SAN DIEGO—At the ACR Convergence 2023 panel, Actions with Impact: Health Policy and Global Rheumatology during the annual Global Summit, four experts covered a range of policy issues relevant to rheumatologists and their patients around the world.
Dr. Edens
The first half of the session was dedicated to reproductive rights. Coughi Edens, MD, FAAP, and Maria del Carmen Zamora-Medina, MD, discussed abortion legislation in the U.S. and Mexico, respectively.
In states where abortion is criminalized, doctors may delay or withhold treatment with teratogens to avoid the risk of pregnancy termination. As a result, patients with rheumatic disease who can become pregnant, even if they aren’t planning to, have a harder time obtaining prescriptions for such drugs as methotrexate, negatively affecting their treatment.
Dr. Edens explains that, globally, abortion laws are trending more progressive over time; the U.S. is a notable exception. In June 2022, the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization ruled the Constitution does not confer a right to abortion and returned abortion regulation to state legislatures.
Fifteen states now have a total ban on abortion, forcing many people to travel out of their state for an abortion. According to Dr. Edens, 45% of patients in the U.S. cannot access a surgical abortion without driving over 90 minutes.1 The cost of such a trip is prohibitive for low-income and rural patients.
Dr. Zamora-Medina
As Dr. Zamora-Medina said, “In this context, women’s ability to dictate the course of their lives and the terms of their reproductive citizenship have depended entirely on where they live and whether they have the economic and social capital to navigate the legal, geographical and bureaucratic barriers.”
Repercussions of abortion restrictions include high rates of abortion complications and pregnancy-related deaths. States with stringent abortion restrictions typically have a lower minimum wage and fewer labor protections.2 Dr. Edens pointed out that for individuals who can become pregnant, these factors contribute to an increased wage gap and greater difficulty accessing higher education and entering the workforce.
In contrast to the U.S., the past two decades have seen tremendous advances for abortion rights in Mexico. In 1931, the Federal Penal Code criminalized abortion for both the patient and the provider, and revoked the licenses of healthcare workers who were found to have performed abortions. But by 2000, new legal exceptions were introduced, and in 2007, Mexico City legislature passed legislation that permitted elective abortion within the first 12 weeks of pregnancy.3
People from all over Mexico traveled to Mexico City to obtain legal, safe abortions. “Capacity, efficiency and quality improved rapidly,” said Dr. Zamora-Medina, resulting in a sharp decline in maternal morbidity. The Interrupción Legal del Embarazo (ILE) program, a public sector program to provide free abortion services, was a great success. Seven thousand patients received legal abortion services in the program’s first year alone.3 In 2023, elective abortion was decriminalized in Mexico at the federal level.
Juvenile Arthritis Foundation Australia Spurs National Change
Ms. Munro
The next speaker, Jane Munro, MBBS (Hons), FRACP, MPH, MHSM, discussed her work as a member of the Medical and Scientific Panel for the Juvenile Arthritis Foundation Australia (JAFA), a nonprofit organization devoted to improving juvenile arthritis care on a federal level in Australia. Founders Stephen Colagiuri, MD, and Ruth Colagiuri were inspired to start JAFA after their granddaughter was diagnosed with juvenile arthritis. They were shocked by the lack of resources available to juvenile arthritis patients and their families.
JAFA lobbied the Australian parliament for national change. One significant event in 2021 brought juvenile arthritis patients themselves before their federal representatives, where they talked about the disease’s impact on their lives. In the years since, millions of Australian dollars have been allocated to juvenile arthritis research grants, and JAFA’s efforts to spread awareness and make care more accessible have received broad government support. Dr. Munro explained that one crucial facet of JAFA’s work is securing funding to train medical professionals in the treatment of juvenile arthritis and stressed the importance of a multidisciplinary team.
Improving JIA Treatment Worldwide
Finally, Waheba Slamang, MBChB, FCPaed (SA), MPhil Paed Rhem (UCT), discussed her work improving health systems for juvenile musculoskeletal disorders in middle- and lower-income countries.
Dr. Slamang explained there is a lack of global guidance and strategic response for juvenile musculoskeletal disorders due to poor infrastructure, underinvestment and cost. These disorders are considered low priority, but because they are chronic, they place a heavy burden on healthcare systems. Dr. Slamang emphasizes the need for more accessible treatment for these disorders is tremendous, with more than a million children in Asia living with juvenile idiopathic arthritis (JIA), and more than 500,000 in Africa.
Access and affordability of medicines for JIA can be improved by adding them to the World Health Organization’s (WHO) Essential Medicine List (EML). Once a medicine has been added to the list, there are processes in place to increase its availability, standardize care, and even formalize cost agreements that make the drug more affordable to patients. But for a medication to be added to the list, the WHO must accept proof that it’s necessary. Dr. Slamang says this has been a challenge with JIA drugs because researchers can’t conduct the same kind of randomized, double-blind studies with children that they can with adults. Without such studies to document the necessity of such drugs as anakinra and tocilizumab for JIA, the WHO has declined to add them to the EML.
Overall, these speakers illustrated the many ways that policy and legislation affect rheumatological practice and equitable access to care. All four speakers urged medical practitioners to get involved with advocacy and to care for patients by working toward structural change on a government level.
Glen K. Rodman is the assistant editor of The Rheumatologist.
References
- Alterio M, Von Davies R, Tobias M, et al. A geospatial analysis of abortion access in the United States after the reversal of Roe v Wade. Obstet Gynecol. 2023 Nov 1;142(5):1077–1085.
- Badger E, Sanger-Katz M, Miller CC, et al. States with abortion bans are among least supportive for mothers and children. The New York Times; 2022 Jul 8.
- Becker D, Olaviarrieta C. Decriminalization of abortion in Mexico City: The effects on women’s reproductive rights. Am J Public Health. 2013 April;103(4):590–593.
