-care/
Published Date: Mon, 20 May 2024 09:00:00 +0000
Michelle Andrews
Fri, 17 May 2024 09:00:00 +0000
For many patients, seeing a nurse practitioner has become a routine part of primary care, in which these “NPs” often perform the same tasks that patients have relied on doctors for.
But NPs in specialty care? That's not routine, at least not yet. Increasingly, though, nurse practitioners and physician assistants are joining cardiology, dermatology, and other specialty practices, broadening their skills and increasing their income.
This development worries some people who track the health workforce, because current trends suggest primary care, which has counted on nurse practitioners to backstop physician shortages, soon might not be able to rely on them to the same extent.
“They're succumbing to the same challenges that we have with physicians,” said Atul Grover, executive director of the Research and Action Institute at the Association of American Medical Colleges. The rates NPs can command in a specialty practice “are quite a bit higher” than practice salaries in primary care, he said.
When nurse practitioner programs began to proliferate in the 1970s, “at first it looked great, producing all these nurse practitioners that go to work with primary care physicians,” said Yalda Jabbarpour, director of the American Academy of Family Physicians' Robert Graham Center for Policy Studies. “But now only 30% are going into primary care.”
Jabbarpour was referring to the 2024 primary care scorecard by the Milbank Memorial Fund, which found that from 2016 to 2021 the proportion of nurse practitioners who worked in primary care practices hovered between 32% and 34%, even though their numbers grew rapidly. The proportion of physician assistants, also known as physician associates, in primary care ranged from 27% to 30%, the study found.
Both nurse practitioners and physician assistants are advanced practice clinicians who, in addition to graduate degrees, must complete distinct education, training, and certification steps. NPs can practice without a doctor's supervision in more than two dozen states, while PAs have similar independence in only a handful of states.
About 88% of nurse practitioners are certified in an area of primary care, according to the American Association of Nurse Practitioners. But it is difficult to track exactly how many work in primary care or in specialty practices. Unlike physicians, they're generally not required to be endorsed by a national standard-setting body to practice in specialties like oncology or cardiology, for example. The AANP declined to answer questions about its annual workforce survey or the extent to which primary care NPs are moving toward specialties.
Though data tracking the change is sparse, specialty practices are adding these advanced practice clinicians at almost the same rate as primary care practices, according to frequently cited research published in 2018.
The clearest evidence of the shift: From 2008 to 2016, there was a 22% increase in the number of specialty practices that employed nurse practitioners and physician assistants, according to that study. The increase in the number of primary care practices that employed these professionals was 24%.
Once more, the most recent projections by the Association of American Medical Colleges predict a dearth of at least 20,200 primary care physicians by 2036. There will also be a shortfall of non-primary care specialists, including a deficiency of at least 10,100 surgical physicians and up to 25,000 physicians in other specialties.
When it comes to the actual work performed, the lines between primary and specialty care are often blurred, said Candice Chen, associate professor of health policy and management at George Washington University.
“You might be a nurse practitioner working in a gastroenterology clinic or cardiology clinic, but the scope of what you do is starting to overlap with primary care,” she said.
Nurse practitioners' salaries vary widely by location, type of facility, and experience. Still, according to data from health care recruiter AMN Healthcare Physician Solutions, formerly known as Merritt Hawkins, the total annual average starting compensation, including signing bonus, for nurse practitioners and physician assistants in specialty practice was $172,544 in the year that ended March 31, slightly higher than the $166,544 for those in primary care.
According to forecasts from the federal Bureau of Labor Statistics, nurse practitioner jobs will increase faster than jobs in almost any other occupation in the decade leading up to 2032, growing by 123,600 jobs or 45%. (Wind turbine service technician is the only other occupation projected to grow as fast.) The growth rate for physician assistants is also much faster than average, at 27%. There are more than twice as many nurse practitioners as physician assistants, however: 323,900 versus 148,000, in 2022.
To Grover, of the AAMC, numbers like this signal that there will probably be enough NPs, PAs, and physicians to meet primary care needs. At the same time, “expect more NPs and PAs to also flow out into other specialties,” he said.
When Pamela Ograbisz started working as a registered nurse 27 years ago, she worked in a cardiothoracic intensive care unit. After she became a family nurse practitioner a few years later, she found a job with a similar specialty practice, which trained her to take on a bigger role, first running their outpatient clinic, then working on the floor, and later in the intensive care unit.
If nurse practitioners want to specialize, often “the doctors mentor them just like they would with a physician residency,” said Ograbisz, now vice president of clinical operations at temporary placement recruiter LocumTenens.com.
If physician assistants want to specialize, they also can do so through mentoring, or they can receive “certificates of added qualifications” in 10 specialties to demonstrate their expertise. Most employers don't “encourage or require” these certificates, however, said Jennifer Orozco, chief medical officer at the American Academy of Physician Associates.
There are a number of training programs for family nurse practitioners who want to develop skills in other areas.
Raina Hoebelheinrich, 40, a family nurse practitioner at a regional medical center in Yankton, South Dakota, recently enrolled in a three-semester post-master's endocrinology training program at Mount Marty University. She lives on a farm in nearby northeastern Nebraska with her husband and five sons.
Hoebelheinrich's new skills could be helpful in her current hospital job, in which she sees a lot of patients with acute diabetes, or in a clinic setting like the one in Sioux Falls, South Dakota, where she is doing her clinical endocrinology training.
Lack of access to endocrinology care in rural areas is a real problem, and many people may travel hundreds of miles to see a specialist.
“There aren't a lot of options,” she said.
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By: Michelle Andrews
Title: The Lure of Specialty Medicine Pulls Nurse Practitioners From Primary Care
Sourced From: kffhealthnews.org/news/article/nurse-practitioners-trend-primary-care-specialties/
Published Date: Fri, 17 May 2024 09:00:00 +0000
Did you miss our previous article…
https://www.biloxinewsevents.com/clean-needles-save-lives-in-some-states-they-might-not-be-legal/
Ed Mahon, Spotlight PA and Sarah Boden, WESA
Fri, 17 May 2024 09:00:00 +0000
Kim Botteicher hardly thinks of herself as a criminal.
On the main floor of a former Catholic church in Bolivar, Pennsylvania, Botteicher runs a flower shop and cafe.
In the former church's basement, she also operates a nonprofit organization focused on helping people caught up in the drug epidemic get back on their feet.
The nonprofit, FAVOR ~ Western PA, sits in a rural pocket of the Allegheny Mountains east of Pittsburgh. Her organization's home county of Westmoreland has seen roughly 100 or more drug overdose deaths each year for the past several years, the majority involving fentanyl.
Thousands more residents in the region have been touched by the scourge of addiction, which is where Botteicher comes in.
She helps people find housing, jobs, and health care, and works with families by running support groups and explaining that substance use disorder is a disease, not a moral failing.
But she has also talked publicly about how she has made sterile syringes available to people who use drugs.
“When that person comes in the door,” she said, “if they are covered with abscesses because they have been using needles that are dirty, or they've been sharing needles — maybe they've got hep C — we see that as, ‘OK, this is our first step.'”
Studies have identified public health benefits associated with syringe exchange services. The Centers for Disease Control and Prevention says these programs reduce HIV and hepatitis C infections, and that new users of the programs are more likely to enter drug treatment and more likely to stop using drugs than nonparticipants.
This harm-reduction strategy is supported by leading health groups, such as the American Medical Association, the World Health Organization, and the International AIDS Society.
But providing clean syringes could put Botteicher in legal danger. Under Pennsylvania law, it's a misdemeanor to distribute drug paraphernalia. The state's definition includes hypodermic syringes, needles, and other objects used for injecting banned drugs. Pennsylvania is one of 12 states that do not implicitly or explicitly authorize syringe services programs through statute or regulation, according to a 2023 analysis. A few of those states, but not Pennsylvania, either don't have a state drug paraphernalia law or don't include syringes in it.
Those working on the front lines of the opioid epidemic, like Botteicher, say a reexamination of Pennsylvania's law is long overdue.
There's an urgency to the issue as well: Billions of dollars have begun flowing into Pennsylvania and other states from legal settlements with companies over their role in the opioid epidemic, and syringe services are among the eligible interventions that could be supported by that money.
The opioid settlements reached between drug companies and distributors and a coalition of state attorneys general included a list of recommendations for spending the money. Expanding syringe services is listed as one of the core strategies.
But in Pennsylvania, where 5,158 people died from a drug overdose in 2022, the state's drug paraphernalia law stands in the way.
Concerns over Botteicher's work with syringe services recently led Westmoreland County officials to cancel an allocation of $150,000 in opioid settlement funds they had previously approved for her organization. County Commissioner Douglas Chew defended the decision by saying the county “is very risk averse.”
Botteicher said her organization had planned to use the money to hire additional recovery specialists, not on syringes. Supporters of syringe services point to the cancellation of funding as evidence of the need to change state law, especially given the recommendations of settlement documents.
“It's just a huge inconsistency,” said Zoe Soslow, who leads overdose prevention work in Pennsylvania for the public health organization Vital Strategies. “It's causing a lot of confusion.”
Though sterile syringes can be purchased from pharmacies without a prescription, handing out free ones to make drug use safer is generally considered illegal — or at least in a legal gray area — in most of the state. In Pennsylvania's two largest cities, Philadelphia and Pittsburgh, officials have used local health powers to provide legal protection to people who operate syringe services programs.
Even so, in Philadelphia, Mayor Cherelle Parker, who took office in January, has made it clear she opposes using opioid settlement money, or any city funds, to pay for the distribution of clean needles, The Philadelphia Inquirer has reported. Parker's position signals a major shift in that city's approach to the opioid epidemic.
On the other side of the state, opioid settlement funds have had a big effect for Prevention Point Pittsburgh, a harm reduction organization. Allegheny County reported spending or committing $325,000 in settlement money as of the end of last year to support the organization's work with sterile syringes and other supplies for safer drug use.
“It was absolutely incredible to not have to fundraise every single dollar for the supplies that go out,” said Prevention Point's executive director, Aaron Arnold. “It takes a lot of energy. It pulls away from actual delivery of services when you're constantly having to find out, ‘Do we have enough money to even purchase the supplies that we want to distribute?'”
In parts of Pennsylvania that lack these legal protections, people sometimes operate underground syringe programs.
The Pennsylvania law banning drug paraphernalia was never intended to apply to syringe services, according to Scott Burris, director of the Center for Public Health Law Research at Temple University. But there have not been court cases in Pennsylvania to clarify the issue, and the failure of the legislature to act creates a chilling effect, he said.
Carla Sofronski, executive director of the Pennsylvania Harm Reduction Network, said she was not aware of anyone having faced criminal charges for operating syringe services in the state, but she noted the threat hangs over people who do and that they are taking a “great risk.”
In 2016, the CDC flagged three Pennsylvania counties — Cambria, Crawford, and Luzerne — among 220 counties nationwide in an assessment of communities potentially vulnerable to the rapid spread of HIV and to new or continuing high rates of hepatitis C infections among people who inject drugs.
Kate Favata, a resident of Luzerne County, said she started using heroin in her late teens and wouldn't be alive today if it weren't for the support and community she found at a syringe services program in Philadelphia.
“It kind of just made me feel like I was in a safe space. And I don't really know if there was like a come-to-God moment or come-to-Jesus moment,” she said. “I just wanted better.”
Favata is now in long-term recovery and works for a medication-assisted treatment program.
At clinics in Cambria and Somerset Counties, Highlands Health provides free or low-cost medical care. Despite the legal risk, the organization has operated a syringe program for several years, while also testing patients for infectious diseases, distributing overdose reversal medication, and offering recovery options.
Rosalie Danchanko, Highlands Health's executive director, said she hopes opioid settlement money can eventually support her organization.
“Why shouldn't that wealth be spread around for all organizations that are working with people affected by the opioid problem?” she asked.
In February, legislation to legalize syringe services in Pennsylvania was approved by a committee and has moved forward. The administration of Gov. Josh Shapiro, a Democrat, supports the legislation. But it faces an uncertain future in the full legislature, in which Democrats have a narrow majority in the House and Republicans control the Senate.
One of the bill's lead sponsors, state Rep. Jim Struzzi, hasn't always supported syringe services. But the Republican from western Pennsylvania said that since his brother died from a drug overdose in 2014, he has come to better understand the nature of addiction.
In the committee vote, nearly all of Struzzi's Republican colleagues opposed the bill. State Rep. Paul Schemel said authorizing the “very instrumentality of abuse” crossed a line for him and “would be enabling an evil.”
After the vote, Struzzi said he wanted to build more bipartisan support. He noted that some of his own skepticism about the programs eased only after he visited Prevention Point Pittsburgh and saw how workers do more than just hand out syringes. These types of programs connect people to resources — overdose reversal medication, wound care, substance use treatment — that can save lives and lead to recovery.
“A lot of these people are … desperate. They're alone. They're afraid. And these programs bring them into someone who cares,” Struzzi said. “And that, to me, is a step in the right direction.”
At her nonprofit in western Pennsylvania, Botteicher is hoping lawmakers take action.
“If it's something that's going to help someone, then why is it illegal?” she said. “It just doesn't make any sense to me.”
This story was co-reported by WESA Public Radio and Spotlight PA, an independent, nonpartisan, and nonprofit newsroom producing investigative and public-service journalism that holds power to account and drives positive change in Pennsylvania.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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By: Ed Mahon, Spotlight PA and Sarah Boden, WESA
Title: Clean Needles Save Lives. In Some States, They Might Not Be Legal.
Sourced From: kffhealthnews.org/news/article/clean-needles-syringe-services-programs-legal-gray-area-risk-pennsylvania/
Published Date: Fri, 17 May 2024 09:00:00 +0000
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