The director-general of the World Health Organization has declared Zika virus a “public health emergency of international concern” — a PHEIC, pronounced “fike,” rhymes with spike, if you want to sound like a member of the WHO emergency committee.
It’s natural to be concerned when the WHO declares an epidemic — it has only done so three other times in its history: the 2009 influenza outbreak, an upswing in polio cases in 2014, and the West African Ebola outbreak in 2015. The question is: What makes the WHO concerned and how concerned should we be?
In this case, the disease itself is not as scary as the complications that have been linked to the virus — associations that have not yet been confirmed. Declaring a PHEIC allows the WHO to coordinate the international response, release emergency funds to better study the virus and confirm those potential complications as quickly as possible.
Here’s what we know. First, we know the virus is spreading quickly. The mosquito that carries the virus can be found from South America up to our hot and humid southeastern states in the U.S. And because the virus only arrived in the Western Hemisphere in 2014 — perhaps because of the World Cup or other sporting events — no one here has immunity to it, making it easy for mosquitoes to spread the virus. Some experts believe the virus can spread throughout the Americas, wherever the mosquito lives.
All this makes Zika sound scary, but we also know that up to 80 percent of people who catch the virus do not even display any symptoms. Those that do tend to have a mild illness with joint pain, a rash, red eyes and a fever, all of which resolve in four to seven days. No deaths have been reported so far that directly link to the virus. This is a far cry from Ebola, which causes a hemorrhagic syndrome that leads to death in as many as 50 percent of cases. Zika virus is worrisome in that it may cause horrible birth defects, but, put simply, it is not as scary as Ebola.
Still, it is the unknown that also concerns the WHO. While we know there has been an uptick in cases of children born with small heads (called microcephaly) in Brazil, it is not yet clear whether Zika virus caused the birth defect. There has also been an increase in cases of Guillain-Barré syndrome, a very rare neurological complication of some viral illnesses, and these cases may also be linked to Zika virus. So far, none of these links have been proven, which is why the WHO and CDC are calling for a rapid response to address Zika transmission and study the virus so we know better what we’re dealing with.
PHEICs can be declared in cases like Ebola to raise awareness about extremely dangerous pathogens. But Ebola-like situations are not the only reason to declare a PHEIC. The WHO can also declare one to rapidly advance the scientific agenda to confirm or debunk worrisome but unproven syndromes associated with an illness. That, it seems, is the WHO scenario with Zika.
In short, not all epidemics of international concern are equally dangerous. Sometimes, declaring a PHEIC is the fastest, most efficient way to marshal the resources to help us get answers to the most burning questions as quickly as possible.
Ebola is terrifying; Zika isn’t there — at least, not yet. But all of these studies will help tell us how much of a public health threat the virus truly is.
David Scales, M.D., Ph.D. is a third year resident in internal medicine at Cambridge Health Alliance who wrote his dissertation on how the WHO plans for and responds to health crises.
If you’re a sexually active woman of childbearing age and not using birth control, public health officials say you should stop drinking alcohol — completely. That includes beer, wine or any other alcoholic beverage you might be considering.
In a report out Tuesday, the U.S. Centers for Disease Control and Prevention notes that exposure to alcohol, even in the first weeks of pregnancy, puts developing babies at risk for fetal alcohol spectrum disorders, “characterized by lifelong physical, behavioral, and intellectual disabilities.” Because these disorders are completely preventable by abstaining from alcohol, and because officials say there is “no known safe amount of alcohol” that women can drink at any time during pregnancy, their basic message is: “Why take the risk?”
“Women wanting a pregnancy should be advised to stop drinking at the same time contraception is discontinued,” the report concludes. “Health care providers should advise women not to drink at all if they are pregnant or there is any chance they might be pregnant.”
Here’s more from the CDC news release:
An estimated 3.3 million U.S. women between the ages of 15 and 44 years are at risk for exposing their developing baby to alcohol because they are drinking, sexually active, and not using birth control to prevent pregnancy, according to a new CDC Vital Signs report. The report also found that 3 in 4 women who want to get pregnant as soon as possible do not stop drinking alcohol.
Alcohol use during pregnancy, even within the first few weeks and before a woman knows she is pregnant, can cause lasting physical, behavioral, and intellectual disabilities that can last for a child’s lifetime. These disabilities are known as fetal alcohol spectrum disorders (FASDs). There is no known safe amount of alcohol – even beer or wine – that is safe for a woman to drink at any stage of pregnancy.
About half of all pregnancies in the U.S. are unplanned and, even if planned, most women will not know they are pregnant until they are 4-6 weeks into the pregnancy when they still might be drinking.
During a telephone briefing with reporters, Anne Schuchat, the CDC’s deputy director, said:
What we’re recommending is women who are not trying to get pregnant make sure they have a conversation about birth control and how to avoid becoming pregnant. If they are not using contraception and are fertile and are drinking they could be at risk… One in two deliveries in this country occurs to someone who wasn’t actually trying to get pregnant when they got pregnant. So we do think that fertile woman that are not using contraception ought to be aware that they may become pregnant and that drinking during even that first couple of weeks of pregnancy can be risky.
The American College of Obstetricians and Gynecologists responded to the CDC report in a statement from its president, Mark DeFrancesco:
Obstetrician-gynecologists have long recognized that use of alcohol during pregnancy can lead to fetal alcohol spectrum disorders (FASD), and that the effects of fetal alcohol exposure can last a lifetime. During gestation, alcohol can quickly reach the fetus’s underdeveloped liver and brain through the placenta, leading to a wide range of birth defects and developmental disorders. That’s why ACOG recommends that women completely abstain from alcohol during pregnancy.
Ob-gyns should routinely screen women regarding their alcohol use, both before and during pregnancy, and should provide support for women to stop use of alcohol when planning a pregnancy or when becoming pregnant.
However, as the CDC notes, roughly half of all pregnancies in the United States are unintended. In many cases of unintended pregnancy, women inadvertently expose their fetuses to alcohol and its teratogenic effects prior to discovering that they are pregnant. This is just another reason why it’s so important that health care providers counsel women about how to prevent unintended pregnancy through use of the contraceptive method that is right for them. There are many benefits to helping women become pregnant only when they are ready, and avoiding alcohol exposure is one of them.
The birth defects associated with alcohol during pregnancy are completely preventable. It is essential that all health care providers, especially ob-gyns, make clear to their patients that there is no amount of alcohol use that is safe during pregnancy. ACOG thanks the CDC for this important report, which will help to raise awareness of the risk associated with any use of alcohol during pregnancy.
Starting in 2016, the federal health law requires small employers to offer their full-time workers health insurance. In anticipation of the change, some fast-food restaurants looked to get around the law by making more workers part time. Now some owners are rethinking that approach.
At a Burger King off Highway 99 in California’s Central Valley, a half-dozen workers in black uniforms scurry around, grabbing packets of ketchup and stuffing paper bags with french fries.
Tiana Mua has worked here part time for almost a year. She’d like to be full time, but at this Burger King only the managers are full time. (The company didn’t respond to an interview request.)
Mua said that’s the situation at fast-food joints all over town. “They’re cutting back on all the jobs, and a lot of people have been let go and everything already,” Mua said.
One reason: The local economy is bad. People aren’t eating out as much, and sales are down. But there’s another reason that might explain why fast-food employees aren’t getting more hours: Obamacare.
Starting Jan. 1, businesses with 50 or more full-time employees must offer health insurance to all full-time staff or pay a hefty fine. Employers with 100 or more workers had to start offering coverage last year. But smaller businesses that operate on lower margins, especially restaurants, complained loudly about the cost.This story is part of a partnership that includes KQED, NPR and Kaiser Health News. It can be republished for free. (details)
And some fast-food franchise owners figured out a way to avoid paying for coverage: Just make as many workers as possible part time. A U.S. Chamber of Commerce survey found nearly 60 percent of small franchise businesses said they would make personnel changes like this.
“The ones that did it successfully did it three or four years ago,” says Kaya Bromley, an attorney who helps employers comply with the Affordable Care Act. But, Bromley said, some of the restaurant owners who cut hours to sidestep the health law now regret it.
“A lot of the fast-food franchisees that did this,” she said, “are now coming back and saying, ‘It was a great idea for reducing the number of people that I have to offer benefits, but now I can’t run my restaurants.’ ”
They tell her it has been a nightmare trying to manage a part-time staff.
“Because you’ve got people who are less loyal, you’ve got people who are less skilled — who don’t understand the business,” she said. There’s also more employee turnover.
Bromley has seen many of those restaurants reverse course. “Employers think that there’s a shortcut here or there, and then they realize, yeah, that shortcut really hurt me more than it helped me,” she said.
The people hurt most by all the workforce management gymnastics are the people at the bottom of the restaurant pecking order who want to advance, but can’t, said Angelo Amador, vice president of labor and workforce policy for the National Restaurant Association.
“Someone who’s working part time, but wants more hours so they can move up the ladder, they can’t get the hours,” he said. “It ends up taking out that middle rung of employees.”
Amador said Obamacare has made restaurants less flexible, mainly because it defines full-time work as 30 hours a week or more, and most other laws restaurants have to comply with, like overtime pay, define full time as 40 hours. He thinks the Affordable Care Act should be changed for consistency.
“It would be much easier if we could have one definition of full time,” he said.
At the Carl’s Jr. in Chowchilla, California, manager Silvia Campos tries to keep as many workers full time as possible. She says it makes her job easier. “It’s a small town,” she said. “For me, it’s hard to find a really good employee.”
But some workers don’t want more hours. Their part-time salary is low enough that they’re eligible for government coverage in California through Medicaid.
Some workers say they’re better off making less money and getting their coverage free from the state.
Patients suffered no extra harm when doctors training to be surgeons were allowed to work longer shifts, a study released Tuesday concludes, adding to a push to relax the strictest limits on resident hours.
The New England Journal of Medicine study comes as the Accreditation Council for Graduate Medical Education is reassessing requirements that prevent residents from working extremely long stretches or back-to-back shifts. Those rules were enacted in 2003 and strengthened in 2011 amid concerns that sleep-deprived residents were more likely to make serious errors.
Since then there has been push back from residency program directors concerned that the rules created new dangers for patients by abruptly forcing interns to leave in the middle of treating a patient or surgery. They also complain the rules interfere with resident education because it is harder for a trainee to follow their patients.
The study released Tuesday conducted a direct experiment by tracking patient outcomes after loosening the rules for doctors in 58 surgical residency programs. It found that their patients did not die or suffer complications any more than at 59 residency programs that did not waver from the current rules.
“We believe the trial results say it’s safe to provide some flexibility in duty hours,” said Dr. Karl Bilimoria, the main author and a professor of surgery at the Feinberg School of Medicine at Northwestern University in Chicago.
Some previous studies had come to similar conclusions, but this one has been anticipated because of its more rigorous methods. The trial has drawn protests from Public Citizen and the American Medical Student Association, which said researchers put patients and residents at risk by waiving the rules.Use Our Content This KHN story can be republished for free (details).
The groups assert that the experiment, funded by the American Board of Surgery, the American College of Surgeons and the accreditation council, was never likely to find a significant difference in patient outcomes, since most elements of patient care — the physicians, specialists, nurses and other clinical workers — remained unchanged.
“Research on the deleterious effects of chronic sleep deprivation is just overwhelming,” said Dr. Deborah Hall, president of the medical student association. “I’m concerned we’re going to walk away from a lot of progress that’s been made without overwhelming data [showing] that residents aren’t subject to the ordinary limits of human neurobiology.”
In an editorial also published in the journal, Dr. John Birkmeyer, chief academic officer at Dartmouth-Hitchcock, a health system in New Hampshire, came to a different conclusion than Bilimoria did. Birkmeyer wrote the experiment’s results “effectively debunks concerns that patients will suffer as a result of increased handoffs and breaks in continuity of care.”
Rather than roll back the rules on duty hours, he argued that surgeons should find safer ways to treat patients without relying on “overworked” residents.
“To many current residents and medical students, 80-hour (or even 72-hour) workweeks and 24-hour shifts probably seem long enough,” Birkmeyer wrote. “Although few surgical residents would ever acknowledge this publicly, I’m sure that many would love to hear, ‘We can take care of this without you. Go home, see your family, and come in fresh tomorrow.’”
The research was conducted in the academic year that began in fall 2014. One group of residency programs followed the existing rules, while the other programs were allowed to remove several strictures.
Residents in the experimental group could stay at the hospital longer than 28 hours in a row, the current maximum. They did not have to be given at least eight hours off between shifts. Residents who worked a 24-hour shift no longer had to wait 14 hours before returning to the hospital. And first-year residents could work more than 16 hours in a row, a limit set in 2011.
After analyzing medical records for 65,849 patients in the control group and 72,842 in the experimental group, the researchers found no significant difference in death or complication rates. They also surveyed 4,330 general surgery residents and found that those with the more flexible schedules rated their overall well-being and morale no different than did those with strict rules.
“We’re very encouraged by the findings,” said Dr. Maya Babu, a neurological surgery resident at the Mayo Clinic and president of the Resident and Associate Society of the American College of Surgeons. “We feel very strongly that flexibility is important to provide opportunities to learn and to have patient ownership, to see patients from the time they’re admitted through surgery the next day.”
Seven percent of residents exempted from the duty limitations said they left during an operation at least once a month, while 13 percent of those following the rules said they left. Thirty percent of the experimental group said they missed an operation at least once a month, while 42 percent of those with standard rules said they missed one. A third of the test group said they turned a patient over to another doctor in the middle of dealing with them, while nearly half of the control group recalled doing so.
Dr. Michael Carome, director of Public Citizen’s Health Research Group, a patient safety advocacy organization, said the study should have objectively assessed the hours residents worked and the effects on their health and patients, rather than rely on surveys. He said the study also did not track whether residents in the control group adhered to the stricter limits on how long they could work.
“The study didn’t collect any meaningful data on resident health outcomes,” Carome said.
The most major restrictions on resident duty hours put into place in 2003, such as a maximum workweek of 80 hours a week and a minimum of one day off every seven, were not tested in the study and are expected to remain in place.
The paper was scheduled to be presented Tuesday at the Academic Surgical Congress in Jacksonville, Florida. A similar experiment, looking at internal medicine residents, is still in progress.
Most fans of James Joyce’s novel Ulysses celebrate the day of the novel’s action, June 16, also known as Bloomsday. I knew a Joyce specialist who used to honor the day by eating a gorgonzola sandwich on white bread with a glass of burgundy—he said he couldn’t face the grilled mutton kidneys. Fans of the work skew toward the rabid side.
Today, February 2, is the 134th anniversary of Joyce’s birth, and this day is another good opportunity for those rabid fans to commemorate all of Joyce’s works, especially Ulysses. Ulysses was published in February 1922 by Shakespeare and Company in Paris. But Ulysses, arguably Joyce’s best known work, almost didn’t get published in the United States, or any other English-speaking country. That’s where American law intersects with Joyce’s literature.Ulysses was serialized in the United States in the magazine The Little Review in 1921, the year prior to the publication of the full novel. The 13th chapter, also known as the Nausicaä episode, shocked many readers with its masturbation scene. The New York-based publishers of the magazine, Margaret Anderson and Jane Heap, were successfully prosecuted in New York for obscenity for mailing the Nausicaä episode issue through the U.S. post. Heap and Anderson were charged with the violation of the Comstock Act of 1873, which criminalized the sending of any “obscene, lewd, or lascivious book…” in the mail. For the next twelve years, Ulysses was banned in the United States and was only available to Americans who got smuggled copies from Paris, as the book was banned in Great Britain as well.
At the time of Ulysses’ publication, the Hicklin test, from the English court case of Regina v. Hicklin 3 L.R. – Q.B 360 (1868) was used by the U.S. courts as the legal definition of obscenity. The Hicklin test was “…whether the tendency of the matter charged as obscenity is to deprave and corrupt those minds who are open to such immoral influences, and into whose hands a publication of this sort may fall.” Bennet Cerf, the founder of the American publishing firm Random House, wanted to publish Ulysses in the United States. He worked with Random House legal counsel and co-founder Morris Ernst to orchestrate the seizure of one copy of Joyce’s Ulysses by U.S. customs, sent to Cerf from Paris in May 1932. Ernst believed that the only way to defend Ulysses was to “…convince the government to declare the Ulysses a modern classic” (Birmingham, p. 297); there is an exemption for classics in the Tariff Act of 1930 (19 USCA § 1305). Cerf arranged to have literary reviews pasted inside the front cover of the book that the customs officer seized.
Woolsey’s decision in United States v. One Book Called “Ulysses,” determined that Ulysses could be admitted into the United States. In his remarks, Woolsey noted that “…in Ulysses, in spite of its unusual frankness, I do not detect anywhere the leer of the sensualist” (Moscato and LeBlanc, 310). Further, “‘[Joyce] has honestly attempted to tell fully what his characters think about’, no matter the consequences. Some of those thoughts were sexual, but, he pointed out, ‘it must always be remembered that his locale was Celtic and his season spring.’” (Birmingham, p. 309) Woolsey wrote, “In many places … it seems to me to be disgusting,” but nothing, he added, had been included in it as “dirt for dirt sake.” He noted that Joyce’s stream of consciousness literary technique required him to reflect the thoughts of his characters, even if the characters were people a reader might not want to meet. “But when a real artist in words, such as Joyce undoubtedly is, seeks to draw a true picture of the lower middle class in a European city, ought it to be impossible for the American public legally to see that picture?” (Moscato and LeBlanc, 311).
While other major works of literature also created tests to the legal application of the definition of obscenity—Lady Chatterley’s Lover, Fanny Hill, An American Tragedy—Joyce’s Ulysses and Woolsey’s decision changed the future of publishing in the United States. The decision of the American courts to allow publication of the work also set a precedent for other countries to allow Ulysses to be distributed, although that took more time—Britain did not end its ban on Ulysses until 1936; Ireland never banned it, but it never sold there until decades after its release either. Once reviled and burned in both the United States and Great Britain, Ulysses is now a universal cultural artifact. Bloomsday is celebrated all over the world, and Ulysses is, as Joyce predicted, keeping professors busy arguing over what he meant for a century and counting.
Want to read more about it? We have these related materials in the collections:
KF224.R33 U5 United States of America, libelant vs. one book called “Ulysses”, Random House, Inc., claimant / United States District Court, Southern District of New York.
KF224.R33 U53 1984 Moscato, Michael and Leslie LeBlanc. The United States of America v. one book entitled Ulysses by James Joyce : documents and commentary : a 50-year retrospective.
KD277.L39 The Law reports. Court of Queen’s Bench.
KF4772 .I53 2016 An indispensable liberty : the fight for free speech in nineteenth-century America / edited by Mary M. Cronin ; contributions by David W. Bulla, Jon Bekken, Sandra Davidson, Nancy McKenzie Dupont, Joseph Hayden, Lee Jolliffe, Paulette D. Kilmer, Erika Jean Pribanic-Smith, Debra Reddin van Tuyll, Janice R. Wood.
PR6019.O9 U4 1934 Ulysses.
PR6019.O9 U4 2015 The Little Review Ulysses.
PR6019.O9 U6257 2014 Birmingham, Kevin. The Most Dangerous Book: the Battle for James Joyce’s Ulysses.