The Steep Hill We Still Need to Climb with Covid

I live in Minnesota, where summers are short and highly valued. We Northeners spend our winter daydreaming and planning our summer activities, which was probably even more true during this Covid winter. My plans include backyard dinners, weekends at the lake with family and friends, enjoying the bounty of Twin City restaurants and biking along our extensive network of trails. Unfortunately, some of those plans may not be a reality due to the rising Covid cases in MN. And this predicament is what has brought me the most frustration over the past year; the failure of individuals to follow simple guidelines around masks and social distancing as well as the reluctance to get the vaccine.

My clinic is administering hundreds of vaccines each week and I ask every patient if they wish to be put on the waiting list. This includes pregnant patients, as the evidence is strongly supporting benefit to both mother and unborn child with no evidence of negative side effects. At the time of this writing, 50% of Minnesotans have received their first dose of a vaccine. We need 75-80% of the nation to be vaccinated in order to achieve herd immunity and put an end to this pandemic. Getting the last 25% of the population vaccinated is the steep hill that will take longer and require more encouragement than vaccinating the initial 50%.

I need all of those who have been vaccinated or are waiting for their chance at a vaccine to push our nation up that remaining steep hill. Talk to family and friends who may be reluctant to be vaccinated about your experience with the vaccine. Comment on falsehoods that you see on social media. Restrict your unmasked social interactions to only those adults who have been vaccinated. Continue to wear masks in public until we can achieve herd immunity and the prevalence in the the community is very low. I have included some facts below that address the most common falsehoods I hear from patients during my discussions.

  1. The vaccine is too “new” and I want to see how others do first before I get it myself. mRNA technology was first developed in the 1990’s and has been studied in flu, Zika, rabies and CMV. Widespread use of the technology did not become necessary until a worldwide pandemic occurred. Covid-19 is that event. Are we really that selfish as a nation that we won’t take a miniscule risk of getting a new vaccine in order to protect our friends and family?
  2. I know lots of people who have had Covid and they weren’t that sick. This was especially true during the initial wave of Covid in 2020 but has become less true in 2021 as the Covid variants have become more common. Our hospital beds are now filled with much younger patients who are not succumbing to Covid but who are going home on oxygen for weeks to months. The existence of long haulers disease is a reality that we are seeing more frequently with chronic fatigue, shortness of breath and foggy memory months after initial recovery.
  3. The vaccine can cause infertility by changing the DNA of my cells. mRNA never enters the nucleus of the cell where DNA is housed. Rather, it works as a “messenger” telling the cell to make a protein that is displayed on the outside of the cell and initiates an immune response. There is no live virus involved in the vaccine and the mRNA is broken down as soon as its message is received by the cell.
  4. I have had Covid, or think I had Covid, so don’t need to be vaccinated. I have seen multiple patients who have had Covid twice. Natural immunity has been shown to only last 3 months while vaccine immunity has now been proven to still be effective at 6 months post vaccination and is probably closer to a year of immunity. If you have had Covid, the initial reaction to the vaccine is no different than if you have not had Covid.
  5. People get “sick” after the vaccine. While many people develop a low grade fever and body aches within the first 24 hours after getting the vaccine, this is not a Covid illness but the immune system reacting to the messenger and gearing up for a fight against future infection. If you talk to anyone who has had a moderate case of Covid with days of high fever, fatigue and body aches they would greatly prefer the mild 24 hours of post vaccine reaction.

People want to hear from others they trust about their experiences getting the vaccine as well as the reasons they were vaccinated. Please help health care providers spread the word and get us to herd immunity in the next few months. A Minnesota summer is approaching and I am excited to enjoy all of what is has to offer.

Why getting a Covid vaccine can be a powerful Social Justice statement

I signed up for my chance to get the Covid vaccine within five minutes of being notified that I was eligible. I wanted to protect myself, my patients and my family as well as get back to a more normal lifestyle. I assumed that the majority of my colleagues in healthcare would do the same. We have all seen or heard of the devastating effects that this illness can have on our patients and their families. The science behind the vaccine is sound and the effectiveness impressive. For those reasons and others, I was extremely disappointed when I learned that just less than 50% of eligible healthcare providers at my hospital had taken the opportunity to get the vaccine. The most common reason cited for declining to be vaccinated was “I plan on waiting to see how the vaccine affects others”. We have seen how it affects others – that is the purpose of a large study size that both the Pfeizer and Moderna vaccines have published.

If the science behind the vaccine doesn’t convince you to get your shot, I’m willing to try a second argument. The recent increase in awareness around social inequities has lead many Americans to educate themselves about Social Justice initiatives. People of color (POC) have been inordinately affected by this virus in numerous ways. They are at higher risk of contracting the virus due to overcrowded and often multigenerational housing as well as occupying a large percentage of front line jobs. Risk factors for more severe Covid illness, such as hypertension, diabetes and obesity, are more prevalent in POC. Front line workers often don’t have health insurance and delay accessing a medical facility until they become very sick and further along in their illness. Historical injustices around experimentation with black bodies to further the advance of science has also increased their hesitancy to receive the vaccine.

If you are a white healthcare provider, the most vocal Social Justice statement you can make today is to get your vaccine. Actions speak louder than words. We need to prove to our patients and colleagues who are POC that we care enough about their health and the injustices that have been perpetuated against them to get a vaccine that will decrease the overall viral load in our communities. Getting a vaccine may cause most of us to feel a bit uncomfortable. Compare that to the uncomfortable feeling that POC encounter daily due to the lingering effects of racism that still exist in this country. For a change, let’s see white people leading the charge in this newest social justice initiative.

How Adoption Made me an Ally

Twenty-three years ago when we first contemplated the adoption of a child, I imagined how it would change a child’s life. Our family was able to offer two loving parents, three siblings and an upper middle class lifestyle. At the same time, I had misgivings about taking a child out of their culture and replacing it with another and the hole that might create in their future life. When we made the decision to adopt a second time three years later, I had those same thoughts. Now that these two children are young adults, I realize that adoption changed both their life and mine in ways that I hadn’t imagined and have made me an ally for the complex emotions and stories that define transracial adoptions.

I recognized that our family would look different to outsiders – three biological sons and 2 Asian daughters, five kids when the norm was two. What I didn’t realize is that the interactions my daughters had with the outside world beyond our family, the circumstances that led to the disruption of their original family and the more recent charged conversations around immigration would forever change how I view the world.

International American adoption has benefitted when societies undergo social disruption and are unable to care for families and orphans. It started with the orphans created by the Vietnam War, continued with the social disruption after the Korean War, the One Child Policy of China, extreme poverty in Central and South America due to militia governments and most recently the physical disruption of Haiti after the earthquake. Over the years I have learned that the majority of these adopted children are not true orphans but placed for adoption or abandoned by their families due to a lack of social supports, malnutrition, unaffordable medical bills and desire for a male heir. I have had to struggle with the knowledge that my participation in this system works to perpetuate these structures by infusing money into a country that does not see a need to change their internal policies.

When others remarked how “good, blessed, lucky, fortunate” our daughters were to be raised in an American family, I instantly thought of the opposite connotations that raised regarding their biologic families. The Chinese and Korean families that had been affected by our daughters adoptions made choices that I don’t know if I could have made if faced with similar circumstances. Would I be willing to walk away from one of my biologic children if I thought they had a chance for an improved life outside of our family?

Over the past 4 years as immigration has led to heated discussions and my daughters have moved beyond our protected household and out into the greater world, I have had to reconcile the immigration story of our family with the stories of families south of the US border who have fought to keep their children by making a harrowing journey to a better life. Why is our family put on a pedestal by other Americans while those families waiting in refuge camps are seen as opportunistic and dangerous? Does our American culture value your black/brown body more if you are raised in a white household?

Adoption is complicated… and so is being a parent. I would not change anything about our journey and am immensely grateful that my life and view of this world has been affected by each one of my children. My ongoing task is to be an ally – one who listens to the experiences of others outside of mainstream white America and helps to amplify their voices.

On Reproductive Choice: The faith difference between Melinda Gates and Amy Coney Barrett and what that means for women

I recently finished Melinda Gates book, “The Power of Lift”, and was most impressed by the intersection of her strong Catholic faith and her views on reproductive choice. The Catholic church is often seen in sharp disagreement with not only abortion but also the use of contraception. Ms Gates acknowledges this dissonance and then lays out a thoughtful argument as to why she is able to honor her Catholic faith while at the same time using her platform and funding thru the Gates Foundation to increase access to contraception that enables women to make informed decisions about whether and when to have children. It has been proven that spacing of pregnancies reduces maternal and newborn deaths as well as increases the health of children already in the family.

Foremost, Gates admits that it is not only difficult but also misogynistic for a celibate male hierarchy to be allowed to make decisions about the reproductive life of woman when these same rules can harm the mothers and the children they birth by perpetuating the cycle of poverty. It is her empathy with poor women and children, per the Franciscan teachings of the church, that has led her foundation to provide funding for innovative contraceptive options as well as increased access to these options. Thru her travels in the developing world, she came to understand that contraception prevented millions of unsafe abortions by preventing unwanted pregnancies. While 93% of Catholic women in the US have used contraception, the Catholic church was working to prevent women outside of the US from having those same choices.

Amy Coney Barrett is also Catholic but has chosen to use her faith as a way to limit reproductive options for women in this country. If she becomes the next Supreme Court Justice she may be the deciding vote in overturning access to legal abortions. Even more timely are her views on the Affordable Care Act and what that means for women and their reproductive health. Prior to the ACA, women were required to pay for contraception and could be charged more for health insurance as having babies is a costly endeavor. After the ACA was passed and the more reliable, but costly, long term contraceptive options became available for free, unintended pregnancies and teen pregnancies plummeted and the abortion rate hit its’ lowest point, dropping 14%.

Ms Barrett has a developing world example in her own home. Two of her children are adopted from Haiti. Abortion in Haiti is illegal and reliable contraception difficult to obtain. Poverty is endemic as is the role of men in controlling women’s lives. When women are unable to feed their growing families, they often place a few of their children in a religious sponsored orphanage with the intent that “when my situation improves, I will go back and get my children”. Most of these mothers are never reunited with their children because their poverty does not improve.

I have worked intermittently in Haiti as an ob/gyn physician since 2006. Some of the most horrific situations I have encountered are when desperate woman seek an illegal abortion. The maternal mortality can be exceedingly high when unskilled providers perform medical or surgical abortions. This may be the future of our country if we restrict access to contraception at the same time that we make abortion illegal.

Religious faith can be a powerful force for doing good, as evidenced by the work of Melinda Gates and her leadership in increasing access to contraception, which she believes, and has been factually proven, to lift women out of poverty. . It can also be a force that demonizes the tragic choices that women in poverty sometimes have to make in order to support their children. That is the faith of Amy Coney Barrett.

Dear Educators,

Five months ago, most of us in the medical profession were where you are now. Unsure of what our jobs would look like in the next few weeks and months as well as concerned about our health and that of our families. Who would be making our work place decisions and would they have both the health of medical providers as well as patients in mind. Would we have access to protective gear as well as tests so that we would know who was infected. Would our most vulnerable patients have access to sufficient medical care. The good news is that we are 5 months smarter than we were and have better answers to the questions. The bad news is that we are 5 months down the road and still seeing increasing cases as well as the ongoing belief from some that this is still a “hoax”.

If I could give you some advice, this is what I have learned.

  1. Best practices will change weekly. This is not just due to improved information but also due to rising and decreasing (hopefully!) prevalence in your area. Often when I see a neglected email about an updated protocol, I don’t bother to read it if more than 3 days old because I know there will be an updated version before I finish reading the previous protocol. Get used to change as this is a new virus and we are constantly learning more each day
  2. Trust the people who are making the decisions that drive the protocols. You may not always agree, but you will waste much needed energy if you try to second guess the decisions. This is a time to adopt a military attitude; decisions made at the top that are carried out without debate from those on the front line.
  3. Realize that the parents/students/teachers who disagree with a decision will be the ones who make the most noise. The crowd that agrees will be busy working and getting sh*t done (per usual).
  4. Healthcare and education are both inequitable. This is a time when we need to put more effort into those patients/students who could suffer greater harm. In my profession, we rapidly created a modified obstetrics schedule for high risk and low risk patients, with less in office visits for low risk patients so that we could devote our limited use of PPE to high risk patients that required more face to face time. Teachers will need to find creative ways to do the same.
  5. Share ideas that work both within and outside your school. The amount of conference calls/journal articles/social media groups that I listened to or read helped me feel that there were others who had the same frustrations and also the same successes.
  6. Thinking about returning to the classroom is much more scary than actually being in the classroom with students. It only takes a few weeks to get used to wearing a mask for 8 hours, most teachers were already washing their hands numerous times during the school day and now you don’t have to see runny noses on students as said nose will be behind a mask. Good news is that we should see a much lower incidence of colds and influenza this fall. Australia and South America, which are now in their winter, have already seen dramatic drops in these illnesses as the practices that prevent Covid also reduce other virally transmitted diseases.
  7. Finally – you will hear many more appreciative comments and thank yous. In the early days of Covid, it always put a smile on my face when I saw the chalk thank you drawings on the hospital sidewalks. Parents remember all to well the difficulties they encountered teaching their children in the spring. I am hopeful that they will have a new appreciation for the job that you do and be willing to help their children navigate the unknown road ahead.

Bookclubs: A call to Action against Racism

I live in Minneapolis, Minnesota. Until recently most Americans had difficulty finding us on a map in the middle of the country. Because of George Floyd and police brutality we will be forever linked to the events that occurred on May 25th, starting a chain of protests across our nation and beyond. My emotions since then have turned from profound sadness to anger and now to needing to create some long lasting justice out of this event.

Over the past week I have reached out to acquaintances that have been active in racism education, inquiring whether they could speak to my bookclub and help us to understand our history as well as a new way forward. The answer I received was short and to the point. “Nope. Thanks for asking but we (African Americans) have been writing about this for years and now white people need to use all that material to educate themselves.”

I am hopeful that this will be a “different time and a different season”, the words spoken by Al Sharpton at George Floyd’s eulogy, and this can finally be the time to change the conversation around racial inequality. But for that to happen, we need to move beyond protesting and determine how we got to this point before change happens. Americans in rural parts of this country, who may never see a person of color other than on tv, are just as much in need of education as those of us who interact with a multi-racial population every day. Rural or urban, books and tv are available to all of us.

I would like to see book clubs, ubiquitous in every state and country, as a good starting point to ignite discussions around racism as well as a path forward for change. Each community in this country is unique and therefore transformation should also be unique. The discussion of a book is an opportunity to better understand what the author intends while also attempting to recognize how each reader uses their worldview and life experiences to form an opinion.

If every book club in this country would commit to reading one book on racism each year for the next five years, we could continue this conversation and affect change both in our community and in our children. Arm yourself with knowledge and allow the written words and experiences to open up a different world. Don’t walk away when the discussions become uncomfortable. It is in that space that understanding can happen. Ask your local independent bookstore to not only order your chosen book but to also stock additional books about racism so that other patrons may benefit. And finally, when your book club has finished the book, please donate them to the public library so that there is a supply for those who are unable to afford purchasing books.

Children and teens are no different. They need to see children that look like them in a story as well as children that appear different and have experiences that they see as foreign. When children/teens don’t hear diverse stories of others, they learn to fear what is unknown….just like adults. Book clubs can use their financial capabilities to purchase and donate books to school libraries and classrooms while also stocking those same books on home bookshelves for their children to read.

The lists of anti-racist books are endless and include both fiction and non-fiction. Out of this list of 61 books by Ibram X. Kendi, I think most book clubs could find a few that interest them. Children’s books don’t necessarily need to highlight racism, but can help to initiate conversations about differences and how we react to those differences in people, whether it is skin tone, religion, country of origin or socio-economic level.

We as white Americans are responsible for making this a different time and season. We need to commit to move the anti-racist caravan forward, however slowly, to create a better world for our children.

The new Wild West – Procuring PPE

Although it has just been 5 weeks since the United States went into quarantine, it seems much longer for hospitals and clinics that are not only trying to care for both Covid and non-Covid patients but also attempting to secure supplies of personal protective equipment (PPE) for their health care workers. Hospitals have first priority for masks, leaving clinics woefully under-supplied. Luckily, I am part of a large group of women who volunteer their sewing skills to create reusable menstrual pads for distribution in developing world countries. We repurposed the cotton used in the construction of the Days for Girls menstrual kits to make fabric masks. Other groups throughout the city had the same idea and soon elastic for the ear loops was difficult to obtain.

Ingenuity during this pandemic has been incredible and others have shared their solutions via the internet. The University of Florida designed a mask using recycled blue surgical wrap, normally thrown away after it has been used to protect sterilized instruments. This material is flexible, 99% impermeable to pathogens and can be re-sterilized multiple times for reuse. Our sewing group moved from fabric masks to the blue wrap material without a hitch in the process and soon had constructed 500 masks for both clinic and hospital use. Since then we have welcomed five additional sewing groups and will have finished 2500 masks by the end of this week. The masks are being used at both North Memorial Hospital and Voyage Healthcare clinics. As shipments of mass produced surgical masks make their way to our healthcare businesses, we hope to redirect the energy of all these seamstresses and provide masks to local organizations who may need them in the coming months.

Why American doctors and nurses are ill suited to handle a pandemic

This statement includes me. Healthcare in America is different, both good and bad, than anywhere else in the world. When questioned, most Americans think of our country as leaders in medical technology and innovation. This pandemic is showing that perception to be far from the truth, as well as bringing to light the flaws in our training and how we practice when faced with a serious contagious disease.

Infectious disease pandemics don’t happen on our shores. We hear about Ebola in West Africa, dengue fever in South American, hepatitis and SARS in Asia, malaria in Africa, but we don’t experience the day to day reality of what that means. Our only experience is influenza, and despite the availability of a vaccine for this infectious disease that kills 30,000 to 40,000 each year, only around 40% of our population is immunized. Basic infectious disease precautions, such as hand-washing or staying home when we are sick, are often overlooked in our efficient and rushed society. Physicians have been shown to have the poorest performance in the hospital setting when it comes to sanitizing their hands between patients.

American healthcare is a disposable society. Nothing is reused between patients, even if it can be re-sterilized, to prevent cross contamination and increase infection. Three months ago we would have been reprimanded for wearing the same mask between two patients. Now we are reusing that same mask for a week. Surgical drapes and gowns are disposable. In my work in Haiti and Vietnam, almost all instruments are reusable, gowns and drapes are cloth and rewashed and sterilized, masks are worn until they are unusable. Healthcare in America needs to learn to use our resources better, especially in a time of plenty so that we have reserves for times such as these.

Most of us are highly specialized. As an ob/gyn, I have never managed ventilator settings and only performed one intubation in medical school. I would be ill equipped to help out in an ICU setting. The same is probably true for the majority of American doctors if we were called into service to start IVs and draw blood. In hot spots such as NYC and New Orleans, fourth year medical students are allowed to graduate early if they are willing to work in a hospital caring for Covid patients. These newbie physicians have more of the needed skills than those of us 10 years out from medical school.

As physicians and nurses, our daily work most often results in the recovery and improvement of a patients health. We are not accustomed to caring for a patient for 2-3 weeks, with all of the medical technology that we have available, and then seeing that patient die despite our best efforts. In places like New York City, health care workers are not returning to work as they are unable to psychologically handle the senseless deaths they see daily. America has not experienced a war zone on its shores since the Civil War. This is a war zone when it comes to death, an experience that other parts of the world have seen more recently.

Informed consent is something that is drilled into our heads from early on in our training. Patients need to be given all of the options for their medical care, free from our personal judgement, along with the risks and benefits of each option. Covid doesn’t allow us that luxury. Often, patients have to be intubated emergently and informed consent is not an option. When ventilators are in limited supply some high risk patients, such as those with a terminal disease, may be offered comfort care rather than aggressive management.

When Covid is still fresh in our minds, but not in our bodies, Americans and healthcare professionals need to reexamine how we can change our medical system for the better so that our future response to an infectious disease is more streamlined and less chaotic. We need to use the innovation that makes us world renown to equip us for a new tomorrow.

Health Care Providers are stressed….and it’s not what you think

I would like to thank everyone who has reached out to to health care providers and expressed their gratitude for our work. The sidewalk in front of the hospital is full of chalk messages of encouragement that we see when we walk into work each day. But unless you are a physician in a current “hot spot” such as New York City or New Orleans, the rest of us are spending our time waiting. Waiting for the anticipated surge of patients that most of us have not seen happen as of yet and hope that won’t happen. The anxiety involved in the wait can be worse than being in the battle.

In preparation for the possibility of a marked increase in cases, our clinic doors have been closed to the majority of patient visits. This is not only to decrease the risk to patients of sitting in a crowded waiting room, but also to decrease the risk of transmission to health care providers as well as to conserve the supply of personal protective equipment (PPE).

Although the financial focus has been on the layoffs in the hospitality industry, health care workers are being laid off in unprecedented numbers. Numerous ambulatory clinics have made the difficult decision over the past weeks to furlough a large contingent of their employees. If there are not patients coming in our doors to generate revenue, we cannot continue to pay the majority of employee salaries. Many of the staff that I work with are not only co-workers but also friends. Some have more resources than others. As a small business, we need to make sure that the business is there and viable when this is over, so that we are able to rehire our employees. Hospitals have asked nurses and operating room personnel to take paid time off as operating room schedules have moved to emergency only cases. Physicians are taking enormous pay cuts of 50% or more.

This list of stresses could go on and on but here are just a few more that I have heard over the past few weeks.

  1. Family members that work in health care. The majority of us, physicians, nurses, respiratory therapists, love our jobs and have passed that on to our children. Many of them have followed us into the profession of caring for others. My oldest son is an RN on the Covid rule-out floor in Vegas. My sister is an RN in a cardiac cath lab where emergency procedures are the norm and there is no time to ask a patient questions about Covid symptoms.
  2. As medical professionals, we are often the source of factual knowledge for our friends and family members. Now many of us are being asked questions about hoax-type cures, unproven theories about the origin of the virus and when this will end. My best advice is to follow whatever Dr Fauci says. He has been thru this before with other epidemics and speaks truth to power.
  3. The realization that many of us will probably become infected. Despite best practices, 10-20% of health care providers in China and Italy have been infected. The percentages in Singapore and Hong Kong were much lower as they had better access to PPE and fewer patients. That is why it is so important that Americans follow the simple rules of social distancing, handwashing and keeping your hands away from your face. The less of you that are in need of care, the lower the percentage of health care workers that will be infected. It will also give us time to improve our supply of PPE.
  4. The lack of leadership from the top of our country. Rather than implementing uniform best practices determined by a scientific, medical committee that has access to the latest world-wide information, we are forced to make up our own policies with the information that we can glean from our colleagues in the hardest hit areas. These policies often differ from hospital to hospital and create angst among employees as to what is most correct. While our colleages in Seattle and New York are taxed with caring for massive numbers of patients, they are also trying to disseminate what they have learned so that they rest of us are better armed for the battle.
  5. The realization that Americans will forget what science has tried to teach us. I continue to have pregnant patients refuse the flu vaccine (despite its demonstrable efficacy) so I can imagine that many Americans will refuse the Covid 19 vaccine in the future. This pandemic has demonstrated that co-morbidities such as diabetes, hypertension and obesity, can put a person more at risk than advanced age. Maybe the need to stay at home, go for walks to relieve boredom and cook real food will give Americans an incentive to consider further beneficial lifestyle changes in the future.

Thank you again for your thoughts and words of encouragement. Just realize that our stressors are some of the same as yours…but also different.

Period Poverty

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My kids loved creating tree houses, similar to the picture above, in our back woods. They even asked to sleep in them a few times but were never able to make it past the first hour. Imagine sending your daughter to one of these huts that is far removed from your house each month for 5-7 days when they have their period believing that your daughter is “unclean” and cannot share food or lodging with the rest of the family. That is the practice in many areas of rural Nepal and the rustic structures are referred to as menstrual huts. Each year there are reports of several women dying due to smoke inhalation, snake bites or freezing.

Those of us who live in more developed countries may feel that the stigma of menstrual huts is not something we need to be concerned about. But developed countries have their own way of shaming women who menstruate. Many religions do not allow women to fully participate in their faith while they are menstruating as menstrual blood is considered ritually unclean. In the Orthodox Jewish culture, women have many restrictions for 2 weeks each month (the week of menses and the week following) and must bath themselves in a ceremonial bath before returning to their “clean state”. Orthodox Christianity does not allow women to receive communion while they are menstruating. Muslim women cannot enter a mosque, participate in Ramadan prayers or fasting and must complete a ritual washing before they become clean again and can participate in religious activities.

Most of us remember our middle/high school years when we could be excused from gym classes for the “illness” of menstruation. Our first hint that monthly bleeding could be expected was usually conveyed in secretive tones with the caveat that we were not to share the information widely. Although we do not partake in a ritual bath, many advertisements around menstruation products use the words fresh, clean and deodorized. I am often reassuring both young girls and women that menstrual blood does not need to be bright red to be healthy.

The tampon tax exists in 32 states, whereby tampons and pads are taxed as luxury items with a surcharge of 6-9%. While band-aids, sunscreen and condoms can be included in deductions from Health Savings Accounts, pads and tampons are excluded. Tampons and pads can’t be purchased through government assistance programs like SNAP or Medicaid and shelters and food banks say that they’re among their most-requested items. Most of us are familiar with the scrambling needed when you get unexpected bleeding and although we can afford pads and tampons, would appreciate the availability of free hygiene products available in schools and universities as they are in Scotland.

When my daughters want me to pick up tampons or pads on my Target trips, they often screenshot me a pic of the exact product. When we were in China, accessing pads (no tampons available) required finding a pharmacy and asking for the product at the desk as they were not displayed on the shelves. Only one brand and style available. Girls in these countries are fortunate to have hygiene products available as girls in developing countries, especially those in rural areas, have no products available and often are relegated to using rags that need to be rewashed and dried each month. The proportion of girls who stay in school after they get their period takes a dramatic downward turn as they are unable to manage their bleeding when away from home.

Imagine using this bathroom to manage your menses. There is no lock on the door to keep it shut, no window to provide light, no receptacle for used pads, no hook to hang your clothes if you need to change clothing due to an accident. This is the most common type of bathroom that exists in rural schools in developing countries.

Period Poverty exists in areas throughout the world as girls and women are limited in their ability to go about their daily lives, limited financially with extra monthly expenses, limited in their ability to participate in religious functions, limited in school attendance and as demonstrated by menstrual huts – their lives can be in jeopardy.