It’s the cracks that let the light get in

Bob Hatcher

Happy New Year!  May the year ahead be special for you, your family, Rabun County and for our nation.

The last days of a month or of a year are so special. They are times for reflection and for starting out on a new path.  I love beginnings. Beginnings of a new day are the very best.  Beginnings of a new month permit us to consider work on a fairly significant task.  Beginnings of a new year permit us to play with even bigger challenges.

Beginnings reach out to me and ask: what’s in store for the day ahead, the month ahead and the year ahead.  Each day is so special and so is each month and each year.

Our minister at the Saint James Episcopal Church, Stephen Hall, is always inspiring.  The twinkle in his gentle smile lights up the face of his congregation over and over again. Sometimes his smile says “I’m content.”  Other times it’s a Cheshire cat smile on his face that says “I know something.” And if our faces, in the congregation sitting before him, cannot be lit up by his favorite subject, the subject of love, we have missed the point of life.

The final line of Les Miserables encourages us to see God through love. “To love another person is to see the face of God” is how this great production ends. How powerful is this line!!

On December 20^th, Stephen Hall quoted Leonard Cohen’s words:

Ring the bells that still can ring.

Forget your perfect offering.

There is a crack in everything.

That’s how the light gets in.

Each of us can begin each day, month or year seeking the answer to one question: how can I reach out to others or to just one specific person in love today, during the upcoming week or the year ahead?

We need not worry about how big an effect our love may have.  It may be just the right amount of light for a person needing love. So let it out over and over again, that love within you. And, again, HAPPY NEW YEAR!

Three of Randy Plausch’s rules for living put it this way:

#1: TIME IS FINITE. Time must be explicitly managed, like money.

#2: You can always change your plan, but only if you have a plan.  I’m a big believer in TO-DO lists.

#3: Ask yourself “Are you spending your time on the right things”?

Share on Facebook

Silent Night in Bethlehem

Dr. Bob Hatcher

On my third trip to Amman, Jordan, my friend Dr. Gary Stewart covered for me.  He took over my teaching responsibilities for one day and off I went in a bus to Jerusalem. What a day lay ahead of me.

First stop on the way over was just before we crossed the river Jordan. The great river Jordan is no longer all that great. It has become a filthy muddy stream. The water crisis in the Middle East has changed this river, threatening its very existence. Huge withdrawals for irrigation, rapid population growth, and a paralyzing regional conflict have drained nearly all the water from this fabled river.

In 2008 large sections of the Jordan River were reduced to a trickle, the water level so low that grass fires spread freely across the Jordan Valley between Israel and Jordan.

Because of long delays at the checkpoint, it was early afternoon before I arrived in Jerusalem.  I hired a driver immediately and we made two stops. First we went to the Holocaust museum. The Hall of Remembrance is stark with severe concrete walls and a low tent-like roof. It stands empty, save for the eternal flame. Engraved in the black floor are the names of 21 Nazi extermination camps, concentration camps and killing sites in central and eastern Europe

The approach to the Hall of Remembrance is lined with trees planted in honor of non-Jewish men and women – “Righteous among the Nations” – who, at the risk of their own lives, attempted to rescue Jews from the Holocaust.

Approximately 1.5 million Jewish children perished in the Holocaust. They are specially remembered in the nearby Children’s Memorial, an underground cavern.

The Memorial to the Deportees is a cattle-car which was used to transport thousands of Jews to the death camps. Perched on the edge of an abyss facing the Jerusalem forest, the cattle-car symbolizes both the impending horror, and the rebirth which followed the Holocaust.

Late that afternoon we went to nearby Bethlehem. Well below street level I saw the place the manger was where Jesus was born.  I sat memorized by the sounds of 15 to 18 German teenagers singing Silent Night in German, sounding for all the world like my mother and her identical twin (of German lineage) singing Silent Night in German each Christmas.  It was emotionally so powerful, thinking of Jesus’ birth and of my mom and her sister.

The next morning that same driver picked me up very early and drove me on the route Christ walked carrying the cross. The Via Dolorosa is the route tradition says Jesus followed from his condemnation by the Romans to the spot where he was buried after the crucifixion. I was able to enter the garden of Gethsemane.  There was not another soul there. Several of the gnarled olive trees, it is said, were there when Christ was there. Who knows if they were.  That doesn’t matter.

My visit was incredible, simply one of the most powerful experiences in my life.

Share on Facebook

The Global Pattern of Vasectomy Use

Vasectomies, or male sterilization, are a highly underutilized method of family planning, although they are safer, simpler, less expensive and equally as effective as female sterilization. Throughout the world, vasectomies are one of the least used and least known methods of contraception¹. The number of female sterilizations exceeds the number of male sterilization in a 5 to 1 ratio. This divide has been increasing since 1982 (Figure 1). In the developed world, female sterilization is twice as common as male sterilization. In Asia, it is 8 times more common, while in Latin America and the Caribbean it is 15 times more common. The rates of male sterilization in sub-Saharan Africa are too low for an accurate comparison. Worldwide, approximately 43 million couples rely on vasectomy, while approximately 210 million couples rely on female sterilization as their method of family planning.

 Figure 1: Estimated Number of Couples Worldwide Relying on Vasectomy and Female Sterilization (in millions), 1982-2007

The need for family planning services will continue to rise as desire for contraceptive use grows and as the population of the world increases. While the need will increase, the donor assistance for family planning is projected to decline and in many areas health care resources will become increasingly constrained. Vasectomy use should be promoted because it is one of the most cost-effective contraceptive methods and it is low-cost for clients over time. Due to the relative simplicity of performing a vasectomy, it can be offered in a wide variety of settings including primary health care clinics and private physicians’ offices.

The percentage of women who are relying on vasectomy as their method of contraception is higher in developing countries than it is in developed countries (2.5% vs. 4.5%). The vasectomy prevalence is highest in Oceania and North America (United States and Canada) (Figure 2). In North America, 12% of married women of reproductive age are using vasectomy as their contraceptive method, while in Oceania 10% of women are using this method. In Africa, the prevalence of vasectomy is extremely low. While the percentage of individuals who rely on vasectomies is fairly low in Asia, the number of people who have received vasectomies is high at 22.5 million. Asia accounts for 77% of vasectomies worldwide. China and India alone have 70% of the world’s vasectomy users.

Figure 2: The Global Pattern of Vasectomy Use 

Vasectomy is more common than female sterilization in only 5 countries. These countries are Bhutan, Denmark, the Netherlands, New Zealand and Great Britain. In 8 countries worldwide, (Australia, Bhutan, Canada, the Netherlands, New Zealand, the Republic of Korea, Great Britain and the United States), the prevalence of vasectomy use exceeds 10%. New Zealand has the highest prevalence of vasectomy at 19.3%. It has been a widely used method of contraception since the 1970s. In the 1980s, it became more widely used than female sterilization². A survey conducted in the late 1990s in New Zealand found that 57% of men aged 40 to 49 had received vasectomies.

 Overall the prevalence of vasectomy is lower in developing countries. The use of vasectomy is particularly low in sub-Saharan Africa. Even though vasectomy services have been introduced in some sub-Saharan African countries such as Ghana, Kenya, Malawi, Rwanda and Tanzania, in the vast majority of sub-Saharan Africa the prevalence rarely exceed 0.1% and has remained relatively stable throughout the past decade. The two African countries with a slightly higher rate of vasectomy are Namibia and South Africa at 0.8%. The prevalence of vasectomies also remains low in Latin America and the Caribbean. The vast majority of countries in this region have a vasectomy prevalence lower than 1% with the exception of Brazil, Columbia, Guatemala and Mexico. These countries have a slightly higher prevalence due to an increase in donor support programs for vasectomies during the 1980s and the early 1990s. Furthermore, with the exception of Bhutan, Iran, and the Republic of Korea, the vasectomy prevalence has steadily declined in Asia over the past 15 years.

The vasectomy is underutilized because of various service-delivery and cultural and community barriers.  While the blame for underutilization has been placed on men, various studies have suggested that men would like to become more involved in family planning and become active participants in avoiding unintended pregnancies.

One group of barriers encompasses those relating to the service-delivery of vasectomies. In many countries, there is a shortage of committed and skilled providers. The providers may have little knowledge about counseling men on the advantages and disadvantages of vasectomies. Even if the providers are trained, their working environment may not be conducive for counseling or surgical procedures. Furthermore, the providers’ attitudes serve as a barrier to vasectomies in many locations. The providers may hold an indifference to vasectomies, a bias against vasectomies, or they may have untested theories about what people want as a method of family planning. Overall, vasectomies are more difficult to obtain than nearly every other family planning method worldwide.

Culture and community aspects influence the ability and willingness of men to obtain a vasectomy. According to Demographic and Health Surveys (DHS), vasectomies are the least known method of family planning. Fewer women said that they had heard of vasectomies than oral contraceptives, IUDs, injectables, condoms or female sterilization. Additionally, vasectomy use can be undermined by cultural ethos and beliefs. In many cultures, men dictate if their wife uses family planning, but do not believe that utilizing a method is their responsibility. Some men hold misconceptions or they believe cultural myths about vasectomies. In certain societies, a widely held belief is that vasectomies are equivalent to castration. Other popular myths include that castration negatively affects sexual function and that it decreases physical strength.

Various strategies should be implemented that aim to increase vasectomy use. Men should be the target of educational campaigns to increase acceptance of and knowledge surrounding vasectomies. Multimedia campaigns have been proven to increase vasectomy use in Brazil, Columbia and Guatemala. When these campaigns were implemented, vasectomy use increased by two fold. Men are generally easier to reach with multimedia campaigns because they usually have an increased access to mass-media and community-level communication. Information should be delivered to men through community talks, home visits, and the mass media to create awareness about vasectomy. Additionally, telephone hotlines can be an effective tool to increase vasectomy use. Telephone hotlines offer men a private and confidential session to learn about vasectomies. Furthermore, men who are satisfied with their vasectomy can be recruited to educate others about their experience in order to increase vasectomy use. Programs in Asia, Latin America and Africa have demonstrated the success of this method.

Vasectomy use can also be increased through targeting the staff and clinics at healthcare centers.  Additional trainings should be offered for staff in order to create competent, committed staff who can effectively communicate with men. The staff members should hold positive attitudes towards vasectomy. The staff should be periodically updated about men’s reproductive health. Staff members should be responsible for fostering a positive attitude about vasectomies in their clients. The staff should also be trained on how to counsel men about the various vasectomy options. It is often times beneficial to promote the “no-scalpel” method. Also, staff that provides family planning services to women should be trained to discuss vasectomies as a contraceptive option Changes should be made in clinics to promote vasectomy use. The clinics should be spacious and contain the necessary supplies and equipment needed to perform vasectomies. 

Vasectomy use can also increased by making services more “male-friendly.” The vasectomy service should encourage the participation of men and treat all men politely and courteously. Providers should encourage women to bring their partner in for counseling and services. Clinics should furthermore extend hours and locations so that the services are readily available to men. Separate hours or a separate clinic for men might encourage more men to come for testing, counseling and perhaps a vasectomy because it provides increased privacy and a supportive environment.

 In most areas of the world, vasectomies are a highly underutilized form of contraception. Overall, the number of female sterilizations performed is five times higher than the number of vasectomies performed. The rates of vasectomies are higher than the rates of female sterilization in only five countries. The rates are relatively high in Oceania and North America, and very low in parts of Asia and nearly all of Africa. There are currently many barriers to vasectomy that stem from inadequate service delivery of vasectomy and from cultural and community beliefs. Strategies aimed to overcome these barriers must be introduced so that the vasectomy prevalence can continue to increase throughout the world.

Works Cited

¹ Jacobstein, Roy, and John Pile. “Vasectomy: The Unfinished Agenda.” ACQUIRE Project Working Paper. Aug. 2007. Web. 21 Nov. 2009. http://http://www.acquireproject.org/fileadmin/user_upload/ACQUIRE/Publications/Vasectomy_Unfinished-Agenda-FINAL_updated.pdf.

² Barone, Mark and John Pile. “Demographics of Vasectomy- USA and International.” EngenderHealth. 2009. Web. 21 Nov. 2009. http://http://www.mdconsult.com/das/article/body/173083966-2/jorg=clinics&source=&sp=22378320&sid=0/N/706390/s0094014309000470.pdf?issn=0094-0143.

³ Pile, John. “Vasectoy Advocacy Package: Safe, Cost-Effective and Underutilized.” The ACQUIRE Project. USAID, 2008. Web. 21 Nov. 2009. http://http://www.acquireproject.org/archive/files/2.0_invest_in_fp_and_lapms/2.2_resources/2.2.2_advocacy_briefs/Advocacy-Brief-5-final.pdf.

⁴“World Contraceptive Use 2007.” United Nations, Department of Economic and Social Affairs, Population Division. 2007. Web. 21 Nov. 2009. http://http://www.un.org/esa/population/publications/contraceptive2007/contraceptive2007.htm.

⁵ Ringheim, Karin. “Factors that Determine Prevalence of Use of Contraceptive Methods for Men.” Studies in Family Planning 24.2 (1993): 87-99.

⁶ Ringheim, Karin. “Reversing the Downward Trend in Men’s Share of Contraceptive Use.” Reproductive Health Matters 7.14 (1999): 83-96.

Share on Facebook

Above is a daigram of what happens when a man has a vasectomy.

Why don’t men get it?  When a man and a woman have decided that they definitely want no more children, vasectomy may be the method to consider first.

A:        Vasectomy makes a vast difference in a man’s vas deferens!  When a man and a woman have decided that they definitely want no more children, vasectomy is often the method to consider first. 

Vasectomy is far less often used than tubal sterilization in spite of being more effective, less expensive and easier to perform than the operation for women.   Vasectomy also has fewer complications, (although both procedures are very, very safe). 

Here is a summary of the problems a mother of three had using the world’s most effective reversible contraceptive and her thoughts about her husband who will not have a vasectomy done. She says

“I am 29 years old with 3 kids and no plans of having anymore. This is my second time using the Mirena IUD. I’ve had it in for about four months now. A month ago I was sitting on the couch and started having very bad pelvic pain.”

“The following day, I went to an urgent care facility, where they told me that I had pelvic inflammatory disease (PID), and wanted me to go to the hospital for intravenous antibiotics. They called my gynecologist, and he said that wasn’t necessary, just for me to come into his office Monday morning. I went to his office and he said there was no infection. He then did an ultrasound and saw free fluid behind my uterus.”

“So, fast forward: ever since then, sex is painful and I also get a stabbing pain in my right ovary. I went back to my doctor’s office today to have another ultrasound done. The doctor came in to do an examination.  Then he touched something that made me fly across the table. He then said he was going to check my Mirena.”

“Last night, after reading your email, I decided to check my strings.  I usually do this monthly and it always seemed they were where they needed to be.  The strings seemed very long and as I was checking them, my Mirena came out…right in my hand!”

“I can’t use any contraceptive estrogen. I am definitely limited on my options.  I would like for my husband to have a vasectomy, but he is too scared.  He had it scheduled and cancelled the day of my IUD expulsion.  My disappointment in him that day was indescribable.  Now, I think that we are just going to use condoms.  I don’t ever plan on having any more kids, but I feel that I gave birth three times and the least he could do is have a little snip.”

I think I agree with this woman and offered to talk to her husband.  I have no idea where in the country they are from so I gave her my phone number.  He hasn’t called.

Unfortunately, we men do less than our share in planning and raising children and in helping to avoid future pregnancies when that becomes a couple’s goal.

Share on Facebook

Spring conferences are spectacular! 

Contraceptive Technology Update Conferences this spring

San Francisco, CA – March 24-27, 2010                                  

Boston, MA – April 14-17, 2010

Just for starters, the FIRST DAY of the main Main Conference:

                                                                                                                                * = Speaking in San Francisco only

San Francisco – Thursday, March 25                                        ** = Speaking in Boston only

Boston – Thursday, April 15

8:00                     Program Overview and Objectives

            Robert A. Hatcher, MD, MPH

            Susan Wysocki, RN, WHNP-BC, FAANP

 8:10                             Understanding and Explaining Contraceptive Risk to Patients

                                    James Trussell, PhD

 8:40                             The US Medical Eligibility Criteria SO IMPORTANT!

                                                Kathryn M. Curtis, PhD (Rx = .5 hr.)

 9:15                             Condoms, With Passion and Pleasure!

            Robert A. Hatcher, MD, MPH

10:30                            Abortion Update 

                              *     Karen Meckstroth,   MD (Rx = .5 hr.)

                              **    Karen Loeb Lifford, MD, ScD

11:00                            Risky Business: Media and the Health of Adolescents

                              *     Victor C. Strasburger, MD

                              **    Michael Rich, MD, MPH

12:30                            CONFERENCE LUNCHEON & DR. FELICIA H. STEWART MEMORIAL LECTURE

                                                (Attendance is optional and requires a reservation. CE credit will be awarded. 

                              *     Topic pending

                                    Malcolm Potts, MB, BChir, PhD, FRCOG

                           **       Topic pending

                                    Judy Norsigian

 2:00                             Hot Off the Press: The New 2010 STD Treatment Guideline        

                                    Willard Cates, Jr., MD, MPH 

 2:30                                      New Data on Long-Acting Reversible Contraception: What’s the Latest?

                                   *        Alison Edelman, MD, MPH

                           ** Eleanor Bimla Schwarz, MD, MS

 3:50                             Vaginitis 

                                    Jeanne Marrazzo, MD, MPH 

I always say, I am the luckiest: I get to hear and see all these talks twice.

Share on Facebook