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Maintaining a Positive Attitude
Alan Franciscus, Editor-in-Chief
HCV therapy is not easy for many people. The side effects
that people experience on therapy range from mild to severe.
In addition to the physical side effects, one may experience
a multitude of psychological problems that can be triggered
by interferon and ribavirin. In order to get through therapy,
sometimes it is simply a matter of equipping yourself with
the necessary tools and strategies.
What are Fibrosis and Cirrhosis?
Liz Highleyman
Chronic infection with hepatitis C or hepatitis B virus
(HCV or HBV) can lead to long-term liver damage including
fibrosis, cirrhosis, and hepatocellular carcinoma (liver cancer).
It is estimated that about 20 percent of people with chronic
hepatitis C will develop cirrhosis, a process that usually
takes 20-30 years.
How to Start an HCV Support Project: Part
2
Alan Franciscus, Editor-in-Chief
Part one of this series discussed
the need for hepatitis C specific support groups. In this
article I will discuss important questions potential support
group leaders need to ask themselves even before starting
a support group, and provide some pointers to help identify
appropriate resources. There is no reason to “go it
alone.”.
HealthWise
Lucinda K. Porter, RN, CCRC
The high price of health care is dominating
some of my social conversations. Other than gasoline, perhaps
nothing more essential is so obviously inflated. Rising health
care costs are occurring at many levels. Hospital, laboratory,
and professional fees are increasing. Insurance is costing
more but covering less. According to a report released by
the Kaiser Family Foundation, health insurance premiums rose
more than 11% this year. Insurance plan deductibles and co-payment
amounts keep rising. Medicare premiums will increase by 17%
in 2005. Prescription drug costs are going up.
Stay informed on the latest news
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Maintaining
a Positive Attitude
Alan Franciscus, Editor-in-Chief
HCV therapy is not easy for many
people. The side effects that people experience on therapy
range from mild to severe. In addition to the physical side
effects, one may experience a multitude of psychological problems
that can be triggered by interferon and ribavirin. In order
to get through therapy, sometimes it is simply a matter of
equipping yourself with the necessary tools and strategies.
Maintaining a positive attitude while on
treatment may be difficult, but it is essential and should
be at the top of your list for side effect management. Although
there is no scientific data at this time to support the notion
that a positive attitude will have an impact on hepatitis
C or treatment outcome, many patients report that attitude
was an important part of staying on therapy. Strive to maintain
a positive attitude, but it would be unrealistic to assume
that you will achieve perfection 100% of the time. The point
is that a positive attitude is a process and not the goal.
Be realistic and don't set yourself up for failure because
this is the time that you need to be gentle with yourself.
Attitude
How do you maintain a positive attitude? There are many steps
you can take:
Before beginning therapy write a list of the reasons why you
are being treated and read the list often.
Reasons to undergo therapy are:
• To improve health
• Live longer
• To feel that you have done all that you can do
• To be alive for your children, grandchildren and loved
ones
• To experience life and all it has to offer
• To simply get rid of the virus
• To put the treatment or hepatitis C behind you
• To have children
• To reduce symptoms and increase quality of life
• To help reach personal and professional goals
• To avoid being a burden to others
Starting the day off with a positive attitude is half the
battle. When you wake up in the morning try to think of one
thing you are grateful for in your life. Examples:
• I feel grateful that I have the opportunity to take
this treatment
• I am grateful for the people in my life
• I am grateful I have a roof over my head or a bed
to sleep in at night
Try restructuring your thought processes. For example:
• Instead of saying "I'm overwhelmed,"
say and believe "I am doing the best that I can"
• If you find yourself thinking "I'm tired,"
try saying to yourself "This will eventually pass"
• When you say "I can't do this," try saying
"I can do this because it is only temporary"
In the evening when you are going to sleep,
look back at your day and define what made you feel better
and what made you feel worse. Congratulate yourself for getting
through the day! Remind yourself that you are one more day
closer to completing treatment and your goal.
Support
Staying positive while on therapy would be almost impossible
if a person did not have a very good support system established
and in place well before starting therapy. Support from as
many areas as possible is critical. Support comes in many
forms, including family, friends, co-workers, and from peers
found in support groups. If you do not already attend a support
group, consider joining one before starting therapy.
Personal Appearance
Keeping a positive attitude requires that you take really
good care of your body, including your appearance. When you
look good you generally feel better. If you wake up in the
morning and feel achy and out of sorts generally, it will
help you feel better if you take the necessary steps to stay
well groomed. Starting your day off feeling fresh will create
a positive influence on your emotions for the entire day.
Try these strategies:
• Shower or bathe daily. Spoil yourself with bathing
products that smell and feel good. Light a candle and listen
to soothing music
• Take care of the hands and nails
• Moisturize, moisturize, moisturize!
• Consider getting a different hair style that would
be attractive, easy to take care of and flattering in case
there is hair loss
• Brush and floss your teeth regularly
• Men - shower and shave or trim facial hair
• Women - if you regularly use make-up, then continue
while on treatment
• Keep finger and toe nails well groomed
• Get dressed even if you will be laying on the couch
(wear comfortable clothing)
• Wear colors that make you feel good
Exercise
Exercise is one of the most important components of health
maintenance, even on therapy. It will help you stay positive,
focused and improve your general well-being. Moderation is
the key to physical activity. Exercise comes in many forms
and does not mean that you have to spend an enormous amount
of money or run a marathon to stay fit.
Examples:
• Stretching
• Walking
• Hula-hooping
• Swimming
• Yoga
• Pilates
Relaxation
Being on HCV medication is stressful. Trying to remember to
take all of the medications, dealing with side effects, a
job and family can greatly overwhelm most people. It is important
that people build in relaxation strategies. Try some of these
to help you with relaxing:
• Meditation—try saying "may I be well"
while you take a deep breath, say "may others be well"
when you exhale
• Prayer—practice your spiritual preference at
least once a day
• Light a candle and listen to music
• Many people hold their breath when they are stressed
out. During these periods try gently breathing in and out
• Sit or walk in a place of natural beauty, such as
a beach, garden, or park
Social Events
Treatment-related side effects and the everyday demands of
life can create some uncertainty. Maintain a social life but
be realistic when scheduling dates or appointments. The surest
way to become depressed is to isolate yourself from family
and friends. However, it is important to talk with family
and friends before starting treatment so that they can be
supportive if you need to cancel or adjust any plans. Sometimes
just the knowledge that you can cancel or leave a social activity
early will help to reduce the stress. Relax and enjoy the
time spent with family and friends.
Daily Strategies
Engage in activities that make you laugh. Choose movies that
are comedies rather than movies with painful themes. Read
the comics, watch sitcoms, use humor - use it during the difficult
moments to get a better prospective. Indulge in a favorite
hobby, but, most of all, learn to pamper yourself.
Back to top
What
are Fibrosis and Cirrhosis?
Liz Highleyman
Chronic infection with hepatitis C or hepatitis B virus (HCV
or HBV) can lead to long-term liver damage including fibrosis,
cirrhosis, and hepatocellular carcinoma (liver cancer). It
is estimated that about 20 percent of people with chronic
hepatitis C will develop cirrhosis, a process that usually
takes 20-30 years.
The Fibrosis Process
Liver fibrosis refers to the accumulation of fibrous scar
tissue in the liver. The formation of scar tissue is a normal
bodily response to injury, but in fibrosis this healing process
goes awry. When hepatocytes (functional liver cells) are injured
due to viral infection, alcohol consumption, toxins, trauma,
or other factors the immune system is activated and the repair
process swings into gear. The injury or death (necrosis) of
hepatocytes stimulates inflammatory immune cells to release
cytokines, growth factors, and other chemicals. These chemical
messengers direct support cells in the liver called hepatic
stellate cells to activate and produce collagen, glycoproteins
(such as fibronectin), proteoglycans, and other substances.
These substances are deposited in the liver, causing the buildup
of extracellular matrix (nonfunctional connective tissue).
At the same time, the process of breaking down or degrading
collagen is impaired. In a healthy liver, the synthesis (fibrogenesis)
and breakdown (fibrolysis) of matrix tissue are in balance.
Fibrosis occurs when excessive scar tissue builds up faster
than it can be broken down.
Fibrosis Risk Factors
Liver fibrosis does not occur at the same rate in all individuals,
and in some people fibrosis remains stable or may even regress
over time. Several factors influence fibrosis progression.
Fibrosis occurs more rapidly in men than in women, and also
in older people, particularly those over age 50. Progression
does not seem to be linear; that is, the process appears to
accelerate later in the course of disease. Immune system compromise
for example, due to coinfection with HIV or use of immunosuppressive
drugs after a liver transplant also has been shown to accelerate
fibrosis. Heavy alcohol consumption is strongly associated
with worsening fibrosis and cirrhosis. Finally, studies indicate
that steatosis (fatty liver) and insulin resistance are associated
with more rapid and severe fibrosis. In contrast, HCV or HBV
viral load and HCV genotype do not appear to have much effect
on fibrosis progression (although genotype 3 is associated
with a higher risk of steatosis).
Advanced Fibrosis and Cirrhosis
Early in the course of fibrosis, a person usually will experience
few or no symptoms. Over years or decades, however, the liver
can become excessively scarred, developing nodules and thick
bands of fibrous tissue (septa) that extend from one area
or portal of the liver to another—a condition known
as cirrhosis. As cirrhosis sets in, scar tissue replaces working
hepatocytes and the basic architecture or structure of the
liver changes, affecting the organ's ability to function.
One such change is the obstruction of the normal flow of blood
through the liver. Early on, this can deprive hepatocytes
of nutrients, causing increased cell death. In an attempt
to restore circulation, new blood vessels form. But these
new vessels do not drain efficiently and accumulating scar
tissue may put pressure on other vessels, causing blood to
back up in the portal vein (portal hypertension). One symptom
is stretched and weakened blood vessels (varices) in the esophagus
and stomach, which may burst and bleed. Compensated cirrhosis
occurs when the liver is heavily scarred but can still function
relatively normally. Decompensated cirrhosis occurs when the
liver is so damaged that its vital functions are impaired.
The organ loses its ability to filter toxins from the blood
and to synthesize important proteins, leading to clinical
symptoms such as cognitive dysfunction (hepatic encephalopathy),
accumulation of fluid in the abdomen (ascites), and prolonged
bleeding. In the most severe cases, cirrhosis may progress
to hepato-cellular carcinoma or end-stage liver disease (liver
failure), necessitating a transplant.
Grading Fibrosis and Cirrhosis
Early fibrosis can be difficult to diagnose
because it is often asymptomatic. Various techniques are under
study to detect fibrosis using noninvasive blood tests, for
example by measuring markers of fibrogenesis and fibrolysis.
But the current "gold standard" for determining
the extent of liver disease is liver biopsy, in which a small
sample of tissue is removed with a needle, stained, and examined
under a microscope. In order to monitor progression in a timely
manner, most experts recommend repeat biopsies every 3-5 years.
Various systems are used to grade fibrosis and cirrhosis.
These include the Knodell Histological Activity Index (HAI),
a modified HAI known as the Ishak system, and the METAVIR
system. All three systems include separate scores for histological
activity (necrosis and inflammation) and fibrosis; inflammation
itself is not a reliable predictor of fibrosis severity. The
Knodell system includes four components, for periportal/bridging
necrosis, interlobular degeneration/focal necrosis, portal
inflammation, and fibrosis, which are added together to yield
a combined score from 0-18. The METAVIR system includes one
score for inflammation (grades 0-4) and one for fibrosis (stages
F0-F4).
METAVIR Fibrosis Stages
• F0: no fibrosis
• F1: minimal fibrosis in one portal of the liver, with
no septa
• F2: some fibrosis in one portal, with rare septa
• F3: bridging fibrosis (septa that extend over adjacent
portals)
• F4: cirrhosis with loss of normal liver architecture
Another system, known as Child-Pugh, is
used to grade the severity of cirrhosis on the basis of laboratory
findings and clinical symptoms including ascites, hepatic
encephalopathy, bilirubin and serum albumin levels, and prothrombin
time (a measure of blood clotting ability).
Treatment and Future Prospects
It was once thought that fibrosis was irreversible, but more
recent research indicates that treatment for hepatitis C or
B can slow or halt fibrosis progression and even reverse existing
liver damage. Studies have shown that fibrosis stabilization
and regression are most likely when HCV positive individuals
treated with interferon-based therapy achieve a sustained
virological response (SVR, continued undetectable HCV viral
load six months after the completion of therapy), but improvement
has also been seen in some partial responders or nonresponders.
In the May 2002 issue of Gastroenterology, for example,
Thierry Poynard and colleagues reported that among patients
with repeated biopsies, 80% who achieved SVR with pegylated
interferon plus ribavirin as well as 34% of nonresponders
showed evidence of improved fibrosis.
It is likely that interferon improves fibrosis by suppressing
HCV replication, allowing the liver to repair itself. But
other medications and herbal remedies appear to have a direct
antifibrotic effect. For example, in the August 1, 2004 issue
of the Journal of Hepatology, Yukihiro Imanishi and
colleagues reported that a traditional Japanese herbal preparation
called inchin-ko-to (TJ-135) down-regulated the activity of
hepatic stellate cells, suppressed the production of collagen
and fibronectin, and inhibited the development of fibrosis
in rats. Much research is ongoing in this area, including
a study of long-term interferon maintenance therapy called
HALT-C. With a better understanding of the mechanisms underlying
fibrogenesis and fibrolysis, it may become possible to design
specific therapies to prevent or reverse fibrosis and cirrhosis.
References
Benyon RC and Iredale JP. Is liver fibrosis
reversible? Gut 46: 443-446. April 2000.
Ghany MG et al. Progression of fibrosis
in chronic hepatitis C. Gastroenterology 124: 97-104. January
2003.
Imanishi Y et al. Herb medicine Inchin-ko-to
(TJ-135) regulates PDGF-BB-dependent signaling pathways of
hepatic stellate cells in primary culture and attenuates development
of liver fibrosis induced by thioacetamide administration
in rats. J. Hepatology 41: 242-250. August 1, 2004
Poynard T et al. Natural history of liver
fibrosis progression in patients with chronic hepatitis C.
The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet
349: 825-832. March 22, 1997
Poynard T et al. Impact of pegylated interferon
alfa-2b and ribavirin on liver fibrosis in patients with chronic
hepatitis C. Gastroenterology 122: 1303-1313. May 2002.
Sobesky R et al. Modeling the impact of
interferon alfa treatment on liver fibrosis progression in
chronic hepatitis C: a dynamic view. The Multivirc Group.
Gastroenterology 116: 378-386. February 1999.
Sud A et al. Improved prediction of fibrosis
in chronic hepatitis C using measures of insulin resistance
in a probability index. Hepatology 39: 1239-1247. May 2004.
Back to top
How to Start
an HCV Support Project: Part 2
Alan Franciscus, Editor-in-Chief
Part one of this series discussed
the need for hepatitis C specific support groups. In this
article I will discuss important questions potential support
group leaders need to ask themselves even before starting
a support group, and provide some pointers to help identify
appropriate resources. There is no reason to “go it
alone.”
Why Do You Want to Start A Support
Group?
The majority of people who start an HCV support group have
very little prior experience with group facilitation or a
medical background enabling them to deal with the questions
about hepatitis C and psychological issues that may be needed
to run a successful support group. It is important to be aware
of these limitations when you start a support group. It is
always easier to take on the demands of a support group if
there is help available from others with a medical background
and from those who have experience with running a support
group. You do not need to be the expert or a person living
with hepatitis C; but it is important to surround yourself
with people who can aid you when you face difficult questions
or situations.
Motive
If you are developing a plan of action for starting a support
group it is important that you consider your motive first.
It can be very difficult to be honest with yourself about
the motivation for running a support group, but it is a very
necessary step. Ask yourself these questions:
• Is it to get your own needs
met?
• Is it to help support others?
• Is it to help yourself and others?
There is nothing wrong with starting a support group to get
your own needs met, but if you are not careful it can sabotage
the most important reason for a support group—to help
others. Another essential purpose of a support group is to
help empower other members to make important life choices,
which will be difficult if you do not identify and serve the
needs of the entire group, not just your own.
Are You Open-Minded and Free of
Bias?
Everyone has certain points of view or biases that could potentially
affect the level of support that should be available to all
support group members. Ask yourself these questions:
• Is there the possibility that I
am biased? Would I be open to talking about any issue as it
relates to hepatitis C, including:
o Interferon based therapies
o Alternative and complementary therapies
o Life style issues
o Gender
o Sexual orientation
o Substance use
• Can I accept all individual members regardless of
their ethnic and cultural backgrounds?
• Am I biased concerning the mode of transmission? Will
I accept others who believe they contracted hepatitis C from
a blood transfusion, injection drug use, or sexual transmission,
etc?
• Can I put my ego and “my issues” aside
for the benefit of the entire group?
All of these questions are extremely important
questions that need to be answered, and the answers will be
helpful in guiding you in the process. More importantly they
will help you fine tune your goals.
Identify Experts
Members of a support group look at the facilitator or support
group leader as an expert in hepatitis C. This can be troublesome
unless the facilitator has a medical background and is thoroughly
educated about hepatitis C. However, it may be important from
the beginning to emphasize that the role of a facilitator
is to assist and direct the support group and is not intended
to supply expert medical advice to the members. This should
be left to patients’ medical providers. It is not even
recommended that the facilitator become the ‘expert’
since it could potentially derail the purpose of a support
group—to support and guide others. This requires that
everyone in a support group become actively involved in the
process and take ownership of the group.
Having said this, it is important that a support group leader
learn as much about hepatitis C as possible, as well as become
knowledgeable about running or facilitating a support group.
Information about hepatitis C is freely available from many
sources, such as the Internet, various governmental agencies,
HCV non-profits and published books on the subject.
Identify Resources
It is important to develop resources to aid you. You may want
to develop a relationship with a local health provider who
can serve as a consultant to the support group. It would also
be useful to have as many experts as possible to consult with
on a wide range of issues, and key people who could potentially
present information to the group members.
Medical institutions and non-profit agencies may also provide
sponsorship and free space to hold the meetings. This would
also help with advertising since the agency could advertise
to their clientele.
Do You Need a Co-Facilitator?
It can be very difficult when you realize that all of the
group members’ support falls on your shoulders. It would
help to ease the pressure if you identify a person from the
beginning who would be willing to step in or share in the
responsibility of running a support group. The benefits of
having a co-facilitator will be discussed in more detail later
in this series.
Learn More about Support Groups
There are many resources to help you learn more about running
and facilitating an effective support group:
• Attend other support groups in your area specific
to hepatitis C. This will help you learn how others run a
support group and will help you find out if the needs of the
HCV population in your area are being served. If the need
is being filled by another group, perhaps the best use of
your time and energy would be to help an existing group. You
may also find that certain people are not being served. The
potential for HCV support groups is unlimited and many more
specific groups can be started to help support the HCV community.
These may be groups that serve Veterans, family members, substance
users, or any other group with specific needs.
• Visit and attend other types of support groups. There
may be 12 step meetings or other disease specific support
groups that would help you understand the support group process
and how to support people with different needs. It is important
that if you do attend other groups for research that you let
them know why you are attending. There is a certain level
of trust that needs to be honored at all times.
• Publications on support groups that will help guide
you through the process of starting a support group.
• Local agencies may offer services or seminars on running
a support group.
Recommended reading:
• The Support Group Sourcebook, by
Linda L. Klein
• Self-help and Support Groups: A Handbook for Practitioners,
by Linda Farris Kurtz
They are both available at Amazon.com.
Part 3 of this series will discuss
the importance of establishing the type of group and factors
such as group size, length of the meetings as well as the
physical space needed to run an effective support group.
Back to top
HealthWise
Lucinda K. Porter, RN, CCRC
The high price of health care is dominating some of my social
conversations. Other than gasoline, perhaps nothing more essential
is so obviously inflated. Rising health care costs are occurring
at many levels. Hospital, laboratory, and professional fees
are increasing. Insurance is costing more but covering less.
According to a report released by the Kaiser Family Foundation,
health insurance premiums rose more than 11% this year. Insurance
plan deductibles and co-payment amounts keep rising. Medicare
premiums will increase by 17% in 2005. Prescription drug costs
are going up.
These rising costs, particularly of prescriptions
drugs are affecting us all, chiseling away at our earnings.
Patricia Barry writes poignantly in an article appearing in
the October 2003 AARP Bulletin, "A widow recently sold
her wedding ring to pay for medicine. Another sometimes begs
for prescription drugs left by friends who've died. Another
on occasion uses pills prescribed for her dog." The Medicare
Prescription Drug Law and the Medicare Prescription Discount
card were intended to reduce prescription drug costs and to
some extent they have. Unfortunately, these programs are confusing
and are not serving those who need the most help.
In my work with patients, I frequently see examples of how
the high cost of prescription drugs and health care can drive
people to creative or desperate measures. Treatment for chronic
hepatitis C virus (HCV) infection is expensive. Patients without
insurance and other economic means or with high deductibles
and prescription co-pay amounts, simply cannot afford HCV
treatment. Some call Stanford Medical Center and other hospitals
in the country, looking for clinical trials that treat their
conditions and provide free medication, lab tests, and clinic
visits. Although not all clinical trials offer free medication
and treatment, when they do this can be an excellent resource.
Before participating in a clinical trial, it is important
to be informed of the entire process before agreeing to be
in a drug trial. In order to judge the feasibility of a study
from a financial standpoint, some questions to ask are:
• What is the purpose of the study?
• What is the drug or combination of drugs being tested?
• What are the potential benefits or risks of my participation
in the study?
• Will I incur any costs? Will the treatment or tests
be free?
• Is a placebo being used? If so, what are the chances
of receiving the study drug versus the placebo? If I receive
the placebo, will I be offered the study drug at the end of
the trial period?
Current treatment for chronic HCV uses peginterferon alfa
combined with ribavirin. Peginterferon alfa is currently marketed
by two companies, Hoffmann-La Roche and Schering. No generic
form of peginterferon alfa is available. Hoffmann-La Roche
and Schering also sell their own brands of ribavirin, but
there is a generic form available. At this time, generic ribavirin
is not necessarily a cheaper alternative. Hopefully competition
will have a healthy influence on the ribavirin market. For
more information about HCV medications, see "A
Simple Guide to Understanding the Cost of HCV Medications,"
by Alan Franciscus, HCV Advocate (May 2003).
Patients are looking for cheaper drugs for all of their medical
problems, not just HCV. The following are some cost-saving
ideas to consider:
• Ask your doctor if there is a cheaper version of your
medication, such as a generic form
• Inquire about free samples
• See if you qualify for a pharmaceutical patient assistance
program. For more information contact Needy Meds www.needymeds.com
or try www.helping
patients.org
• Shop for the best drug price, such as through Costco,
wholesale, or reliable Internet-based pharmacies
• Look for discounted drug prices, such as through your
insurance plan, or AARP. Insurance pharmacy mail order plans
can really cut costs. Some pharmaceutical companies, such
as Pfizer, offer discounted drug prices for everyone without
prescription drug coverage. For more about this, look for
information at the website of the pharmaceutical company that
sells the medication you are taking.
• If it's a drug you are confident you will be taking
for some time and at a steady dose, see if a 90 day supply
costs less than a 30 day supply.
• Join a discount pharmacy program. These programs offer
discounted drug prices for an annual membership fee. If you
are interested in this option, make sure the membership fee
is reasonable and that the program carries the medications
you are taking.
• Compare the price of different strengths of the drug.
Ask your doctor if the pill can be prescribed at a higher
dose and safely divided in half. For instance, if you are
supposed to take a 5 mg dose of a medication every day, it
may be cost effective to purchase a 30-day supply of a 10
mg dose and divide it in two. This would stretch the medication
over a 60 day time period. Do not do this without your doctor's
knowledge because some pills should not be cut.
• A lesser known option is a program called The Medicine
Program. For a fee of $5.00 per medication, this service is
staffed by volunteers who attempt to find free-of-charges
prescriptions. This service can be reached at (573) 996-7300
www.themedicinepro gram.com
• For more information about Medicare programs, call
Medicare at 1-800-MEDICARE (1-800-633-4227) or go to www.medicare.gov
/MedicareReform. Kaiser Family Foundation provides some
interesting information about this program and other health
topics at www.kff.org.
Lately there has been a lot in the press about purchasing
prescription drugs in Canada, Mexico, or overseas. In some
cases this is perfectly legal and other cases it is not. The
laws about this vary, depending on the medication and how
it is being used. Medication from another country is not always
the same or safe and not necessarily cheaper. However, sometimes
it can be the same drug priced at a substantial savings. One
resource that can provide more information about this option
is www.medicine
assist.org
One way to change the direction of health care is through
the political process. Election Day is Tuesday November 2,
2004. Exercise your right to vote. If you are not registered
to vote, you can obtain a National Mail Voter Registration
Form from the Federal Elections Commission web site: http://www.fec.gov/
votregis/vr.htm. This form can be used by every state
in the U.S. to register to vote except New Hampshire, North
Dakota, and Wyoming. Each state has particular deadlines and
instructions listed on the web site. The form is otherwise
straight forward.
Some prefer to vote by absentee ballot. With the 2000 Florida
election results still fresh in our minds, there may be reasons
to consider voting by absentee. Each state has its own requirements
for absentee balloting. Information about your state's Board
of Elections can be found in the telephone Yellow Pages or
on the Internet. Whether in person or by absentee, the point
is to vote. Together, perhaps we can make a difference, one
vote at a time.
© October 2004, Lucinda Porter,
RN, and the Hepatitis C Support Project / HCV Advocate www.hcvadvocate.org
- All Rights Reserved.
Reprint is granted and encouraged with credit to the author
and to the Hepatitis C Support Project.
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