The Author: Laurie Bouck is the co-author (with Michael J. Smith, MD) of The Complete Idiot's Guide to Vaccinations. She writes about health and medicine on her blog, MedFly.
When we travel, I don't wipe down restaurant tables or whip out the hand sanitizer every ten minutes. I know that most germs we might encounter can be knocked out quickly by a healthy immune system. But a few viruses and bacteria, those dangerous enough to have warranted the arduous process of vaccine research and development, give me pause.
Japanese encephalitis, for example, kills 25% of the people who catch it. Hepatitis A can make you seriously ill for months. Polio is still lurking in some corners of the world. Fortunately, vaccines are available to help prevent these infections. For me, vaccines are an easy way to make travel with children safer and less worrisome.
The Centers for Disease Control and Prevention (CDC) designates travel vaccines as either routine, recommended, or required.
Routine vaccines are the standard vaccines and booster shots that are recommended for children (and adults) in the United States. For children, these vaccines are given on a dosage schedule that begins at birth (with the hepatitis B vaccine) and continues into adulthood. Most of these vaccines are given to children in their first few years of life, to create immunity before they might be exposed to a disease.
Recommended vaccines are the vaccines that a traveler might want to get if they visit certain countries or regions. A Japanese encephalitis vaccine is recommended for certain types of travel to parts of Asia, for example, and a typhoid vaccine might be recommended for a trip to India. Even if you don't get these recommended vaccines, though, you can still travel in these areas.
Countries that have required vaccines will need to see written proof of vaccination or vaccination exemption before you are allowed to enter the country. Currently only two vaccines, the yellow fever vaccine and the meningococcal vaccine, are required for entry into certain countries. If a vaccine is required, you will need to show either written proof of vaccination, or a doctor's note exempting you or your child from the vaccine.
The world is not a static place, though, and the vaccines that are recommended or required for travel to certain countries can change. Some diseases are seasonal, with outbreaks more common at certain times of the year. Other diseases increase or decrease in a country when a large population migrates due to civil war, a natural disaster, or even a religious pilgrimage.
Once you know where you plan to travel, check a trusted travel resource, such as the CDC's Travelers Health website, to find out what vaccines your family might need.
Occasionally, a routine, recommended, or required vaccine is temporarily unavailable in the United States due to a manufacturing problem or other issue. If a vaccine you want is not available, talk to you health care provider about what your options are.
This article provides information, not medical advice, about the vaccines your child might need to travel more safely to different areas of the world. To find out what vaccines are best for your family's unique health needs, make sure you talk to a health care provider.
Vaccines contain a modified form or piece of a bacteria or virus, which your immune system responds to by destroying it with specialized cells. Your body then retains some of these battle-hardened cells so that they can quickly stop any future infections with that germ before it can sicken you. This process creates immunity to a disease.
Depending on the vaccine, it can take weeks to months after the vaccination for your body to create this immunity; meanwhile, you could still catch the disease if you are exposed to it. Some vaccines also require multiple doses over time in order for your body to create adequate immunity to the disease.
For these reasons, if you need travel vaccines, it's important to plan ahead. Once you know your travel itinerary, it's best to start any vaccinations your family needs at least four to six weeks before you leave – several months before is best. If you are leaving in less than a month and need travel vaccinations, talk to your health care provider about an accelerated vaccination schedule and other options that can provide some protection against disease.
In many cases, your health care provider can give your family and you the travel vaccinations that you need. If you need a lot of different vaccinations, though, it's best to find a local travel medicine clinic (as opposed to a CVS or general drugstore). These clinics can also give you the paperwork you need for any required vaccinations. To find a travel medicine clinic near you, contact your local health department, visit the CDC's Vaccines website, or visit the website for the International Society of Travel Medicine (see Resources for links).
Infants and young children are normally vaccinated against a wide range of diseases, such as hepatitis B, tetanus, pertussis (whooping cough), seasonal influenza, and measles, with a series of single and combination vaccines given during well-child health care visits. These vaccines often require multiple doses, spaced out over months or years, to create adequate immunity to a disease. By the time a child turns 18, he or she has completed all the doses and booster shots for vaccines against 16 different diseases listed on the current vaccination schedule. The routine vaccination schedule is updated every January on the CDC's website (see Resources for link).
Parents in any state can opt out of vaccinating a child for medical reasons (for example, if a child has a serious immune system problem that could make certain vaccinations dangerous for them). Most states also allow parents to opt out of recommended vaccines for religious or philosophical reasons.
Opting out of a routine vaccination can be risky when you travel abroad, though. Many vaccine-preventable diseases are more common in other countries than in the United States. Vaccine researchers like to remind people that these diseases are "just a plane ride away" in today's world.
Before your trip, make sure that your child's routine vaccinations (and your own) are up to date. Also ask your health care provider whether your child needs to start some routine vaccinations early, or finish some vaccination series on an accelerated schedule, to help protect them from disease when you travel.
Six different vaccines are sometimes recommended or required for international travelers. In most cases, these vaccines are not recommended for children under 1 year old. If you're taking an infant to an area where a vaccine is recommended or required, you will need to take precautions to protect them from exposure to disease, and (if the vaccine is required to enter the area) provide a doctor's note explaining that the child is too young to receive the vaccine.
The CDC's online Vaccine Information Statements provide more details on the symptoms of each vaccine-preventable disease, vaccine doses, and potential vaccine side effects and allergic reactions (see Resources for link).
You might need a typhoid vaccination if you are traveling to South Asia (where the risk of infection is much higher than other areas), Asia, Central or South America, the Caribbean, or Africa. The bacteria that cause typhoid fever are spread by contact with infected human feces, and travelers often catch typhoid fever through food or drinks contaminated with feces. True to its name, typhoid fever usually causes a high fever, along with stomach pain and other problems. Untreated typhoid fever can be fatal.
The typhoid vaccine is recommended if you're visiting a smaller town or rural area where typhoid fever is common, or visiting friends or relatives in an area where typhoid fever is common. Children age 2 and older can receive the typhoid vaccine as a one-dose injection, which provides protection for two years (get the vaccine at least two weeks before you leave). Children age 6 and older can receive the vaccine as a series of four pills, each spaced two days apart, which provides protection for five years (finish the series at least one week before you leave).
Japanese encephalitis, common in rural areas of South and Southeast Asia, is caused by a virus spread by mosquitoes. Infection can cause brain inflammation and other problems; a quarter of people infected with Japanese encephalitis die, and brain damage is common in survivors.
Outbreaks of Japanese encephalitis (sometimes referred to as "JE") are often seasonal, so check your travel dates against the most updated vaccination recommendations online. You might need to get this vaccine if you're planning to spend a month or more in South or Southeast Asia, if you plan to spend time in rural areas, or if you plan to spend a lot of time outdoors (such as camping).
The three-dose vaccine is given over 30 days, although that timing can be halved if needed with an accelerated vaccination schedule. You should finish the series of shots at least ten days before you leave. Children should be one year or older to receive the vaccine, which probably provides protection for two years.
Because hepatitis A is extremely common worldwide, it is both a routine childhood vaccination and an often-recommended travel vaccination for children and adults. Like typhoid, the hepatitis A virus is spread by contact with infected human feces, or food or drink contaminated with infected feces.
Children who catch Hepatitis A often have no symptoms, but they can pass on the infection to adults, who become seriously ill. Hepatitis A affects the liver, causing problems such as nausea and stomach pain. An infection can take months to go away, and in some cases the infection can be fatal.
The routine hepatitis A vaccine is given to children after they turn one year old. They receive two doses at least six months apart. One dose of the vaccine, given at any time before you leave, can also provide protection if you do not have time to get the second dose before your trip. The vaccine is believed to provide protection from hepatitis A for 20 years or longer.
Rabies is a fatal virus spread by the saliva of an infected animal, usually through a bite. The symptoms of rabies infection include hallucinations and seizures. Rabies is rare in the United States, but it is a concern in Asia, Africa, and Central and South America. In these countries, rabies is most often spread by infected dogs, monkeys, bats, and cats.
Although most people get a series of rabies shots only if they are bitten by a rabid animal, travelers who might encounter rabid animals when they are far from medical care can get a pre-exposure (prophylactic, or preventative) rabies vaccine. Children are at special risk for rabies because they often want to play with animals. A pre-exposure rabies vaccine can provide some protection to a child bitten by a rabid animal until you can find medical help.
The pre-exposure vaccine can be given to infants (under 1 year old) or children, in three doses over three to four weeks. If a vaccinated child or adult is bitten by a rabid animal, clean the wound well. Then get another dose of the vaccine as soon as possible, and a final dose three days later.
This five-dose vaccine series can prevent rabies if it is completed before symptoms of rabies appear. Rabies symptoms usually do not begin until weeks or months after exposure.
Like Japanese encephalitis, yellow fever is a virus that can occur in seasonal epidemics and is spread by mosquitoes. The virus, which affects your liver and blood, can cause jaundice, fever, and flu-like symptoms. Yellow fever, which can be fatal, is a concern in tropical South America and sub-Saharan Africa.
The one-dose yellow fever vaccine is approved for children 9 months and older; if necessary, it can be given to children as young as 6 months old. You should get the vaccine at least 10 days before you leave. The vaccine provides immunity for 10 years.
Some countries require an International Certificate of Vaccination or Prophylaxis (ICVP), which proves you have been vaccinated against yellow fever, before you can enter the country. You can get the vaccination and certificate (which is good for ten years) at a yellow fever vaccination clinic (see Resources).
Some of the countries that require an ICVP for entry will waive these vaccination requirements for infants. If you cannot receive the yellow fever vaccination for medical reasons, a doctor's letter explaining the reason might be accepted.
The meningococcal vaccine is a routine childhood vaccination, usually given to children around age 11 or 12. The meningococcal vaccine prevents infection with bacteria that can cause disabling or fatal meningitis (brain infection), blood infections, or pneumonia. These infections can develop quickly and spread easily among people who are living or working in crowded conditions.
Since meningococcal outbreaks can occur seasonally in sub-Saharan Africa, the vaccine is often recommended for travelers to that region. Outbreaks also occur in Saudi Arabia during the Hajj, or pilgrimage to Mecca. If you travel to Saudi Arabia during the Hajj (the date of each year's Hajj is based on the Islamic calendar), the meningococcal vaccine is required for entry; you must provide written proof of vaccination.
The one-dose vaccine is licensed for children as young as age 2. It can also be given to children under age 2 if they need the vaccination to enter Saudi Arabia. It should provide protection for three to five years.
It's important to understand that no vaccine is guaranteed to protect you from a disease. Standard childhood vaccines, for example, are about 75% to 99% effective at preventing disease, depending on the vaccine. The typhoid vaccine for travelers is 50% to 80% effective.
Even if you get the vaccinations you need for your family, you could still catch a disease you were vaccinated against. Following healthy travel trips can help protect you from infectious diseases as well.
Research the health risks for the areas you plan to visit. As a baseline, be sure to keep your children's pacifiers, toys, and hands clean while you travel. Ask your health care provider whether you need to bring any extra medical supplies to stay healthy on your trip.
Is it safe to eat raw foods or should I only eat hot, fully-cooked foods?
Is it safe to drink the water and consume ice, or should I stick to bottled water?
Is it safe to consume unpasteurized milk and cheese?
Do I need to protect myself from insect-borne disease with DEET-based insect repellent or mosquito netting for sleeping?
How else can I protect my family on this trip?
The U.S. State department's website has many healthy travel tips available online (see Resources for link).
About the author: Laurie Bouck is an award winning writer focused primarily on health and medicine. She has co-authored a book on vaccines and written for a variety of well respected journals and magazines. She blogs at MedFly.
Is there a vaccine to prevent TB?
Yes, there is a vaccine for TB disease called Bacille Calmette-Gurin (BCG). It is used in some countries to prevent severe forms of TB in children. However, BCG is not generally recommended in the United States because it has limited effectiveness for preventing TB overall.
It is not one of the CDC's recommended vaccines for Mexico.
Hi. I'm planning to visit London, UK for 1 year with my two sons 8 months and a 6 year old. Do I need any specific vaccinations for the kids?
I would not think you would need anything special for London and the UK but, of course, I don't know your kids' vaccination history. Check the CDC for routine vaccines for the UK.
It sounds like fun to me. Here's the CDC travel info page on Fiji.
I'm travelling with my baby to Mexico. He is too young to have the typhoid vaccination, but my doctor has said it is perfectly fine for him to travel to Mexico. Does anyone have any further information on how safe it is?
Hi josh. Here's the best website for travel health info for Mexico.
I've some mean Jungle bug spray that I'll be bringing with me to India.
I work in China and was cleared of all shots back in SA less than a year ago.
Check the CDC for travel health information for India. Good luck.
Also just noted the comment from Alex. Yes most JE infections are sub-clinical however the fatality rate is high in those that become unwell.
You should check with the CDC travel website. Good luck.
Hi, I am an Indian citizen staying in Italy from last 2 hrs. I have a two month baby and we are traveling to India for 2 months. Do you think I shot get any specific travel vaccination for her. And in India there is a vaccination BCG which is given to infant at 2 day of their life but which is not required in Europe . What should we do please suggest.
Hi Alpa. I can't really speak to specific vaccinations but you could look through: cdc.gov/travel. Good luck.
Traveling with kids can be an exciting way to see the world. We will be featuring this post in our Healthy Travel Tip of the Day on Feb 16th (@TravelReadyMD). Thanks for encouraging healthy travel for families.
Hi there great article, but I think your mortality figures are wrong for Japanese Encephalitis, as all but 0.5% infections are sub clinical.
Thank you so much for such an informative post. This will really help people to travel with children safer and worry free.
What a great article!!! We're going to Thailand in December and January.
We plan on flying to Phuket, maybe a few days in Krabi, then on to Samui. From there a long train trip up to Chiang Mai and we'll have 10 days in the north. Any advice for staying safe and healthy? Do you recommend anti-malarial medicine while we're in Chiang Mai. What are the hospitals in Chiang Mai, Bangkok and the tourist resorts like?
Hi Megan. Sounds like a great trip. The biggest thing you can do for malaria is avoid getting bit in the first place. Use bug repellant with a high DEET content, have it on when you go out in the evening and for going to sleep, use a mosquito net if you're in a malaria zone. Malaria is present in the North but not in Chiang Mai. The closer you get to the Myanmar and Laos borders the more you'll have to be vigilant. The hospitals in Bangkok are great and are western standard hospitals. Chiang Mai also has a good hospital. When you're in the tourist areas there will be a good clinic hospital but for anything serious you'll have to be flown to Bangkok (or Singapore).
The resorts you are going to in Thailand have been pretty much sanitized to American specs. Also, Bangkok has some of the best hospitals in the world and receives vast numbers of Americans looking to escape the US healthcare system.
Enjoy your trip, you'll be OK.
I have been to Thailand many times and never take antimalarials. Unless you will be spending a prolonged period of time in the far north of the country it is unlikely that the benefits of taking prophylactics outweigh the risks (and hassle).
Fantastic article. Thank you. My family will be coming here soon and this was really helpful. Good medical advice for someone like me.
I usually travel to more "safe" destinations that don't require shots or medicine but am currently planning to visit family in Malaysia and China with my son and daughter so this was very good to read.
Heading to Singapore, Thailand and India in January 2013 with my 9 year old and this was really helpful. Thanks.


It appears that TM just farted and many users across the nation are experiencing inexplicable slowdowns. There has been no official word from TM as of yet and it appears to only affect some international sites such as Facebook.
Whether this is in line with their planned upgrades as per this announcement is anyone's guess. As such this may affect VPN speeds.
Achieving less than 50KBps download speed on local server… Good job TM.
Improved by leaps and bound now. Getting over 1Mbps download and more than 0.2Mbps upload. Maybe upgrades are done or line is not busy now since it's 1 am.
What is weird is that the line is smooth when I turn off VPN. But when I turn on VPN, the line gets really choppy and tends to disconnect/reconnect more often than not… What is going on, I wonder!
Speeds have been erratic past 2 days, full speed followed by godawful slowdowns. I don't use BolehVPN so can't comment, but ftp speeds to Boleh seedbox is similar to http fluctuations – which means random IPs produce random results. Who knows what TM is doing to be honest.


"They laughed," she says. "But later, the same people were sitting in here crying. You don't know how you're going to feel until it happens to you."
When Kathleen Leone and her husband Raymond first opened their funeral home in the Carroll Gardens section of Brooklyn, Kathleen could hear the neighbors outside on the street laughing at the sign: "All Pets Go to Heaven Pet Funeral Home."
Kathleen and Raymond grew up in this neighborhood and for 21 years they've operated a funeral home for humans, but still their neighbors laughed or came inside just to gawk when they opened the new establishment. People with pets, even. One can imagine Kathleen sitting patiently through it all, like a mother waiting for her hyperactive kids to wind themselves down. She's been working in the death industry for two decades now. Her feelings aren't so easily bruised. "They laughed," she says mildly. "But then, later, I had these same people sitting in here crying. You don't know how you're going to feel until it happens to you."
All Pets Go to Heaven has been in operation for two years now and it seems very much part of the neighborhood. The Leones describe it as an "all service" pet funeral home, providing burials and cremations, both private and communal, wakes in the Victorian viewing room, online counseling for the grief-stricken, memorial cards and plaques, embalming and even freeze-dried taxidermy.
It's housed in a large, handsome brownstone on a street of brownstones. Raymond's parents own the building and his brother lives upstairs. Brown awnings shade the windows and are stamped with the silhouettes of rabbits and frogs.
Even though every year more and more hip young Manhattanites are moving into Carroll Gardens, it still feels like a working-class Italian neighborhood. There are religious shrines in some of the front yards and small markets run by fathers and their sons. And there's the pet funeral home. As soon as I stepped into the viewing parlor and saw the small, powder-blue coffin for the small male dog or cat, I knew I was among people who weren't afraid of family feeling.
"I just had a wake for a Rottweiler, day before yesterday," Kathleen tells me. "He's being buried this morning. His owner's a single woman. She's burying him with a blanket she crocheted when she was a girl that was supposed to be for her first child. But she never married, never had any children. The dog was her son." Kathleen's the mother of three girls and very pregnant with the fourth. She has short blond hair, a strong face and brown eyes that look tired this particular morning, only a couple of weeks away from her due date. She's a registered nurse, and before she and Raymond opened up All Pets, Kathleen was a nursing supervisor in a long-term care facility for the elderly. Her daughters are named after her and Raymond's mothers and grandmothers. She describes herself as "old-fashioned" and says that their clients are just "regular Joes that come in off the street."
We talk at Kathleen's desk, in the middle room of the funeral home. In the front is the viewing parlor, where rows of chairs face the little blue coffin and a statue of St. Francis of Assisi. In the room behind us, there's a wide selection of urns displayed on shelves. Some are shaped like dogs; some look like pretty cookie tins and are stamped with kittens' faces or flowers.
The engravable urns are the most popular, according to Kathleen. They come in dark and light woods, white or gray granite and white marble, and are engraved with the deceased pet's name. The dates of birth and death and a photograph are applied to the front -- the smaller ones cost $125.
"In the past there were no options for people [whose pets have died]," Kathleen says. "Just our being here raises a question in people's minds -- oh, what am I going to do when my pet dies?" The options she and her husband provide raise more questions: Burial or cremation? Would I visit a grave? Do I need them nearer to me? On the mantelpiece? If I give a wake, who would come? And should I have a religious service or just read a poem?
Kathleen's right: The very presence of a pet funeral home causes you to think -- if not about what you want to do for your pet when it dies then about animals and where they fit into our lives, and about the rituals we have around death and the ways we circumscribe love.
The Rottweiler was the biggest animal that has been brought to the funeral home so far -- 52 inches long, running the entire length of Kathleen's freezer. He was only 6 years old when he passed away. "His owner was in shock," Kathleen says. "She thought maybe he got depressed when her mother got sick and that killed him."
The smallest animal was a goldfish named Poppy. His owner wanted him cremated. "I tried to convince her just to bury it," Kathleen says. "I said, you're not going to get hardly anything back, if you get the flick of an ash -- and that's about what she got back -- but she wanted that. I gave her the urn because it was ridiculous not to. Firing up the cremator costs the same amount of money whether it's a cat or a goldfish."
Kathleen had a goldfish herself at one time, and though she was sorry to see it pass on, she couldn't grieve for the fish like she would a dog or a cat. "But you know what? Someone could say, 'How can you feel that for a cat?' I think it's about security and love. That goldfish? That was what she had to come home to at night."
When I ask Kathleen what's the most unusual request she's ever gotten in the pet funeral business, she says, "I don't find anything to be unusual. Everything is individual, so it's not unusual." For a moment she seems to regard me almost warily, but it's not the look of a wounded person; it's sharper, more measuring than that.
"Your customers seem to be mostly women," I say to her, and she says quickly, almost sternly, no, not really, it's women and men, gay and straight, young and old, we get them all.
She's cremated two pythons for two different customers. Cato and Bruno. Bruno's the one she remembers because he was beautiful and big,about 150 pounds. The owner was a bouncer in a Manhattan club. He told Kathleen that he had his apartment climatized for the snake. He opted for cremation and a Roman urn.
"Actually I was surprised I didn't hear from him afterward," Kathleen says, since the more grief-stricken clients often feel the need to stay in touch for a while and the bouncer was pretty shaken up.
"But he had his friends," she remembers. "They came with him. I mean, he didn't have a viewing or anything, but his friends all came with him when he brought the python in and when he picked up the cremains, they all came with him again. So he had a good support system there."
It's always easiest for Kathleen when the clients want to tell her everything about the pet, especially if they choose to have a wake. Then she can spend those two hours talking to them about their animal and not just coming in and out of the room, asking if they're all right and if they want some water.
"Most of my people will bring photo albums and share the pictures of their pets with me, tell me about the one funny incident, the one bad incident -- you know, talk about the guilt of how they feel when they yelled at him," she says. "And I'll take them through what I need to do at that point to help them get over those guilty feelings."
She sees no difference between the human and the pet funeral business -- mourning is mourning, she says.
"Right now, I have a man whose pet is still living. His wife passed away within the last few months. She's out in St. Charles cemetery and he said he wasn't prepared for her death, and now the dog he's had for 14 years is pretty much ... on her last leg and he wants to be prepared.
"He doesn't want the same thing to happen to him, you know -- the emotions -- as when his wife passed away," she continues. "He wants to be prepared, so I've been talking to him on the phone throughout this week, two, three days a week. He wants to bury [the dog] out at the cemetery, which is very close to St. Charles, so this way he could do two visits in one day."
Kathleen didn't grow up with animals. Just one family dog, she says, and her sister got to have a turtle, a very small turtle, because "we didn't have the space, my mother worked full time, my father worked full time and there was a big stress on education, that was your first priority."
Her husband, Raymond, was the one with the zoo in the backyard. "Pigs, cows, snakes, everything," she laughs. "Believe it or not, when I first met him, they had pheasants flying in their house, they had goats in the backyard. They used to run pony rides in the neighborhood."
"So do you love animals more now, I mean, working in this business?" I ask her.
"I notice them more," she says, sounding careful again.
"Well, has running this business changed you?"
"Not really," she replies. For a minute I think she's just determined to make sure I find nothing strange or unusual about the pet funeral business, but maybe she's just telling me the truth.
"I used to be a regular Joe, working 8 to 4, Monday through Friday, and now I work by appointment when it's convenient for my clients," she explains. "Otherwise I'm really doing basically the same thing I was doing before -- I'm serving the public and I'm providing a service that's necessary. I come from a family of doctors and nurses, so we're all community service."
Finally, I get her to admit to one difference when I ask her if she ever gets her heart broken on this job.
"Yes, that's part of the business," she says. "I mean some people can detach themselves. I found that I was able to do it better -- function in the role of a nurse than I can function in the role of a funeral manager.
"As a nurse, my specialty was geriatrics and I felt that, all right, they had lived a very fulfilling life and they're here now, they're in a long-term care facility and I'm doing whatever I can to make the best of the rest of their life. I made every day fun. I made sure recreation was scheduled; I ran parties, dancing, singing, art. I really investigated their lifestyles," Kathleen continues, "so if they were just some antisocial people, they like to have their cup of tea and their crossword puzzle, like my mother, then I made sure that was maintained. I never forced them to do anything.
"So I felt satisfied, but here you don't have the time. I try to get as much information as possible but I don't have a lot of time. There I had years, you know? Here I don't. I have a very small window to work with."
On my last visit to the funeral home, I have the odd desire to ask Kathleen for a job. She has to take maternity leave, doesn't she? But I never get up the nerve. I feel incredibly peaceful sitting at her desk in the funeral parlor while she tells me the story of a young man named Elvis who had a wake for his cat, though no one in his family could understand.
"I felt so bad for him, he broke down in pieces," she says. "He was a real bruiser, someone you would think wouldn't shed one tear and I had to scrape him off the floor." His mother looked appalled; his girlfriend rolled her eyes. Kathleen sat with him, speaking to him about his cat. She paid no attention to the nonbelievers in the room. "I'm not going to leave the person who's come to me out in the cold," she says.
Elvis still calls her from time to time, though now it's every few months, instead of every week, so Kathleen knows he's worked through his grief; he's feeling better.
And my feelings about Kathleen have changed also. At first, I saw her as a brave defender of a misunderstood, even ridiculed love -- "How can you be so upset for a dog?" But finally, I could see that in defending and protecting these loves, she was protecting love itself, in whatever form it takes -- "Crying for a hamster, for God's sakes!"


text:
Q: How can I show the index of a grid matrix-like on a matplotlib.pyplot.subplot2grid? I would like to show the index of a matrix on a matplotlib figure.
Let say that our matrix is square with index ['A','B','C']. I would like to see something like:

A
B
C

A
fig1
fig2
fig3

B
fig4
fig5
fig6

C
fig7
fig8
fig9

My code is the following:
import pandas as pd
import numpy as np
import matplotlib.pyplot as plt
import itertools

string = 'ABC'
combinations = itertools.combinations(string, 2)
data = dict()
for combination in combinations:
    begin = np.random.random()
    data[combination] = np.linspace(begin, begin+1,20).reshape(10,2)

fig = plt.figure(figsize = (15,15))

all_plot_positions = range(1, len(string) * len(string)+1)
plot_positions_used = []
for key in data:
    X, Y = np.meshgrid(data[key][:,0], data[key][:,1])
    Z = 2*X + Y**2

    i, j = string.index(key[0]), string.index(key[1])

    ax = plt.subplot2grid((len(string), len(string)), (i, j))
    CS = ax.contourf(X, Y, Z)
    cbar = plt.colorbar(CS)

    ax = plt.subplot2grid((len(string), len(string)), (j, i))
    CS = ax.contourf(X, Y, Z)
    cbar = plt.colorbar(CS)

for i in range(len(string)):
    ax = plt.subplot2grid((len(string), len(string)),( i,i))
    ax.set_xticks([])
    ax.set_yticks([])

fig.subplots_adjust(hspace = 0.5, wspace = 0.5)
fig.savefig('fig.pdf')

And my output:

As you see, There is not index.
In addition (but this could be a second question), I also would like to show only one colorbar that represent all the graphs.

redpajama_set_name: RedPajamaStackExchange


text:
Get Ready to Dress Up BTS in the New BTS WORLD Mobile Game
Sara Delgado
You Can Now Order Your BTS Bias in Doll Form
Khalid Hinted That the Long-Awaited BTS Collab Is Coming Soon
BTS Fans Think New Japanese Single "Lights" Sounds Like a "Warm Hug"
The BTS ARMY Can Help Write Their ARMYPEDIA — Here's How
Cue our excitement!
Frazer Harrison
Right now, there's probably no fandom that is bigger or more ready to hype up their faves than BTS's fanbase, the BTS ARMY. Since the group formed in 2013 and burst onto the scene in a major way, the ARMY has been devoted to streaming their music, following their every move on social media, unpacking clues about their new albums and music videos, seeing them at live shows and events, and basically making sure the whole world knows about all things BTS. Now, it looks like the ARMY can actually put all of their knowledge of and love for BTS in one place: the ARMYPEDIA, a Wikipedia-like site dedicated to BTS.
According to a press release about the ARMYPEDIA, which is set to officially launch on Monday, February 25, BTS wants to recruit the ARMY to record six years worth of memories because if anybody knows BTS as well as they know themselves, it's the ARMY. So how will fans be able to add in their own information about BTS to the ARMYPEDIA? The release states that a campaign to promote the ARMYPEDIA has been launched in 7 international cities (Seoul, Tokyo, Los Angeles, New York City, London, Paris, and Hong Kong) and that 2,080 QR codes (a number representing the number of days that have gone by since BTS formed six years ago) in the shape of puzzle pieces that have "Hey ARMY! Lost this?" written on it, which have been scattered across those cities for fans to scan. Each puzzle piece corresponds to a specific date in BTS timeline, so when an ARMY member scans a QR code either online or offline, they'll be able to access the ARMYPEDIA page for that date and then write in the relevant BTS information.
https://twitter.com/Golden_kku/status/1098627802578935808
So, once you, an ARMY member, have successfully snagged a QR code, how exactly do you scan it to access the date it corresponds to? Luckily, Armypedia.net has a step by step guide on how to do this. In the tutorial, you'll see an example of a locked page that requires the QR code to be scanned in. Once you pop in the code to the locked page, fans will be required to answer a trivia question about BTS. The fan who gets the question right wins the puzzle piece and is able to go in an enter information into that ARMYPEDIA entry. Basically, you better be a diehard fan who is ready to play because BTS isn't messing around.
Fans will be able to add information to ARMYPEDIA pages in the form of written messages, videos, or art. As you add information, you will earn points that will be tallied up once the ARMYPEDIA closes to fan contributors on Mar. 24, 2019. The top-earning 2,080 ARMY contributors will then win a special Big Hit Entertainment gift.
The ARMY has already spotted QR codes popping up IRL and have posted about it, so make sure you keep your eyes peeled and stay plugged into Twitter for possible code sightings — you definitely don't want to miss out on the chance to participate.
Want more from Teen Vogue? Check this out: BTS Member RM Said It's a "Miracle" They Haven't Broken Up Yet
Keywordsnews musicBTS

redpajama_set_name: RedPajamaCommonCrawl


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Smart to the last
Monocle editor in chief Tyler Brûlé remembers Karl Lagerfeld, creative director of Chanel, Fendi and his eponymous label, who died yesterday.
On a sunny Tuesday in early December last year I had the good fortune to spend an hour with Karl Lagerfeld at the Mercer in New York. I was told that we'd have no more than 20 minutes to talk but, having interviewed Karl several times over the past 25 years, I knew that we could end up spending the whole afternoon talking about whether Hamburg was better than Berlin, his love of daily newspapers (particularly the Frankfurter Allgemeine) and his aversion to the term "marketing". In the end we discussed Brand France, the evaporation of mystery in society, the importance of deadlines, the question marks over Chancellor Merkel and the need for craftsmanship in the design industry. Along the way we digressed to countless other topics and, by the time we wrapped up, there was enough for a sizeable audio documentary about the state of the modern world. Karl was a walking museum: formidable, deep, rich and full of delightful fables. Never afraid to speak his mind, he reminded us that the world has perhaps become a bit too brittle, that having a point of view should be celebrated and that understanding specific codes is an essential element of enduring as a designer.
Bernie Sanders has thrown his hat into the ring for the 2020 US elections – and could bring down the house.
America's most popular senator, 77-year-old Bernie Sanders, is taking a second shot at "political revolution". Yesterday the self-proclaimed Democratic socialist announced that he's running for the party leadership again. Unlike in 2016 he has thrown off the shackles of an underdog candidacy, emerging as a 2020 frontrunner with strong name recognition and campaign infrastructure. But while his policies of universal healthcare and free college education were radical three years ago, today a spate of progressives, from Elizabeth Warren to Kamala Harris, are running on similar issues. His message simply isn't as unique now as it was in then. Still, despite the crowded field, Sanders remains the Democrats' best shot at taking the White House.
China's vision for a regional technology hub will mean closer ties to Hong Kong – and that's not necessarily a bad thing.
While the international community marvels at the scale of China's Belt and Road Initiative, Beijing appears intent on forging stronger links between its cities at home. The Greater Bay Area, announced this week, is a masterplan to create an economic region spanning 11 cities along the Pearl River Delta, hinging on Hong Kong, Macau, Shenzhen and Guangzhou. The idea is to build a sprawling centre of technology innovation in the south by 2035. Closer ties with mainland China will worry some in Hong Kong. But chief executive Carrie Lam has welcomed her city's prominent position in the blueprint. It could also provide a long-term solution to one of Lam's biggest headaches: Hong Kong's housing shortage. As road and rail connections with southern China improve, overcrowded Hong Kongers may one day choose to commute from the mainland.
Going round in circles
Europe-wide Brexit fatigue is setting in as Theresa May brings a new version of her deal to the table.
It's back to Brussels for UK prime minister Theresa May, who this evening will make a last-ditch attempt to win concessions from the EU on her Brexit deal. One wonders at her capacity for rejection: she's shouted down in the House of Commons then confronted by po-faced committees in Brussels. A new report commissioned by Euronews suggests that she might have saved herself all the bother, as it claims that a large number of Europeans already think that the UK is no longer part of the EU. The largest number of misinformed people are in France and Italy, where nearly one third believe that Brexit has already happened. Anand Menon, director of think-tank The UK in a Changing Europe, believes Europeans are losing interest. "Lengthy political processes mean people get bored – and, more importantly, assumptions like this are understandably made." Given the stakes, now is the worst time to succumb to Brexit fatigue.
Beirut, Hamra
The Menu: Food Neighbourhoods
We head to Hamra, an area that combines authentic hole-in-the-wall coffee sellers and breakfast joints with new bars and bistros. Our guide is Monocle correspondent Lizzie Porter.
Monocle Films / Global
The Monocle Guide to Hotels, Inns & Hideaways
Video didn't kill the radio star and apartment-sharing apps haven't scuppered our enduring need for hotels. It's this sincere belief that proved to be the rallying cry for our latest book, which covers everything from hoteliers' trade secrets to holiday recommendations.


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Justia › US Law › Case Law › Oklahoma Case Law › Oklahoma Supreme Court Decisions › 2016 › Oklahoma Coalition for Reproductive Juctice v. Cline
Oklahoma Coalition for Reproductive Juctice v. Cline
Justia Opinion Summary
In 2011, the Oklahoma Legislature enacted H.B. 1970, prohibiting the off-label use of Mifeprex (generally known as "mifepristone" or "RU-486") and misoprostol (brand name Cytotec) for use in abortions. The effect of H.B. 1970 was to ban medication abortions in Oklahoma. In the first pronouncement ("Cline I"), the Oklahoma Supreme Court, following "Planned Parenthood of Southeastern Pennsylvania v. Casey," (505 U.S. 833 (1992)), affirmed the district court's decision that H.B. 1970 was unconstitutional. Appellees then filed a petition for certiorari in the United States Supreme Court. The U.S. Supreme Court granted the petition and certified two questions to the Oklahoma Supreme Court: whether H.B. 1970 prohibited "(1) the use of misoprostol to induce abortions, including the use of misoprostol in conjunction with mifepristone according to a protocol approved by the Food and Drug Administration; and (2) the use of methotrexate to treat ectopic pregnancies." In "Cline II," the Oklahoma Court answered both questions affirmatively. The U.S. Supreme Court then dismissed the petition for certiorari as improvidently granted. In 2014, in response to the Cline II decision, the Oklahoma Legislature passed H.B. 2684, amending Title 63, Section 1-729a of the Oklahoma Statutes. H.B. 2684 was approved by the Governor and became effective on November 1, 2014. The Bill restricted Mifeprex and misoprostol use for abortions to the FDA-approved final Mifeprex label, prohibits methotrexate use for abortions except to terminate ectopic pregnancies, provides for liability of physicians who knowingly or recklessly perform an abortion in violation of H.B. 2684, and makes doctors subject to discipline and liability for violating H.B. 2684. Plaintiffs the Oklahoma Coalition for Reproductive Justice and Nova Health Systems filed this challenge to H.B. 2684's restriction of off-label use of Mifeprex in the district court against the Oklahoma Commissioner of Health and the Executive Director of the Oklahoma State Board of Medical Licensure and Supervision (State). While this case was pending before the district court, the Oklahoma Supreme Court enjoined enforcement of H.B. 2684 until its constitutionality "is fully and finally litigated." The dispositive question presented was whether H.B. 2684, violated either of two sections of the Oklahoma Constitution: Article V, Section I or Article V, Section 59. The Court answered in the negative.
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OKLAHOMA COALITION FOR REPRODUCTIVE JUSTICE v. CLINE
2016 OK 17
Case Number: 114307
Decided: 02/23/2016
THE SUPREME COURT OF THE STATE OF OKLAHOMA
NOTICE: THIS OPINION HAS NOT BEEN RELEASED FOR PUBLICATION. UNTIL RELEASED, IT IS SUBJECT TO REVISION OR WITHDRAWAL.
OKLAHOMA COALITION FOR REPRODUCTIVE JUSTICE, on behalf of itself and its members; and NOVA HEALTH SYSTEMS, d/b/a REPRODUCTIVE SERVICES, on behalf of itself, its staff, and its patients, Plaintiffs/Appellees,
TERRY L. CLINE, in his official capacity as Oklahoma Commissioner of Health; and LYLE KELSEY, in his official capacity as Executive Director of the Oklahoma State Board of Medical Licensure and Supervision, Defendants/Appellants.
ON APPEAL FROM THE DISTRICT COURT OF OKLAHOMA COUNTY,
THE HONORABLE PATRICIA G. PARRISH, PRESIDING
¶0 In the district court, Plaintiffs challenged H.B. 2684 as unconstitutional under several theories. The district court agreed and found H.B. 2684 to be unconstitutional. Defendants appeal, only presenting Plaintiffs' theories that H.B. 2684 violates two sections of the Oklahoma Constitution and the question of issue preclusion based on this Court's opinion in Cline v. Okla. Coalition for Reprod. Justice, 2013 OK 93, 313 P.3d 253. This Court retained the appeal for disposition.
REVERSED AND REMANDED.
Patrick R. Wyrick, Cara N. Rodriguez, Jared B. Haines, Office of the Attorney General, Oklahoma City, Oklahoma, for appellants.
J. Blake Patton, Walding & Patton PLLC, Oklahoma City, Oklahoma, for the appellees.
¶1 The dispositive question presented to this Court is whether H.B. 2684, ch. 121, 2014 Okla. Sess. Laws 375-80 (codified at 63 O.S.Supp. 2014, § 1-729a), violates either of two sections of the Oklahoma Constitution: Article V, Section I (vesting legislative authority in the Oklahoma House and Senate); or Article V, Section 59 (prohibiting special laws). We answer in the negative. A challenge to H.B. 2684 as violative of any other Oklahoma constitutional provision or as violative of the United States Constitution is not before this Court, and we are thus limited in our decision.1
I. HISTORY
¶2 In determining the questions now before this Court, it is necessary to review H.B. 2684's predecessor, H.B. 1970, ch. 216, 2011 Okla. Sess. Laws 821-23 (codified at 63 O.S.Supp. 2011, § 1-729a), and our two pronouncements addressing it. In 2011, the Oklahoma Legislature enacted H.B. 1970, prohibiting the off-label use of Mifeprex (generally known as mifepristone or RU-486) and misoprostol (brand name Cytotec) for use in abortions.2 The effect of H.B. 1970 was to ban medication abortions in Oklahoma. Cline II, 2013 OK 93, ¶ 25, 313 P.3d at 262.
¶3 In the first pronouncement, this Court, following Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992), affirmed the district court's decision that H.B. 1970 was unconstitutional. Okla. Coal. for Reprod. Justice v. Cline, 2012 OK 102, ¶ 3, 292 P.3d 27, 27-28 (Cline I). After this Court rendered the Cline I decision, the appellees filed a petition for certiorari in the United States Supreme Court. See Cline v. Okla. Coal. for Reprod. Justice, 133 S. Ct. 2887 (2013). The U.S. Supreme Court granted the petition and certified two questions to this Court: whether H.B. 1970 prohibits "(1) the use of misoprostol to induce abortions, including the use of misoprostol in conjunction with mifepristone according to a protocol approved by the Food and Drug Administration; and (2) the use of methotrexate to treat ectopic pregnancies." Cline II, 2013 OK 93, ¶ 8, 313 P.3d at 257. In Cline II, our second pronouncement, we answered both questions affirmatively. Id. ¶ 1, 313 P.3d at 255. The U.S. Supreme Court then dismissed the petition for certiorari as improvidently granted. Cline v. Okla. Coal. for Reprod. Justice, 134 S. Ct. 550 (2013).
¶5 In 2014, in response to the Cline II decision, the Legislature passed H.B. 2684, amending Title 63, Section 1-729a of the Oklahoma Statutes. H.B. 2684, ch. 121, 2014 Okla. Sess. Laws 375-80. H.B. 2684 was approved by the Governor and became effective on November 1, 2014. In H.B. 2684, the Legislature made 16 factual findings, including that the use of medication-inducing drugs presents significant risk to women, the complications of abortion-inducing drugs were higher than those for surgical abortions, fourteen women had died after off-label use of abortion-inducing drugs, and the Federal Drug Administration (FDA) had been unable to determine whether the off-label use caused the deaths.3 The Legislature expressed its intent that the act not prohibit all medication abortions or the use of methotrexate in treating ectopic pregnancies. H.B. 2684, ch. 121, 2014 Okla. Sess. Laws 377, § 1-729a(A)(16) ("[T]his act does not ban the use of misoprostol in chemical abortion (and allows it as part of the FDA-approved Mifeprex regimen) . . . .").
¶6 H.B. 2684 restricts Mifeprex and misoprostol u se for abortions to the FDA-approved final Mifeprex label, prohibits methotrexate use for abortions except to terminate ectopic pregnancies,4 provides for liability of physicians who knowingly or recklessly perform an abortion in violation of H.B. 2684, and makes doctors subject to discipline and liability for violating H.B. 2684. Id. at 377-79, § 1-729a(C)-(H). Because the Mifeprex label only allows its use for 49 days after the last menstrual period and Mifeprex off-label use allows for its use up to 63 days, the effect of H.B. 2684 is to ban the use of the Mifeprex and misoprostol drugs for pregnancies between 49 and 63 days from the last menstrual period.
¶7 The Oklahoma Coalition for Reproductive Justice and Nova Health Systems (Plaintiffs) filed this challenge to H.B. 2684's restriction of off-label use of Mifeprex in the district court against the Oklahoma Commissioner of Health and the Executive Director of the Oklahoma State Board of Medical Licensure and Supervision (State). The Plaintiffs alleged, as a factual matter and without submitting evidentiary support, that H.B. 2684 will prevent some of Reproductive Services' patients from obtaining a medication abortion and will prevent others from receiving the medical treatment according to the most current scientific evidence and advances in medicine. The Plaintiffs challenged H.B. 2684 as violating rights guaranteed by the Oklahoma Constitution, including the right to due process by limiting women's rights to choose to terminate a pregnancy, to bodily integrity, and to equal protection; violating the Oklahoma constitutional prohibition against special laws; and improperly delegating legislative authority. As stated in the first paragraph, only the last two challenges are properly before this Court.
¶8 While this case was pending before the district court, this Court, in an interim proceeding, enjoined enforcement of H.B. 2684 until its constitutionality "is fully and finally litigated." Okla. Coal. for Reprod. Justice v. Cline, 2014 OK 91, ¶ 1, 339 P.3d 887. Both sides then moved for summary judgment in the district court. The district court rendered judgment in favor of the Plaintiffs, finding that H.B. 2684 is a special law in violation of Article V, Section 59 of the Oklahoma Constitution. The State appealed, raising only the questions of issue preclusion, unauthorized delegation of legislative authority, and special law under Article V, Section 59. We retained the appeal for disposition and asked for additional briefs specifically addressing the differences in H.B. 1970 and H.B. 2684.
II. STANDARD OF REVIEW
¶9 Summary judgment settles only questions of law. Pickens v. Tulsa Metropolitan Ministry, 1997 OK 152, ¶ 7, 951 P.2d 1079, 1082. The standard of review of questions of law is de novo. Id. Summary judgment will be affirmed only if the appellate court determines that there is no dispute as to any material fact and that the moving party is entitled to judgment as a matter of law. Id. Summary judgment will be reversed if the appellate court determines that reasonable men might reach different conclusions from the undisputed material facts. Runyon v. Reid, 1973 OK 25, ¶ 15, 510 P.2d 943, 946.
III. THE UNDISPUTED FACTS WHICH ARE SUPPORTED BY COMPETENT
EVIDENTIARY MATERIALS
¶10 Medication abortion is a procedure for terminating a pregnancy using medications alone. In the United States, medication abortion generally follows a protocol using both Mifeprex and misoprostol, which are taken one after the other respectively. Methotrexate is used to abort ectopic pregnancies. In 2000, based on previously conducted clinical trials, the FDA approved Mifeprex's final printed label (FPL) pursuant to Subpart H of Part 314, Subchapter D, Chapter I, Title 21 of the Code of Federal Regulations, entitled "Accelerated Approval of New Drugs for Serious or Life-Threatening Illnesses." The Mifeprex FPL only applies to marketing and distribution by the manufacturer, and it requires:
(1) Mifeprex distribution only to doctors who have read and understand the prescribing information,5
(2) three office visits for patients,
(3) administration of Mifeprex "only in a clinic, medical office, or hospital, by or under the supervision of a physician able to assess the gestational age of an embryo and to diagnose ectopic pregnancies,"
(4) patients to read the medication guide and read and sign the patient agreement before treatment,6
(5) administration of one dose of 600 milligrams(mg) of Mifeprex,
(6) oral administration of 400 micrograms (g) of misoprostol given two days later unless an abortion has been confirmed,
(7) a follow-up visit about fourteen days after the administration of the Mifeprex to confirm complete termination of the pregnancy,
(8) warning to patients that some women may experience vaginal bleeding or spotting up to sixteen days,7 and
(9) warning to patients that heavy or moderate bleeding is an indication of an incomplete abortion.
This protocol was approved for use up to the first 49 days after a woman's last menstrual period. The FPL states that before administrating Mifeprex, physicians should provide patients with an explanation of the procedure along with a copy of the medication guide and patient agreement. The FPL also states that afterward, the physician should provide notice to the manufacture of any ongoing pregnancy or serious adverse events. It is uncontested that the FDA's requirements apply to the manufacturer and are marketing restrictions and other special distribution conditions, but the requirements do not restrict or control a doctor's practice of medicine or the use of medication once it is distributed.
¶11 Within a year of the FDA's approval of Mifeprex in 2000, ninety-six percent of medication abortions did not follow the FPL or the protocol used in the clinical trials on which the FPL's approval was based. Since the FPL's approval, eight fatal bacterial infections have been reported in the United States where the women were administered Mifeprex and misoprostol for a medication abortion and did not follow the FPL, but followed an off-label protocol. The FDA has not established a casual connection between the off-label protocol and the deaths. However, the FDA now warns on the FPL about the risk of a bacterial infection following Mifeprex's use.8 These same fatal bacteria also occur following other obstetric and gynecologic processes. The ACOG materials state that the off-label protocol is more effective with fewer adverse effects. Mifeprex is on the list of medications that require a Risk Evaluation and Management Strategy (REMS).9
¶12 Plaintiff Reproductive Services follows an off-label protocol which is endorsed by the American College of Obstetricians and Gynecologists (ACOG). The ACOG recommended off-label, or evidence-based, protocol is based on "good and consistent scientific evidence" and includes vaginal, buccal, and sublingual administration of misoprostol by the patient away from a clinic. The ACOG off-label protocol provides for administration of one 200 milligram dose of Mifeprex, compared to the 600 milligrams of FDA on-label protocol, followed by 800 micrograms of misoprostol to be patient administered, compared to FDA's protocol of 400 milligrams to be doctor administered. The ACOG materials provide that medication abortions can be provided safely through nonphysician clinicians and that the protocol can be used for up to 63 days of gestation (calculated from the last menstrual period).
IV. IMPROPER DELEGATION OF LEGISLATIVE AUTHORITY
¶13 The Plaintiffs contend that H.B. 2684 improperly delegates legislative authority to the FDA. Articles IV and V of the Oklahoma Constitution are the foundation underlying Oklahoma's non-delegation doctrine. Article IV, Section 1 requires separation of the three branches of government. Okla. Const. art. IV, § 1. Article V, Section 1 vests legislative authority "in a Legislature consisting of a Senate and House of Representatives." Okla. Const. art. V, § 1. Based on these two provisions, it is well settled that the Legislature may not delegate its policy-making authority. Tulsa Cnty. F.O.P., Lodge No. 188 v. Bd. of Cnty. Comm'rs of Tulsa Cnty., 2000 OK 2, ¶ 8, 995 P.2d 1124, 1129. Although the Legislature is restrained from delegating policy-making authority, it can nonetheless delegate rule-making authority to implement its policies. Id. ¶ 9, 995 P.2d at 1129.
¶14 The Plaintiffs rely on City of Okla. City v. State ex rel. Okla. Dept. of Labor, 1995 OK 107, 918 P.2d 26 (Oklahoma City), Democratic Party of Okla. v. Estep, 1982 OK 106, 652 P.2d 271, and In re Initiative Petition No. 366, 2002 OK 21, 46 P.3d 123, for support that H.B. 2684 improperly delegates legislative authority to the FDA. In Oklahoma City, this Court determined that Oklahoma's Minimum Wages on Public Works Act, 40 O.S.1991, §§ 196.1 to 196.14, violated Article IV, Section 1 and Article V, Section 1 of the Oklahoma Constitution by delegating "the power to determine prevailing wages to [the United States Department of Labor] without setting standards for the exercise of that determination." Oklahoma City, 1995 OK 107, ¶ 1, 918 P.2d at 28. The provisions required the Oklahoma Labor Commissioner to adopt the United States Department of Labor's prevailing wage on an on-going basis. Id. ¶ 9, 918 P.2d at 29. The act allowed the United States Department of Labor to change Oklahoma's prevailing wage law without legislative action. Id. ¶ 8, 918 P.2d at 29.
¶15 In In re Initiative Petition No. 366, State Question No. 689, 2002 OK 21, 46 P.3d 123, this Court ruled an initiative petition unconstitutional before it was submitted to a vote of the people. The petition called for the State Board of Education and the State Board of Regents for Higher Education to promote principles, but failed to state any principles. Id. ¶ 16, 46 P.3d at 128. Because the legislation failed to provide guidelines for implementing rules, the legislation was deemed to have improperly delegated the Legislature's authority by allowing agencies unfettered discretion to make law. Id. ¶ 18, 46 P.3d at 129.
¶16 Similarly to In re Initiative Petition No. 366, in Estep, this Court ruled that the Oklahoma Campaign Finance Act, in effect at the time, violated the non-delegation doctrine. 1982 OK 106, ¶ 1, 652 P.2d 271, 272. The act allowed the Campaign Commission unfettered discretion to promulgate rules without legislative standards for guidance. Id. ¶ 16, 652 P.2d at 277. These three cases teach that the Legislature, or the voters acting as a legislature through the initiative process, delegates its authority when it enacts legislation giving an agency (particularly a federal agency that is not bound by Oklahoma's legislative policies) the power to alter Oklahoma law. When the Legislature allows an agency, or other entity, to make rules without sufficient legislative guidelines by setting binding policy on the agency, the Legislature has unconstitutionally delegated its authority to determine Oklahoma policy.
¶17 With this lesson in mind, the question before us is whether H.B. 2684 allows the FDA to change Oklahoma abortion laws by changing a FPL of currently approved drugs or adopting a FPL for future drug approvals or whether it restricts only Mifeprex, misoprostol, and methotrexate to the current Mifeprex FPL when used for inducing abortions. We are guided by well-established principles in assessing the conformity of a challenged state statute to our fundamental law. Liddell v. Heavner, 2008 OK 6, ¶ 16, 180 P.3d 1191, 1199-1200. Our state constitution is a bulwark to which all statutes must yield. In reviewing a statute for conformity to Oklahoma's constitution, we begin with a presumption of constitutionality. Id. A statute will be upheld unless it is clearly, palpably, and plainly inconsistent with the Constitution. Id. The party challenging a statute's constitutionality has a heavy burden to establish that it is in excess of legislative power. Id. Bound by these rules, we must, if possible, construe H.B. 2684 as not allowing the FDA's decisions to change Oklahoma law; the means of doing so is to apply H.B. 2684's restrictions only to Mifeprex, misoprostol, and methotrexate use in abortions, excluding ectopic pregnancies, according to the current Mifeprex FPL.
¶18 Subsection B(1) of H.B. 2684 defines "[a]bortion-inducing drug" as a "medicine, drug, or any other substance prescribed or dispensed with the intent of inducing an abortion." The next sentence limits the previous sentence by stating "[t]his includes off-label use of drugs known to have abortion-inducing properties which are prescribed specifically with the intent of causing an abortion, such as misoprostol (Cytotec), and methotrexate." This second sentence only refers to drugs which were in use at the time of H.B. 2684's enactment, not drugs subsequent to its enactment. Because we give meaning to all words in a statute, we must construe these sentences as limiting the definition to drugs known at the time of H.B. 2684's enactment to have abortion-inducing properties and prescribed with the specific intent of causing an abortion. See Moore v. Hayes, 1987 OK 82, ¶ 7, 744 P.2d 934, 937. ("Legislative enactments must be interpreted so as to render every word and sentence operative, rather than in a manner which would render a specific provision nugatory.") To construe the statute to include any future FDA-approved abortion-inducing drugs would make the second sentence superfluous. And the almost complete incorporation of the Mifeprex FPL in H.B. 2684 only strengthens this construction.
¶19 Both the Plaintiffs' and the State's evidence show that the only three drugs which come within this definition are Mifeprex, misoprostol, and methotrexate. The parties do not even mention other drugs in the submissions or evidence. Thus, we read H.B. 2684 as defining abortion-inducing drugs to include only Mifeprex, misoprostol, and methotrexate, the only currently known drugs prescribed and used with the intent of causing an abortion. No other drugs fall within Subsection B(1)'s definition of abortion-inducing drugs.
¶20 We next turn to Section D of H.B. 2684 which prohibits the use of all abortion-inducing drugs with the exception of the Mifeprex FPL protocol. Having defined abortion-inducing drugs as Mifeprex, misoprostol, and methotrexate (except when used in ectopic pregnancies), Section D prohibits the off-label use for intentional abortions of Mifeprex, misoprostol, and methotrexate, allowing only the Mifeprex FPL protocol for these three drugs when they are used to induce abortions.
¶21 In addition to limiting the definition of abortion-inducing drugs to the three referenced in the bill, the Legislature has shown its intent to restrict only these three drugs in other parts of H.B. 2684. Subsection B(4) defines the Mifeprex regimen as the regimen found in "the FDA-approved Mifeprex" FPL and as the only FDA-approved abortion-inducing drug regimen. Subsections E through H parrot the Mifeprex FPL and clarify the Legislature's intent that H.B. 2684 only allows the use of the Mifeprex FPL to induce abortions using the three mentioned drugs.
¶22 H.B. 2684 restricts the use of only Mifeprex, misoprostol, and methotrexate to the Mifeprex FPL protocol when they are used to induce abortions. In so doing, it does not allow the FDA any authority. Rather, H.B. 2684 merely incorporates the Mifeprex FPL as the only allowed use of Mifeprex, misoprostol, and methotrexate in medication abortions, and unlike Oklahoma City, it does not allow a federal agency's actions to affect Oklahoma's law. Simply, H.B. 2684 is not unconstitutional as an improper delegation of legislative authority.
V. SPECIAL LAW
¶23 The Plaintiffs also challenge H.B. 2684 as a violation of the Oklahoma Constitution, Article V, Section 59. Section 59 provides:
Laws of a general nature shall have a uniform operation throughout the State, and where a general law can be made applicable, no special law shall be enacted.
Okla. Const. art. V, § 59. To determine whether a statute violates Section 59, we must begin with the three-pronged inquiry identified in Reynolds v. Porter, 1988 OK 88, ¶ 13, 760 P.2d 816, 822. "1) Is the statute a special law or general law? 2) If the statute is a special law, is a general law applicable? and 3) If a general law is not applicable, is the statute a permissible special law." Id. We examine each prong in turn.
A. Is H.B. 2684 a Special or General Law?
¶24 We must identify the subject the law seeks to classify ("the class") to determine whether H.B. 2684 is a special or general law. Elias v. City of Tulsa, 1965 OK 164, ¶ 9, 408 P.2d 517, 519. "A statute relating to all persons or things of a class is a general law; one relating to particular persons or things of a class is a special law." Reynolds, 1988 OK 88, ¶ 14, 760 P.2d at 822. Where a class is underinclusive, the statute is a special law. Id. ¶ 21, 760 P.2d at 824.
¶25 In Reynolds, the Court first identified the overarching subject classified by the legislation--limitations of civil actions. Id. ¶ 18, 760 P.2d at 823. The Reynolds legislation carved out special treatment for "actionable medical malpractice claims which cannot be discovered with reasonable diligence until after three years." Id. As the statute carved out a subclass apart from all statutes on limitations of civil actions, it was underinclusive and a special law. Id.
¶26 The Plaintiffs argue H.B. 2684 is a special law in two ways: 1) the law classifies the drugs Mifeprex and misoprostol only for off-label use in ending a pregnancy from any other off-label use of the drugs; and 2) the law classifies only women who seek and doctors who provide abortions from all other women seeking or doctors providing medical care. The district court agreed with the Plaintiffs, ruling that the general class must be all FDA-approved drugs or all FDA drugs approved under Subpart H. The State argues that H.B. 2684 is a general law that seeks to classify all abortion-inducing drugs.
¶27 H.B. 2684 incorporates 16 provisions of legislative findings, each related to the use of abortion-inducing drugs. H.B. 2684, ch. 121, 2014 Okla. Sess. Laws 375-77, § 1-729a(A)(1)-(16). We have already construed H.B. 2684 to regulate only Mifeprex, misoprostol, and methotrexate and only when used to induce abortions. Just as the legislation in Reynolds was a special law because it classified a smaller class than all limitations on civil actions, so too is H.B. 2684 as it classifies Mifeprex, misoprostol, and methotrexate only when used as abortion-inducing drugs. We agree with the Plaintiffs that the subject of H.B. 2684 does not cover the use of these drugs in any other instance or any other drugs; therefore, H.B. 2684 is a special law. According to Reynolds, it is subject to further scrutiny.
B. Is a general law applicable?
¶28 The second prong of the Reynolds inquiry is to determine if a general law is applicable. 1988 OK 88, ¶ 13, 760 P.2d at 822. More specifically, the question is whether "the subject of the legislation is reasonably susceptible of general treatment or . . . there is a special situation possessing characteristics impossible of treatment by general law." Id. ¶ 15, 760 P.2d at 822. The subject of H.B. 2684 is Mifeprex, misoprostol, and methotrexate when used as abortion-inducing drugs. To determine if the subject is susceptible to general treatment, we examine the nature and objective of the legislation and the conditions and circumstances of its enactment. See id.
¶29 The Plaintiffs maintain a general law could better address the subject of the legislation, arguing that a law that encompasses all off-label uses of FDA-approved drugs is the more appropriate vehicle for general treatment. Therefore, H.B. 2684 would fail the second prong of the Reynolds inquiry. The State argues that a general law would not be feasible as it would regulate far beyond the scope of H.B. 2684--for instance, a general law regulating all uses of misoprostol would ban uses such as the induction of labor. We agree with the State.
¶30 Section 16 of H.B. 2684 lays out the statute's nature and purpose--to ban the off-label use of Mifeprex, misoprostol, and methotrexate when used as abortion-inducing drugs. The factual findings, specifically the deaths and hospitalizations caused by off-label use of Mifeprex and misoprostol and the dangers of methotrexate, establish the basis for their legislative restrictions by special law. Based on our construction of H.B. 2684, we agree that the Legislature specifically tailored a special law to address the use of Mifeprex, misoprostol, and methotrexate when prescribed with the intent of inducing abortions. To broaden the scope with a general law would force the Legislature to restrict off-label use of these and other drugs without a showing of harm from the off-label use. The regulation of the use of Mifeprex, misoprostol, and methotrexate when used as abortion-inducing drugs does not currently present characteristics for general treatment; we therefore agree with the State that a general law is not applicable under prong two of the Reynolds inquiry.
C. Is the legislation a permissible special law?
¶31The third prong of the Reynolds inquiry requires this Court to "determine if the special legislation is reasonably and substantially related to a valid legislative objective." Reynolds, 1988 OK 88, ¶ 16, 760 P.2d at 822. In Reynolds, the Court scrutinized each of the legislation's aims with the classification to determine if there was "a degree of correlation between" them. Id. ¶ 23, 760 P.2d at 825. The legislation at issue was a three-year limitation on the amount of recoverable damages in a medical malpractice action even though a claim's existence was not discoverable during the three years. Id. ¶ 1, 760 P.2d at 818. One aim the Legislature put forth was to control the cost of medical malpractice insurance. Id. ¶ 22, 760 P.2d at 825. The Court rejected any correlation between the legislative aim and the class as no documented legislative findings existed to show that the class, actionable medical malpractice cases not discovered until after three years, created "an excessively high incidence of losses that it calls for special statutory treatment." Id.
¶32 Here, the Legislative objectives advanced by the State are two fold: 1) to protect women from dangerous off-label use of abortion inducing drugs; and 2) to require physicians to follow the Mifeprex FPL regime. H.B. 2684, ch. 121, 2014 Okla. Sess. Laws 376, § 1-729a(A)(15). These objectives must be reasonably and substantially related to H.B. 2684's underinclusive class, Mifeprex, misoprostol, and methotrexate when used as abortion-inducing drugs. For the first objective, the Legislature has taken great pains to incorporate 16 legislative findings documenting the danger off-label use of these medications have for women when used as abortion-inducing drugs. The documented cases of death and injury are not disputed by the Plaintiffs, but we must acknowledge the Plaintiffs' evidence which identifies the dangers of pregnancy and wide-variety of much more dangerous practices not regulated by the statute. However, it is not the place of this Court to question legislative wisdom. EOG Res. Mktg., Inc. v. Okla. State Bd. of Equalization, 2008 OK 95, ¶ 20, 196 P.3d 511, 521 ("It is not the role of this Court to question the desirability, wisdom, or logic of a valid statutory classification.").
¶33 Here, the State's evidence shows that the class restricted by H.B. 2684 is reasonably and substantially connected to protecting women, and so too to for the State's second objective, to require physicians to follow the Mifeprex FPL. Because the evidence is mixed, we must defer to the Legislature, when examining the evidence under Oklahoma's special law provision, and the Legislature's function as a policy-making body when it has support for its acts. While H.B. 2684 is a special law, it is a permissible special law as the legislative aims are reasonably and substantially related to the class H.B. 2684 seeks to protect.
¶34 We find that H.B. 2684 does not violate the non-delegation doctrine of Article V, Section 1 because H.B. 2684 incorporates the current Mifeprex FPL, restricting only the off-label use of Mifeprex, misoprostol, and methotrexate when used to induce abortions. H.B.2684 is unaltered by any future FDA actions. We find also that H.B. 2684 does not violate Article V, Section 59 of the Oklahoma Constitution. This opinion does not address other Oklahoma constitutional provisions nor any United States constitutional provisions which H.B. 2684 may violate as those questions are not before this Court and are, thus, improper considerations until presented to this Court. We also must recognize that, by the States' own evidentiary materials, more restrictions on abortions result in higher complication rates and in decreased women's safety. Because H.B. 2684 is the only effective Oklahoma legislation restricting abortion at this time, we need not address the impact of future abortion-related restrictions on H.B. 2684's constitutionality.
¶35 The district court's judgment is reversed. The matter is remanded to the district court for a determination of H.B. 2684's validity under other constitutional provisions, both state and federal. The stay entered in Okla. Coalition for Reprod. Justice v. Cline, 2014 OK 91, 339 P.2d 887, for HB 2684, remains in place until the constitutionality of the Act is fully and finally litigated.
Concur: Reif, C.J., and Kauger, Winchester, Taylor, and Gurich, J.J.
Concur Specially: Combs, V.C.J. (by separate writing).
Dissents: Edmondson, J.
Not Voting: Watt and Colbert, JJ.
1 As a non-dispositive issue, the Plaintiffs claim that the district court and this Court are bound by many facts and issues that were determined in Cline v. Okla. Coalition for Reprod. Justice, 2013 OK 93, 313 P.3d 253 (Cline II). Specifically, the Plaintiffs contend that the courts in the present case are bound by
[t]he Act's restriction of the use of the drug RU-486 or "any other abortion inducing drug, medicine or other substance" in the manner and to the regimen set forth in the medication FPL when used for abortion is so completely at odds with the standard that governs the practice of medicine that it can serve no purpose other than to prevent women from obtaining abortions and to punish and discriminate against those who do.
Cline II, 2013 OK 93, ¶ 27, 313 P.3d at 262.
Under the doctrine of issue preclusion, "once a court has decided an issue of fact or of law necessary to its judgment, the same parties or their privies may not relitigate that issue in a suit brought upon a different claim." Miller v. Miller, 1998 OK 24, ¶ 25, 956 P.2d 887, 897. Only the question of whether this finding "was necessary and essential to the outcome of that prior case" is at issue here. State ex rel. Tal v. City of Okla. City, 2002 OK 97, ¶ 20, 61 P.3d 234, 245. "[T]he issue is necessarily determined if the judgment would not have been rendered but for the determination of that issue." Nealis v. Baird, 1999 OK 98, ¶ 51, 996 P.2d 438, 457-58.
In Cline II, this Court was not asked to rule on the restrictive use of RU-486 (Mifeprex), but on the restrictive use of misoprostol and of methotrexate. The quote on which the Plaintiffs rely could be excised from Cline II without changing this Court's answer to the certified questions. We therefore disregard the Plaintiffs' issue-preclusion argument.
2 Misoprostol's label specified that it was for use in treating gastric ulcers. Cline II, 2013 OK 93, ¶ 12, 313 P.3d at 258.
3 Section A of H.B. 2684 provides:
A. The Legislature finds that:
1. The U.S. Food and Drug Administration (FDA) approved the drug mifepristone (brand name "Mifeprex"), a first-generation [selective] progesterone receptor modulator ([S]PRM), as an abortion-inducing drug with a specific gestation, dosage, and administration protocol;
2. The FDA approved mifepristone (brand name Mifeprex) under the rubric of 21 C.F.R., Section 314.520, also referred to as "Subpart H", which is the only FDA approval process that allows for postmarketing restrictions. Specifically, the Code of Federal Regulations (CFR) provides for accelerated approval of certain drugs that are shown to be effective but "can be safely used only if distribution or use is restricted";
3. The FDA does not treat Subpart H drugs in the same manner as drugs which undergo the typical approval process;
4. As approved by the FDA, and as outlined in the Mifeprex final printed labeling (FPL), an abortion by mifepristone consists of three two-hundred-milligram tablets of mifepristone taken orally, followed by two two-hundred-microgram tablets of misoprostol taken orally, through forty-nine (49) days LMP (a gestational measurement using the first day of the woman's "last menstrual period" as a marker). The patient is to return for a follow-up visit in order to confirm that the abortion has been completed. This FDA-approved protocol is referred to as the "Mifeprex regimen" or the "RU-486 regimen";
5. The aforementioned procedure requires three office visits by the patient, and the dosages may only be administered in a clinic, medical office, or hospital and under supervision of a physician;
6. The Mifeprex final printed labeling (FPL) outlines the FDA-approved dosage and administration of both drugs in the Mifeprex regimen, namely mifepristone and misoprostol;
7. When the FDA approved the Mifeprex regimen under Subpart H, it did so with certain restrictions. For example, the distribution and use of the Mifeprex regimen must be under the supervision of a physician who has the ability to assess the duration of pregnancy, diagnose ectopic pregnancies, and provide surgical intervention (or has made plans to provide surgical intervention through other qualified physicians);
8. One of the restrictions imposed by the FDA as part of its Subpart H approval is a written agreement that must be signed by both the physician and patient. In that agreement, the woman attests to the following, among other statements:
a. "I believe I am no more than 49 days (7 weeks) pregnant",
b. "I understand that I will take misoprostol in my provider's office two days after I take Mifeprex (Day 3)", and
c. "I will do the following: return to my provider's office in two days (Day 3) to check if my pregnancy has ended. My provider will give me misoprostol if I am still pregnant";
9. The FDA concluded that available medical data did not support the safety of home use of misoprostol, and it specifically rejected information in the Mifeprex final printed labeling (FPL) on self-administering misoprostol at home;
10. The use of abortion-inducing drugs presents significant medical risks to women, including but not limited to abdominal pain, cramping, vomiting, headache, fatigue, uterine hemorrhage, viral infections, and pelvic inflammatory disease;
11. Abortion-inducing drugs are associated with an increased risk of complications relative to surgical abortion. The risk of complications increases with advancing gestational age, and, in the instance of the Mifeprex regimen, with failure to complete the two-step dosage process;
12. In July 2011, the FDA reported 2,207 adverse events in the United States after women used abortion-inducing drugs. Among those were 14 deaths, 612 hospitalizations, 339 blood transfusions, and 256 infections (including 48 "severe infections");
13. "Off-label" or so-called "evidence-based" use of abortion-inducing drugs may be deadly. To date, fourteen women have reportedly died after administering abortion-inducing drugs, with eight deaths attributed to severe bacterial infection. All eight of those women administered the drugs in an "off-label" or "evidence-based" manner advocated by many abortion providers. The FDA has received no reports of women dying from bacterial infection following administration according to the FDA-approved protocol for the Mifeprex regimen. The FDA has not been able to conclude one way or another whether off-label use led to the eight deaths;
14. Medical evidence demonstrates that women who utilize abortion-inducing drugs incur more complications than those who have surgical abortions;
15. Based on the foregoing findings, it is the purpose of this act to:
a. protect women from the dangerous and potentially deadly off-label use of abortion-inducing drugs, and
b. ensure that physicians abide by the protocol approved by the FDA for the administration of abortion-inducing drugs, as outlined in the drugs' final printed labeling (FPL); and
16. In response to the Oklahoma Supreme Court's decision in Cline v. Oklahoma Coalition for Reproductive Justice (No. 111,939), in which the Oklahoma Supreme Court determined, in contravention of this Legislature's intent, that this act prohibits all uses of misoprostol for chemical abortion and prohibits the use of methotrexate in treating ectopic pregnancies, it is also the purpose of this act to legislatively overrule the decision of the Oklahoma Supreme Court and ensure that should such questions be presented before that Court in the future it will reach the proper result that this act does not ban use of misoprostol in chemical abortion (and allows it as part of the FDA-approved Mifeprex regimen) nor prevent the off-label use of drugs for the treatment of ectopic pregnancy.
4 Each time the ban on off-label use of methotrexate in H.B. 2684 is discussed, the exception for methotrexate use for ectopic pregnancies should be understood even though not continuously repeated.
5 These doctors must also be able to provide surgical intervention in cases of incomplete abortion or severe bleeding or make such plans through others, to assure patient access to medical facilities equipped to provide blood transfusions and resuscitation, and to sign and return a prescriber's agreement.
6 For the patient agreement in the Mifeprex FPL, see U.S. Food and Drug Administration, Patient Agreement: Mifeprex (mifepristone) Tablets (last visited Nov. 23, 2015), http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111361.pdf.
7 The warning also notes that eight percent of women experience this type of bleeding for more than thirty days.
8 The Mifeprex FPL now warns:
Serious and sometimes fatal infections and bleeding occur very rarely following spontaneous, surgical and medical abortions, including following Mifeprex use. No causal relationship between the use of Mifeprex and misoprostol and these events has been established."
9 REMS are "plans that use risk minimization strategies beyond the professional labeling to ensure that the benefits of certain prescription drugs outweigh their risks." U.S. Food and Drug Administration, A Brief Overview of Risk Evaluation & Mitigations Strategies (REMS) (last visited Nov. 23, 2015) http://www.fda.gov/downloads/AboutFDA/Transparency/Basics/UCM328784.pdf.
COMBS, V.C.J., with whom GURICH, J., joins, concurring specially:
¶1 I concur with the majority's determination that H.B. 2684, ch. 121, 2014 Okla. Sess. Laws 375-80, does not violate the non-delegation doctrine of Okla. Const. art. 5, § 1 and is a permissible special law that does not violate Okla. Const. art. 5, § 59. However, although the Legislature has the authority to draw upon many resources in drafting and creating legislation, and the final language of legislation may adopt in toto the FDA's final printed protocol, H.B. 2684 is not without some overreach.
¶2 Once again, those who do not practice medicine have determined to insert themselves between physicians and their patients, with the insistence they know what is best when it comes to the standard of care. It is undisputed that the FDA's final printed labeling does not restrict or control a doctor's practice of medicine or the use of medication once it is distributed. The FDA understands the role of physicians in adhering to the best possible standard of care. In the form of H.B. 2684, the Oklahoma Legislature has chosen to ignore this. While H.B. 2684 does not prohibit all medication abortions, it nonetheless binds Oklahoma physicians and their patients to the FDA's final printed labeling, regardless of whether evidence and the judgment of the medical community indicate it is not the best method for providing medication abortion.
¶3 As the majority notes, ninety-six percent of medication abortions do not follow the final printed labeling or the protocol used in the clinical trials on which the label's approval was based. See Cline v. Oklahoma Coalition for Reproductive Justice (Cline II), 2013 OK 93, ¶21, 313 P.3d 253. Plaintiff Reproductive Services follows an off-label protocol endorsed by the American College of Obstetricians and Gynecologists (ACOG). ACOG determined that evidence-based medication abortion protocols such as the one used here are superior to the FDA-approved regime in terms of efficacy and adverse effects.1 Dr. Daniel A. Grossman, co-author of the ACOG Practice Bulletin Medical Management of First-Trimester Abortion, stated in his affidavit: "in my opinion, HB 2684 serves no valid, medical purpose and will harm women by forcing them to receive inferior medical care." Affidavit of Daniel A. Grossman in Support of Plaintiff's Motion for Partial Summary Judgment, p. 3 , R. Vol. 1, Tab 7, App. 2.
¶4 In Cline II, 2013 OK 93, this Court examined a prior statute requiring adherence to the FDA's final printed labeling for abortion-inducing drugs. We noted with disapproval the law's drastic interference in the role of physicians and agreed with the determination of the district court that restricting the use of abortion-inducing drugs to the regime in the final printed labeling "'is so completely at odds with the standard that governs the practice of medicine that it can serve no purpose other than to prevent women from obtaining abortions and to punish and discriminate against those who do.'" Cline II, 2013 OK 93, ¶27 (quoting Okla. Coal. for Repro. Justice v. Cline, No. CV-2011-1722, slip op., ¶7 (Dist. Ct. Okla. Cnty. May 11, 2012)). H.B. 2684 requires adherence to a protocol in contravention of prevailing medical standards; one that simultaneously shrinks the window in which medication abortion is accessible to the women of Oklahoma. This Court's above-quoted statement from Cline II remains apt. Further, the medical community should take heed: now that the Legislature has declared itself willing to dictate medical protocol and practice within this limited context, what areas of the practice of medicine are next?
1 See ACOG Practice Bulletin No. 143: Medical Management of First-Trimester Abortion (March, 2014), at pp. 2 and 11, Ex. B to Grossman Aff., R. Vol. 1, Tab 7. The Summary of Recommendations and Conclusions in the Practice Bulletin Provides in pertinent part:
The following recommendations are based primarily on good and consistent scientific evidence
(Level A):
Based on efficacy and adverse effect profile, evidence-based protocols for medical abortion are superior to the FDA-approved regimen. Vaginal, buccal, and sublingual routes of misoprostol administration increase efficacy, decrease continuing pregnancy rates, and increase the gestational age range for use as compared with the FDA-approved regimen.
Regimens that use low doses of mifepristone (200 mg) have similar efficacy and lower costs compared with to [sic] those that use mifepristone at 600 mg.
Women can safely and effectively self-administer misoprostol at home as part of a medical abortion regimen.
Medical abortion also can be provided safely and effectively by nonphysician clinicians.
Follow-up after receiving mifepristone and misoprostol for medical abortion is important, although an in-clinic evaluation is not always necessary.
Misoprostol-only medical abortion regimens are significantly less effective than those that use a combination of mifepristone and misoprostol.
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Netflix Gem #87: Stake Land
Posted by Becky Belzile | Dec 7, 2016 | Netflix Hidden Gems | 0 |
Dark Sky Films
Stake Land (2011)
Director: Jim Mickle
Synopsis: A vampire hunter and his teen apprentice seek a free life in the wake of a vampiric apocalypse.
Overview: The Walking Dead premiered in 2010 amidst a slew of post-apocalyptic scenarios. As an obvious artistic response to culture, audiences were both enthralled with watching the fall of mankind and inspired by the will to survive they saw onscreen. This isn't a new phenomenon; since humanity was able to comprehend life and death we've been fascinated or afraid of our own end. Unfortunately this theme of apocalyptic horror has become well-worn by now but there is one slice of delightfully bloody pie you may have missed in the buffet of cinema, and that is Stake Land.
Stake Land has achieved cult status for good reason, becoming a fan-favourite for its heart and effort alone. Not only do we get a brutal wasteland to traverse, but one filled with vampires instead of zombies. This movie is like that good trail mix with the chocolate in it. You've seen all the parts before. You might not like them all individually, but somehow they work together to create something that's acceptable to your palate. Even exciting, at times. Stake Land brings you the apocalypse with a scattered remnant of human beings hunted by vampires, a coming-of-age tale with a teenager and a bitter but soft-hearted loner. And what would the apocalypse be without scary religious cults? This one calls themselves the Christian Army of Aryans and they pose an even more powerful threat to our heroes as they venture north to New Eden (Canada, obviously) looking for a better life. These fringe fanatics begin to take control of the country while everyone else just hopes they'll wake up from the nightmare so they can live their lives normally again. Surprise! It's all relevant again in 2016!
While Stake Land started out as a hobby for director Jim Mickle and star Nick Damici, something they'd just do on the weekends together when they had spare time, once producer Larry Fessenden caught whiff of the project he saw its potential and encouraged them to make a feature. This resulted in a well-loved low-budget horror film whose cult status only grows. Sometimes it can feel like the world is in a drought of respectable vampires. For those of us who were just too young for Buffy and then too old for Twilight, we had no hand to guide us through our teens and toward quality vampire content immediately relevant to all our fears. Stake Land plays like a graphic novel about vampire hunters without the stylized fights and action, the perfect alternative for people who weren't fond of the overly-sexy teen vampires who were popular at the time. These vampires are scary, blood soaked and full of rage.
This movie is not without its flaws, but it's easier to overlook them because the characters are likable even in their canned stock form. Mister (Damici) seems like just another hardass loner who doesn't talk much and Martin (Connor Paolo) is a super-sensitive teen struggling with, you know, normal teen stuff like how his entire family was killed by vampires. Still for some reason, by the end you really care what happens to them… even though you probably know what's going to happen to them. For those who find even more enjoyment in it than I did, there are also seven prequel webisodes that give further background information on characters and expands the universe (which feels small at times). If you just can't get enough, a sequel originally titled The Stakelander (now Stake Land 2) was released on SyFy in October of this year as a direct continuation of the events in Stake Land. If you'd like to revisit the sub-genre and catch something that maybe flew under your radar, give this one a shot on Netflix.
Featured Image: Dark Sky Films
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Becky lives on the west coast of Canada, devouring horror movies and perpetually rolling her eyes.
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'An honour to serve'
(Photo: Samoa Observer)
By Sarafina Sanerivi, 03/06/2016
Fa'asaleleaga No. 3's new Member of Parliament, Tofa Li'o Foleni, is honoured.
For the first time in more than 40 years, he has become the first person from Saipipi to represent their constituency in Parliament.
To the businessman who won with 561 votes, the honour is not something he takes lightly.
"All I can say for now is that I am very happy and honored," he told the Sunday Samoan yesterday.
First and foremost, he wants to thank God.
"I know that he made this possible for me and I am grateful to him for His blessings; I owe everything to Him."
Secondly, Tofa wanted to thank his village of Saipipi and everyone who supported him and had given him their trust.
"I know the competition was tough within our constituency and I am thankful to each and every one of you who have voted for me and who have granted me this great opportunity to represent our district.
"I also want to congratulate my opponents for putting up a tough fight for our constituency. I know we all entered for the same reason and that is to help our people and to serve our district with honour."
Lastly, Tofa wanted to thank the constituency of Fa'asaleleaga No.3 for their support.
"I know a new position or calling comes with a lot of challenges and I know it's going to be a very bumpy road," he said.
"But I know that with God everything is possible."
Moreover, Tofa believes that he cannot do the job alone; therefore, he needs the support of the people of the constituency.
"Now that you've given me the chance to be your voice in Parliament, I humbly ask for your support as well. Together, we can take Fa'asaleleaga No.3 to the next level."
Tofa Li'o Foleni is from the villages of Saipipi and Sapapali'i. He is married to Tuliafiafi Tofa and they have four children.
He is a businessman and he also spent more than forty years of his life working for the Ministry of Education.
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"I'm talking about how it started. If it wasn't for me there would be no nonu in Samoa. Mr. Williams you don't have full information to this case. You should have full information for the case" - La'auli Leuatea Polataivao


Ranchi, the city of waterfalls, is the capital of Jharkhand. With people of various cultures living in, Ranchi has different stories after its name. The city is home to several reputed institutes, sports centers, stadiums, international Library, and several tourist attractions. The city is the motherland to several international sports persons like Mahendra Singh Dhoni, Indian Cricketer, Deepika Kumari, International Level Archer, etc. Several research institutes like ICAR, IINRG, IIAB and several educational institutes and universities like BIT, IIM, NIFFT, RIMS, Ranchi University, Central University of Jharkhand, Birsa Agricultural University etc make the city a great educational hub.
The Indian Institute of Management of Ranchi is established in 2010 and soon stood in top ranks as the best b-schools of India. The campus is functioning from a temporary campus and soon would occupy the permanent campus.
Post Graduate Diploma in Management (PGDM), Post Graduate Diploma in Human Resource Management, Doctoral Program, and Executive Program are the major programs that are offered. The Doctoral program is a full-time program and the Executive Program is a part-time program. Various Executive Programs are designed for the short period and informed timely.
Common Admission Test (CAT) score is required for the admission into PGDM. The admission process includes Written Ability Test (WAT) and Personal Interview. For the admission into Fellow Program, the candidate must hold a Master's Degree/ a Bachelor Degree in Engineering/ any professional qualification like CA / ICWA / CS besides holding good score in CAT / GATE / GMAT / UGC or CSIR – JRF. The admission process includes an interview for the shortlisted candidates.
The placement committee of the institute helps the students in different ways that the student may get final placement in a reputed company with a higher pay package. Yet, the career aspirants have huge employment opportunities in Ranchi itself as the city is hosting several companies. The students who wish to have self-employment has various resources in the city.