Tuesday, September 10, 2019

Girls Need Gender Equity. Period.

UPDATE: Only ONE day after I published this post, a Kenyan school girl committed suicide after being shamed by her teacher for having her period and nothing to prevent her from bleeding on her clothes. In 2017, Kenya passed a law requiring free sanitary towels for schoolgirls. Yet a teacher shamed her by calling her "dirty" and told her to leave the classroom to stand outside. Later that day when she went to fetch water (a backbreaking chore many African girls are expected to do daily), she took her own life. This issue is deadly serious.

Let's talk about something so normal, so commonplace that everything about it should be common knowledge...but isn't. I'm talking about menstruation. Periods. Are you still with me? I hope so. Because if you're a guy who doesn't know that much about it, that puts you in a dangerous position as a voter! Even if you're a woman who has to deal with it every month, there are probably some aspects about it for women and girls in poverty that you might not have considered. Access to menstrual hygiene products are a matter of gender equity and human dignity.

Good on ya', Cameron!
Because I'm a mom of a couple of teenage girls now, I've been thinking lately about how much unnecessary struggle could be eliminated if there weren't such a stigma around discussing periods. Adolescent girls caught unawares wouldn't have to sneak around at school asking to borrow a pad like they're begging for contraband drugs. This embarrassment adds anxiety to all sorts of life situations. Perhaps some folks remember what happened when Marjory Stoneman Douglas High School in Parkland tried to make their school safer from gun violence by mandating all students use clear backpacks. Many of the girls were mortified that their feminine hygiene products would be on full display, so in a display of strong ally-ship, student Cameron Kasky went viral by putting a box of tampons in HIS backpack to help the girls not feel so singled out.

Don't be uninformed like Ryan.
Read this blog or go to a health class.
In general, we should all be making life for menstruators easier by treating it as the mundane occurrence it is and making sure everyone knows the basics of menstrual health.  For approximately one week, a menstruating person (using the word "person" here to acknowledge that some trans men and non-binary people do have periods) is going to need a change of pad or tampon every couple of hours to absorb involuntary bleeding of the uterus lining through the vagina. (That sentence was put in there just to get everyone up to speed lest we have anyone like poor Ryan Willams who went viral for ignorantly tweeting that a woman should "control ur bladder") It's happening all around us all of the time! 

Now, let's look at three instances where U.S. policy affects women and girls already living in poverty and distress. 

American Women and Girls in Poverty
"Period poverty" is what happens when someone literally cannot afford period products because of lack of income. It's all too common in the U.S. because SNAP (Supplemental Nutrition Assistance Program) benefits cannot be used for pads or tampons. A report published by Obstetrics and Gynecology found that of the low-income women surveyed here in St. Louis, sixty-four percent were not able to afford needed period products in the past year. Twenty percent of those women faced that problem every month.  Almost every woman knows what it's like to be caught off guard and have to just use some toilet paper or kleenex or whatever is on hand to not bleed through clothes. Yet not all of us have to face that every single month. Girls at school can go to the nurse, but as the lovely young lady in this video from United for Access explains, sometimes the nurse's office is crowded and she feels very embarrassed to ask. Every month, she has to be embarrassed about her poverty and her body. That takes a serious toll on a young woman developing her identity and self-worth.

These are the kinds of things lawmakers (who, let's face it, are mostly still men) should consider when they consider the unfair, but commonplace taxing of menstrual hygiene products. Most states tax them because they are seen as "non-essential items." Minnesota, Illinois, Pennsylvania, New York, Massachusetts, Maryland, New Jersey, Connecticut, and Florida have all outlawed the "tampon tax."

WHAT CAN WE DO? Here in St. Louis, we can donate to St. Louis Alliance for Period Supplies. It's an initiative of the St Louis Area Diaper Bank. See if there is something like that you can support in your own community. Or, you can be like the science teachers in my kids school: For a while there were baskets in the restrooms near the science classrooms filled with period products they bought with their own money with a sign that said "Free. From the Women of Science." Gadzooks, I love those women. Also, if your state still has a tampon tax, you can contact your state senator and representative and ask them to repeal the tax on feminine hygiene products.

Global Girls Education
The affects of period poverty are even more dire in areas of extreme poverty around the world. Thankfully, the academy award winning documentary "Period. End of Sentence." has helped bring awareness to the issue, but that film is only a small part of the solution. When communities of extreme poverty have a cultural bias against sending girls to school (because they are expected to watch younger siblings, fetch water, or get married), it's common for schools not to have appropriate washrooms or sanitary supplies. Girls find it easier to stay home than to face the shame and stigma of people knowing that they are on their period. Some NGO's have focused on these needs, knowing when an average of 8 out of every 30 days in a month have to be missed, girls are likely to drop out of school entirely. Dignity Period is a St. Louis non-profit that helps distribute pads to girls and women in areas of Ethiopia where even talking about menstruation is taboo.

WHAT CAN WE DO? Donations to Dignity Period or other organizations like it are always welcome. You can also contact your U.S. senators to ask them to sign onto the "Keeping Girls in School Act." It does many things to address barriers to education outlined here in this Borgen Project blog post and one of the things specifically mentioned is the "inadequate sanitation facilities and products 23 available at secondary schools."

Women in Detention
It has long been a complaint that women in prison can be subjected to inhumane treatment when they are denied feminine hygiene products. In several states, lawsuits have been brought against states where period products were withheld. At best, prisoners had to re-use pads or wad up toilet paper to use. At worst, as in Alabama, female prisoners were required to trade for tampons and pads with sex acts performed on guards. The abuses in human rights surrounding period products continue to be in the news surrounding our immigration detention centers where some young migrant girls are only allowed one pad or tampon per day. The emotional indignity of wearing smelly, soiled clothes while being denied showers combined with the health dangers of such neglect constitutes circumstances that appalled United Nations Human Rights Chief Michelle Bachelet.

WHAT CAN WE DO? The state prison situation will vary by state, but the immigration detention centers are a federal issue. Contact your U.S. representative and your senators by phone or letter to tell them that you think the situation is inhumane and that they cannot hold families in such conditions indefinitely.

Wednesday, September 4, 2019

Why is TB Testing So Difficult in Children?

Have you ever had your child tested for tuberculosis (TB)? It's not required in all American school districts, but in our school it's required of all 8th graders before they head off to service projects in the fall. Chances are you might have had this done if you are in a caregiving profession like daycare or occupational therapy. Whenever I hear Americans surprised that tuberculosis still even exists, it's further evidence to me that my global advocacy work on tuberculosis treatment and prevention is still needed. This bacterial infection is still found in EVERY country in the world and it is the leading infectious cause of death worldwide. TB sickens 10.4 million people a year and kills 1.7 million of them. Since 2015, it has been the leading global infectious disease killer, surpassing even HIV/AIDS! Tuberculosis is a global pandemic that kills one person about every 18 seconds, according to TB Alliance

Happily, TB is treatable and - in almost all cases - curable. Yet at the RESULTS International Conference for the past two years, I've been hearing about how the main problems with the fight against TB have to do with lack of advances in methods of treatment as well as diagnostics. With a highly infectious airborne disease like TB, diagnosis is of critical importance. If you can't find it, you can't fight it. We're failing to deliver quality treatment to 40% of people in the world who are sick with TB. And who is bearing the biggest burden of this failure? Children. 

Dr. Jeffrey Starke, director of Children's Tuberculosis Clinic at Texas Children's Hospital, told Infectious Diseases in Children, "Children are the most neglected group of individuals regarding controlling TB." Today, 90% of children with TB go untreated. Combine that with the fact that children usually respond very well to TB treatment, even for drug-resistant TB, and that tells me that a lot of kids could be saved if we could better diagnose them. 

My question of the day is: "Why is it so hard to accurately test kids with TB?"

First, let's be clear about two kinds of TB since each requires a different test. There is TB infection, which is when someone has inhaled the bacteria and the body contains the infection in the lungs. At that stage it is serious and requires a course of preventive antibiotics, but it is NOT ACTIVE and it is NOT CONTAGIOUS. Then, there is the active form when the relatively dormant infection becomes TB disease. Active TB, usually found in the lungs, is life-threatening and must be treated with antibiotics. When occurring in the lungs, it can be spread through coughing, though once a patient is on effective treatment they quickly become non-infectious. 

In the US, 9105 people developed the disease in 2017 and another 13 million have the infection according to the CDC. According to an estimate published in the Lancet in 2019, more than 30,000 people in the US have a form of TB infection that is multi-drug resistant. 

Clinical Exams
Let's start with the simple clinical examinations. Most people associate tuberculosis with a persistent cough, but for kids a cough is not a prominent way TB presents. Adults can describe other symptoms like night sweats, and weight loss, but tiny kids might not be as verbal about such things. If an x-ray machine is available, the disease will show up there for adults. But children don't usually get cavities in their lungs that would indicate the presence of TB. That makes it harder, but not impossible, to make an accurate diagnosis.

Good news! No bump.
My daughter doesn't have TB!
PPD Injection Test
Now let's look at the injection test that my child just had. In the U.S., we have a standard purified protein derivative (PPD) test that is given to both kids and adults. A small shot of PPD is administered just under the top layer of skin, which will cause a small bump to form. After 2 days, a medical professional needs to check to see that the bump disappeared to indicate the patient doesn't have TB. There are a few problems with this.
  1. The test takes 2 days for a result, so that is obviously inconvenient.
  2. Many kids in developing countries get a BCG vaccine, which helps prevent some forms of childhood tuberculosis and would test positive. That would be a false positive, however, since it would not indicate TB infection. 

Hold up right there. A TB vaccine? Why doesn't everyone use that? Because the BCG vaccine isn't a reliable way to prevent kids from being infected with TB or developing TB disease. It does protect younger children against certain complicated and lethal forms of TB, but the efficacy varies and it does not protect against TB disease in the lungs, which is the most common form. So, it's better than nothing in countries with a high TB burden, but it screws up PPD test results.

Ok, so that PPD test doesn't work for a lot of situations. What's next?

IGRA Blood Test
The best alternative to the PPD skin test is a blood test for infection called IGRA. This is a rapid test and will not be affected by BCG, but it is more expensive than PPD and so it is not available everywhere.

Sputum Test
The usual method for diagnosing active TB disease is to test sputum, a mixture of saliva and mucus coughed up from the respiratory tract. One problem with this method is that is that it's hard for little kids to cough up the sputum. But you can get a sample from the stomach because children often swallow the sputum. You can also find TB germs sometimes in spinal fluid or lymph nodes, but those samples aren't super easy to collect. A low-tech way to test the sputum is to look at it under a microscope, but those tricky kids tend to have fewer bacteria and the TB might not be detectable that way. Only 1 in 3 children with TB test actually positive with a sputum test.

If a community is lucky, they can test using a GeneXpert system that can rapidly detect TB and whether it's a drug-resistant strain in under two hours. Wow! No wonder this was heralded as a breakthrough tool. It's still a relatively new tool as it was launched in 2010. It takes a while for something like GeneXpert to get to underfunded medical facilities in communities of extreme poverty. The commonly used system costs about US$17,000, not to mention a widely varying installation cost of US$2600-7000. So, "wow" indeed. I can see why everyone doesn't have one yet. 

So, now you and I both know a bit more about TB testing. Probably the main reason testing is so difficult for both the infection and the disease is that very little money has been put into the research and development of new tests, particularly ones that are work for kids. TB is vast problem and this is one of the many reasons why we need a spirit of global cooperation among governments to tackle this disease the way we fight HIV/AIDS and polio. The best thing that you and I can do about TB right now is to call our senators right now and ask them:

"Would you support U.S. efforts to control and treat TB and drug-resistant TB? I'd like to senator to sign onto the Stop TB Now Act, which has the number S. 2438.  It updates old and, in some cases, obsolete instructions to USAID about how to end TB. It imposes new requirements, including a full program evaluation and better coordination."

Thursday, August 22, 2019

Soap Brings Health and Dignity

As the school year begins, moms are running around trying to make sure that everyone has everything they need to start the school year off right. Teachers need kleenex and Clorox wipes for the classroom, high schoolers need whatever the heck binder types the teacher asked for, the Starbucks donation box needs some more backpacks for kids who don't have one. But another mundane, yet oh-so-necessary item is on my mind: Soap.
Soap is one of those things you don't think about much until you don't have it. Soap protects us all from getting sick and spreading illness to others, so everyone can keep going to school and work. It keeps our skin clear (or clearer anyway). It keeps us from being smelly so other people don't shy away from us because of our body odor. When you add those all up, soap gives us dignity.
Soap is also one of the very necessary items that you cannot buy with food stamps along with toilet paper, laundry detergent, shampoo, deodorant, feminine hygiene products and diapers. If you're having trouble imagining what it feels like to live without those things check out Pamela Covington's book "A Day at the Fare" that I reviewed this summer. 
Everyone needs to be clean and on my mind especially are the kids sitting alone in schools across America with so many problems that a lack of soap might not even make the top five. There are lots of reasons why kids might be ostracized by peers, but one very real and very fixable reason can be body odor. Now, I KNOW I'm not alone in the world of moms in having had to find ways to try to convince adolescent kids that they stink when they don't shower. It's so common among pre-teens to genuinely not know why people don't want to sit near them when they're fouling the air around them. It's painful to consider that a simple lack of soap is adding to the social isolation of kids in poverty. 
Thank goodness that in St Louis, we have Circle of Concern. The text on their website reads: "Feeding families is just the beginning." Their food pantry provides fresh, nutritious food for over 600 families each month that reside in the Parkway, Rockwood and Valley Park school districts of Greater St Louis. Circle of Concern has a limited supply of personal care items and is currently in need of soap.
Wherever you are when you're reading this, please consider making a donation of soap and care products to a facility like Circle of Concern. It's not only a gift of health, but a gift of dignity.