Erosion of healthcare for those who need it most

The UK and US differ in healthcare funding models and political structures, but both national governments are intervening in ways that further disadvantage those who already experience the worst health outcomes. Maternal and neonatal mortality are highest in the poorest sectors of the population (doi:10.1136/bmj-2022-e071154; doi:10.1136/bmj.o1019).12 But UK legislation requires invoicing those not “ordinarily resident” in the UK for their care and referring anyone who does not pay promptly to the Home Office, which is responsible for immigration enforcement.1 The policy risks patients avoiding necessary healthcare and runs counter to best practice for the treatment of migrants, refugees, and asylum seekers (doi:10.1136/bmj-2021-068821).3 However, the effect of this misguided policy may pale compared with changes in the US, which looks set to overturn federal legislation legalising abortion (doi:10.1136/bmj.o1184).4 Such a move is predicted to lead to a 20% rise in pregnancy related deaths, disproportionately affecting black and low income Americans, and to a rise in unsafe illegal abortions, as well as increasing numbers of vulnerable children and a risk of prosecution for those who miscarry (doi:10.1136/bmj.o1019; doi:10.1136/bmj.o1206).25

The case of a pseudonymous unmarried woman (Roe) who sued a Texas district attorney (Wade) is totemic to second wave feminism. In 1973 the Supreme Court ruled unconstitutional the Texas law that prohibited abortion except in the case of threat to the mother’s life (doi:10.1136/bmj.o1184).4 It balanced the rights of the fetus and the mother by ruling abortions should be at maternal discretion in the first trimester, regulatable by the state in the second, and prohibited in the third except to save the mother’s life.6 The ruling was based on the right to liberty (interpreted as privacy) enshrined in the 14th amendment to the US constitution. But the Supreme Court is now weighted in favour of anti-abortion conservatives, who seem ready to dismiss this argument. If Roe v Wade is overturned campaigners fear that other rights depending on the same foundations may also disappear, including contraception and consensual same-sex intimacy (doi:10.1136/bmj.o1206).5

The US is already deeply divided between Republican led states that make abortion very difficult to obtain and Democrat led states, primarily in the west and northeast, that provide services more liberally (doi:10.1136/bmj.o1122; doi:10.1136/bmj.o1184; doi:10.1136/bmj.o1206).457 And up to half of state legislatures have passed or are poised to pass more restrictive legislation if Roe is overturned, including Texas’s “heartbeat” law—preventing abortion after a fetal heartbeat is detectable, except to save the life of the mother—and laws criminalising abortion in Louisiana and Oklahoma (doi:10.1136/bmj.o1019; doi:10.1136/bmj.o1206).25 Up to 60% of women of childbearing age in the US may find themselves resident in states that deny them abortion, many with no exception for rape, incest, or risks to the mother. Some states will also criminalise women who cross state lines to seek an abortion, preventing women from travelling to states that would provide abortion, such as New York, New Jersey, and Connecticut, as well as to Canada and Mexico (doi:10.1136/bmj.o1184).4 The risks to those who are already disadvantaged by poverty or immigration status will rapidly become severe.

The Supreme Court will rule on a Mississippi law that bans abortion after 15 weeks, in part relying on contested arguments about whether and when a fetus can feel pain (doi:10.1136/bmj.o1225).8 As researchers on all sides of the arguments file briefs in support or opposition, and with various medical bodies supporting the status quo(doi:10.1136/bmj.o1225),8 is this really a point on which landmark legal precedent should turn?

Debate also seems likely to continue on the extent to which vaccination helps reduce symptoms of long covid. Vaccination is known to reduce the subsequent incidence of long covid if people are vaccinated before they are infected, but what about vaccination after infection? Despite the largest study to date (doi:10.1136/bmj-2021-069676),9 the picture remains less clear. On a population level, a course of two vaccinations seems to reduce by a small proportion the number of people with long covid symptoms among those infected before vaccination. But for an individual with long covid, vaccination may have some positive effect, no effect, or even, in rare cases, make symptoms worse (doi:10.1136/bmj.o988).10 Until we can clearly define long covid and understand the underlying mechanisms, and whether they are affected by vaccination, it will be hard to make a confident recommendation for an individual.