Category Archives: Genetics & Birth Defects

A sick newborn, a loving family and a litany of wrenching choices


By Jenny Gold

SAN FRANCISCO — Anne and Omar Shamiyeh first learned something was wrong with one of their twins during their 18-week ultrasound.

The technician was like, well there’s no visualization of his stomach,” said Anne. “And I was like, how does our baby have no stomach?”

It turned out that the baby’s esophagus was not connected to his stomach. He also had a heart defect. At the very least, he was likely to face surgeries and a long stay in intensive care. He might have lifelong disabilities.

This was only the start of an eight-month ordeal for the Shamiyeh family. Continue reading


Pediatricians recommend individualized counseling for parents of extremely premature infants


Premature infant's tiny hand being held By Jenny Gold

For the tiniest infants — those born before 25 weeks in the womb — survival is never guaranteed, and those who make it may be left with severe disabilities.

These micro-preemies are born in what’s known as the “grey zone.”  Whether or not to resuscitate them depends on the decisions made by individual hospitals, doctors and parents. Decisions can vary greatly even among hospitals in the same area.

A new statement from the American Academy of Pediatrics aims to improve the way those decisions are made. The statement suggests that doctors individualize counseling for parents based on the particular baby’s chances of survival and the family’s goals for their child. Continue reading


UW scientists, biotech firm may have cure for colorblindness | The Seattle Times


EyeJay and Maureen Neitz, husband-and-wife scientists who have studied the vision disorder for years, have arranged an exclusive license agreement between UW and Avalanche Biotechnologies of Menlo Park.

Together, they’ve found a new way to deliver genes that can replace missing color-producing proteins in certain cells, called cones, in the eyes.

via UW scientists, biotech firm may have cure for colorblindness | The Seattle Times.


States reluctant to regulate fertility services


IVF egg thumbBy Michael Ollove

The Utah legislature took a step last week into territory where state lawmakers rarely tread.

It passed a law giving children conceived via sperm donation access to the medical histories of their biological fathers. The law itself stirred no controversy. The oddity was that the legislature ventured into the area of “assisted reproduction” at all.

Assisted reproductive technology (ART) helps infertile couples to conceive. Compared to many other industrialized nations, neither the U.S. nor state governments do much to oversee the multibillion-dollar industry.

“The United States is the Wild West of the fertility industry.”

“The United States is the Wild West of the fertility industry,” Marcy Darnovsky, executive director of the Center for Genetics and Society said, echoing a description used by many critics of the regulatory environment surrounding ART. Continue reading


Quantifying the ‘Angelina Jolie effect’


Actress’ impact on genetic testing for breast, ovarian cancer is ‘global and long lasting’

Angelina Jolie - Photo courtesy of the UK Foreign and Commonwealth Office

Angelina Jolie – Photo courtesy of the UK Foreign and Commonwealth Office

By Mary Engel / Fred Hutch News Service

Sept. 18, 2014

The so-called Angelina Jolie effect not only is real but has been “global and long lasting,” leading to a twofold increase in the number of women getting genetic testing to help determine their risk for hereditary breast cancer, according to new studies from the United Kingdom and Canada.

The number of women found to have a genetic mutation that increased their risk also has doubled.

And contrary to concerns that women at low risk for hereditary breast cancer would flood testing centers, researchers said that those being tested are women like Jolie who have a family history of breast cancer or who have personal risk factors such as ethnicity.

Certain ethnic groups, including Ashkenazi Jews, have a higher prevalence of BCRA mutations, which significantly increase breast cancer risk.

Women got the correct message

“What surprised us was that we didn’t get the worried well,” said Dr. Andrea Eisen, head of preventive oncology for breast cancer care at the Sunnybrook Odette Cancer Centre in Toronto and an author of the Canadian study, in a phone interview.  “We got women who got the correct message. That was gratifying.”

Jolie disclosed in a May 2013 op-ed in The New York Times that she had undergone a preventive double mastectomy after finding that she carries the rare BRCA1 gene mutation, which dramatically raises her risk of breast and ovarian cancers. Continue reading


Women’s Health – Week 36: Pelvic Floor Disorders


tacuin womenFrom the Office of Research on Women’s Health

The term pelvic floor refers to the group of muscles and connective tissue that form a sling or hammock across the opening of a woman’s pelvis.

These muscles and tissues keep all of your pelvic organs in place so that the organs can function correctly.

A pelvic floor disorder occurs when your pelvic muscles and connective tissue in the pelvis is weak due to factors such as genetics, injury, or aging. Continue reading


New study again finds higher rate of rare neurological birth defects in central Washington


Washington MapA new study has again found a higher rate of a rare neurological birth defect, anencephaly, in Yakima, Benton and Franklin counties, Washington state health officials said Tuesday.

The study identified seven cases of the birth defect in these three counties in 2013, which translates into a rate of 8.7 per 10,000 births. That rate is similar to the rate seen in 2010-2012 and remains well above the national rate of 2.1 per 10,000 births, health officials said. Continue reading


Insurers question value of some genetic tests


3d Chromosome with DNA visible insideBy Michelle Andrews

The day when a simple blood test or saliva sample can identify your risk for medical conditions ranging from cancer to Alzheimer’s disease seems tantalizingly close.

But while advances in genetic testing increasingly give people critical information that may help prevent disease, genetics experts say sometimes the hype around these tests has outstripped the science.

Insurers, meanwhile, generally only cover tests if there’s strong scientific evidence that it can provide a health benefit to patients.

“The utility of some tests is not as clear as we’d like to think,” says Sharon Terry, president and CEO of the Genetic Alliance, an advocacy organization aimed at promoting health through genetics. “These technologies are advancing at a really rapid rate, and they’ll make a big impact on health. But the data gathering you need to do to determine clinical utility is difficult.” 

Insurers don’t cover a $99 genetic test sold directly to consumers by 23andMe that provides information about more than 240 genetic health conditions and traits that the company says can help people understand their health risks and carrier status for inherited disease, among other things.

In November, the Food and Drug Administration ordered the company to stop marketing the test because the agency concluded it was a medical device and subject to FDA review and approval, which it hadn’t received. In early December, the company announced it would stop selling its health-related genetic reports while it undergoes federal review.

Insurers commonly cover many diagnostic genetic tests that are ordered by doctors, for example, tests to look for rare diseases like cystic fibrosis in infants or children.

Insurers will typically also cover preventive genetic tests if the patient meets criteria based on family history or other risk factors, and if there’s an effective test with proven clinical benefit that’s recommended by a standard-setting organization like the U.S. Preventive Services Task Force.

In such cases, insurers also typically cover genetic counseling to first collect someone’s family and personal history to determine whether that patient is a candidate for a particular genetic test, and then help patients understand their results, says Rebecca Nagy, president of the National Society of Genetic Counselors.

Coverage is generally routine, but in recent years some health plans have begun paying a declining percentage of the cost of testing, says Nagy. “Companies that were covering a test at 90 percent are now covering it at 80 percent,” she says. Testing can be pricey. A genetic test for the BRCA mutations, for example, may cost $3,000 or more.

Under the Affordable Care Act, most health plans must make genetic counseling and testing available without any out-of-pocket cost to women whose family history indicates they have a higher than average risk of having mutations in the BRCA1 or BRCA2 genes that predispose women to breast and ovarian cancers. The ACA prevention coverage requirements are based on recommendations by the U.S. Preventive Services Task Force, which doesn’t recommend other preventive genetic tests.

Women frequently request genetic testing for breast cancer mutations because they believe their risk is higher than it is, say experts.

This is particularly true since the actress Angelina Jolie disclosed that she had a double prophylactic mastectomy to guard against breast cancer after learning she has a mutation in the BRCA1 gene.

But if a woman’s only family history of the illness is one relative who developed breast cancer at age 65, for example, that, by itself, doesn’t mean she’s at higher risk, says Nagy. With counseling, “many times we can give them reassuring numbers.”

In September, health insurer Cigna began requiring genetic counseling for members who were interested in three “commonly ordered and commonly misunderstood” genetic tests, says David Finley, the company’s national medical officer.

The tests covered by the new requirement are those for the BRCA mutations for breast and ovarian cancers, colorectal cancer and Long QT syndrome, an inherited heart condition that can cause sudden, potentially fatal heart arrhythmias.

Doctors who order these tests don’t necessarily suggest patients receive genetic counseling, even though national organizations recommend it, says Finley.

“From our perspective, the only way to make sure that patients are getting the information and taking the time that they need about these tests is to require that they see a genetic counselor,” he says.

Like other insurers, Cigna typically doesn’t cover genetic tests that don’t provide clinical benefit to the patient. “You don’t test for testing’s sake,” says Susan Pisano, a spokesperson for America’s Health Insurance Plans, a trade group.

One of the tests insurers generally don’t cover identifies which of three versions of the APOE gene someone carries. The APOE gene is associated with late-onset Alzheimer’s disease, and someone with two so-called “e4” versions of the gene is at higher risk of developing the disease.

“[The APOE test] is ordered fairly frequently, but we don’t pay for it,” says Cigna’s Finley. “It’s not enough for a test to be accurate and scientifically reliable, it has to benefit the patient. And with the APOE test I don’t think they’ve met those standards.”

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


Twitter chat on pregnancy and childbirth with Group Health’s Dr. Jane Dimer, Tuesday, December 10


hashtagJane Dimer, MD – an OB/GYN and chief of Women’s Services for Group Health – on Tuesday, Dec. 10 from 12-1 pm for an hour-long Twitter chat on pregnancy and childbirth. Dr. Dimer will be covering a variety of topics from getting pregnant to delivery, and answering your questions.

Topics will include:

  • Preparing your body for pregnancy
  • Nutrition
  • Is this normal?
  • Pregnancy myths
  • Making a birth plan
  • Delivery
  • Back to work/breastfeeding

When: Tuesday, Dec. 10 from 12-1 pm

autism thumbnail

Lack of eye contact in early infancy may be sign of autism, study


From the National Institutes of Health

Eye contact during early infancy may be a key to early identification of autism, according to a study funded by the National Institute of Mental Health (NIMH), part of the National Institutes of Health.

Published this week in the journal Nature, the study reveals the earliest sign of developing autism ever observed — a steady decline in attention to others’ eyes within the first two to six months of life.

“Autism isn’t usually diagnosed until after age 2, when delays in a child’s social behavior and language skills become apparent. This study shows that children exhibit clear signs of autism at a much younger age,” said Thomas R. Insel, M.D., director of NIMH. “The sooner we are able to identify early markers for autism, the more effective our treatment interventions can be.”

autism eye

Decline in eye fixation reveals signs of autism present already within the first 6 months of life. Data from a 6-month-old infant later diagnosed with autism are plotted in red.

Data from a typically developing 6-month-old are plotted in blue. The data show where the infants were looking while watching a video of a caregiver. Source: Warren Jones, Ph.D., Marcus Autism Center, Children’s Healthcare of Atlanta, and Emory University School of Medicine.

Typically developing children begin to focus on human faces within the first few hours of life, and they learn to pick up social cues by paying special attention to other people’s eyes.

Children with autism, however, do not exhibit this sort of interest in eye-looking. In fact, a lack of eye contact is one of the diagnostic features of the disorder.

To find out how this deficit in eye-looking emerges in children with autism, Warren Jones, Ph.D., and Ami Klin, Ph.D., of the Marcus Autism Center, Children’s Healthcare of Atlanta, and Emory University School of Medicine followed infants from birth to age 3.

The infants were divided into two groups, based on their risk for developing an autism spectrum disorder. Those in the high risk group had an older sibling already diagnosed with autism; those in the low risk group did not.

Jones and Klin used eye-tracking equipment to measure each child’s eye movements as they watched video scenes of a caregiver. The researchers calculated the percentage of time each child fixated on the caregiver’s eyes, mouth, and body, as well as the non-human spaces in the images. Children were tested at 10 different times between 2 and 24 months of age.

By age 3, some of the children — nearly all from the high risk group — had received a clinical diagnosis of an autism spectrum disorder. The researchers then reviewed the eye-tracking data to determine what factors differed between those children who received an autism diagnosis and those who did not.

“In infants later diagnosed with autism, we see a steady decline in how much they look at mom’s eyes,” said Jones. This drop in eye-looking began between two and six months and continued throughout the course of the study.

By 24 months, the children later diagnosed with autism focused on the caregiver’s eyes only about half as long as did their typically developing counterparts.

This decline in attention to others’ eyes was somewhat surprising to the researchers. In opposition to a long-standing theory in the field — that social behaviors are entirely absent in children with autism — these results suggest that social engagement skills are intact shortly after birth in children with autism. If clinicians can identify this sort of marker for autism in a young infant, interventions may be better able to keep the child’s social development on track.

“This insight, the preservation of some early eye-looking, is important,” explained Jones. “In the future, if we were able to use similar technologies to identify early signs of social disability, we could then consider interventions to build on that early eye-looking and help reduce some of the associated disabilities that often accompany autism.”

The next step for Jones and Klin is to translate this finding into a viable tool for use in the clinic. With support from the NIH Autism Centers of Excellence program, the research team has already started to extend this research by enrolling many more babies and their families into related long-term studies.

They also plan to examine additional markers for autism in infancy in order to give clinicians more tools for the early identification and treatment of autism.

Grant: R01MH083727

About the National Institute of Mental Health (NIMH): The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and care. For more information, visit

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit

NIH…Turning Discovery Into Health®


Jones W, Klin A. Attention to eyes is present but in decline in 2-6-month-old infants later diagnosed with autism. Nature, Nov. 6, 2013.




Science on Stage: Staged readings of “The Sequence” by Seattle playwright Paul Mullin



Northwest Association for Biomedical Research and Seattle Public Theater will present ‘Science on Stage’ – staged readings with the director and cast of Seattle playwright Paul Mullin’s play ‘The Sequence.’

Bathhouse Theater at Green Lake with pre- or post-play discussions

Oct. 5 –   Saturday,   2pm          post-play discussion for NWABR members    – 3:45pm

Oct. 12 – Saturday,   2pm           post-play discussion for the public                   – 3:45pm

Oct. 13 – Sunday,     7pm           pre-play discussion for NWABR donors           – 6:00pm

Tickets:  $20 for NWABR members, $22 for all others, available online or at the door.

Play Synopsis:  Sequencing of the human genome was a public race – and a personal war!  Strong personalities, emerging technology and differing views on public vs. private DNA ownership fueled the race to obtain the first human DNA sequence.  Covering the story was a young journalist worried about her own destiny with breast cancer and the information that her genome sequence would uncover.

More information and online ticket information are available at or contact Reitha Weeks at for information about group sales.

Proceeds support NWABR programs.

Coarctation thumbnail

The $13 Test That Saved My Baby’s Life. Why Isn’t it Required For Every Newborn?


by Michael Grabell

On July 10, my wife gave birth to a seemingly healthy baby boy with slate-blue eyes and peach-fuzz hair. The pregnancy was without complications. The delivery itself lasted all of 12 minutes. After a couple of days at Greenwich Hospital in Connecticut, we were packing up when a pediatric cardiologist came into the room.

We would not be going home, she told us. Our son had a narrowing of the aorta and would have to be transferred to the neonatal intensive care unit at NewYork-Presbyterian Hospital at Columbia, where he would need heart surgery.

It turned out that our son was among the first in Connecticut whose lives may have been saved by a new state law that requires all newborns to be screened for congenital heart defects.

It was just by chance that we were in Connecticut to begin with. We live in New York, where such tests will not be required until next year. But our doctors were affiliated with a hospital just over the border, where the law took effect Jan. 1.

As we later learned, congenital heart problems are the most common type of birth defect in the United States. The Centers for Disease Control and Prevention estimate that about one in 555 newborns have a critical congenital heart defect that usually requires surgery in the first year of life.

Many cases are caught in prenatal ultrasounds or routine newborn exams. But as many as 1,500 babies leave American hospitals each year with undetected critical congenital heart defects, the C.D.C. has estimated.

Typically, these babies turn blue and struggle to breathe within the first few weeks of life. They are taken to hospitals, often in poor condition, making it harder to operate on them.

By then, they may have suffered significant damage to the heart or brain. Researchers estimate that dozens of babies die each year because of undiagnosed heart problems.

The new screening is recommended by the United States Department of Health and Human Services, the American Heart Association and the American Academy of Pediatrics. Yet more than a dozen states — including populous ones like Massachusetts, Pennsylvania, Florida, Georgia, Wisconsin and Washington — do not yet require it.

The patchy adoption of the heart screening, known as the pulse oximetry test, highlights larger questions about public health and why good ideas in medicine take so long to spread and when we should legislate clinical practice.

Newborns are already screened for hearing loss and dozens of disorders using blood drawn from the heel. The heart test is even less invasive: light sensors attached to the hand and foot measure oxygen levels in the baby’s blood. This can cost as little as 52 cents per child.

Our son’s heart defect was a coarctation of the aorta, a narrowing of the body’s largest artery. This made it difficult for blood to reach the lower part of his body, which meant that the left side of his heart had to pump harder.

A: Coarctation (narrowing) of the aorta. 1:inferior caval vein, 2:right pulmonary veins, 3: right pulmonary artery, 4:superior caval vein, 5:left pulmonary artery, 6:left pulmonary veins, 7:right ventricle, 8:left ventricle, 9:main pulmonary artery, 10:Aorta.

A: Coarctation (narrowing) of the aorta. 1: inferior caval vein, 2: right pulmonary veins, 3: right pulmonary artery, 4: superior caval vein, 5: left pulmonary artery, 6:left pulmonary veins, 7: right ventricle, 8: left ventricle, 9: main pulmonary artery, 10: aorta. – Source: Wikipedia

In the hospital, though, he appeared completely healthy and normal because of an extra vessel that newborns have to help blood flow in utero. But that vessel closes shortly after birth, sometimes revealing hidden heart problems only after parents bring their babies home.

Depending on the heart defect, the onset of symptoms can be sudden.

This is what happened to Samantha Lyn Stone, who was born in Suffern, N.Y., in 2002. A photograph taken the day before she died shows a wide-eyed baby girl lying next to a stuffed giraffe. The next morning, her mother, Patti, told me, she was wiping Samantha’s face when she heard a gurgle from the baby’s chest.

Before her eyes, Samantha was turning blue. Blood began to spill from her mouth. Ms. Stone dialed 911, and minutes later, a doctor who heard the call over a radio was there performing CPR. Samantha went to one hospital and was flown to another.

But the damage was irreparable. Samantha had gone 45 minutes without oxygen: She lapsed into a coma and died six days later.

It wasn’t until several years later that Ms. Stone learned about the pulse oximetry test. “This could have saved my daughter,” she told me. “There is no parent that should ever have to go through what I went through.”

Pulse oximetry is not a costly, exotic procedure. Most hospitals already have oximeters and use them to monitor infants who suffer complications. You can buy one at Walmart for $29.88.

A recent study in New Jersey, the first state to implement the screening, estimated that the test cost $13.50 in equipment costs and nursing time. If hospitals use reusable sensors similar to those found on blood-pressure cuffs, the test could cost roughly fifty cents.

As medical technology advances, few screenings will be so cheap or simple. Recent years have seen controversy over prostate cancer and mammography screenings. Medical ethicists have to weigh the costs of each program and the agony caused by a false positive against the lives saved.

But with pulse oximetry, the false positive rate is less than 0.2 percent — lower than is seen for screenings newborns already get. The follow-up test is usually a noninvasive echocardiogram, or an ultrasound of the heart. A federal advisory committee came down in favor — three years ago.

“There’s really no question, scientifically, this is a good idea,” said Darshak Sanghavi, a pediatric cardiologist and a fellow at the Brookings Institution. “The issue is, how do we change culture?”

Opposition has taken two forms. One is from doctors who believe policy makers shouldn’t interfere with how medical professionals do their jobs. The other is from smaller hospitals, which worry about access to echocardiograms and the costs of unnecessary transfers.

These concerns can be addressed fairly easily. Nurses in New Jersey and elsewhere have been able to work the test into their normal routines. A rural hospital should already have a protocol to transfer a newborn in serious condition. If Alaska can do it, less remote states can, too.

But this is not simply a rural health care problem. Cardiologists and neonatologists I’ve spoken with said they knew of hospitals in New York City, Boston and metropolitan Atlanta that weren’t screening newborns for heart defects.

“It’s completely the luck of the draw of where you deliver,” said Annamarie Saarinen, who has pushed for the screening since her daughter narrowly avoided leaving the hospital with an undetected heart defect.

Fortunately, our son’s condition was also caught and corrected. The only lasting effects are a three-inch scar on his side and checkups with a cardiologist. He will live a normal life. He will be able to play sports and climb things he’s not supposed to.

Shouldn’t every baby have that chance?

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Birth defects study in south central Wa finds no common causes, Department of Health


From the Washington State Department of Health

Birth defects study in south central WA is inconclusive — no common causes

Magnifying GlassOLYMPIA – A state-led study into several cases of a rare birth defect in Yakima, Benton, and Franklin counties has revealed no common exposures, conditions, or causes.

State and local public health investigators found no significant differences between women who had healthy pregnancies and those affected by anencephaly, a rare neural tube defect.

Anencephaly is a fatal birth defect that results from incomplete formation of the brain during the first month of pregnancy. An unusually high number of anencephaly cases in Washington prompted the study, which was led by the state Department of Health in cooperation with local health officials and the Centers for Disease Control and Prevention.

Typically, one or two anencephaly cases would be expected in about 10,000 annual births. The investigation found about eight cases per 10,000 births in the three-county area of Yakima, Benton, and Franklin.

Anencephaly and a related spinal cord disorder known as spina bifida are often caused by a lack of the B-vitamin folic acid in the mother’s diet.

Other factors include certain medications, diabetes, pre-pregnancy obesity, or previously having a child with a neural tube defect.

The study examined medical records from January 2010 through January 2013 and looked at possible risk factors including family history, pre-pregnancy weight, health risk behaviors such as supplemental folic acid and medication use, and whether the woman’s residence received drinking water from a public or private source.

No significant differences were found when comparing cases of anencephaly with healthy births in the three county area. Although the number of affected pregnancies was large for this area, larger numbers are often needed to identify causes. Medical record reviews might not have captured all information, preventing a cause from being identified.

The higher than expected number of anencephaly births in the region could be coincidental. Still, state health officials will keep monitoring births in the region through 2013 to see if the elevated number of affected pregnancies continues and if more can be learned about causes.

State and local health officials say women of childbearing age should follow the U.S. Preventive Services Task Force recommendation of taking 400-1000 micrograms of folic acid daily, either from foods fortified with folic acid or a supplement.

They also advise seeing a health care professional when planning a pregnancy or as soon as pregnancy is recognized, and making sure to provide a list of all medications and nutritional supplements that are being used.

Women who are pregnant or planning pregnancy should be sure that drinking water from private wells is tested at least annually for nitrate and bacteria. If levels exceed standards, an alternate source of drinking water should be used.

More information on anencephaly is available on the Centers for Disease Control and Prevention Birth Defects website. Information on testing private well water is on the state Department of Health Drinking Water website.


UW Medicine to “affiliate” with PeaceHealth – Seattle Times


seattle-times-logo-squareUW Medicine and PeaceHealth have agreed to create a “strategic affiliation,” with details to be spelled out by the end of September, Seattle Times health write Carol Ostrom reports.

PeaceHealth, a not-for-profit system based in Clark County and founded by the Sisters of St. Joseph of Peace, operates nine hospitals and physician groups in Alaska, Washington and Oregon, and a Medicaid health plan.

Ostrom writes:

The two organizations said they will remain legally separate and independent, but critics of such affiliations noted that after Swedish Medical Center used such language in an affiliation with Providence Health & Services last year, it stopped doing elective abortions and closed its hospice service.

The U.S. Catholic Bishops’ Ethical and Religious Directives for Catholic Health Care Services restrict such services as abortion, birth control, sterilization and patients’ rights regarding end-of-life treatment.

Seattle Times staff columnist Danny Westneat questions the growing role of the Catholic church in healthcare in Washington state.

By the end of this year, half of our state’s medical system will be Catholic-run, as measured by number of hospital beds. That’s the highest share in the nation, and rising fast — up from about 30 percent just last year. Somehow our godless state has become Ground Zero for faith-based medicine.

He asks:

We’d never turn our education system over to one church to run. Why are we doing it with health care?

To learn more: