Salk or Sabin? Using Both Polio Vaccines is Best, Study Reports

New research shows that the inactivated, injectable polio vaccine boosts mucosal immunity, making it an ideal tool to use with the oral vaccine to end poliovirus transmission. (Image: ©

New research shows that the inactivated, injectable polio vaccine boosts mucosal immunity, making it an ideal tool to use with the oral vaccine to end poliovirus transmission. (Image: ©

New research appears to have resolved a polio vaccine debate raging for more than 50 years: Is it more appropriate to use the oral, attenuated vaccine developed by Albert Sabin, MD, or the inactivated, injectable vaccine that Jonas Salk, MD, introduced?

The answer, based on a study published online today in Science, is that using both is best.

“This study has really revolutionized our understanding of inactivated polio vaccine and how it can fit within the global eradication program to help get this finished as quickly as possible,” coauthor Bruce Aylward, MD, MPH, the World Health Organization’s (WHO) assistant director-general of polio, emergencies and country collaboration, said during a press briefing.

Sabin’s oral formulation became the vaccine of choice in global eradication efforts because it induces superior mucosal immunity, is easy to administer, and costs less. Local immunity at mucosal surfaces such as those lining the gastrointestinal, respiratory, and urogenital tracts is important because they’re major entryways for viruses and other pathogens to enter the body.

However, the oral vaccine also has drawbacks. Mucosal immunity wanes over time, so multiple doses are necessary. Revaccination can be difficult or impossible in conflict zones such as Afghanistan, Nigeria, and Pakistan, where poliovirus remains endemic.

Also, the virus used to make the oral vaccine is weakened but still alive. It can be shed in feces, which increases local, national, and international transmission risks. On very rare occasions it can cause polio in the person who is vaccinated.

Scientists already knew that the inactivated vaccine prevented paralytic polio disease by spurring antibody production. But they weren’t certain about its role in mucosal immunity. So an international research team led by Hamid Jafari, MD, director for polio operations and research at WHO, enrolled nearly 1000 children in a clinical study to determine whether the inactivated vaccine boosts mucosal immunity. The trial took place in the Uttar Pradesh state of northern India, a longtime stronghold for the virus.

Children in the trial already had received multiple doses of oral vaccine as part of immunization programs. For the trial, they randomly received 1 dose of inactivated or oral vaccine, or no vaccine. Four weeks later, all the children received a 1-dose challenge with oral vaccine. At 3 follow-up periods during the next 2 weeks, the investigators measured poliovirus excretion in their stool—a sign of being infectious.

Compared with the control group, children who received the inactivated vaccine excreted anywhere from 39% to 76% less virus in their stool, depending on poliovirus type and children’s age. Older children excreted more virus than younger children. Only the older children who received oral vaccine excreted significantly less virus than controls.

“Giving inactivated polio vaccine makes people very, very less infectious,” Jafari said during the press briefing.

Since 1988, global eradication efforts have reduced polio cases by 99%. But Jafari said that effort now is at a crossroads. Endemic polio is confined to unstable regions that often are inaccessible to outsiders. “Yet the virus in these areas persists with incredible tenacity and threatens the increasingly vulnerable populations in polio-free countries with a weak or conflict-affected health system,” he noted.

“Inactivated polio vaccine will be a powerful additional tool in our arsenal to fight this disease in these remaining areas,” Aylward added.

The Global Polio Eradication Initiative’s strategic “endgame” plan calls for the introduction of inactivated polio vaccine by the end of 2015 in countries now using only the oral vaccine. “Both vaccines complement one another and should be used to interrupt the final chains of transmission to obtain a polio-free world in the most rapid and effective way possible,” coauthor Roland Sutter, MD, the WHO’s coordinator for research and product development, polio operations and research, said during the briefing.


JAMA Forum: Tackling the Ebola Epidemic

Lawrence Gostin, JD

Lawrence Gostin, JD

The Ebola virus epidemic in West Africa is now out of control, but it shouldn’t have come to this. Ebola virus disease (EVD) is a preventable disease, but the current epidemic is challenging efforts to contain it. Previous outbreaks that have occurred since the virus was first detected in 1976 have been confined to rural areas. This time, EVD has reached the urban landscape, with people and animals congregating together. Extensive travel across land borders and by air is furthering its spread.

Why Ebola Is Out of Control

The most affected countries—Guinea, Liberia, and Sierra Leone (with recent spread to Nigeria, which currently has a dozen cases)—are ranked lowest in global development and do not have the basic infrastructure to contain the Ebola epidemic. Even with international help, it will take at least 6 months to bring the crisis under control, according to Médecins Sans Frontières/Doctors Without Borders. For now, Ebola is spreading unchecked because of such factors as fragile health systems in resource-poor countries, cultural practices, and deep-seated distrust.

Broken Health Systems

Being treated or working in a hospital in affected states is hazardous. Health professionals are the most susceptible: they typically care for infected patients without personal protective equipment and infection controls; they lack training in differential diagnosis of and treatment for EVD; and they are underpaid. Patients, too, perceive that hospitals in the affected countries are unsafe places that offer little effective treatment. Consequently, patients with Ebola-type symptoms stay away, and those who need treatment for myriad health problems—from AIDS and malaria to cancer and heart disease—remain untreated in the community.

The persistence of traditional burial and other cultural practices in West Africa also make it more difficult to contain Ebola. Loved ones come in close contact with the deceased, including ritual touching and bathing. Burial practices create the conditions for transmitting EVD, which then can be spread throughout the community. Another practice, consuming bush meat, which might include animals that are reservoirs for Ebola virus, is a traditional source of food, especially for poor Africans, providing life-sustaining protein. Women, as the traditional caregivers, are more likely to contract the virus than men.

Further challenging attempts to contain the spread of Ebola are common misperceptions, such as the belief that aid workers from medical groups were spreading the disease. Public education has been neglected and governments have curtailed accurate news reporting about the crisis. Epidemic control requires trust and an informed public, so risk communication is fundamental to controlling Ebola’s spread.

Ethical Issues

Also related to the issue of trust has been the use of scarce experimental therapies. More than 20 Ebola outbreaks have erupted in sub-Saharan Africa, yet the world was unprepared for the current tragedy, with no licensed vaccines or treatments. (This lack of readiness would not have surprised Albert Camus. As he wrote in The Plague, “Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads.”)

An experimental drug called ZMapp, which has neither been proven effective nor tested for safety in humans, was available in scarce amounts and was administered to 2 US aid workers and, reportedly, to a Spanish priest. The last remaining doses have now been delivered to West Africa, but the initial perceived preference given to white foreign workers fueled a sense of injustice. Although selecting who should get the untested treatment is an agonizing choice, it’s my opinion that priority should be given to African health workers, who die of Ebola in far greater numbers than do foreign workers. In any case, it is vital that allocation decisions be made fairly and transparently. The decision to treat the foreign workers was made behind closed doors without community consultation. Going forward, high-resource countries should create public-private partnerships to ramp up development and rigorous evaluation of vaccines and treatments.

Militarization of a Disease

Adding to the distrust that hinders attempts to control the epidemic is local populations’ fear not only of Ebola but also of the militarization of the disease. Countries have erected cordons sanitaires (guarded lines preventing anyone from leaving), but are using ancient methods to enforce the quarantine. In West African hot spots, armed troops have established blockades, closed roads, and banned travel beyond the guarded perimeter.

As a result, the populace is finding it hard to obtain food and other basic necessities. Targeted travel restrictions may be necessary, but there is a smarter way to go about them, through humane care and incentives. Governments should provide people with nourishing food, health care, and psychosocial support. Transmission hot zones can’t be ignored, but neither can the needs and human rights of communities.

What Can Be Done Now? A “Health Systems Fund”

Fragile health systems are at the root of the problem, and bolstering them is a key to fighting Ebola and preventing another uncontrolled outbreak. Affected countries are unprepared for Ebola’s complexities; they are unable to provide all their people basic health services, much less the requirements of an Ebola response, including full body protective gear, specially trained health workers, isolation units, and advanced laboratory capacity with higher biosafety capabilities. Building strong health systems would rebuild the most basic community asset: trust. Looking ahead, the international community should mobilize to provide sustainable funding scalable to needs.

This crisis represents a manifest failing of the international community, particularly its wealthier members, which ought to have been generous in supporting surveillance and response capacities obligatory under the International Health Regulations (IHR). The World Health Organization (WHO), the World Bank, and the United States Agency for International Development, among others, have made notable pledges of support. But what the region needs now is an assurance that these funds will be ample and sustainable.

To address this need, I propose an emergency, and then an enduring, “Health Systems Fund” administered by WHO (with participation of local governments and civil society) and supported by high-resource countries. Considering the funding needs, an immediate (emergency) down payment of $200 million is needed for the affected countries and their at-risk neighbors. The money should be spent to strengthen health systems. Building on recent pledges of support, these additional funds could reward and motivate frontline health workers, ensure humane conditions in communities subjected to cordon sanitaire, and establish surveillance and response preparedness.

This fund would be surprisingly affordable, with this initial installment of funding representing only 1% of international health assistance. Growing the fund over time into a multibillion dollar funding channel for lower-income countries would finally make it possible to mobilize the resources envisioned in the IHR, as well as the growing global commitments to universal health coverage. Eventually, the fund might be merged with the Global Fund to Fight AIDS, Tuberculosis and Malaria into a new Global Fund for Health.

It is in all states’ interests to contain health hazards that may eventually travel to their shores. But beyond self-interest are the imperatives of health and social justice: a humanitarian response that would actually work, now and for the long term.


About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Diagnosing Obstructive Sleep Apnea is Covered in New Guideline

A new clinical guideline advises that people who are excessively sleepy during the day should be evaluated for obstructive sleep apnea and, if needed, undergo a sleep study. (Image: ©

A new clinical guideline advises that people who are excessively sleepy during the day should be evaluated for obstructive sleep apnea and, if needed, undergo a sleep study. (Image: ©

People who are unusually sleepy during the day for no apparent reason should be evaluated for obstructive sleep apnea and, if needed, undergo a diagnostic sleep study, according to a new clinical guideline.

Published today in the Annals of Internal Medicine, the guideline from the American College of Physicians (ACP) is based on reviews of peer-reviewed studies published from 1966 through May 2013. The ACP’s review of the medical literature evaluated how effectively different types of sleep tests can diagnose sleep apnea.

In people with obstructive sleep apnea, breathing slows or briefly stops because the airway becomes blocked during sleep. The result is poor sleep and excessive daytime sleepiness. Obesity is the best-documented risk factor, according to the guideline.

“Obstructive sleep apnea is a serious health condition that is associated with cardiovascular disease, hypertension, cognitive impairment, and type 2 diabetes,” ACP President David Fleming, MD, said in a statement. “It is important to diagnose individuals with unexplained daytime sleepiness so that they can get the proper treatment.”

Obstructive sleep apnea affects about 10% to 17% of the US population, according to the ACP. Estimates vary because researchers have used different criteria to define the condition in clinical studies.

Clinical symptoms include unintentionally falling asleep, daytime sleepiness, unrefreshed sleep, fatigue, insomnia, and snoring. For patients with these signs and no other potential causes of obstructive sleep apnea—thyroid disease, gastroesophageal reflux, or other respiratory conditions, for example—the guideline recommends a sleep study.

The preferred type of sleep study is polysomnography conducted overnight with observation in a sleep laboratory. Polysomnography monitors breathing, airflow, brain activity, blood oxygen levels, and certain muscle movements during sleep.

However, polysomnography is expensive and requires specialized equipment and personnel. For patients without access to a sleep laboratory and who don’t have other chronic medical conditions, the ACP recommends portable sleep monitors that can be used at home or in a hospital.

Fleming said diagnosing obstructive sleep apnea is in line with the ACP’s High Value, Cost-Conscious Care Initiative, which addresses providing quality care while reducing unnecessary costs.

“Prior to diagnosis, patients with obstructive sleep apnea have higher rates of health care use, more frequent and longer hospital stays, and greater health care costs than after diagnosis,” he said.

Irregular Work Hours May Increase Diabetes Risk, Study Shows

Working irregular hours may increase the risk of developing diabetes, according to a new study. (Image: ©

Working irregular hours may increase the risk of developing diabetes, according to a new study. (Image: ©

A new study adds diabetes to the list of health ailments linked with working irregular hours outside of a usual 9-to-5 schedule.

The findings show that people who’ve ever had shift-work jobs have a 9% increased risk of developing diabetes compared with those who consistently worked daytime hours. The study, published online today in Occupational and Environmental Medicine, also showed that the increased risk was highest, 42%, in people who worked rotating shifts involving daytime, evening, and nighttime hours.

Men who worked irregular hours had a 37% increased risk of developing diabetes compared with 9% for women. The researchers called the sex difference “an interesting phenomenon.” They said the finding “suggests that male shift workers should pay more attention to the prevention of [diabetes], and provides a clue for future study of how the biological mechanisms of shift work and [diabetes] are affected by gender.”

The study is a meta-analysis based on 12 studies involving 226 652 participants, including 14 595 who had diabetes. Despite previous research that linked shift work with increased risks of breast cancer and of heart attack, study results attempting to show an association with diabetes have been inconsistent.

But several physiological clues are known, the study authors noted. “Some studies have shown that insufficient sleep and poor sleep quality may develop and exacerbate insulin resistance,” they wrote. “Evidence from epidemiological investigation has confirmed that shift work is associated with weight gain, increase in appetite, and adiposity, which are major risk factors for [type 2 diabetes].” Irregular work hours may influence diabetes risk by leading to harmful changes in blood pressure and cholesterol levels, they added.

Diabetes is a major public health challenge in industrialized and developing countries, the study authors noted. “By the year 2025, the number of cases of type 2 diabetes mellitus will have increased by 65% to reach an estimated 380 million individuals worldwide,” they wrote.


After Chikungunya Virus Transmission Detected in United States, Health Authorities Brace for Wider Spread

US public health authorities are targeting the mosquitos, like this female Aedes aegypti, that spread chikungunya, a virus that causes severe joint pain. Image: CDC/James Gathany

US public health authorities are targeting the mosquitos, like this female Aedes aegypti, that spread chikungunya, a virus that causes severe joint pain. Image: CDC/James Gathany

The chikungunya virus has officially arrived in the United States. On July 17, public health authorities confirmed the first 2 cases of local transmission of the virus in the United States in Florida.

An abrupt onset of a fever higher than 102°F and severe pain or swelling in multiple joints are hallmarks of chikungunya infection, said Anna M. Likos, MD, MPH, state epidemiologist and director of the division of disease control and health protection at the Florida Department of Health. Patients may also develop a rash, muscle pain, or headache, according to the US Centers for Disease Control and Prevention (CDC). On average, symptoms appear 3 to 5 days after exposure but can occur 1 to 12 days after exposure.

The spread of chikungunya virus within the continental United States was not unexpected, said health authorities. On December 2013, the World Health Organization reported the first local transmission of chikungunya virus in the Western Hemisphere, in the Caribbean. Within months, the disease spread through much of the Caribbean and Central and South America.

Reflecting this spread, the number of US travelers who became infected with the virus during travel to affected regions also has rapidly climbed, with 234 as of July 15, according to the CDC.

The species of mosquitoes that spread the virus, Aedes aegypti and Aedes albopictus, live in the southeastern United States and parts of the Southwest, and A albopictus can also be found in the Mid-Atlantic states and lower Midwest. Amy Vittor, MD, PhD, an infectious disease physician at the University of Florida, noted that the currently circulating strain of chikungunya in the Americas is spread more easily by A aegypti, which is less common in the United States than A albopictus.

However, chikungunya is unlikely to spread as extensively in the continental United States as it has in the Caribbean and other parts of the Americas. J. Erin Staples, MD, PhD, medical epidemiologist with the CDC’s division of vector-borne diseases in Fort Collins, Colorado, noted that US individuals spend far less time outside and typically have air conditioning and door and window screens.

The spread of chikungunya infection in the United States will likely be similar to the spread of dengue virus, which is transmitted by the same mosquitoes. Staples noted that during 2013 there were about 2.4 million cases of dengue reported in the Caribbean and Central and South America, 773 travel-related cases in the United States, and 48 cases of local transmission in the continental United States. However, in contrast to dengue, for which many infections are mild or asymptomatic, an estimated 80% of people infected with chikungunya will likely develop symptomatic disease. Most recover, but some have lasting joint pain.

During the last large-scale chikungunya outbreak in 2006 in Africa and Southeast Asia, a single mutation caused a change in the virus that allowed A albopictus to spread it more efficiently. Vittor explained that if a similar mutation occurs in the currently circulating strain, the United States will be at greater risk of local transmission.

“It will be a game changer,” she said.

Public health officials in Florida are working to quickly curb spread of the virus. The department has reached out to public health directors and physicians throughout the state and is trying to identify every travel-associated and locally transmitted chikungunya case. Once a case has been identified, the department works with local mosquito control agencies to prevent local transmission by stepping up mosquito abatement efforts.

“We are taking steps to ensure we are finding every case,” said Likos.

The Florida Department of Health recommends that individuals living in or visiting areas where chikungunya infection is spreading take steps to prevent mosquito bites throughout the day (because the mosquitoes that carry the virus are active and bite during the day), by using insect repellent, wearing long sleeves, and making sure window and door screens are intact and closed. The department also recommends that Floridians be careful to remove standing water from boat covers, pots, and other places water collects to eliminate potential breeding sites for chikungunya’s mosquito vectors.

Updated information about chikungunya is available on the CDC’s website.

More Flu Patients Get Antibiotics Than Antivirals, Study Reports

Antiviral medications such as oseltamivir are too infrequently prescribed for patients with the flu, according to a new study. (Image: ©

Antiviral medications such as oseltamivir are too infrequently prescribed for patients with the flu, according to a new study. (Image: ©

Prescriptions for antibiotics outpaced those for antiviral medications by 2 to 1 among patients with confirmed influenza at several care centers during the 2012-2013 flu season, according to a new study.

The findings, published today in Clinical Infectious Diseases, show that many patients at high risk of developing complications from the flu missed out on antiviral medications’ potential benefits. At the same time, others were exposed to adverse effects from antibiotics that offered them little or no benefit and contribute to antibiotic resistance.

The investigators analyzed data from 6766 patients treated for acute respiratory illness at 5 ambulatory care centers in the US Influenza Vaccine Effectiveness Network. Participants in the study were at least 6 months old, had a cough for not more than 7 days, and were tested for influenza with polymerase chain reaction (PCR).

Among all participants, 7.5% received a prescription for an antiviral medication—oseltamivir or zanamivir, which are neuraminidase inhibitors that specifically target the influenza virus. Of the entire group, 35% had PCR-confirmed influenza.

However, the investigators noted that few clinicians adhered to published guidelines. Antiviral medication is recommended for patients whose flu symptoms began within the previous 2 days and have risk factors for developing complications: being aged 2 years or younger or 65 years or older, pregnant, morbidly obese, or having 1 or more chronic illnesses, including compromised immunity.

But only 19% of the 1021 high-risk patients in the study who presented within 2 days of symptom onset were prescribed antiviral medications. Among the 2366 participants with PCR-confirmed influenza, 15% received an antiviral prescription. Of the 1825 patients with PCR-confirmed influenza for whom antiviral and antibiotic data were available, 30% were prescribed an antibiotic and 16% received an antiviral prescription. Antibiotic prescribing data covered amoxicillin-clavulanate, amoxicillin, and azithromycin.

The investigators noted that antiviral prescribing patterns varied widely among the 5 study sites, from 9% to 19% of patients with PCR-confirmed influenza. Antiviral prescriptions also were less frequent among children than adults, including high-risk children younger than 2 years.

In an accompanying editorial, Michael G. Ison, MD, MS, of the Northwestern University Feinberg School of Medicine in Chicago, wrote that the study “clearly demonstrates that antiviral treatment was underutilized and antibacterial therapy was likely overutilized by clinicians caring for outpatients with influenza.”

Ison added that a particularly troubling aspect of the findings “is that these [participants] were seen at centers with expertise in influenza research that should, theoretically, be more attuned to the importance of antiviral therapy, particularly in the high-risk [patients].”

He also noted that the study may underestimate antibiotic prescriptions for influenza because, in addition to the 3 for which data were available, other antibiotics such as cephalosporins and fluoroquinolones may be prescribed for acute respiratory infections. The drugs not only contribute to major public health risks from antibiotic resistance, they also expose patients to the risk of adverse effects including diarrhea and severe inflammation of the colon caused by Clostridium difficile infection.

The study’s authors wrote that their findings “reinforce the need for continuing education on the appropriate use of antibiotic and antiviral agents for patients presenting with acute respiratory illness.”


JAMA Forum: Women’s Rights Are Human Rights—Aren’t They?

Eli Adashi, MD, MS

Eli Adashi, MD, MS

So far, this summer has brought some interesting developments in the area of international women’s rights. Although precious few gains made it to the winning column, those that did were worth the wait. The common thread for these developments was Congress’s annual push-and-pull ritual in crafting the FY 2015 State and Foreign Operations Appropriations spending bill, which includes a large proportion of funding for US global health programs.

Here are some of the highlights.

Peace Corps Volunteers and Abortion Coverage

Since 1979, health coverage for Peace Corps volunteers has excluded coverage for abortions, even in the context of rape, incest, or when a pregnancy endangers a woman’s life. No other federal employees, and that includes Peace Corps employees, are similarly constrained. In a surprise move on June 24, the House Appropriations Committee approved an amendment to the House version of the State and Foreign Operations Appropriations spending bill (HR 5013) for next year, proposed by Rep Nita Lowey (D, NY), to remove this exclusion on Peace Corps volunteers in cases of rape, incest, and life endangerment.

This outcome could hardly have been anticipated. The House Appropriations Committee’s actions followed in the footsteps of its Senate counterpart, which approved a comparable measure on June 19 within the framework of its version of the spending bill (S 2499). The amendment, previously introduced as a stand-alone bill known as the Peace Corps Equity Act of 2013(S 813), was reintroduced in the Senate in May by Sen Jeanne Shaheen (D, NH). Given the bicameral consensus on this matter, all indications are that the provisions in question will be deemed exempt from further negotiation between the chambers and that coverage for abortion in the face of rape, incest, or life endangerment will in all likelihood be available to Peace Corps volunteers when the appropriation legislation is enacted into law later this year.

Global Gag Rule

The Senate version of the State and Foreign Operations Appropriations spending bill (again inspired by an amendment proposed by Sen Shaheen) also included a provision to permanently repeal the 1984 “global gag rule,” also known as the Mexico City Policy. This requires US-funded foreign nongovernmental organizations (NGOs) to certify, as a condition for receiving family planning assistance, that they would not perform or promote abortion as a method of family planning, even with funds from another source. The policy further requires US-funded foreign NGOs to refrain from providing information, referrals, or access to legal abortion and from advocating for local laws that would legalize abortion or provide access to it.

The global gag rule is currently in a state of abeyance by dint of an Executive Order by President Obama. The amendment, which would permanently repeal the policy if signed into law, was approved in the Senate committee with a significant bipartisan margin of 19 to 11.

In contrast, the House Appropriations Committee unveiled a FY15 State and Foreign Operations Appropriations spending bill that would reinstate the global gag rule. As articulated under the provision titled “Limitations on Family Planning/Reproductive Health,” the House version of the appropriation bill “prohibits funds for population planning activities or other population assistance to foreign nongovernmental organizations that promote or perform abortion, with certain exceptions.” An amendment by Rep Barbara Lee (D, CA) to strike the global gag rule from the draft version of the House bill failed on a vote of 19 to 25. If past precedent is any indication of the final outcome, any and all language applicable to the global gag rule is likely to be deleted in the upcoming conference between House and Senate negotiators, as it has under previous Democratic administrations.

United Nations Population Fund

Congress also revisited, as it does annually, the multilateral funding of the United Nations Population Fund (UNFPA) to support the UNFPA’s quest to ensure universal access to reproductive health. In this context, the House’s version of the FY15 State and Foreign Operations Appropriations spending bill included a proviso stipulating “no funds for the United Nations Population Fund.” An amendment by Rep Rose DeLauro (D, Conn) to reverse the funding ban in the draft bill was defeated on a vote of 20 to 26.

In contrast, the Senate version of the spending bill resolved that $37.5 million “shall be made available for the United Nations Population Fund” subject to the condition that the “UNFPA does not fund abortions.” While the final resolution of this intercameral disagreement is far from certain, past precedents suggest that the UNFPA will live to be funded another year.

The time frame for the enactment of the House and Senate committee–approved bills remains to be determined. However, with only a limited number of days left on the legislative calendar before the new federal fiscal year (October 1, 2014) and with adjournment planned for the 2014 midterm November elections, floor action seems unlikely. More likely than not, an interim (if unresolved) version of bill will likely be incorporated into a “continuing resolution,” until such time that a lame duck session of Congress convenes after the election.

The arcane congressional debate on the funding of international women’s health services may come across as a surreal throwback to times long gone by. It is precisely this harsh if improbable reality which prompts one to wonder all over again: women’s rights are human rights—aren’t they?


About the author: Eli Y. Adashi, MD, MS ( is a professor of medical science and the former dean of medicine and biological sciences at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. A member of the Institute of Medicine, the Association of American Physicians, and the American Association for the Advancement of Science, Dr Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, ethics, and social justice. A former Franklin fellow, Dr Adashi served as a senior advisor on Global Women’s Health to the Secretary of State office of Global Women’s Issues during the first term of the Obama Administration.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.