Iatrogenic

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What a beautiful word, iatrogenic. How better to characterize the origins of the COVID19 Pandemic.

Understatement

Share |April 25, 1953 Nature Magazine #4356 page 737, probably the greatest British/English understatements of all time. In publishing the structure of deoxyribose nuclei acid, James Watson defined the formula for life.  “It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.”

Public Health Failure

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Once upon a time, Public Health kept the water safe and enforced quarantine for highly contagious diseases. Physicians were highly educated, judgmental and organizationally disciplined.

Since the HIV epidemic, liberal planing introduced two changes. 1. Liberals passed legislation forbidding routine testing for HIV and tightened the rules insuring patient’s medical confidentiality to the point of stiffening both continuity of care and medical education. 2. An overgrown medical bureaucracy introduced rules based medical care based on guidelines with disciplinary measures against physicians not following those guidelines. 

If nothing else, the CoV2 pandemic exposed these failures. Firstly, the inertia of Public Health in reacting to the pandemic lead to a faster and broader spread of the disease. Rules based guidelines became obsolete by the time they are published. Contact tracing and quarantine was overwhelmed. Secondly, guidelines denied the use of treatments not supported by as yet incomplete double blind studies. 

Universal rules forgo regional variability and the magic of multiple trial and error, an end of the scientific method. Medical bureaucracy insisted on a negative interpretation of the relevance and validity of many published clinical trials, not completed and interpreted by themselves. These acronymous agencies, CDC, FDA, NIH, HHS and a plethora of others placed greater value on population wide studies, statistics and completion of years long studies. The inertia of time alone rendered their judgments irrelevant. This egregious denial of care from government entities resulted in many unnecessary deaths and continues to do so today. 

Traditionally, the consideration of multiple clinical trials and clinical judgment was the prerogative of individual clinicians viewing multiple variables. Any clinical physician knows that treatment is highly individual and enhanced by the presence of a trusted physician, and that most clinical studies contain a bias of one sort or another: independent variables, clinical bias, incompetence, statistical or just plain inertia. Then enters political bias. Hospital employers even licensing agencies got into the act threatening  consequences for any deviation from their negative guidelines.

The generations long history of treating Influenza included off label drugs with antiviral efficacy and support with multiple strategies including optimal treatment of underlying conditions and support of the immunize system. The same could apply to COVID19. With a death rate over 20% for patients over 70, physicians needed to be free to treat early and try options.

In the heat of the pandemic, with rigid guidelines, other serious conditions were neglected. Guidelines, algorithms and artificial intelligence fell far short of adequate management of the multiple problems and fast changing threats.

Protocalized Medicine

Share A new term from NEJM Hospital Medicine, promises wider hospital gross profit margins, decreased continuously of care and frequent disregard for coexisting conditions. 

Early Treatment COVID19

Share | I’m disappointed in ID coverage of early treatment of COVID 19.

Physicians have been marginalized or fired for attempting early treatment. Various treatment modalities were discounted and later revised. Early treatment might have saved many lives. I don’t think the journal gave adequate clinical coverage of either the controversy or the lost opportunity for early treatment. Never mind the damage done to physicians attempting to practice traditional medicine. Even the laying on pod hands and the reassuring presence of a trusted physician has a positive neurohumeral strengthening of the immune system. 

Was this failure of early treatment not a shortcoming of overly rigid evidence base, standardization and protocols?

Authoritarian Medicine

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It was three am in Nandi International Airport in Fiji. All of the passengers had cleared customs and left the terminal. Only three of us remained. It was not hard to spot the other doctor, an ENT from Homberg, Germany. The third gentleman was a British Health Service bureaucrat from England in Fiji to share the English version of central management of healthcare with the emerging Fijian Healthcare system. We were all waiting for rides which may not have anticipated our early arrival.

Wolfgang and I immediately hit it off. We were both volunteers with Rotary International, in Fiji to participate in a Health Fair throughout many of the underserved villages. After a few minutes, the Englishman came over and introduced himself enthusiastically presenting his views on standardized healthcare. Wolfgang and I spent the next two hours arguing that standardization negated the scientific nature of clinical practice, where in trial and error takes place massively throughout the profession resulting advancements in care for the patient, communicated almost by word of mouth on a realtime basis. We argued that statistics and scientific studies were a necessary reference but not a certain conclusion. Many studies were selected for or conflicted by those conducting the studies and many studies proved wrong by subsequent trial but with substantial time lag.  Neither side won the argument back then, and our rides soon arrived.  This airport debate was twenty years ago, and the evolution of  authoritarian medicine dominated English medicine and now distorts healthcare in the US. 

The American version of authoritarian medicine features additional elements of greed and politics, along with massive bureaucracy. Starting with the theory of "Evidence based Medicine," medical science became the purview of the growing medical bureaucracy, then hospital administrators, corporate medicine, politicians and big pharmacology. The burdens today's physicians face, match or exceed the burdens of various religious dictates during the Dark Ages. No longer medical science and patient care, doctors now practice with political correctness, censorship and manipulated evidence. Today, I read that the AMA has come out in support of Critical Racial Theory. Politics and greed have no business in medical practice and patient care. Patient care, patient satisfaction, current science, treatment outcome, the physicians judgment and local medical societies should be the only authority in medical practice. Authoritarian-guidelines negate the scientific method and inductive reasoning. Evidence is good. guidelines can help, but bureaucratic regulation or administrative regulation cannot. Now the AMA wants to replace merit based medical school admission standards with social standards. Such a move favors corporate medicine and social medicine producing young obedient feldshers who will not question the authoritarian mandates or the political and economic motives -- over clinical judgment, medical science and patient care. We desperately need to reaffirm the Aesculapian mandates of Western medicine and resist the Marxist authoritarianism, greed and politicalization of medicine.

Ivermectin

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"YouTube videos mentioning ivermectin in treatment of Covid-19 were removed or demonetized, as well as Twitter pages locked. Further, in Big Media, even the most credentialed independent and expert groups who recommend ivermectin based on a large body of irrefutable evidence are labeled as “controversial” and purveyors of “medical misinformation.” (My own Face Book and Twitter posts as well -- arguing for early physician treatment of COVID19, even if only holding hands.)

A health system structured to function in this manner is clearly vulnerable to and overly influenced by entities with financial interests. Further, in Covid, such systems have evolved into rigidly operating via top-down edicts and widespread censoring. This allows little ability for emerging scientific developments not funded by Big Pharma to be disseminated from within the system or through media or social media until years later when, and if, a Big RCT is completed. This barrier has presented as an enduring horror throughout the pandemic given the widespread loss of life caused by the systematic withholding of numerous rapidly identified, safe and effective, repurposed medicines for fear of using “unproven therapies” without “sufficient evidence” for use. Alternatively, and for the first time in many physicians’ careers, those who seek to treat their patients with such therapies, based on their professional interpretation of the existing evidence are restricted by their employers issuing edicts “from above.” They are then forced to follow protocols that rely predominantly on pharmaceutically engineered therapeutics." From the FLCCC, https://covid19criticalcare.com/videos-and-press/flccc-releases/flccc-alliance-statement-on-the-irregular-actions-of-public-health-agencies-and-the-widespread-disinformation-campaign-against-ivermectin/

Starting with the theory of "Evidence based Medicine," medical science became the purview of the growing medical bureaucracy, then hospital administrators, politicians and big pharma. The burden todays physicians face matches or exceeds the burden of various religions in the Dark Ages. No longer medical science and patient care, but now political correctness, censorship and manipulated evidence. Today, I read that the AMA has come out in support of Critical Racial Theory. Politics and greed have no business in medical practice and patient care.

Democracy to Globalism to Oligarchy to Communism to Orwellian Dystopia

Share | https://www.amazon.com/dp/B08M1XBXFZ

Existentialism

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I think truth, fact and meaning are three distinct things. I think some of the willingness of journalists to engage in fake news comes from projecting and confusing meaning with truth or actual fact. I read statements such as, “It is an existential threat.” From my interpretation of existential, that would mean only a threat the journalist’s mind.

Listening to Jordan Peterson at the Oxford Union, I would ask him his interpretation of the above and his definition of existential. Think I’ll check out his book on meaning. Peterson has an interesting suggested book list.

Mexican Border Crisis

Share |Is this the masked image of American Communism?

Globalization or Democracy

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https://www.amazon.com/dp/B08M1XBXFZ

HIV the Hidden Pandemic

Share | https://www.jwatch.org/fw117539/2021/02/21/lancet-series-tackles-us-hiv-epidemic?query=pfwTOC&jwd=000020094311&jspc=GP

The Lancet takes aim at the US HIV burden, the highest of any of the G7 nations. In dramatic contrast to the quarantine, contact tracing, social isolation, distancing and masks demanded by Public Health for the COVID19 pandemic; HIV patients and those living an alternative lifestyle demand and receive the exact opposite. Hospitals, clinics and physicians can not test for HIV without written permission. While hospital admitting lab tests still include a routine test for Syphilis, routine testing for HIV is not included. Only a difficult strategy of universal precautions affords protection for other patients and hospital personnel. Surgical and obstetric cases must be carried out with the assumption of risk, requiring extensive shielding against the inevitable spattering of blood. The risky behavior, personal privacy and confidentiality if not silence demanded by the HIV community was political from the start. If testing, quarantine, contact tracing and isolation had been required from the first case of HIV, there would have been no epidemic in the US, or if HIV did spread by undiagnosed immigration, it would have been contained. Indeed, COVID19 would have been contained too if China had not deliberately denied its threat and encouraged its spread.

As a nation, we were more than willing to suffer quarantine and contact tracing for Syphilis, Tuberculosis, Poliomyelitis and even Mumps. The contrast between the protocols for HIV and COVID19, however, illustrate the compromise needed between Constitutional freedoms of choice and the suspension of that freedom in the face of a highly communicable and highly fatal disease. The choices needed to balance a fair compromise might better be made by medical judgements than by politicians. Even so, there will be an inevitable difference between clinical opinion and that of public health. It becomes even more problematic when public health becomes politicized or politicians intervene. 

New England Journal of Medicine (NEJM)

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This is a slow take on some serious questions. First of all what is the NEJM doing writing a political editorial accusing the president of mismanaging the COVID pandemic? The assertions, largely untrue, beg both academic and scientific credibility. NEJM publishes Journal Watch and other CME articles and enjoys an authoritative role at the heart and sole of academic medicine. 

 

The second thing that seemed strange was NEJM’s guidelines for treating COVID19. The guidelines have come to be a treatment imperative for a number of reasons mainly medical-legal. These published guidelines restrict treatment with antiviral drugs to when the patient requires high oxygen flow rates. By then it’s too late. One might assume that some if not most hospitalists will follow those guidelines. So doing, goes against all intuitive medical judgment and appears to be in contradiction to all experience in treating influenza and Vanderbilt’s rather spectacular success in containing Ebola, 11 cases, 4 deaths, 2 nurses and a doctor recovered.

 

Directing criticism of President Trump’s management of the Chinese virus seems misplaced. Trump cut off travel from China well before WHO condoned it and shortly after CDC trace managed and guaranteed the first known US case in Illinois. The president furthermore held daily public briefings with CDC physicians and evoked the emergency measures act to manufacture personal protection supplies, drugs, test kits and respirators all of which were cut off from the Chinese manufacturing and supply chain. US manufacturers came through in heroic fashion.

 

Guidance for masks, testing, distancing, isolation and quarantine were driven home from the podium. The economy shut down and the rest is history. The responsibility for balancing deaths from the pandemic with deaths and displacements from the shutdown is awesome and there may never be an acceptable solution, but not for lack of leadership.

 

Public health is a state run institution, a fact largely misunderstood by the media. Furthermore, masks and isolation authority runs contrary to the legality of individual freedom of choice. What ever mandate that’s legal, comes at the state level. Also, public health is not a clinical specialty. There was always a disconnect between clinical medicine and public health. Most physicians choosing public health do so not to see patients. 

 

It’s a matter of opinion, but at this point in the pandemic, management might better be directed by clinicians, medical schools especially. Public health has exhausted its role in preventing the spread of the virus, maybe it was a lost cause from the time the CCP deliberately encouraged its worldwide spread. Clinical medicine can do much to reduce the death rate with early treatment. The case for early treatment was dramatic with Trump’s rapid recovery at Walter Reed.

 

Googling publication of NEJM, revels  mass distribution if not publication of the NEJM in China, in Chinese. I wonder just how much investment, domination and ownership the Chinese Communist Party (CCP) now enjoys with what amounts to the backbone of continuing medical education (CME) in the US. 

Not a conspiracy theory but serious questions about the integrity and possible subversion of the NEJM.

 

Time for Clinical Medicine

Share | We should be focusing on the various immune antibody cocktails  and early treatment. Prevent deaths, lung and organ damage more than the spread of cases, a transition from public health to clinical medicine. Get bureaucracy out of the way, and deliver massive amounts of the early treatment modalities to primary care physicians. Treatment > prevention, family physicians should have access to these treatments, treat early and treat often. The President has it right. Treat early like the first line physicians treated him, when hospitalized with shortness of breath, it’s already too late.

Early Treatment

Share |Pure speculation, based in part by POTUS’s rapid recovery and apparently greater success rates in under developed or what we thought of as under developed countries in treating COV-2

Our reluctance to use unapproved off label therapies in the treatment of COVID19 in the US, seems both endemic and contra intuitive. The guidelines published by the NEJM limit initiation of remdesevir to patients requiring high flow rate oxygen. Physicians have been sanctioned for advancing off label treatments, and I wonder how patient care came to depend on bureaucratic permission. Furthermore, Science Published an article suggesting dysfunctional FDA approval processes and questionable studies causing major delays.

Clinical medicine often conflicts with Public Health interests, and the treatment phase of this pandemic may be such a conflict with the, can I say, less respected health care and public health authority. Have we failed to make the transition from public health measures to serious aggressive individual patient care?

Globalization or Democracy

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COVID 19 challenges medicine to the limits of public health, diagnosis on the molecular level and treatment at that level as well. The pandemic also challenges medicine's economic structure. Physicians should take a serious look at the medical economics of Chinese Globalism.

I’ve spent the last few years writing my book, Globalization or Democracy, and in a sense the work was a rewrite of my life’s goals. Prior to the Korean War, I was in my senior year at KU with a major in economics and a pathway to graduate school in the East to study international commerce. I had a fascination with the macroeconomics of trade. I knew about business along the Mississippi, growing up in St Louis and about wheat from high school and college in Kansas and, on occasion, the wheat harvest. Jon Ise was the highly respected economist and professor at Kansas; his grass roots economics and the extensive, required two-year Western Civics course, left an indelible impression.

Half-way through my senior year, the Chinese crossed the Yalu River and I was not quite far enough along in credits to be exempt from the draft. I joined the Air Force with the intent to fly. It did not work out quite that way. I got married. Son John came along and I followed my fathers and my brother’s path into medicine. I never quite got over the economics, however, and for that matter the need to fly.

After retirement, what was I to do but move to Alaska and fly a seaplane charter operation for ten years, the best ten years of my life, and after that with and a 50 Emeritus medal for medical practice from the University of Michigan, I wrote my book on economics.

Economics was there all the time, the grass roots fundamentals of supply and demand. It was there as I hung my shingle in Littleton, CO, and as I managed partnerships, two incorporated clinics, and both starting and managing a rural community health clinic in a remote Colorado cattle town. Supply and demand and liquidity was there as I ran a single pilot, part 135 air charter company in Alaska. Furthermore, an economics education did not hurt me in decades of equities market investing. All of that past experience came together as I wrote about the futility, yea the threat of Globalism and the CCP lead cartel of Internationalism.

As we wake up in a COVID 19 pandemic, June of 2020, with economic recovery and social chaos, we have only one not so clear choice and that is the Chinese Communist Party’s, Globalism, advanced as China’s new world order or not. It’s Chinese dystopia or Democracy. Globalism started out as an ideal but oligarchs, greed and the PLA soon bent Globalization to its own self interest while we all contributed. I’ve attempted to outline the economics that drove the failure of an internationalist dream that goes beyond contemporary economist’s assertions. Always a contrarian, one must see what the market misses. I think, contemporary economists, for the most part, take an idealistic approach of moral equivalency, meaning that just about anything multiculturalism dishes out, should be taken as economic fact. I think economists fear for their reputations, their tenure and their, for the most part, high paying jobs.

In any case, if you read Globalism or Democracy, you will be reading about my life and the path I did not take.  Enjoy

EHR

Share |EHRs are trying to do the wrong thing. A clinical note, consultation or completed H&P express an elegant succinct communication between physicians and an ongoing novel of a patients progress. Not only does each encounter, each patient, each disease present a unique narrative, but each specialty and each physician contribute a unique perspective. No way can a team or an EHR reflect the color or content of a patient encounter. The physician dictated note alone can capture the subtleties of an encounter or facilitate continuity of care. The nightmare of entering EHRs in the presents of a patient pales by comparison to reading an EHR and trying to find what the previous physician was thinking among the vastness of irrelevant and superfluous misinformation, pages and pages of it.
       EHRs should be the preview of nurse alone and relegated to a separate file, Nurses Notes. Physician notes, dictated by the physician alone should constitute the official record. All the legislated requirements and their execution can remain in the nurse’s EHR.
       

Health Care

There will never be an agreement, so what we ned is health care for Democrats in one system and healthcare for Republicans in another. Then both parties can have exactly what they want. In a perfict world, the two systems would turn out to be the same.

Cocktail

A team from Harvard and MIT formulated a cocktail of small molecules to treat hearing loss. Ingrediants not specified, the cocktail, fed to mice and cochlear cells in vitro, stimulates cochlear stem cells and the growth of functioning hair cells. The only problem may be the question of the growth factoron other  epithelial stem cells. 

OK, so do you want to look like a gurilla withgood hearing or stick with your Phonak hearing aids, no volenteers?

Cell Reports 2017 zFeb 21; 18: 1917

A second, possibly more practicle cocktail, reported in 

Proc Natl Acad Sci USA 2017 Mar 28; 114:3509

Proved a dietary supplement highly effective in preventing the post. partum blues. The cocktail comprised of 2 gm tryptophan, 10 gm tyyrosine and bluebarry juice qsad, given day 3, 4, 5 after delivery effectively mitigated the post partum elevated mono amine oxidase (MAO-A) levels. The small study was so dramatically successful as to hope for more serious later post partum depression benefits.

Female Genital Mutilation (FGM)

"According to reports, several young Somali girls were brought from Minnesota, one of twenty-four states that have passed legislation to make female genital mutilation (FGM) illegal according to state laws, to Michigan, one of twenty-six states in which FGM has not been made illegal in state law, where Dr. Nagarwala, with assistance from Mrs. Attar, performed the procedure outlawed by federal law in a medical office owned by Dr. Attar.

“Since 1996, there have been specific federal criminal penalties for performing FGM/C in the United States on anyone under 18 years old, including fines, up to 5 years in prison, or both. In 2013, Congress amended the federal statute related to FGM/C to criminalize the knowing transportation of a girl under 18 years old from the United States for the purpose of performing FGM/C abroad—often referred to as ‘vacation cutting,’ ” according to the June 2016 Government Accountability Office’s report Female Genital Mutilation/Cutting.

The current federal statute, which codifies both the 1996 law and the 2013 law can be seen here at U.S. Code Title 18  Part I  Chapter 7  § 116 – Female genital mutilation.

Surprisingly, neither the 1996 federal law that outlawed FGM, nor the 2013 federal law that outlawed “vacation cutting” requires health care providers to report known or suspected instances of FGM to local, state, or federal health authorities or law enforcement. Current federal law criminalizes the practice of FGM, but does not specifically require reporting on it, though health care providers are obligated to report instances of child abuse, a category in which FGM falls.

With this paucity of reporting data, two recent studies, one by the Population Reference Bureau (PRB), another by the Centers for Disease Control (CDC), have used demographic analysis to estimate that the number of women who have “undergone” FGM or are “at risk of the procedure” in the United States exceeds 500,000.

“Female genital mutilation/cutting (FGM/C), involving partial or total removal of the external genitals of girls and women for religious, cultural, or other nonmedical reasons, has devastating immediate and long-term health and social effects, especially related to childbirth,” the Population Reference Bureau (PRB), a non-profit research organized funded in part by the Bill & Melissa Gates Foundation, reported in February 2016.

“In 2013, there were up to 507,000 U.S. women and girls who had undergone FGM/C or were at risk of the procedure, according to PRB’s data analysis. This figure is more than twice the number of women and girls estimated to be at risk in 2000 (228,000). The rapid increase in women and girls at risk reflects an increase in immigration to the United States, rather than an increase in the share of women and girls at risk of being cut. The estimated U.S. population at risk of FGM/C is calculated by applying country- and age-specific FGM/C prevalence rates to the number of U.S. women and girls with ties to those countries,” PRB reported.

PRB’s “at risk” estimates were based on demographic analysis, rather than actual reported incidents of FGM in the United States.

They made the common sense assumption that young girls raised in immigrant households where the country of origin is one where the FGM incidence has been documented to be high are “at risk” since those cultural practices are not left in the home country by the family but are likely to continue in the United States.

“Just three sending countries—Egypt, Ethiopia, and Somalia—accounted for 55 percent of all U.S. women and girls at risk in 2013 (see Table 1). These three countries stand out because they have a combination of high FGM/C prevalence rates and a relatively large number of immigrants to the United States. The FGM/C prevalence rate for women and girls ages 15 to 49 is 91 percent in Egypt, 74 percent in Ethiopia, and 98 percent in Somalia. About 97 percent of U.S. women and girls at risk were from African countries, while just 3 percent were from Asia (Iraq and Yemen),” PRB explained.

“FGM/C has gained attention in the United States in part because of the rising number of immigrants from countries where FGM/C is prevalent, especially sub-Saharan Africa. Between 2000 and 2013, the foreign-born population from Africa more than doubled, from 881,000 to 1.8 million,” the PRB report added:

This type of violence against women violates women’s human rights. There are more than 3 million girls, the majority in sub-Saharan Africa, who are at risk of cutting/mutilation each year. In Djibouti, Guinea, and Somalia, nine in 10 girls ages 15 to 19 have been subjected to FGM/C. Some countries in Africa have recently outlawed the practice, including Guinea-Bissau, but progress in eliminating the harmful traditional practice has been slow.1 Although FGM/C is most prevalent in sub-Saharan Africa, global migration patterns have increased the risk of FGM/C among women and girls living in developed countries, including the United States.

“CDC published a report in 2016 estimating that 513,000 women and girls in the United States were at risk of or may have been subjected to FGM/C in 2012,” according to the June 2016 Government Accountability Office’s report Female Genital Mutilation/Cutting. The CDC report found the virtually the same results PRB found using 2013 data:

While subject to certain limitations, this represents a substantial increase—about threefold—from CDC’s prior estimate of 168,000, which was based on 1990 data.CDC attributed this increase to a sharp rise in recent decades in the U.S. population originating from countries where FGM/C is commonly practiced, and noted that the increase occurred despite FGM/C prevalence not increasing or seemingly falling in many of these countries.

“In the report for the 2012 estimate, the authors said that until scientifically valid data are collected, the approach used provides the best available information on the potential levels of FGM/C,” GAO wrote:

CDC and others have acknowledged that collecting more scientifically valid data would be difficult due, in part, to the cultural and legal sensitivity of the
information needed. International efforts to collect data on the actual occurrence of FGM/C have faced similar challenges. Starting in October
2015, however, the United Kingdom began requiring health care providers in England to report through a nationwide database any instance of FGM/C described to them or discovered during physical exams. (emphasis added)

Recent press reports indicate that the methodologies used in both the CDC report and the PRB report are supported by at least one instance where health care providers actually tracked the incidence of  FGM among recent immigrants to the United States from a country in which it is a very common cultural practice.

“In Phoenix, Arizona, a staggering 98 percent of Somali women being treated at the Refugee Women’s Health Clinic have been circumcised, founder Dr. Crista Johnson said. She estimates the Somali community is at least 12,000-strong,” NBC News reported in 2014.

But the work by the Refugee Women’s Health Clinic in Phoenix accurately reporting on the incidence of FGM among recent immigrants to the United States is the exception in a public health system that is not required to specifically report suspected or actual incidents of FGM by law in most jurisdictions and is reluctant to do so for a variety of ideological and institutional reasons.

“Despite the fact that FGM in all forms has been explicitly illegal in the United States since 1996, legislation criminalizing the practice has not been comprehensively implemented or enforced, and community members, social service providers and law enforcement officials often fail to identify, report or investigate incidents of FGM,” Sanctuary for Families reported in 2013:

Anecdotal evidence indicates that female genital mutilation also continues to be performed within the United States. Typically, FGM in the U.S. is carried out by traditional practitioners who operate covertly and illegally. When U.S. health care providers carry out the procedure, they frequently come from countries where the practice is prevalent, and they operate on girls from their own communities at the request of a child’s parents.

“Some states have enacted laws specifically criminalizing FGM/C, while other states may pursue FGM/C offenses under other related statutes, such as child abuse laws,”  according to the June 2016 Government Accountability Office’s report Female Genital Mutilation/Cutting:

In some instances, states require that an occurrence of FGM/C be reported.

DOJ indicates that two states, Illinois and Tennessee, have mandatory reporting for FGM/C.

All states have mandatory reporting laws governing child abuse, which may apply to reporting FGM/C depending on the relevant circumstances and particular statutory requirements.

Some state laws address other areas of FGM/C, such as provisions prohibiting “vacation cutting” or provisions for community education and outreach.

“Local law enforcement and child protection officials told us that immigrant communities may underreport due to cultural norms, victims’ reluctance to betray their community or family members, and concern about potential effects on their immigration status and that of their family members. In addition, although many professionals who may be in contact with girls at risk for FGM/C are mandatory reporters (e.g., health care, school, and child care officials), they may be uncertain about whether FGM/C should be reported,” according to the Government Accountability Office’s June 2016 report Female Genital Mutilation/Cutting:

For example, health care providers we spoke with stated that they may not report instances of girls being at risk of or subjected to FGM/C due to uncertainty about mandatory reporting requirements (e.g., if FGM/C occurred before arriving in the United States), or because they prefer to counsel parents on the consequences of FGM/C to change parents’ position on the issue.

School officials we spoke with had little or no experience encountering FGM/C among their students, in general, and school officials may not be certain of what actions are appropriate when they encounter suspicions of FGM/C, which can affect reporting. For example, an official from a nongovernmental organization that works with Somali women said teachers contacted them for guidance on dealing with suspicions of vacation cutting.

In addition, a former school psychologist who now works with a national organization told us about an instance when school officials had suspicions of vacation cutting that was not
reported.

However, they did not confirm these suspicions with the student or her family, out of concern that she would be pulled out of school and her home environment would be disrupted. Without clear evidence that FGM/C had occurred, the officials decided to provide the student with general support for trauma.

States’ mandatory reporting requirements vary across jurisdictions, are dependent on the relevant facts and circumstances, and would be subject to some level of interpretation by
the reporting official. These factors can make it challenging to determine the appropriate course of action when encountering potential instances or risks of FGM/C on minors

The public health establishment–at the federal, state, and county levels–has been reluctant to look for and report on female genital mutilation (FGM) data, just as it has been reluctant to report on the incidence of latent and active tuberculosis (TB) among resettled refugees.

An example of this reluctance when it comes to reporting on active TB among refugees is the hidden blockbuster discovered by Breitbart News in January that 1,565 refugees have been “diagnosed with active TB since 2012, three times more than previously reported.”

Many state government health departments that report active TB among refugees make the data very difficult to find.

Other state government health departments simply fail to fully report active TB among refugees, and many county governments, particularly those in urban areas controlled by Democrats, refuse to comply with the public health reporting requirements of the Refugee Act of 1980, particularly with regards to latent TB.

Public data on the incidence of FGM–which occurs almost exclusively among the immigrant population arriving from Africa, the Middle East, and the Near East–is far more difficult to obtain than public data on the incidence of active TB.

Every state has had very clear reporting standards about the incidence of active TB among the entire population for well over half a century–in many states for more than a century.

Such is not the case with FGM, because the barbaric practice was virtually unknown in the United States until the significant upswing over the past several decades in the arrival of immigrants from countries where it is has been a common practice for centuries.

“I think it’s more than mere reluctance,” an attorney familiar with the refugee resettlement program tells Breitbart News about the reluctance of public health officials to obtain and report data on FGM.

“I think it’s a deliberate, ideological approach of moral equivalency, meaning that just about anything multiculturalism dishes out, should be respected and accepted – and the PC bureaucracy backs them up,” the attorney says.

“Public health and medical care in general, is not supposed to be a judgment, and because FGM has been made illegal in the U.S. with individual states even passing their own laws, it’s made it easier for public health departments to opt out of addressing it, leaving it instead to law enforcement agencies,” the attorney adds.

"If there is any doubt, just look at the annual refugee health reports like the one for Texas that has extensive data about health issues related to arriving refugees; they report on STDS but there is nothing about FGM, a condition that for many women who have been mutilated, brings life-long medical issues,” the attorney concludes.

The 2014 Refugee Health Report issued by the state of Texas, for instance reports, extensively on the rates of syphilis for refugees over the age of 15, but includes no data on FGM.

Refugee health reports for the states of California, Utah, Arizona, Minnesota, Indiana, and Florida follow a similar pattern.

The Centers for Disease Control’s (CDC) guidelines to medical professionals responsible for conducting the initial domestic medical screenings of refugees arriving in the United States for resettlement by the federal government specifically recommend genital examinations, which would clearly identify arriving refugees who are FGM victims. However, a significant number of those screeners may not be following those recommendations, or may delay the examinations indefinitely based on language in the guidelines that states “[i]n refugees who previously experienced trauma (e.g., sexual assault victims), the anal and genital examination may be postponed until the refugee establishes a trusting relationship with a provider.”

That apparent failure misses key information that could help stop the spread of the barbaric practice in the United States, as adult women arriving in the country who are already victims of FGM are likely to be in family situations where their daughters are at risk of being subjected to the same abuse in this country.

Common sense suggests that the PRB’s and CDC’s estimates of the number of girls in the United States at risk for FGM is likely to be very close to the true incidence of FGM in this country today.

The public health establishment’s long record of hiding and obscuring data that accurately reflects the true public health status of immigrants and refugees, however, appears to be one of the major stumbling blocks in identifying and eradicating this barbaric practice in the United States, as is the lack of specificity in the underlying federal and state statutes."

Coppied in block from Britbart because their link does not work and this problem rises to the level of an epidemic conspiricy of sexual assault and the message is urgent likewise. The origional article may be from the Detroit Free Press.

I'm licensed in Michigan and my Interpritation of Michigan State law requires reporting of sexual assault on a minor. I once saw a case of FGM in Colorado. The young girl was unable to urinate and in extreem pain. her Aunt brought her in without consent of the parents. I was able to catheterize and get her to a gynachologist for a more lasting repair. The case was reeported. Parental consent gives way to   Sexual assault and life threatening circumstances ind injury, indeed.

Mutilization does not fully charactorize the disfigurement I encountered. If this FGM is religion, such a religion is savage and uncivilized.