Our Problem With Infant Mortality

This piece was published in the Belzoni Banner, Belzoni, Mississippi, July 31, 1991.

Our Problem Of Infant Mortality

Infant mortality is a large problem in Humphreys County. In 1969 thirty percent of babies born that year died before the end of the first year of their lives. That is almost one child in three. Many babies die as a result of infectious disease, cardiac and respiratory diseases. Many die as a result of complications of the placenta or as a result of complications of maternal problems. Some babies even die from accidents.

One of my concerns is that many of the young mothers fail to obtain prenatal care. According to the Mississippi State Department of Health report on Vital Statisitics in 1969 most mothers received prenatal care in some form; most even received care beginning in the first trimester, but many (some thirty-five percent) received prenatal care late in the course or had received no prenatal care at all.

This situation is grave. The reasons for this problem is unclear. No doubt some of the problem is due to finanacial reasons; some, I suspect is out of ignorance. Many mothers cannot afford to obtain adequate prenatal care. Either money or transportation is a problem. Some, however, probably feel that they do not need prenatal caare. Some of themothers of the newly pregnant probably delivered their babies without prenatal care.

There is, too, a component of fear and denial here, too. Many teenage mother are afraid to tell their mothers oor someone that they are pregnant and postpone seeking prenatal care until the pregnancy and delivery are undeniable.

Prenatal care is provided by the health department. Until recently, however, mothers desiring private obstetrical care were required to go to Indianola, Greenwood, Greenville, or Jackson for care. Now, Belzoni has acquired physician OB services.

Still there is the problem of teenage pregnancy. Many of the mothers are teenagers. Can these mothers adequately care for their babies emotional and social needs? Many mothers are undereducated. Will these mothers have enough skills to provide adequately for the child's food, clothing and shelter needs? Can these youn women handle the social forces and problems with which they will be faced entering the twenty-first century? And what about drugs-will these children become become victims of parents who choose drugs over their children's needs?

...and Humphreys County is not the only place that has high infant mortality. India, Ethiopia, Sub-Sahran Africa, South America, and Central America, all have the same problems. Time and again there are pleas to send moneh to feed the "Poor" and we have poor right here in Humphreys County.

What do the medical, educational, religious and public helath systems have to do to get more help for young mothers? Will lectures help? Home visits? Transportation services? Where is the money going to come from and is throwing money at the problem going to help it?

These are large and complex social issues-issues that must be faaced by the public and private sectors.

Maybe we should put a moratorium on Medicaid mothers having babies like we have put a moratorium on thinkyng and acting responsible. Maybe we could require teenage mothers to work fulltime in their first trimester....or maybe we should have free prenatal and OB services? Or maybe we could legalize teenage spading? If these "suggestions" sound ludicrous it is only that we recognize that teenage pregnancy is not just their problem; it is our problem as well. The poor girls having babies are not just Black. Many people would simpoly ignore Them. Let us face it many of the mothers are White.

The support for infant mortality must come from You. The next time your hear about your child's pregnancy it is time for you to pick up your phone, and not to gossip, but to make sure your child is not pregnant and if she is, to see to it that she get prenatal care-prenatal care here in Belzoni, not miles away-unless you don't mind driving your little girl 22 miles to take care of her baby. You should see to it that your grandchild can get care. it's time to drop the "I'm better than you" approach/ attitude that gets inbred in minds when we look the other way too much. Black babies and White babies get born the same way and they die the samae way.

Wake up, Mississippi. Move ahead and preserve the unborrn child's birthright to good health and a life Before long there may be...

c 1991 Cheryl L. Branche, M. D.

Help your needy patients get free medication

This piece was published in Medical Economics on September 20, 1999.

Help your needy patients get free medication

Enroll them in assistance programs offered by pharmaceutical manufacturers—and watch the quality of their lives improve.

By Cheryl L. Branche, MD

The author, a general practitioner in Jackson, MS, for several years, recently moved to New Zealand.

For most physicians, managing a chronic illness without medication is inconceivable. Yet for many patients, paying for the prescriptions is just as impossible. As the cost of drugs skyrockets, many poor patients have to decide which pills they can get and how often they can afford to take them.

While practicing at a clinic for the homeless in Mississippi, I found a way to get free medications for many of my patients through patient assistance programs offered by about 50 major pharmaceutical companies.

These programs provide free products to eligible patients. My patients have received a wide variety of medications, from nicotine patches to AZT, covering the needs of most chronic illnesses, including heart disease, hypertension, arthritis, diabetes, and mental illness. (The programs don't help in acute care situations, however, because it can take weeks to receive the drugs.)

With a little extra time and organization, any physician can use these programs to help needy patients.

Agnes W. is an insulin-dependent diabetic. An obese woman in her 60s, she also has angina, osteoarthritis, and hypertension. Although she works as a cab driver, she's homeless.
One day, Ms. W. came to me complaining that she wasn't feeling well. Her blood sugar was so high that I sent her to the ER. Later, she told me she had stopped taking her insulin. She was on eight or nine different medications, but she couldn't afford them all.

As Ms. W. sat in my office, I contacted Lilly Cares, the patient assistance program at Eli Lilly, the manufacturer of Humulin. She qualified for the program. When I told her that she would receive a free and refillable supply of the drug, she was grateful and relieved.

Many of my patients, especially the elderly, have multiple medical problems and receive more prescriptions than they can afford to fill. It's common for patients to take a medication every two or three days—instead of daily, as prescribed—if reducing the dosage doesn't make them feel too bad. This allows them to stretch a one-month supply to two or three months.

Virtually every physician has at least one patient down on his luck. With help, that patient doesn't have to miss any medications.

Using the patient assistance programs helps make medical care a reality for poor patients by enabling them to get the drugs they need and take the medication as prescribed.
Here are the basics of dealing with these programs:

Verifying eligibility. Although the exact rules vary by company, most programs require that the patient be a US citizen.

Most of the programs are available only to patients who have no private health insurance and are ineligible for Medicare or Medicaid. Some companies, however, will help patients who have private insurance but lack coverage for outpatient prescription drugs. Assistance is also sometimes available to Medicaid patients who exceed allowable expenses. For example, Mississippi's Medicaid limits the number of medications for most adults. A patient who exceeds the allowed amount may qualify for assistance with the additional prescriptions.

The programs generally are open only to patients whose income falls below a certain level, usually the federal poverty line. Although most application forms don't request specific income information, the programs do require that the physician certify that the patient meets the requirement.

Many programs will take medical expenses into consideration when determining income eligibility. Even lower-middle-income patients can qualify, if heavy medical expenses drop their net income below the poverty level. This happens often for AIDS patients, whose medical expenses are extremely high.

Applying for assistance. List all the medications your patient takes for chronic conditions, including the manufacturers' names, addresses, and phone numbers.

Call each drug company and ask for the patient assistance program. Request a list of covered medications and enrollment applications. The company usually can fax this information to you. The list of covered products changes frequently, so call to update your information regularly. You can also find a list of patient assistance programs along with contact and other information at the Web site of the Pharmaceutical Research and Manufacturers of America (www.phrma.org/patients).

Most of the information you'll need for the application can be found on the patient's chart. Other information, such as income and expenses to verify eligibility, must come from the patient.
Mail completed forms immediately. Some programs will even accept applications over the phone.

I like to work with the patient on the application. Going through the process creates a bond between us, raises the patient's self-esteem, and reduces her feelings of helplessness. We call the company, figure out the details, and complete the paperwork together. Patients seem to appreciate the attention, and they learn that they are able to help themselves.
Don't underestimate the need for sensitivity. Disclosing information about income or assets is just as invasive for poor patients as it is for wealthy individuals.

Dispensing the medicine. Most programs mail the products to the physician's office. Patients typically receive a one- to three-month supply for each prescription. The drugs must be stored in a cool place that's easily accessible to all staff members. At our clinic, the supplies are kept in the sample closet.

It's important to record the shipment's arrival and place a copy of the packing sheet in the patient's medical file. Promptly call the patient to pick up the medications.
Some drug companies mail out coupons that can be redeemed at a pharmacy. Just give the coupon to the patient.

Many patient assistance programs allow for refills of the free products. At follow-up visits, check to see whether the patient needs a new supply of medicine.

Maintaining accurate records. Be prepared for lots of paperwork and phone calls when you start dealing with the programs. But once you're familiar with the process, things should run smoothly. I'm able to manage assistance programs for more than 50 patients with the help of a nurse and a good filing system.

Make no mistake, using patient assistance programs can be time-consuming. It takes an average of 30 minutes to enroll a patient in each program; some people are eligible for several programs for different medications. While I choose to do much of the work myself, a nurse or office assistant could handle many of the management tasks.

Whoever runs the program needs to gather the information required for each application, keep track of all correspondence and shipments, notify patients when the drugs come in, and maintain the files.

To avoid getting overwhelmed by paperwork and shipments, it is vital to maintain a well-organized filing system. Information about the patient assistance programs should be easily accessible by not only you, but also by other physicians in your practice, your nurse, and office staff.

I place all documents relating to the patient assistance programs in each patient's medical file, including copies of the enrollment forms and original prescriptions, and supporting documents such as letters and packing slips. I also instruct my staff to treat any mail about the programs as if it were a lab report: pull the patient's file and place it on my desk with the letter.
To keep track of the many different programs, what they cover, and what they require, I also have a separate file for each drug company involved. In each folder I place information about the company's program, enrollment applications, products offered, and a copy of the enrollment packet for each of my patients in the program.

Detecting which patients are financially unable to take medication as prescribed isn't always easy. Patients rarely volunteer that money is a problem or that they're not taking their medications. You have to be alert to evidence of noncompliance, and use some gentle prodding to discover which patients are having financial problems. If a hypertensive patient's blood pressure is not going down, it's possible he just can't afford the prescription. And that's where these programs can help.

Patient assistance programs aren't perfect. To get free medications, your patients will have to give up some privacy, and you and your staff will have to give up some time.

There's also the danger of choosing a medication because it's covered by a patient assistance program, not because it's the best choice for the patient. For each patient, you'll have to balance medical needs carefully with social and financial issues.

The benefits of these programs outweigh any problems in using them. Patients appreciate the attention and effort, and they become more willing to follow your advice. They'll finally be able to take the medications they need, not just the ones they can afford.

Cheyrl Branche. Help your needy patients get free medication. Medical Economics 1999;18:57.

Subungual Tumors

This piece was published in Nail Pro in September 2007.

NAIL CLINIC By Cheryl L. Branche, M. D.

Subungual Tumors
Learn to look out for these abnormalities on your clients' nails.

As a nail professional, you have the opportunity to observe the ongoing condition of your clients' nails with an informed eye. When you see an abnormality of any kind, you should think about a possible cause. While you don't need to speak about specifics, bring your observations to the client's attention and suggest that a physician check out the suspicious bump or spot. You may enable your client to benefit from the early diagnosis of a potentially debilitating disease.

For example, you can prevent unnecessary health problems through the early detection of subungual tumors. The term "subungual" refers to the location of the tumor—under the nail. Subungual tumors can be benign (noncancerous) or malignant (cancerous). In this Nail Clinic, we'll also discuss subungual tumors that are present as pigmented lesions.

Tumor Facts

• Many subungual tumors are the first signs of skin cancer, which develops largely as a result of too much sun exposure.
• Malignant melanoma, the deadliest form of skin cancer, can be present as a band of black or dark brown pigment on nails, most often seen on the thumb nail or the big toenail.
• What look like warts on the nail fold or nailbed could instead be squamous cell carci­nomas. Refer clients to their physicians.
• To protect nails, wear gloves while outside or using household chemicals, stay away from the cuticles during services and usetop coats or polishes with LUV protection.

Source: The Skin Cancer Foundation (http://www.skincancer.org/)

Benign Tumors

Several types of benign tumors exist. Subungual exostosis is a firm, tender nodule that protrudes from the distal edge of the nail, most commonly found at the medi­al edge (the side of the nail closest to the center of the body) of the big toe. The nail becomes brittle and eventually breaks or is removed. A glomus tumor is an exqui­sitely tender growth or group of blood vessels that appears as a red or purple stain at the base of the nail plate. The tumor will blanch (turn white) if you press on the nail bed. Bleeding, ingrown nails and abnormalities of the nail plate are symptomatic of glomus tumors. Sometimes, the tumor causes longitudinal ridging or lifting of the nail plate itself. This type of tumor is relatively uncommon, but a single tumor is more common in women; men more commonly develop multiple tumors.

Pyogenic granulomas are usually benign and form after some sort of trauma is inflicted upon the nail bed. These tumors may pres­ent as onycholysis and may cause pain. Similar tumors may form in response to medical treatments that involve certain drugs.

The subungual osteochondroma is rare. Usually slow-growing and painful, this fleshy tumor can lift the nail plate as it grows.

Keratin implantation cysts are cysts lined with keratin and most commonly occur after trauma to the nail.

NAILPRO SEPTEMBER 2OO7

[Photo]A blue nexus, similar to ones found on the skin usually apear on the moon of the fingernail first.

[Photo]Glomus tumors can cause Ingrown nails or lifting of the nail plate.

Subungual keratocanthomas are most commonly seen in adolescents and young adults. Usually painful, they often start as small lesions that are easily seen under the edge of the nail plate.

Fibrous dermatofibromas are pain­less and tend to lift the nail plate.

The enchondroma is an uncommon, cartilage-like tumor that arises within bone. When located near the tip of the finger, the expanding tumor causes tenderness. The client may experience a swollen, club-like finger, nail deformity and abnormal pigmentation.

Acquired digital fibrokeratoma appears abruptly and enlarges rapidly; it manifests in adulthood and can become bothersome if projections of the tumor catch on clothing, the client picks at it or the nail plate becomes distorted.

Malignant Tumors

Some types of malignant and premalignant lesions involve the subungual area. Some cancers grow very slowly, while others grow quickly and cause consider­able destruction.

Squamous cell carcinoma is a slow-growing, nonaggressive, low-grade tumor that usually occurs on the hand—specifically, on the thumb or the index finger—or the big toe. Exposure to sun and X-rays, trauma, ingestion of arsenic and viruses associated with warts are thought to be causally related.

Knowing what your
client faces during
tumor treatment may
be helpful.

This condition, seen commonly in women older than 50, is usually present as a red plaque with swelling, tissues that easily bleed, drainage, ulceration, tenderness and/or nail deformity. It can be confused with a keratocanthoma. Squamous cell carcinoma may also cause infection of the nail; as a result, the tumor can be misdiagnosed as a viral condition, eczema or an infection.

Bowen's disease causes a slow-growing tumor that occurs most commonly in the first three fingers and in males between 50 and 70 years old. This appears as a plaque with a wart-like surface, and the nail may become discolored. Bleeding and drainage may suggest cancer.

Pigmented Lesions

Subungual tumors may be present as pigmented lesions. Acral lentiginous melanoma may
be present as a nail plate deformity or as a pigmented longitudinal streak. Melanomas are mosi commonly found on the thumb.

NAILPRO SEPTEMBER 2OO7

Blue nevus and lentigo tumors may also be present as a subungual pigment. (On a black client's nails, multiple dark bands are common and not indicators of disease.) The subun­gual melanoma frequently starts as a pigmented stain on the lunula—also known as the moon—resembling a hematoma (blood) under the nail. The stain becomes a pigmented band and may cause nail splitting, nail dystrophy and a vegetating tumor that appears in later stages. Carefully observe any pig­mented spots on a client's nails; if the band widens, the pigment diffuses at its base or the pigment spreads onto the cuticle or surrounding tissues, alert your client and urge her to visit her doctor or a dermatologist.

Treatment Options

You should learn what restrictions, if any, you need to consider during nail services for clients who are undergoing tumor treatment. If your client shares her physician's diagnosis with you, know­ing what your client faces during tumor treatment may be helpful.
Surgery. If a tumor is benign, the physician may opt to remove it or not, depending on whether the growth is bothersome or if the location pres­ents difficulties. When dealing with precancerous or malignant tumors, treatment typically requires removal. Sometimes the tumor can be com­pletely removed with a biopsy, which requires no further treatment. Most surface tumors can be cut from the skin quickly and easily with a curette (an implement with a sharp, spoon-like end) combined with an electric current to control bleeding and kill remaining tumor cells. If this method is employed, the remaining scar tissue is likely to be flat and whiter than the surrounding skin. In another method of surgery called Mohs' technique, which is used mainly tor malignant tumors, the tumor is shaved off one thin layer at a time. Each layer is checked under a microscope for cancer cells until the entire growth is removed. The degree of scarring depends on the location and size of the tumor.

Cryosurgery. Extreme cold can be used to treat certain small skin cancers or tumors. Liquid nitrogen is applied to the tumor to freeze and kill abnormal cells. Once the area thaws, the dead tis­sue falls off. The client may experience pain and swelling; after the area heals, a white scar may form.

Laser therapy. Laser therapy uses a narrow beam of light to remove or destroy tumor cells. Surgeons often use lasers for tumors that involve only the outer layer of skin; after treatment, very little scarring occurs.

Radiation and chemotherapy. Malignant skin tumors respond well to radiation therapy, which uses high-energy rays to damage cancer cells and stop their growth. Radia­tion therapy may cause a rash or leave the skin dry or reddened. Abnormal skin color or texture may develop and become more noticeable as time goes on. Topical chemotherapy refers to the use of anti-cancer drugs in a cream or lotion that is applied directly to the skin over a period of time. Inflammation is common during treatment, but scarring usually doesn't occur.

Although a nail technician doesn't diagnose medical problems, you can play a vital part in every client's heath and well-being by observing her nails. Be suspicious of nail lesions and think about the conditions that may cause an unusual nail appearance. You may be the only person in your client's circle to encourage her to seek early diagnosis and treatment.

Cheryl Louise Branche is a retired M.D. living and working in New York as a consultant.

SEPTEMBER 2007 WWW.NAILPRO.COM

Take Advantage of the Exchange Rate in New Zealand

This piece was published in Transitions Abroad Magazine September/October 2000 and appears on the web at http://www.transitionsabroad.com/ /publications/magazine/0009/new_zealand_bargains.shtml

Take Advantage of the Exchange Rate in New Zealand

By Cheryl Branche

Budget is the buzzword in New Zealand where the U. S. dollar is worth two NZ dollars. Example: The YMCA offers a 2 bedroom apartment with TV, phone and bath for under NZ$110. A single room is only NZ$37 per night.

Public tranportation, available beween most citites, is also inexpensive. From Christchurch through Arthur's pass, with stops along the way to Greymouth on the West Coast, the Tranz Alpine Express fare is NZ$55 and takes you past some of the most splendid views of the Southern Alps. Travel up and down the east coast is even less expensive. From Christchurch to Dunedin costs NZ$35 one way, and from Christchurch to Queenstown NZ$40.

The cheapest way to eat is to cook your own meals. Most hotels have cooking facilities and grocery stores are nearby, If you must eat out, ask the locals to recommend good, inexpensive restaurants.

The least expensive activities are the walking track and self-guided tours (Walking track guides are available at the visitor information centers). The glow worm caves on the West Coast are fascinating, but visit them with a local, instead of a guided tour.

With a good map and a good sense of direction, the great outdoors are yours. Hire a car if you are traveling with more than two other people.

Cheryl Branche is a retired American physician who lives in Christchurch, New Zealand.

Obesity and You

This piece was written and published in the Belzoni Banner newspaper in 1991.

Obesity and You

By Cheryl L. Branche, M. D.

Belzoni, Mississippi

Obesity, a large health problem affecting thousands of Americans, can be a source of embarrassment, low self-esteem, and deteriorating health. Obesity refers to an excess of body fat and can be diagnosed when the subscapular skinfold thickness is greater than 19 mm in males or greater than twenty-five millimeters in females. Most often people use the term 'obese' to describe a fat person or a person who is over-weight.

In the United States, obesity is related to socioeconomic status, age, and race. Women who are in the lower socioeconomic classes are six time more likely to be obese than those in the upper classes. A woman is more likely to gain weight as she ages. According to a recent study, African-American women will find it more difficult to lose weight.

Obesity is caused by a decreased ability of the body to metabolize food, that is convert food to energy. It is not so surprising, then that when one consumes large volumes of nutritious food or even large volumes of food high in calories and low in nutrients ( ghetto hunger), one can become obese.

Once becoming obese, losing weight can be difficult, but here are some steps that may help you.

1. Eat three nutritious meals a day.

2. Drink ten to twelve glasses of water a day.

3. Exercise. A brisk twenty minute walk three times a week will do wonders.

4. Do not forget to take some time to learn about your health.

Read, attend lectures, and talk with your doctor.


Your health is important.