A mood of fear is engulfing the country which might very well affect the midterm elections. Hopefully people will react rationally and reject the Republicans who promote unwarranted fears, play politics, and advocate for counterproductive responses such as travel bans. Unfortunately but this is not the probable response.
As I discussed last week, even citing a report on Fox, we have no need to fear Ebola as long as proper precautions are taken.
There is no need to panic, or initiate measures which would be counterproductive such as a travel ban at this time. There is no meaningful problem with Ebola in this country and the biology of the virus makes it unlikely we will have a problem in the future. The nature of Ebola makes it a serious problem in countries without a Public Health infrastructure, but not in countries like the United States.
To date we have had exactly one patient with Ebola come into the country beyond medical personnel transported back here. Despite some serious mistakes being made, he did not infect a single person in the general population. The spread was limited to two nurses who cared for him at the most infectious stage, but before this stage the viral load is very low and Ebola is not likely to spread. This is also why, despite people who did come into contact with him having traveled, not a single other person has contracted Ebola.
Ebola is a serious problem in countries without sufficient infrastructure to deal with it, and if we are ever to be at serious risk it would be due to more widespread infection outside of the United States first. Our major focus must be on eradicating Ebola in West Africa, and anything which hinders this will make this more difficult and be counterproductive.
We also must closely track those who have been exposed, and a travel ban would also make this far more difficult. One of the major reasons for Ebola spreading in West Africa is an atmosphere which causes people who have been exposed to hide this until they are very sick and courageous. We must avoid an atmosphere such as this in the United States if we are going to prevent spread here.
Nigeria has not closed its borders to travelers from Guinea, Sierra Leone and Liberia, saying the move would be counterproductive. “Closing borders tends to reinforce panic and the notion of helplessness,” Shuaib said. “When you close the legal points of entry, then you potentially drive people to use illegal passages, thus compounding the problem.” Shuaib said that if public health strategies are implemented, outbreaks can be controlled, and that closing borders would only stifle commercial activities in the countries whose economies are already struggling due to Ebola.
Similarly, Republicans are playing on exaggerated fears of terrorism and unfounded claims that the Affordable Care Act will cause increases in premiums when insurance companies are actually reporting plans for lower premium increases than were the norm prior to Obamacare.
Flatline managed to provide an episode of Doctor Who which successfully combined elements of both horror and humor. While not a totally original idea, it was something not seen on Doctor Who before, and realistically few television shows manage to come up with ideas which have not been influenced by other works. Think of it as if the residents of Flatland by Edwin Abbott Abbott were to invade earth, with a touch of The Adams Family thrown in.
Besides the idea of two dimensional beings invading, there was the added component of the TARDIS shrinking when the “structural integrity is compromised.” This did contradict The Name of the Doctor which showed such leaking to cause the TARDIS to swell in size, not shrink. The shrinking of the TARDIS, with the Doctor trapped inside, did enable Clara to take a leading role in this episode. This whole situation was quite difficult for the Doctor: “I mean this is just embarrassing. I’m from the race that built the TARDIS. Dimensions are kind of our thing.”
The Doctor did win out in the end. Ultimately the aliens from the two dimensional world were defeated by their inability to distinguish a two dimensional picture of a door from a real three dimensional door.
With the Doctor separated from the action for most of the episode, Clara took on the role of the Doctor, including taking on a companion, Rigsy, and calling herself the Doctor:
Rigsy: “What are you the doctor of?”
The Doctor: “Of lies.”
Clara: “Well, I’m usually quite vague about that. I think I just picked the title because it makes me sound important.”
The Doctor: “Why, ‘Doctor Oswald,’ you are hilarious.”
Clara did show Rigsy the inside of the shrunken TARDIS leading to the classic comment, “It’s bigger on the inside.” This set up the Doctor’s response: “I don’t think that statement has ever been more true.”
Clara also showed that she can act like the Doctor, from using the Sonic Screwdriver to using his tactics:
Clara: “I just hope I can keep them all alive.”
The Doctor: “Ha. Welcome to my world. So, what’s next, ‘Doctor Clara’?”
Clara: “Lie to them.”
The Doctor: “What?”
Clara: “‘Lie to them.’ Give them hope. Tell them they’re all going to be fine. Isn’t that what you would do?”
The Doctor: “In a manner of speaking. It is true that people with hope tend to run faster, whereas people who think they’re doomed …”
Clara: “Dawdle. End up dead.”
The Doctor: “So, that’s what I sound like?”
Ultimately, when Clara asked if she did a good job, the Doctor did respond, “You were an exceptional Doctor, Clara. Goodness had nothing to do with it.” We still have the question from the start of the season as to whether the Doctor is a good man, and whether they are doing good.
The most amusing gag of all in the episode was seeing the Doctor’s full sized hand emerge from the tiny TARDIS to walk it away from an oncoming train. The episode was very light on Danny Pink, but we did have another amusing scene with Clara talking on the phone with Danny, hiding the fact that she was in danger. The previews do show him taking an active part next week, but it still remains unclear whether we will ultimately see a return to two teachers from Coal Hill School being companions aboard the TARDIS as was teased last summer.
The ending scene with Missy took a different turn from her previous scenes, with Missy saying, “Clara, my Clara. I chose well.” It has already been suggested that it was Missy who gave Clara the Doctor’s phone number back in The Bells of Saint John, but we still have no idea as to what Missy’s overall plan is. Also uncertain is whether this has any connection to Clara’s role in The Name of the Doctor to become fragmented in time and have a role in each of the Doctor’s regenerations.
The writers this season do seem to be writing as if some of the past events have not taken place, almost starting fresh with Clara and the Peter Capaldi Doctor. Even going back to the season premiere in Deep Breath, the Clara who saw each regeneration in The Name of the Doctor should not have been as surprised by seeing the changes in the Doctor after his regeneration. Perhaps the events of The Time of the Doctor, with the Doctor gaining additional regenerations and not dying on Trenzalore, also mean there was never a giant TARDIS tomb for the Doctor and Clara never was fragmented in time. The Missy story line might wind up providing a completely different version of Clara’s life.
The Doctor Who Extra for Flatline is above.
While both the Doctor and now Clara having claimed to be a doctor without formal qualifications, there are some actual doctors who have done considerable harm despite having true medical degrees. One example, Dr. Henry Cotton, has appeared on cable television shows in the past week both on The Knick (at the start of his career and Boardwalk Empire (near the end). He was a real person. Henry Cotton believed that psychiatric problems were based upon infections and his treatment often began with pulling the teeth of psychiatric patients. If this did not provide a cure, then he would proceed to remove other organs which he believed were the cause of the infection. Needless to say, in an age before antibiotics, such unnecessary surgery could have catastrophic results. At one point during his career Cotton even had a nervous breakdown. He responded by pulling his own teeth, then proclaimed himself to be cured and returned to work.
Knowing the factual basis behind Dr. Cotton’s life leaves me concerned about Gillian Darmody’s fate after she told Dr. Cotton that she felt she was cured. We already saw another woman at the asylum undergo surgery, and Cotton would not be likely to accept Gillian’s assessment that she is cured without surgically removing what he believes to be the site of her infection. Being the final season, Boardwalk Empire does have the ability to show tragic endings for its characters. This included the deaths of two long time characters last week. While Boardwalk Empire is ending, The Knick just ended its first season and has done an excellent job of showing what medical care was like back in 1900 and the development of new ideas such as transfusions.
News came in last week that a cable series which debut last summer, Manhattan, was renewed. While I have not seen the series, I feel comfortable in recommending this show about the development of the atomic bomb based upon several favorable reviews. (Although I have not seen Manhattan yet, do I get any points for reading Joseph Kanon’s novel, Los Alamos, several years ago?)
Still no news on whether Continuum will be renewed.
I would also recommend another new cable series which I did see the premiere of last weekend, The Affair. The main story involves an affair from the viewpoint of both parties, each telling their version for half the episode. We have narrators who are unreliable at least due to the faults in human memory. There might be additional reason for intentional deceit as we found that the stories are being told as part of a possible criminal investigation years afterwards, similar to in the first season of True Detective. It also reminds me of William Landay’s novel, Saving Jacob, in which there are glimpses of future questioning but we don’t know who the accused is or the crime until the end of the novel.
The creator of The Affair, Sarah Treem, discussed the dual narratives in an interview at The Hollywood Reporter:
With Noah and Alison remembering different accounts of the same stories, the series explores the notion of objective truth. Do you think there’s such a thing?
I think there is such a thing as objective truth. There are events that actually happen. As individuals our understanding of what happens is often quite limited. Sometimes the only way to get at objective truth is to have multiple people tell their own version of the same event. It is the job then of the interrogator, the therapist, the audience member, whomever, to basically try to find the commonality between the accounts in order to figure out what actually happened. That’s basically what we’re trying to do with this show. We’re not saying there’s no such thing as truth — there absolutely is — but we don’t think that one person is usually the arbiter of the truth. We think that it comes forward in conversation. There’s this quote, I think it’s from Hegel, but it’s the idea that all understanding is dialectic, meaning that nothing gets understood unless it’s as a result of a conversation. That’s how I think of the two sides of this show, that it’s a conversation from which the audience gains an understanding.
Will we see the perspectives of other characters besides Alison and Noah?
Not this season but maybe in subsequent seasons, if we get them.
We see a lot of overlapping stories that vary slightly depending on who’s telling them. What’s it like to have to regularly write two versions of the same event?
It’s a really fun exercise for a writer. It’s just about putting yourself in another character’s perspective, seeing the scene through the other character’s eyes. For the scene at the end of the pilot [where Alison and Cole have sex on their car], I was interested in writing a scene that looked like an attack on one side, and then coming back into it knowing more about what was actually happening to where all of the sudden the scene plays as a very different negotiation. Writers are trained at this because you’re always approaching the story through somebody’s eyes so it’s just a great, enjoyable exercise to go back and think, “Well, I wrote it this way the first time and now let me jump into a different character’s body and a different character’s mind and let me try it again and just see what happens.”
Both Warner (DC) and the various studies which own the rights to Marvel characters have recently released news on their upcoming movie plans. Comics Alliance has more information and has put together the above infographic.
“Batman v Superman: Dawn of Justice,” directed by Zack Snyder (2016)
“Suicide Squad,” directed by David Ayer (2016)
“Wonder Woman,” starring Gal Gadot (2017)
“Justice League Part One,” directed by Zack Snyder, with Ben Affleck, Henry Cavill and Amy Adams reprising their roles (2017)
“The Flash,” starring Ezra Miller (2018)
“Aquaman,” starring Jason Momoa (2018)
“Justice League Part Two,” directed by Zack Snyder (2019)
“Cyborg,” starring Ray Fisher (2020)
“Green Lantern” (2020)
Batman v Superman: Dawn of Justice producer Charles Roven recently gave an interview with more information on the movie, including the origin story for Wonder Woman which is being used.
Unlike Marvel, DC is keeping their movie and television universes separate. While Gotham will probably need to be kept in a separate world of its own, Green Arrow, The Flash, and next Supergirl are forming their own television universe. Many fans are angry that Stephen Amell and Grant Guston won’t be appearing as Green Arrow and The Flash in the Justice League movie. While fans would probably prefer such continuity, it does make it easier to wrote both the television shows and the movies if there is not a need for consistency. We saw how Agents of SHIELD was harmed by a need to postpone mention of HYDRA taking over SHIELD until after Captain America: The Winter Soldier was released.
Marvel fans are getting more excited by what appears to be planned. While Robert Downey, Jr. has not agreed to do another stand alone Iron Man movie, he may be appearing in Captain America 3, which reportedly involves the two being on opposing sides over the Superhero Registration Act. This could also be the end of Chris Evans as Steve Roberts. of There have also been rumors of Marvel making a deal with Sony, which owns the cinematic rights to Spider-Man, to allow him to appear, which sounds plausible as Spider-Man had a role in this storyline in the comics. Several other Marvel characters are also rumored to be appearing.
Meanwhile Emma Stone, when not playing the role of Gwen Stacy in Spider-Man, will be playing Sally Bowles on Broadway in Caberet.
With Twin Peaks coming back we have twenty-five years to catch up on. Mark Frost is writing a book to fill in this gap. I am looking forward to see what they do with the series and which characters return. I do hope that Audrey Horne returns and has a daughter who can tie a knot in a cherry stem with her tongue.
NBC has commissioned Bill Lawrence (Scrubs) to do a remake of the fantastic British sit-com, The IT Crowd. I have mixed feelings about such attempts to remake UK shows here. NBC’s first attempt at a remake, with cast including Joel McHale, was reportedly a total flop and never aired. NBC also failed in adapting Coupling, another excellent British sit-com written by Steven Moffat.
Fox has had their own problems in attempting to remake British shows, both with Gracepoint (a remake of Broadchurch) and Us and Them (a remake of Gavin and Stacey).
On the surface, Republicans have been all over the place regarding the idea of a government official to coordinate handling of Ebola. For example, there’s John McCain. Back in 2009 he attacked Obama over having too many czars:
Obama has more czars than the Romanovs – who ruled Russia for 3 centuries. Romanovs 18, cyberczar makes 20.
“From spending time here in Arizona, my constituents are not comforted,” Senator John McCain (R-AZ) told State of the Union host Candy Crowley Sunday morning. “There has to be more reassurance given to them. I would say that we don’t know exactly who’s in charge. There has to be some kind of czar.”
So Obama appointed an Ebola czar. Ezra Klein explained why Ron Klain is an excellent choice:
Today, the White House will announce that Klain is being named “Ebola czar.” It’s a good choice because it shows a healthy respect for how hard the bureaucratic job of coordinating the Ebola response really is.
The Ebola response involves various arms of the Department of Health and Human Services (particularly, though not solely, the Centers for Disease Control and Prevention), the Pentagon, the State Department, the National Security Council, the World Bank, the World Health Organization, President Obama’s office, private stakeholders, and many, many more.
The “czar” position requires someone who knows how these different agencies and institutions work, who’s got the stature to corral their efforts, who knows who to call when something unusual is needed, who can keep the policy straight…
Actual government experience is badly underrated in Washington. Politicians run for office promising that they know how to run businesses, not Senate offices. “Bureaucrat” is often lobbed as an insult. But in processes like this one, government experience really matters. Nominating Klain suggests the White House is thinking about this correctly: as an effort that requires the coordination of already ample resources, where the danger is that the federal government will be too slow in sharing information across agencies and getting the resources where they need to go.
John McCain’s reaction to the appointment of an Ebola czar was to again attack Obama for doing what he recommended:
“Frankly, I don’t think Mr. Klain fits the bill, as a partisan Democrat, certainly not in any effort to address this issue in a bipartisan fashion,” McCain said Friday evening on Fox News.
“He has no experience or knowledge or background in medicine,” he added.
McCain is hardly the only Republican with irrational attacks. For example, Steven Taylor has looked at even more irrational attacks from Mike Huckabee. The only common thread to Republican response appears to be a knee jerk opposition to whatever Obama does.
The duties of an Ebola czar are exactly the bureaucratic skills which Klain has, not being a medial expert. Of course there is a position in government which should have a background in medicine, and work closely with the Ebola czar. That would be the Surgeon General–a nomination which Republicans have blocked as Obama’s nominee has shown concern for gun violence. Now Democrats are demanding that the Senate vote for approval of the Surgeon General nominee:
More than two dozen House Democrats are calling on the Senate to swiftly approve Vivek Murthy’s nomination to serve as surgeon general to help combat the spread of the deadly Ebola virus in the U.S.
Murthy’s nomination got sidelined after Republicans and vulnerable Senate Democrats voiced reservations about the Harvard Medical School physician’s outspoken views on gun violence and public health. But the House Democrats, in a letter set to be released next week, argue that the Obama administration needs a top official in place to help with the Ebola response.
“The American public would benefit from having a Surgeon General to disseminate information that is desperately needed,” the Democrats wrote. “The Surgeon General can also work to amplify the Center for Disease Control’s actions, reassure the American people, and combat misinformation here at home.”
With some conservatives playing politics with Ebola, it is good to see that Shepard Smith at Fox is being more responsible. See the video above where he explains why there is no reason to panic. Hopefully this will calm down the conservatives who are being incited to panic and see this as reason to vote against Democrats by other conservative voices.
As Shepard Smith explains, there is no outbreak of Ebola in the United States. We had an isolated case of one person with Ebola returning to the United States. Unfortunately, two nurses who cared for him when critically ill contracted the virus. Some mistakes were made. Hopefully what was learned in this case will help reduce the risk of this happening in the future, both in terms of handling patients with Ebola and in monitoring those who care for them. One key point is that Ebola is highly contagious when someone is this critically ill, but it is not contagious before symptoms appear.
Unfortunately far too many people in this country learned epidemiology from The Walking Dead. Some conservatives who otherwise deny evolution are now claiming Ebola could mutate to become an airborne menace–and this is far from the most absurd thing being claimed.
There is no need to panic and initiate bad policy such as a travel ban, which is primarily supported by Republicans. A travel ban is unlikely to be effective and could have several adverse effects. It could make it harder to treat Ebola at its source. Further spread in West Africa would increase the risk of worldwide spread. Adverse effects on commerce in Africa could make it harder for local governments to deal with the problems. People who came from the region would be harder to track as this would give them motivation to come to the United States by less direct routes and deny possible exposure at borders. Even during the SARS outbreak a decade ago, with a disease which actually is airborne, travel bans were found to be unnecessary and ineffective.
It has been a day for bad news related to Ebola. The more serious concern is the apparent transmission of Ebola to a nurse caring for the patient in Texas despite wearing protective gear. It is of concern that these precautions did not prevent the spread to this individual (although it now is reported to have been due to a breach in protocol), but it is at least encouraging that surveillance efforts were successful and the person was quickly identified and precautions taken against further spread.
John McCain, a member of the party which has been protesting the number of czars in the Obama administration, has now called for an Ebola Czar. Perhaps as a first step, the Republicans should reconsider their actions in blocking the appointment of Obama’s nominee as Surgeon General.
Ebola is threatening much of the world’s chocolate supply.
Ivory Coast, the world’s largest producer of cacao, the raw ingredient in M&M’s, Butterfingers and Snickers Bars, has shut down its borders with Liberia and Guinea, putting a major crimp on the workforce needed to pick the beans that end up in chocolate bars and other treats just as the harvest season begins. The West African nation of about 20 million — also known as Côte D’Ivoire — has yet to experience a single case of Ebola, but the outbreak already could raise prices…
The market is worried, too. Prices on cocoa futures jumped from their normal trading range of $2,000 to $2,700 per ton, to as high as $3,400 in September over concerns about the spread of Ebola to Côte D’Ivoire, noted Jack Scoville, an analyst and vice president at the Chicago-based Price Futures Group. Since then, prices have yo-yoed down to $3,030 and then back to $3,155 in the past couple of weeks.
While not yet time to panic, are we now in danger of seeing riots at the supermarkets and hoarding of chocolate?
(Original post updated with further information on the case in Texas and John McCain’s call for an Ebola Czar.)
Bill Maher has previously said he might consider voting for Rand Paul if he were to run against Hillary Clinton for president in 2016. It is certainly understandable why someone might give this a thought in light of Clinton’s hawkish foreign policy views but this idea breaks down with a closer look at Rand Paul. Maher found that Paul is not as anti-war as he would prefer, but another issue is a real deal-breaker:
Maher said he was most attracted to Paul because of the senator’s general views on foreign policy, though he’s not a fan of his recent support for bombing ISIS.
“He’s great on ending the empire, not getting into any more foreign entanglements — I’m even to the left of him on the bombing (of ISIS); he wants to keep bombing ISIS, I want us to stop bombing altogether,” he said.
While Maher donated $1 million to a super PAC backing President Barack Obama in 2012, he has been less than enthusiastic about a potential Clinton presidency, especially when it comes to her foreign policy.
But Maher told Salon there’s stark daylight between him and Paul on a different issue.
“I had drinks with him about two weeks ago. He’s a nice guy, he’s a smart guy. My big problem is I asked him about the environment, which is my big issue,” Maher said. “He had made a comment that was very similar to what Dick Cheney said about a month or two ago, which was basically, ‘Why are we talking the environment when ISIS is out there?’ I said, ‘Senator, y’know, you sounded just like Dick Cheney.’ “
Last month, Paul blasted Clinton for saying climate change marked the “most consequential, urgent, sweeping collection of challenges we face.”
“I don’t think we really want a commander in chief who’s battling climate change instead of terrorism,” Paul said on Fox News.
Maher said that Paul’s answer on the environment was “wholly unsatisfactory” and that the senator would lose his vote based entirely on that issue unless Paul comes up with a better answer.
“This is the deal-breaker issue with me. You’ve got to be good on this or, I’m sorry, not going to happen,” Maher said.
In an ideal world, we would be able to exclude someone such as Hillary Clinton who backed the Iraq war with claims of a connection between Sadaam and al Qaeda. However in such an ideal world, we would also not have a major political party which denies science, including the scientific consensus on climate change. In addition to drumming up fear about terrorism, it makes no sense to say we cannot deal with climate change due to the presence of another problem. It is as if Paul and Cheney are unable to walk and chew gum at the same time.
Salon has more on Rand Paul’s anti-scientific views, related to both climate change and Ebola:
In a breathless “exclusive,” Breitbart News revealed that Paul thinks the Obama administration is misleading the public about the nature of the threat and how the disease is spread. “They’re downplaying and underplaying the risk of this,” Paul claimed. “They keep emphasizing that it’s so hard to transmit. Well if it’s so hard to transmit why are doctors getting it with masks, gloves, boots and hats—the whole works?”
You might think an ophthalmologist (though he’s not board certified) would be more responsible about spreading health panic. But you’d be wrong. “Could we have a worldwide pandemic? The Spanish flu in 1918 killed 21 million people, the plague in the 14th century killed 25 million people; I’m not saying that’s going to happen, I don’t know what’s going to happen. But I think we should have travel restrictions at this point in time coming from Africa,” Paul added.
Health experts shot Paul down almost immediately. “I don’t think that there’s data to tell us that that’s a correct statement, with all due respect,” NIH veteran Dr. Anthony Fauci told CBS’s “Face the Nation.” “We have had experience since 1976 with how Ebola is transmitted. And it is clear that it’s transmitted by direct contact with body fluids, blood, diarrhea, vomit, or what have you.
“And there’s no indication that there is another insidious way that it’s transmitted that we’re missing because of the experience that we’ve had. So, we’ve really gotta go with the evidence base. There’s always hypothesis and surmising about that, but there’s no scientific evidence,” Fauci added.
While Republicans have generally been trying to restrict access to contraception, recently some Republicans have been promoting making oral contraceptives available over the counter without prescription. Many people quickly saw through this. It gives the Republicans a way to claim they are removing a barrier to receiving contraception and avoid situations like the Lobby Hobby case. It also does something else–make contraception less accessible for many women. While the Affordable Car Act requires that contraception be covered without out-of-pocket expense to the woman, many insurance plans do not cover over the counter medications. This is also an incomplete response to the issue as there are many other types of birth control, including forms which many Republicans are attempting to restrict.
Birth Control Pills Should Be Available Over the Counter, But That’s No Substitute for Contraceptive Coverage
September 11, 2014
By Adam Sonfield and Sneha Barot, Guttmacher Institute
In recent weeks, some opponents of the Affordable Care Act’s (ACA) contraceptive coverage guarantee have promoted the idea that oral contraceptive pills should be available to adult women without a prescription. Sens. Kelly Ayotte (R-NH) and Mitch McConnell (R-KY), for example, recently introduced the so-called Preserving Religious Freedom and a Woman’s Access to Contraception Act, a bill that would urge the Food and Drug Administration (FDA) to study whether to make contraceptives over the counter (OTC)—though for adults only.
Making birth control pills available over the counter, if done right, would meaningfully improve access for some groups of women. However, such a change is no substitute for public and private insurance coverage of contraceptives—let alone justification for rolling back coverage of all contraceptive methods and related services for the millions of women who currently have it.
The Policy Behind Over-The Counter Contraception
Making birth control pills available OTC has merit, and the Guttmacher Institute is part of a coalition that has been working toward this goal for years. Leading medical groups have also endorsed such a move, including the American Medical Association and the American Congress of Obstetricians and Gynecologists. By removing the need to obtain a prescription, OTC status would eliminate this potential barrier to contraceptive use and thereby increase access.
This is especially true for uninsured women and those who don’t have time for a doctor’s visit or otherwise can’t readily reach a health care provider. However, if the goal is to truly expand access to contraceptive care—and not just provide cover for undercutting insurance coverage for contraceptives—the case to move birth control pills to OTC status should proceed alongside several other important policies and goals:
Protect contraceptive coverage and full method choice: The ACA requires most private health plans to cover the full range of women’s contraceptive methods and services, without out-of-pocket costs for the patient. This policy eliminates cost as a barrier to women’s ability to choose the method that is best for them at any given point in their lives, an approach that has been proven to make a substantial difference in facilitating access to and use of contraceptive services.
Contrary to what some policymakers and commenters have claimed, giving the pill OTC status would not be an effective substitute for the ACA policy. First, it would do nothing to help women access any contraceptive method other than the pill. This matters, since most women use four or more different contraceptive methods over their lifetime to meet their changing needs. If only the pill were available OTC and contraceptives were no longer covered by insurance, women would face significant new barriers in choosing the method that best suited their needs. Cost is a particularly steep barrier for highly effective methods like the IUD or implant that not only have high upfront expenses, but also require a trained provider for insertion and therefore are not candidates for OTC status.
Even for the pill itself, there is no convincing evidence to suggest that moving it to OTC status would substantially lower out-of-pocket costs to patients, let alone come close to the $0 out-of-pocket cost guaranteed under the ACA policy. Rather, making the pill available OTC, if done at the expense of insurance coverage, would replace one barrier (ease of access) with another (cost). Likewise, greater reliance on Health Savings Accounts or Flexible Spending Accounts, as some opponents of insurance coverage have proposed, would also merely replace full insurance coverage with patient out-of-pocket costs—leaving most privately insured women, particularly low-income women, worse off. Uninsured women on average pay $370 for a full year’s supply of the pill, the equivalent of 51 hours of work at the federal minimum wage of $7.25.
Millions of women already benefit from the ACA’s contraceptive coverage guarantee and these hard-won gains must be protected. Rather than substituting for contraceptive coverage of all methods and related services, OTC status for birth control pills should complement and enhance such coverage.
Strengthen coverage for over-the-counter methods: While the ACA’s preventive care provision specifically requires private health plans to cover certain products with over-the-counter status (including the emergency contraceptive Plan B, folic acid, aspirin to prevent heart disease and tobacco use cessation products), a prescription is needed for these items to be covered—essentially negating the benefits of OTC status. This prescription requirement should be eliminated for any current and future over-the counter contraceptives. Coverage of over-the-counter products without a prescription is already the norm in some state Medicaid programs and in the U.S. military’s Tricare insurance program. Further, ensuring full coverage for over-the-counter contraceptives would prevent “free-riding” by insurance companies that benefit from not having to cover pregnancies that were averted through patient out-of-pocket expenditures.
Ensure equal access for young women: Adolescents and young women, who face greater risk of unintended pregnancy and more barriers to accessing contraception than older women, have among the most to gain from a switch to OTC status. However, recent calls to give birth control pills OTC status as a substitute for contraceptive coverage have specifically excluded minors. That would require women 17 and younger to obtain a prescription, without providing any medical evidence to justify such restrictions. This approach would be harmful to adolescent women and would be counterproductive to helping them avoid unplanned pregnancies and the negative health, social and economic consequences that often follow.
In addition, excluding minors would likely not result in a true over-the-counter status, but instead could put contraceptive pills behind the counter, much as happened when the emergency contraceptive Plan B was first approved for OTC sales. To comply with an age restriction, stores would have to require proof of age via a valid picture ID from any woman who looks young enough to potentially be barred from purchasing birth control pills without a prescription. This would be an added hurdle for millions of women, and it ignores the reality that many young women do not have government-issued forms of photo ID.
Keep politics out of FDA decision making: To switch any drug to OTC status, the typical process involves the drug’s manufacturer submitting an application to the Food and Drug Administration (FDA), which—based on several criteria, including the safety and efficacy profile of the medication—decides whether to grant the request. The evidence is quite strong that providing birth control pills OTC would be safe and effective, including for minors. The FDA process should be driven by the evidence and free from political interference by the administration, Congress and others.
It is troubling but not at all surprising that Senator Ayotte and others who purport to be interested in contraceptive access would preempt the FDA with unfounded calls to bar minors from benefiting from any future OTC status for birth control pills. This echoes the longtime political and legal wrangling over minors’ access to OTC emergency contraceptive pills, despite clear evidence that minors could safely use these products without a prescription.
It is also noteworthy that there are dozens of brands and formulations of birth control pills, most of which would likely have to undergo the lengthy and expensive FDA process to gain OTC status separately. Because formulations of the pill are not medically interchangeable, with some women tolerating specific pills better than others, making one or several versions of the birth control pill available OTC would not benefit all current pill users.
Not A One-Size-Fits-All Policy Solution
Just as birth control methods are not “one size fits all” at any point in a woman’s life, let alone for all of her reproductive years, neither is there a one-size-fits-all policy solution to enhance access to the full range of methods, information and services for women of all ages and income levels, regardless of where they obtain their care. A wide range of approaches is necessary to meaningfully respond to women’s family planning needs in a comprehensive way.
One such approach includes making birth control pills available over-the-counter, if done so without additional costs or barriers to women. Doing so can complement and enhance current efforts to help more women become effective contraceptive users, including the ACA’s significant gains for comprehensive private and public insurance coverage for contraceptive counseling, services and supplies.
If anything, contraceptive coverage should be broadened to cover more women and strengthened to eliminate the prescription requirement for OTC methods that are covered. Other urgent priorities include expanded access to Medicaid, public support for safety-net family planning centers and the Title X national family planning program, comprehensive sex education and the development of new contraceptive technologies.
Truly increasing access to contraceptive care requires a multifaceted approach to meet the needs of all women throughout their reproductive lives. Political talking points will not do it.
This article was originally published on Health Affairs Blog at this link.
Click here for a recent statement from the American Congress of Obstetricians and Gynecologists (ACOG) supporting over-the-counter access to birth control pills as part of a broader dialogue about improving women’s health care as opposed to a political tool.
There was certainly a lot of ridiculous hype today. Apple had their big announcement that their phone and watch can now do what Android devices could do for months, if not years, as long as you don’t want the freedom to configure things the way you want them to work, as opposed to how Apple thinks your devices should work. They were even doing their own live tweeting of the event, showing what control freaks they are.
There might have been a time when Apple was on the leading edge. Now they are just charging more for old tech which has an Apple logo on it. The Apple watch will start at $349–well more than the cost of my Sony Smartwatch II, even with the more expensive metal wrist band. The only real surprise was that the watch will be called the Apple Watch and not iWatch.
When I first responded to the event on Facebook and Twitter as the news came in, I did get a comment questioning the value of a smartwatch. I’ve been using a smartwatch for over two years and do find it to be of value, but I suspect that the majority of people do have little real need for one.
For me, the smartwatch essentially replaces my beeper. I receive many messages a day on my phone, including Facebook notifications, personal text messages, news bulletins, along with messages from the hospital or answering service which previously went over a pager. I need to both make sure I don’t miss any important messages, and know when an incoming message is important enough to respond to immediately versus letting it sit on the phone.
The smartwatch allows me to very quickly see whether an incoming message is urgent, and is far more discreet to check than pulling out a phone every time it vibrates. In some situations this is especially important, such as in a dark movie theater where it would be awkward to turn on the phone every time a message comes in. It also comes in handy if at the pool. I can put my phone safely in a nearby bag, and pick up messages on my waterproof smartwatch. In the event anyone does see me checking messages, people tend to think it is cool to see a message come in over a watch due to the novelty factor, while it often looks tacky to look at a phone when with other people.
Under some situations I just want to use the watch to monitor for important messages. At other times I can read more. This includes text messages, email, RSS feeds, and any notifications which a smartphone app can make.
Plus my smartwatch has an advantage which the Apple Watch does not–it is connected by blue tooth to an Android phone.
Of course there are many other things it can do. Some try to respond to tweets on their smart watch, but personally I think that if you are actually following an ongoing discussion, and especially if you want to type responses, at that point it makes more sense to just use your watch. (I also prefer to use a blue tooth keyboard if doing very much typing). Fitness apps are popular on Android smartwatches and I’m sure that many will use them on the Apple Watch. Some use their watch for fitness apps which track their foot steps every day but I found a limitation to this. I sometimes take the phone out of my pocket to charge during the day, preventing a complete count. While my LG G3 will generally last all day, I hear bigger fears that the iPhones will not do so, and changing the battery during the day is not an option as on many Android phones.
While certainly not essential, my smartwatch will also tell me the weather and remotely control my phone. I haven’t yet used the apps to remotely see the view screen of the camera or take pictures, but I can see situations where this might come in handy. I do use it to remotely control music sent from my phone to a blue tooth speaker. I have impressed friends over for football games when, after a score, I tap my watch and a speaker across the room starts playing Hail to the Victors. Sadly, for the first time since 1984, there was no opportunity to do this last Saturday.
Update: Reading more about the Apple Phone, it does look like some of the fitness/health capabilities are beyond what is currently available for Android. Of course, by the time the Apple Watch makes it to market, there are likely to be even more advanced Android apps. Plus, trusting your private health information with Apple sounds as sensible as sharing your nude selfies with them. Just ask Jennifer Lawrence.
A major problem with narcotic pain medications is the risk of overdose. This problem has led to the DEA announcing last week that hydrocodone combination pain medications such as Norco and Vicodin are being reclassified as Schedule II narcotics, with additional restrictions being placed upon prescribing them. Any measures to help control chronic pain while reducing the incidence of overdose would certainly be welcome. The August 25, 2014 issue of JAMA Internal Medicine presents a study of states which have legalized medical marijuana, showing a reduction in opioid overdoses by almost 25 percent:
Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate (95% CI, −37.5% to −9.5%; P = .003) compared with states without medical cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time…
The study did not indicate the cause of this association. It is speculated that some people with chronic pain might use less opioid when medical marijuana is available. More study is needed to confirm this, but considering the problems faced with opioid overdoses, marijuana should be considered as an alternative. At very least, when considering any potential adverse consequences to legalization of medical marijuana, it must be kept in mind that the currently used medications for chronic pain do have a serious potential for adverse effects themselves.
Marijuana is now classified as a Schedule I drug which prevents prescribing it. (In states where medical marijuana is legal, the change in the law protects those using it from prosecution but marijuana still cannot be prescribed). Many have already questioned the classification of marijuana as a Schedule I drug as it appears to show less risk of problems from overdose compared to current Schedule II and Schedule III drugs. This study suggests that marijuana might also help protect against some of the adverse effects of narcotics.
An unintended experiment in Rhode Island found that when prostitution conducted indoors was decriminalized due to a loophole in the law, there was a decrease in rape and cases of gonorrhea. The Wall Street Journal reports:
A loophole in Rhode Island law that effectively decriminalized indoor prostitution in 2003 also led to significant decreases in rape and gonorrhea in the state, according to a new analysis published by the National Bureau of Economic Research.
“The results suggest that decriminalization could have potentially large social benefits for the population at large – not just sex market participants,” wrote economists Scott Cunningham of Baylor University and Manisha Shah of the University of California, Los Angeles, in a working paper issued this month.
Mr. Cunningham and Ms. Shah got an opportunity to study the effects of decriminalized prostitution on crime and public health because Rhode Island lawmakers made a mistake. A 1980 change to state law dealing with street solicitation also deleted the ban on prostitution itself, in effect making the act legal if it took place indoors. The loophole apparently went unnoticed until a 2003 court decision, and remained open until indoor prostitution was banned again in 2009.
As you might expect, the economists found that decriminalizing indoor prostitution was a boon to the sex business. “Decriminalization decreased prostitute arrests, increased indoor prostitution advertising and expanded the size of the indoor prostitution market itself,” they wrote.
Rhode Island also saw “a large decrease in rapes” after 2003, while other crimes saw no such trend in the state, they wrote. There also was “a large reduction in gonorrhea incidence post-2003 for women and men,” they wrote.
The economists then used several economic models to track the decriminalization’s effects versus other possible causes. They found “robust evidence across all models that decriminalization caused rape offenses and gonorrhea incidence to decrease.” One model estimated a 31% decrease in per-capita rape offenses and a 39% decrease in per-capita female gonorrhea cases due to the decriminalization of indoor prostitution.
This sounds like a strong argument for decriminalizing prostitution.