This document contains the Latvian Citizenship Law of 1991 which details who may and may not claim Latvian citizenship. Distinctions are made between those who lived in Latvia prior to June 17, 1940, and those who entered during the occupation period which began on that date. Individuals who were citizens of Latvia prior to the occupation and their descendants who are residing in other nations may register for Latvian naturalization at any time, but they must renounce any other citizenship. Those residing in Latvia must register for citizenship certification prior to July 1, 1992. Other citizenship requirements include mastering the spoken Latvian language, holding permanent residence in Latvia for at least 16 years, and knowing the main provisions of the Latvian Constitution. Citizenship will not be granted to individuals who fought against Latvian independence; have been imprisoned for a premeditated crime; served in the USSR Armed Forces; have been convicted in court for crimes committed against humanity (including war crimes); have been convicted in court for propagating the ideas of chauvinism, fascism, communism, totalitarianism, class dictatorship, or racial differences, are registered drug offenders, or live without a visible means of support.
Act of 16 October 1991, concerning employment and unemployment. [Excerpts].
This document contains several chapters of Poland's Act of October 1991 defining the role of the State in regulating employment as well as in counteracting unemployment and diminishing its effects. Chapter 1 sets out general provisions and definitions. Chapter 3 covers the employment placement and vocational guidance services to be carried out by the State as well as reimbursements to employers for hiring previously unemployed persons. Chapter 6 details allowances to be made for persons accepting employment outside of their place of residence. The seventh chapter makes provisions for the employment of Polish citizens abroad by foreign employers and the employment of foreigners in Poland. Chapter 8 establishes a compulsory Labor Fund which will collect contributions to cover unemployment benefits and allowances.
Children (Relationship and Legal Position) Act 1991 [1 November 1991].
In 1991, Cyprus enacted a statute dealing with the legal rights of children in relation to inheritance and proof of paternity. The statute holds that a child born during a marriage or within 302 days of the dissolution of a marriage is the child of the husband in that marriage unless the mother remarried during the 302 days, in which case the new husband is presumed to be the father of the child unless it is proved otherwise. The legitimacy of a child born in marriage can only be attacked in court if it can be proved that the mother did not conceive the child from her husband. The only people allowed to bring such action are the husband of the mother, the parents of the husband if he has died, the child, and the mother and first husband. There is a statute of limitations on such actions brought by a husband or a dead husband's parents. A child born out-of-wedlock may be recognized as legitimate if his parents marry at any time after his birth (even after his death). A child born out-of-wedlock may be recognized by a father (if the mother is living, her consent is required). If the father is dead, the paternal grandparents may recognize a child. Recognition always confers retrospective rights to the time of a child's birth.
Declaration of Human and Civil Rights and Freedoms, [22 November 1991].
In 1991, the USSR issued this Declaration of Civil Rights and Freedom to bring its legislation in line with the standards generally recognized by the international community. This document acknowledges the supremacy of recognized international human rights norms to national laws and protects the legal equality of everyone, specifically men and women. The exercise of rights should not infringe on any other's rights, and the use of rights to forcibly change the constitutional system, engender hatred, or propagate violence or war is prohibited. Specified rights include the right to citizenship, the right to life (measures will taken to seek the total abolition of the death penalty), the right to appeal an arrest, and the right to a private life and confidential communications. The right to accommodation is laid out as is the inviolability of accommodation. Freedom of movement is assured as is freedom of thought and expression, freedom of information, and freedom of conscience. Provision is made to excuse a citizen from military service if such service violates his conscience. National affiliation and the right to use a native language are protected. Other rights include the right to assembly, to association, to appeals, to ownership, to engage in entrepreneurial activity, to work, and to decent working conditions. Additional entitlements include social security, skilled medical aid, and education. Those accused or convicted of crimes also have specified rights. In the event of a state of emergency, temporary restrictions may be imposed on rights and freedoms.
Lithuanian Republic Law: "On Lithuanian Republic Citizenship" [5 December 1991].
This document contains the 1991 Law on Lithuanian Republic Citizenship. The first section covers general principles such as who can claim citizenship, what document (a passport) confirms Lithuanian citizenship, the legal status of citizens, the preservation of Lithuanian citizenship upon marriage or the dissolution of marriage, and the preservation of Lithuanian citizenship among citizens who reside outside of the country. Section 2 deals with the acquisition of citizenship, including the means of acquisition, the citizenship of children of citizens, stateless individuals, the citizenship of children whose parents are unknown, conditions for acceptance to citizenship, the oath of allegiance, and the awarding of citizenship to persons who have served the state. Section 3 describes the maintenance of the right to citizenship as well as the restoration, loss, and return of citizenship. The fourth section sets conditions governing the citizenship of children when the citizenship of their parents changes. Section 5 gives the procedure for resolving citizenship disputes, and the final section acknowledges the applicability of international treaties.
[Resolution No.] 46/100. Improvement of the status of women in the Secretariat, 16 December 1991.
On December 16, 1991, the UN General Assembly adopted a resolution to improve the status of women in the Secretariat. The resolution notes that the UN failed to achieve a goal of 30% participation by women in posts subject to geographical distribution by 1990 and recalls the goals for 1995 of a 35% overall participation by women in posts subject to geographic distribution and of 25% participation of women in posts at the D-1 level and above. The resolution then urges the Secretary-General to afford greater priority to the recruitment and promotion of women and to increase the number of women employed in the Secretariat from developing countries and other countries from which women are poorly represented. Member States are encouraged to engage in activities (such as nominations, recruitment, and creating rosters) which support these efforts. The Secretary-General is requested to assign a senior-level official to implement the action program for the improvement of the status of women in the Secretariat and to submit the results of a comprehensive study of the barriers to the advancement of women as well as details of the action program to the General Assembly. A progress report for 1991-95 is to be made to the Commission on the Status of Women.
On December 19, 1991, the UN General Assembly adopted a resolution on women, the environment, population, and sustainable development. The resolution requests that the Commission on the Status of Women make relevant parts of the report of its 36th session (in 1992) available to the Preparatory Committee for the UN Conference on Environment and Development. In addition, UN agencies are asked to strengthen their data collection and capacity-building efforts in the field of women, environment, population, and sustainable development. UN agencies are urged to integrate women as active participants at all levels in the planning and implementation of programs for sustainable development. Finally, the Secretary-General is asked to report on the role of women in the environment and sustainable development at the 48th session of the General Assembly.
Passports Act, 1991 [24 December 1991].
Saint Lucia's Passports Act of 1991 directs the Minister for Home Affairs to issue a passport upon the application of any person who proves that he is a citizen of Saint Lucia. Passports can be withdrawn or cancelled on the grounds of national security or if the holder has been convicted of an offense involving drug trafficking or if the Minister has reasonable grounds to believe that the holder is involved in drug trafficking. No one over the age of 16 years can enter Saint Lucia without a valid passport or other document establishing his nationality and identity and augmented by a photograph. The Act also sets out the penalties for persons guilty of an offense against this Act.
Spouses Property Relations Act 1991 [30 December 1991].
This document summarizes major provisions of the 1991 Spouses Property Relations Act of Cyprus. After defining the terms used, the Act holds that the obligation for maintenance is mutual and that when marriage cohabitation ceases, either spouse may apply to the court for maintenance. Maintenance can vary according to circumstances such as a spouses age, health, and ability to work; whether a spouse has the care of an underage child or a child with a disability; and whether the spouse is in need of training (limited to three years). Other factors affecting maintenance include the duration of the marriage, if the applicant was responsible in a serious way for the dissolution of the marriage, or if the applicant's need for maintenance has been brought about by the applicant's own volition. The amount of maintenance will reflect need and lifestyle, and a maintenance order may be of a temporary nature. The Act also contains provisions which allow a spouse to file a claim for a portion of an increase in assets to which said spouse has contributed. Maintenance amounts will also reflect such factors as the behavior of both spouses during the marriage and dissolution of the marriage. This Act applies to cases filed after January 1, 1991.
France. Crack-down on clandestine employment.
In response to the growing concern of the French people about immigration, the National Assembly passed a bill on December 12, 1991, to provide for stronger measures against clandestine employment and the illegal entry and residence of foreigners. Despite the fact that the French public has been convinced since 1988 that foreigners pose a threat to employment, clandestine employment grew by 7% in 1991. The new Act requires an employer to register a new employee immediately and to issue a certificate of employment. Employers now share joint responsibility for clandestine employment with the workers and will be held jointly liable for the payment of taxes, charges, etc. Clients of prime contractors who hire subcontractors also have obligations to insure that clandestine employment is not occurring. The Act provides harsher penalties for clandestine employment than those which previously existed, including the barring of foreigners from France (with some exceptions) for a period of five years. Since the clandestine employment market involves between 300,000 and 1 million workers, it may be impossible to implement this Act to any great effect.
This UN Resolution on prevention and control of AIDS was adopted on December 20, 1991. The resolution notes that the World Health Organization (WHO) predicts that 30-40 million individuals (90% in developing countries) will be infected with HIV by the year 2000 and that the epidemic will have produced 10-15 million AIDS orphans by that time. The UN expresses concern that the epidemic is increasing rapidly in urban areas and developing countries. The UN recognizes that the epidemic demands a multisectoral response and that discriminatory measures against people with AIDS not only force the epidemic underground where it is more difficult to combat but also infringe upon the human rights of the victims. The resolution stresses the need to promote safer sex behavior and to detect and treat other sexually transmitted diseases as early as possible. It also notes the importance of supplying young people in particular with sex and health education and counseling. All means of transmission should be targeted, including IV drug use and unsafe medical practices, and the status of women should be improved so they can protect themselves from unsafe sex. It is also important that scientific technologies and pharmaceuticals be made available quickly and affordably. The resolution urges Member States to give the AIDS pandemic top priority; to continue to develop national AIDS programs; to develop information, education, and counseling services; to adopt a multisectoral response to the socioeconomic consequences of AIDS; to encourage private sector, community group, and nongovernmental organization involvement; and to protect the human rights of infected individuals. The scientific community is asked to continue research into means of prevention and therapy. The WHO is asked to strengthen information exchange among Member States and to help countries develop plans to deal with the socioeconomic consequences of AIDS to women and children in particular. The Secretary-General is asked to use the capacities of the UN system to plan multisectoral activities and to earmark funds for requested assistance. The information capacity of the UN should be used to intensify public information activities. A report on the implementation of this resolution is to be made to the 47th session of the General Assembly.
On April 3, 1990, Belgium changed its abortion law by amending four sections and repealing one section of its Penal Code of 1867. The law provides that any person who induces an abortion may be fined and imprisoned unless 1) the termination occurs before the 12th week of pregnancy; 2) the termination is performed by a physician in a care establishment, and the pregnant woman is given information and counseling about her legal benefits and rights and alternatives to abortion; 3) the woman is informed of the risks associated with abortion; and 4) the physician is convinced that the woman is determined to end the pregnancy. The earliest time in which the procedure can be performed is six days after the first of the legally prescribed consultations. The woman's informed consent must be given in writing. If a pregnancy has progressed beyond 12 weeks, an abortion can only be performed if the pregnancy jeopardizes the health of the woman or if the child would be afflicted with an incurable pathological condition. The opinion of a second physician is required in such cases. After an abortion, a qualified staff member of the care establishment must provide the woman with information on contraception. No one is obliged to assist in an abortion, but a physician must inform a pregnant woman of his unwillingness to perform the abortion during her first visit.
Is lack of self-esteem a major determinant of teenage pregnancy in the Bahamas?
This study opens with an examination of the magnitude of the problem of adolescent pregnancy which considers the changing pattern of teenage pregnancy worldwide as well as adolescent pregnancy in the Caribbean, provides a rationale for the present study in the Bahamas, and reviews the risks and consequences of teenage pregnancy to maternal health (including psychosocial risks, repeat pregnancies, abortions, and sexually transmitted diseases) as well as to infant health (including congenital abnormalities). The objectives of the present study in the Bahamas were 1) to determine the socioeconomic status of pregnant teenagers, their parents, and the putative father; 2) to describe the preparation of the girls for puberty and menarche; 3) to identify their knowledge about reproduction and contraception; and 4) to make recommendations for action based on the study findings. The study methodology is discussed in terms of the methods available for studying teenage pregnancy, the selection of study indicators, the design of the questionnaire, the choice of the population sample, and data analysis. Characteristics of the study population are presented as are limitations of the study. The results of the interviews with 91 currently pregnant teenagers and 24 teenage mothers conducted during July 28-September 5, 1986, reveal that 1) the teenagers themselves were probably unexpected and unwanted babies and, therefore, lack self-esteem; 2) many of the teenagers came from single-parent families where the mothers worked, the fathers reneged on their responsibilities, and the kinship system was an ineffective social control system; 3) the teenagers had sexual relations with older men for "love"; 4) their sex education came from ill-informed friends and older sisters; 5) information about contraception was limited and inaccurate; 6) early childbearing, while not generating approval, had no sanctions; and 7) the cycle is likely to be repeated. Recommended actions include using existing groups to improve self-esteem, increasing knowledge, educating men and boys about their responsibilities, providing early access to contraception, and researching informal sources for reaching adolescents with information, education, and services.
Understanding adolescents. An IPPF report on young people's sexual and reproductive health needs.
This International Planned Parenthood Report was published in preparation for the 1994 International Conference on Population and Development. The report examines the extent of adolescent sexual behavior, pregnancy, childbearing, and abortion as well as the incidence of sexually transmitted disease (STD) among young people. The lack of sex education is shown to be a contributing factor to these problems, and the rights of adolescents to family planning services are reiterated. The risks and consequences of unknowledgeable adolescent sexual intercourse include early childbearing, unwanted pregnancies, STDs, and sexual exploitation and abuse. Regional perspectives are given for Africa and the Middle East, sub-Saharan Africa, Asia, Latin American and the Caribbean, and industrialized countries. The success in reducing the incidence of unwanted pregnancies, abortion among teenagers, and STD transmission experienced by the Netherlands is described. This section is also enlivened with actual case histories from around the world. The report then turns to policy and program implications arising from adolescent sexuality issues. The provision of information, counseling, and services as well as the involvement of adolescents in programs are targeted as successful initiatives. The provision of contraception for adolescents is then covered, and charts illustrate the unmet need and current contraceptive use in sub-Saharan Africa, North Africa, Asia, Latin America and (separately) in industrialized countries. The successful and constantly evolving program developed by MEXFAM, the IPPF affiliate in Mexico, is then described. The report ends by providing a list of additional reading.
This report summarizes the international conference "Effective Nutrition Communication for Behavior Change," which was held in Paris, France, in 1991 to 1) illustrate mechanisms for achieving nutritional behavior change, 2) develop strategies for changing nutrition behavior in various target groups, and 3) empower teams from developing countries to launch successful nutrition communication programs. The conference included a keynote address "From Nutrition Education to Social Marketing," the presentation and discussion of case studies from eight developing countries and presentations from 12 developing country teams and donor agencies. The case studies presented 1) a model for building partnerships between broadcasters and health professionals in Africa, 2) experience with nutrition behavior change in Egypt, 3) changing dietary behavior through social marketing in Thailand, 4) a national breast-feeding program in Brazil, 5) nutrition interventions achieved in Peru and Nigeria through the cooperation of nutritionists and communicators, 6) highlights of a rural integrated nutritional communication program in Mail, 7) the Philippine experience with social marketing, and 8) the impact of social marketing on megadose vitamin A capsule consumption rates in Central Java. The general discussion led to the uncovering of the following key principles of success: developing a comprehensive and systematic approach to the program, eliciting the support of policy-makers and the health care community, and using a multimedia approach. The case studies incorporated considerations of price, product, promotion, and place in their social marketing models. The necessary of adding a fifth "p," for process became evident, for it is the process used to identify and develop price, product, promotion, and place that is most essential. The decision-making process is also the only aspect of a social marketing program which is guaranteed to be transferrable to another setting.
The Bangladesh Family Planning and Health Services Project (388-0071): evaluation report.
In April 1995, the USAID-funded Bangladesh Family Planning (FP) and Health Services Project (August 31, 1987, through August 30, 1997) was evaluated to assess progress to date and to generate recommendations for the final two years. In general, the project has met or exceeded the following goals for 1997: 1) decreasing the total fertility rate of 4.6 in 1991 to 3.8 (3.4 was achieved in 1993-94); 2) reducing the infant mortality rate of 118 in 1991 to 107 (87 was achieved in the early 1990s); 3) increasing the contraceptive prevalence rate of 40% in 1991 to 50% (44.6 was reached in 1993-94); 4) increasing acceptors from 9.9 million in 1991 to 14.5 million (the initial framework contained an error, and the baseline rate actually was 7.8 million in 1991; 12.1 million are expected for 1997); and 5) increasing immunization of urban women and children from 25% in 1988 to 85%. Other project impacts were a drop of 26% in under-5 mortality and achievement of a maternal mortality rate of 5.5/1000. This report describes the project organization (as too complex), the four components of the project structure (assistance to the public sector, the social marketing company, nongovernmental organizations, and support services), and includes 12 recommendations of ways to take advantage of significant socioeconomic changes, strengthen service quality, stimulate the use of longterm methods, and create a more manageable structure for the follow-on period. The overall assessment is that the project has been a major factor in the expansion of population and health services and has demonstrated how USAID can stimulate the growth of a national program.
A random survey was conducted using the campus voice mail system among 550 students of Princeton University to determine their knowledge of and attitudes about postcoital contraception (which has been available at the university health center for more than 15 years). The survey elicited a response rate of 82% and included demographic information in the data collected. The results showed that 95% (>98% of the undergraduates) of the sample knew about emergency oral contraception (EOC), but 52% of the respondents could not distinguish EOC from RU-486, only 38% knew that the correct time of use was within 72 hours, only 26% knew that EOC was a regimen which used a large dose of combined oral contraceptives, and 25% knew that the effectiveness of EOC is 75%. 54% of the students believed that EOC is associated with unpleasant side effects, and 7% thought there would be serious side effects (this attitude was significantly related to nonendorsement). Only 12% of the students correctly identified the fertile period in the menstrual cycle and understood the timing factors associated with EOC. 80% of the students approved of EOC, and 91% approved in cases of rape. Those who identified themselves as Democrats were significantly more likely to approve, and those who were highly religious were significantly less likely. Ethical concerns were cited by 32% of the respondents, and 57% had health concerns. 84% felt that EOC was readily accessible, but only 43% knew it was available throughout the week. 30% of the students had experience with a situation in which more information about EOC would have been helpful. Regression analysis of these findings revealed that approval was higher among students who knew the ingredients and side effects of EOC, knew of a situation where it would have been helpful, were not religious, and/or were Democrats. Ethical concerns were associated with health concerns, strong religious feeling, Republican affiliation, and a lack of knowledge about ingredients.
Family planning outreach and credit programs in rural Bangladesh.
A 1992 study in rural Bangladesh examined the effects of the Grameen Bank program (which provides credit for women's self-employment schemes) and of home visits by family planning (FP) workers on reproductive norms. Data were gathered through two random samples of women who had been members of the Grameen Bank or the Bangladesh Rural Advancement Committee for at least 18 months. These data were compared with 1) eligible nonmembers from Grameen Bank villages and 2) eligible nonmembers from nonserved villages. Specific hypotheses tested were that 1) FP home visits are positively related to contraceptive use, 2) membership in credit organizations or residence in credit-available villages increases contraceptive use, 3) women's physical mobility increases contraceptive use, and 4) the greater propensity of credit program members to use contraception is not entirely explained by increased mobility. It was found that women living in Grameen Bank villages are 16% more likely to use contraception than women in villages without a program (this is highly significant upon Chi-square analysis). When other variables were controlled in regression analysis, the significant effect of the presence of the Grameen Bank was not explained by the FP home visits, but home visits had strong independent effects (raising contraceptive use rates 21% and 30% among the comparison group and the nonmember credit-village group, respectively) along with age, relative wealth, and presence of a surviving son. A significant difference was also found to be caused by mobility, with 60% of the more mobile using contraception compared with 46% of the less mobile. When "relative mobility" is added to the regression, Grameen Bank membership is still significant; significance disappears for nonparticipants living in a credit-available village. These results indicate that programs which decrease women's isolation and dependence upon men can influence fertility. The presence of a Grameen Bank in a village in combination with a FP outreach program can have a dramatically positive impact on contraceptive usage as reproductive norms change. The study also revealed that fear of side effects and potential health problems associated with contraceptive usage remains a major obstacle to fertility control. Women need increased economic opportunities, improved access to health care, and improved contraceptive quality.
A prospective study of 221 healthy women planning to become pregnant examined the timing of sexual intercourse in relation to ovulation to determine whether time factors influence the probability of conception, the pregnancy outcome, or the sex of the baby. Using urine analysis, the dates of ovulation were determined in 625 cycles. 192 pregnancies were indicated by increased levels of human chorionic gonadotropin, and 129 ended in live births. In every cycle in which pregnancy occurred, intercourse occurred at least once during the six consecutive days that ended with the day of ovulation. None of the 31 cycles in which no intercourse took place during this time span resulted in conception. The proportion of pregnancies ranged from 0.08 with intercourse on the first of these six days to 0.36 with intercourse on the day of ovulation. The probability of a live birth for any given cycle is 0.25 with daily intercourse, 0.22 with intercourse every other day, and 0.10 with weekly intercourse. No lower fertility (due to depletion of the number of quality of sperm) was found with higher frequency intercourse. Analysis of age of sperm versus survival of the pregnancy revealed that only 6% of the conceptions could be firmly attributed to sperm which was three or more days old, but a similar pattern was found in relation to intercourse/ovulation timing in pregnancies which ended in fetal loss or live births. Timing of intercourse in relations to ovulation had no influence on the sex of the baby. These findings suggest that the fertile period lasts about six days and ends upon ovulation and that sperm retain their fertilization ability in the female reproductive tract for about five days.
Funding initiated to help scientists research AIDS. International (Africa).
A fund was initiated in November 1995 by several African states, developed countries, and international agencies to promote research in AIDS in Africa. In establishing the fund, experts cited the importance of conducting research on the continent which is home to 11 of the 15 million AIDS patients. In addition to setting up training laboratories, the fund will provide training fellowships and prizes for research papers. Specific topics which will receive attention include the variety in prevalence rates from one country to another, ways to make the blood supply safe (300,000 people are infected through infusions in Africa each year), the use of traditional medicine to cure the opportunistic infections associated with AIDS, and the socioeconomic factors associated with the disease.
The willingness to pay for medical care: evidence from two developing countries.
This book considers issues surrounding payment for health care in developing countries. The first chapter introduces the work. Chapter 2 illustrates the importance of health care to the development process and the functions of health production. This chapter also considers the main arguments used to justify government intervention in the health care sector in developing and industrialized countries; categorizes medical care as curative, patient-related preventive, and non-patient-related preventive; and discusses the role of price in the health care market. In the third chapter, case studies from the Ivory Coast and Peru are used to show that charging user fees for medical care is a desirable and feasible alternative to government financing. The larger picture of health and health care in West Africa and Latin America is also examined. Chapter 4 presents options in health care financing and describes the welfare analysis of health care demand. Chapter 5 uses evidence from the literature to create a behavioral model of the demand for health care and the resulting empirical specifications. Empirical results for rural Ivory Coast and rural Peru are presented in the sixth chapter, and their implications for policy are demonstrated in Chapter 7 through simulations of the consequences of various pricing policies. The final chapter contains suggestions for future research and for policy implementation. This chapter contains suggestions for governments to introduce user fees while still protecting the poor from adverse effects. The four most important empirical findings of the study are that 1) the demand for medical care is price sensitive, 2) the poor are more price sensitive than the rich, 3) care for children is more price elastic than care for adults, and 4) if the price of one provider increases, patients are more likely to turn to another provider than to self-care.
Certainty and agnosticism about lethal injection in late abortion.
This article was written in support of a claim forwarded by Joan Callahan that fetal intracardiac potassium chloride injection (KCl injection) should be offered to women undergoing second-trimester abortion. Callahan provides three positive arguments for use of the technique: maternal safety, the short-term interests of fetuses, and the longterm interests of fetuses who survive the abortion. The author of this article notes that the fact that KCl injection is currently the safest procedure for the mother is argument enough in favor of offering the procedure. Even physicians who object to the procedure are obligated to inform their patients about it and should be encouraged to help their patients locate a physician willing to perform KCl injection. Callahan's argument about fetal pain is sound but unnecessary as long as KCl injection remains the safest procedure for the mother. The argument about preventing longterm suffering for fetuses who survive late abortion is the weakest because it is impossible to determine whether the fetuses would be better off dead or alive. Hospitals can resolve some of the dilemmas which are associated with KCl injection by having a well thought out and clearly communicated policy about resuscitation of an aborted fetus. Callahan argues that the policy should be a blanket "do not resuscitate." The author is less sure that a blanket policy in either direction would be correct. Since it is impossible to know in advance what is best for the child, other factors must determine whether one policy is preferable to another. These include legal considerations such as the Americans with Disabilities Act which prohibits discrimination against disabled individuals in hospitals.
Introduction: principles for meeting increased demand.
The demand for family planning is expected to increase from 192 million users in 1990 to 286 million in 2000. The USAID has identified five principles on which family planning services must be based to meet this increasing demand. These principles, which apply to all family planning services, including natural family planning (NFP), are that service delivery must 1) emphasize quality of care; 2) expand to serve larger populations in more cost-effective ways; 3) evolve to accommodate a diverse, younger population and improved method mix; 4) include cooperation by all sectors, i.e., government, private voluntary organizations, and for-profit groups; and 5) be sustainable. The papers in this session address how NFP service delivery programs can follow these principles to improve the quality and availability of services and contribute to efforts to meet increasing demand. They will focus on the importance of the following factors: a clear understanding of the service delivery organization's goals and objectives in light of the organization's purpose and the needs of the community it serves; mechanisms to ensure quality of care, including measurable standards and supportive supervision; an information system that can be used for a variety of purposes; and a system of responsible financial management that ensures continuity of the program as well as efficient, effective service delivery. (full text)
At what stage is NFP service delivery?
An initial reaction of the participants was that modern natural family planning (NFP) as a "product" or "theory" has been accepted as valid, but that the delivery of the "product" has not been well developed or very well established. Some believed that NFP had not even yet reached a demonstration phase or, at most, was only at the very beginning of a demonstration phase. The following indications of this stage of development were stated as follows: there is still very little public knowledge about modern NFP, and when there is knowledge or use of NFP, it is still associated with the traditional calendar method; new groups of acceptors need to be identified, particularly those who have never known that NFP is an effective method; NFP needs to be included in recognized, national family planning programs; and NFP should demonstrate and prove that it is cost-effective and that it is beneficial to family planning. The session also included a discussion on ways to modify behavior to make periodic abstinence more acceptable. (full text)
The missing link: why NFP is still "the best-kept secret".
The importance of continuing to bring scientific data to the attention of the medical community was stressed. Information on topics such as natural family planning (NFP) effectiveness and the documentation of dissatisfied and successful users of NFP was emphasized. It was also recommended that medical professionals be utilized in selected roles, such as consultants, to stimulate their interest and respect for the natural methods. The need for patience and perseverance in seeking support for NFP, not only from the medical profession but from the clergy and various religious groups, was discussed as well. It was suggested that positive words be used to describe NFP such as "scientific" and "modern" family planning with "No side effects." Ideas about marketing NFP through existing women's organizations and infertility intervention programs were explored, along with a plan to initiate fertility awareness programs in schools. The final recommendations were to target resources in the community, presenting NFP as a positive option. It was noted that NFP does not profit by attempting to discredit other family planning methods. (full text)
Various forms of financial support for NFP teachers.
Creative ways to compensate natural family planning (NFP) teachers need to be developed. Because each program has its unique circumstances, there are many different strategies to be explored: the recovery of costs through client revenues; investigation into third-party reimbursement; financial support from the Catholic church and other organizations; and the bartering of services. In programs without funds to offer teachers, alternative means of compensating enterprising NFP teachers need to be established. Examples include continuing education opportunities, articles about NFP teachers in client newsletters, and providing social functions that enable the teachers to interact with one another. (full text)
Providing NFP counseling within a family planning clinic.
It is necessary to have the support of the clinic staff and an atmosphere of respect and tolerance for the beliefs and practices of all clients, staff, and administrators. Such an atmosphere of respect includes the recognition that natural family planning (NFP) is a viable alternative to other family planning methods, as well as the acknowledgement that there is no one family planning method that is good for everyone. The presentation of all method options should include, therefore, the advantages and disadvantages of each of the methods. Others believed that NFP instructors should teach only NFP and that it should be taught in a private area. The NFP instructor could work on a part-time basis and be available to provide services to more than one clinic. It was recognized that NFP needs more publicity and positive support in general from organizations, including the Catholic church. (full text)
Making periodic abstinence more acceptable to NFP users.
The participants felt that the term "periodic abstinence" was negative and should not be used. It was suggested that the focus be on new dimensions of the relationship, including "outercourse." For example, couples can lack the ability to love fully and comfortably when the sexual aspects of marriage are overemphasized, rather than the emotional aspects, particularly feelings of love and tenderness. Periodic abstinence should not be identified with puritanism or the withholding of love, but rather with a period to rediscover, refuel, and revitalize the love of the couple. Periodic abstinence can be used positively to challenge a couple's customary patterns of relating by removing the focus on sexual intercourse. This can be seen as an opportunity for the couple to increase their awareness of and sensitivity to each other from which feelings of love and tenderness grow deeper. This approach should be taught early in the relationship, as part of the relationship, rather than attempting to change established behavior and attitude patterns at a later stage in the relationship. Therefore, periodic abstinence and alternative expressions of affection should be a natural part of children's education and development. (full text)
The fertility awareness method: extent of use, potential, and research needs.
Little research has been done on the fertility awareness method (FAM) in developed countries and even less in developing countries. Some of the questions addressed in this discussion included: Is FAM of sufficient promise and interest to be a concern? Is more information required on its acceptability, effectiveness, and continuation rates? The research literature was briefly reviewed and new studies mentioned. When comparing "pure" natural family planning (NFP)--that is, the use of abstinence during the fertile period--with mixed methods--such as the use of barriers during the fertile period--the results have generally found that the mixed method has slightly higher pregnancy rates. Mixed use may be underreported because the users may be embarrassed or afraid to mention barrier use. Not everyone liked the term "fertility awareness method." There was also disagreement about whether FAM should be standardized and whether users should be taught how to use condoms correctly. Some felt it was cumbersome to use two methods and that people using barriers might become lax in their monitoring of the fertile period and their fertility signs. It was suggested that Contraceptive Technology (journal) describe FAM in the next updated issue. The following research questions and priorities were proposed: Who is using FAM and why? What is the use effectiveness of FAM by user characteristics (education, religion, duration of use, quality of education)? What reasons are given when people do not use the method successfully? Does fertility awareness education improve condom use? How do NFP and FAM compare when studied prospectively? (full text)
Natural family planning (NFP) services are provided through an increasing variety of public- and private-sector programs, including community-based programs, ministries of health, family planning programs, religion-based programs, and others. To improve the availability of NFP services and increase the options for family planning clients in the 1990s, NFP programs must continue to be offered through a variety of channels. The purpose of this session is to identify the gaps in current NFP service delivery and to summarize recommended strategies to expand NFP programs. The presentations in this session cover topics that include the development of national NFP programs in the US and Kenya, how NFP programs have expanded through the health sector in three developing countries and through education centers in the Ivory Coast, NFP services provided through multimethod family planning programs and nontraditional approaches, and new opportunities for NFP service delivery. Discussion focuses on how to expand NFP into a variety of service delivery programs; other settings appropriate for NFP expansion also are proposed. (full text)
The right not to know HIV-test results [letter]
Temmerman and colleagues report 5.9% of HIV-positive women being chased out of the house, beaten by their partner, or committing suicide. The situation was worse than this, since 13 of 66 (19.7%) who told their partners were subjected to such treatment. Most women who chose not to tell their partners (73%) may have included those with most reason to fear violence, Temmerman and co-workers relied only on spontaneous reports from women, so the true violence rate might have been higher. It is hardly surprising that so many women chose not to disclose their status. It is surprising that such effects have not been systematically documented in the past, although several workers have referred to the issue in passing. In a study of discordant Zairean couples Kamenega and colleagues reported that culturally-sensitive counseling of couples (rather than individuals) had "prevented several separations, episodes of intrafamilial violence and eventual divorce." North and Rothernberg reported anecdotally in the US two women who were shot and many others who were injured or abandoned after revealing to their partners that they were infected with HIV. Among seropositive heterosexual women in our clinics in London, concerns about possible partner violence have been frequently voiced. Violence against women associated with partner notification is, of course, part of wider difficulties resulting from power imbalances between men and women in most societies. Such difficulties are not restricted to women. Brown and co-workers reported that 3 of 120 UK gay men had experienced violence as a result of telling others about their status. Temmerman and colleagues conclude that their findings are grounds for women not being forced to know their status. They are also grounds for counselors playing a much more direct part in helping patients to tell partners rather than merely exhorting the patient to do so, and for providing much more extensive support to couples after a positive test result. At the very least studies in this area need to monitor the extent of this problem more directly than hitherto. (full text)
Cambodia. Programmatic approach to IEC on reproductive health.
Various UNFPA-funded population programs are now in place in six provinces and the capital and some more are in the pipeline. The ones currently being implemented include projects on maternal and child health and birth spacing, national population census, improvement of family health of displaced persons, and socio-economic research. Those in the pipeline are population education in the school system, gender and population issues, and population and environment. All the programs mentioned have implications for information, education and communication (IEC). To implement these programs effectively, UNFPA and the government realized the need for IEC support. To provide a coherent, integrated and holistic approach to the provision of IEC support to all the UNFPA-funded population activities, a programmatic approach to IEC was developed with the assistance of CST adviser on population communication, Mr. Francisco Roque. The IEC program will basically support the government policy of providing voluntary birth spacing services as a means to promote better maternal and child health through IECM activities; and to provide adequate information to selected target groups required to bring about desired behavioral changes in responsible reproductive decision-making and lifestyle. The target groups to be reached include: service providers and health workers, policymakers and administrators, women of reproductive age, men, and the adolescents aged 15-19 as well as teachers and trainers. The IEC interventions hope to create awareness of the benefits of birth spacing, introduce population concepts in curricula and appropriate health/teaching materials in selected medical schools and secondary schools, reduce misconceptions, provide proper counseling, and sustain government's interest and commitment to the population program. (full text)
Cambodia. MOE to introduce population education in three subjects.
Cambodia is currently undertaking reforms of its educational system both in structure and substance. Under these reforms, the Ministry of Education (MOE) is revising its curricula and textbooks in selective subjects. The government and UNFPA saw a timely opportunity to introduce population education concepts into three subjects, geography, home science, and moral education and civics from grades 7 to 12. To pave the way for this activity, the UNFPA and the government discussed the development of a pilot project that will concentrate first on the training of small numbers of professional educators and development of a first draft of curricula and textbooks including teacher's guides which could be tried out in this pilot stage and reproduced during the second phase. The project document has been prepared with the assistance of CST adviser on population education, Mr. Ansar Ali Khan, based in CST Bangkok, and is now under review. (full text)
Maldives. Package on population education for special interest groups developed.
The Population Education Program of the Non-Formal Education Center has developed a package of Population Education for Special Interest Groups comprising a learning package and fieldworker's guide. The learning package is especially developed for teaching population education for out-of-school populations. Special interest groups in Maldives include newly married couples, adolescents, and working youth. Produced under the guidance of UNESCO, Bangkok, the package contains 36 different materials such as posters, charts, leaflets, booklets, stories, and illustrated booklets which may be taught in 36 to 45 periods. The materials deal with eight themes, namely, family size and family welfare, population and resources, delayed marriage and parenthood, responsible parenthood, population-related values and beliefs, women in development, AIDS/STD, and respect for old people. Accompanying the learning package is the fieldworker's guide used to teach the package. It contains individual guides for each of the 36 learning materials. The guide gives the titles of the materials, format, objectives of the materials, messages, target groups, and an overview of the content of each learning materials. The methodologies used for teaching the learning materials include role playing, group discussion, questioning, brainstorming, survey, creative writing, problem-solving and evaluation. The package will be used by fieldworkers to conduct island-based population education courses. (full text)
Nepal. Teacher educators trained.
As part of its teacher training program series on population education, the Population Education Unit of the Tribhuvan University organized a one-week training course on population education from 5-11 July 1994. Attended by 20 teacher educators who are involved in teaching population education in their respective campuses, the training provided opportunities for upgrading the participants' knowledge, and changing their attitudes and behavior with regard to population concepts. It also developed their skills in more effective methodologies for teaching population education in their campuses. The Faculty of Education, through its Population Education Unit, has been introducing population education in its teacher training program under the UNFPA-funded country program. This is done through incorporating population education contents into different subject areas such as health education, geography and economics in the curriculum of Proficiency Certificate Level, Bachelor Level and Master Degree. In addition, it has been offering population education as major subject at the Proficiency Certificate Level in Mahendra Ratna Campus. Thirteen resource persons from Tribhuvan University, Curriculum Development Center of the University and UNFPA Field Office and Country Support Team, Kathmandu, provided lectures on the following topics: population education in Asia and the Pacific, population situation in Nepal, demography and population dynamics, population theories, curriculum development in population education, teaching methods, human sexuality, STDs and AIDS, population education program, research, and population policy. (full text)
Descriptor terms related to 37 articles dealing with the oral question of abortion and taken from a printed database specializing in Catholic applied ethics were scanned for clusters with respect to the Anglo-American or European origin of the articles. To identify types within the data Configural Frequency Analysis was used. Application indicated a dominant interest in the process of ethical decision-making in Anglo-American Catholic bioethics. The assumption that European Catholic bioethicists discuss the morality of abortion primarily in terms of an anthropological debate focused on the moral status of prenatal life could not be validated statistically. (author's)
A Muslim perspective on female circumcision [editorial]
Western observers are unable to understand why women would want to practice clitoridectomy, just as they are perplexed at the vocal, if mostly inarticulate, rejection by many Muslims of the Cairo conference. The battle lines which get drawn have on one side public health professionals, development organizations, and feminists, and on the other side conservative and "fundamentalist" Muslims who, if they are heard at all, sound impossibly antediluvian. Many Muslims, including myself, are uncomfortable with both sides. What is needed is an alternative to this polarization. The alternative I propose is the Islamic legal discourse, which might best be described as the discursive arena in which issues of societal importance get worked out. That positive change can come about from within--using the Islamic discourse--is possible because Islamic discursive systems are broad and nuanced enough to accommodate a wide variety of medical and public health endeavors. Meaningful social change and improved public health could come about by stimulating and recovering the many Islamic sunnah (exemplary) practices which are so conducive to physical and material well-being. By dealing change through existing, and proven, traditional formats, Muslims would be able to effect valuable and meaningful change in their communities. Muslim communities should not become dependent on and indentured to Western agencies and their own nation-states to solve the problems they face, including the tragic consequences of widely practiced infibulation and clitoridectomy; instead we need to apply our own traditional practices and to support an indigenous Islamic legal discourse. (author's)
Barrier methods of contraception.
Although a recent Cavalieri d'Oro et al. article correctly concludes that while barrier methods reduce the risk of gonorrhea and HIV, they may be less consistent for other diseases, the review does not include the female condom, the newest method of barrier contraception. Laboratory tests have shown polyurethane, the material of which the new condom is manufactured, to be impermeable to HIV and cytomegalovirus. Similar permeability studies using bacteriophages smaller than hepatitis and HIV show the membrane to be a complete barrier. As such, one may expect polyurethane to be the raw material from which male condoms will be made in the future. One clinical study assessed the prevention of reinfection with Trichomonas vaginalis among 104 women who had sexual intercourse with infected male partners. No woman who used the female condom during every act of sexual intercourse became infected. 14% of nonusers and 14% of inconsistent users were, however, reinfected. A study by Soper et al. found use of the female condom to not be associated with genital trauma. Leeper and Conrardy subjected the female condom and the male condom to the standard ASTM water leak test to find a 0.6% incidence of leakage from pinholes and tears for the female condom compared to 3.5% with the male condom. The risk of semen leakage during actual use as identified by acid phosphatase was 2.7% with the female condom and 8.1% with the male condom. Perfect users of the female condom may expect a 2.6% probability of failure over six months' use. Perfect use, however, reduces the annual risk of acquiring HIV by more than 90% among women who have sexual intercourse twice weekly with an infected male.
Onapristone (ZK 98.299): a potential antiprogestin for endometrial contraception.
Antiprogestin drugs such as RU 486 (mifepristone), ZK 98.299 (onapristone), and HRP 2000 block progesterone action at the receptor level. They bind to progesterone and glucocorticoid receptors, which leads to an antagonistic instead of an agonistic response. Treatment with these antiprogestins, depending upon the dose, retards endometrial development and impairs gonadotropin release, thereby blocking ovulation. The hypothalamus, pituitary, and endometrium, however, differ in their sensitivity to the antiprogestins, with the endometrium being sensitive to doses which do not seem to affect ovulation. The authors report on their study of the effects of onapristone upon the fertility; menstrual cycle length; duration of menses; serum estradiol, progesterone, and cortisol concentrations; and endometrial morphologic features in adult bonnet monkeys for four-seven consecutive cycles. The study was undertaken to assess the feasibility of using onapristone as a contraceptive agent and to determine its mechanism of action. Onapristone was dissolved in benzyl benzoate and then diluted in castor oil (1:10, vol/vol). 0.5 ml of the vehicle was used to administer each dose subcutaneously. Five monkeys were treated subcutaneously with the vehicle, four monkeys each with 2.5 mg of onapristone, and five each with 5 mg of onapristone. The study found low-dose onapristone treatment throughout the menstrual cycle to prevent pregnancy without disturbing the menstrual cycle and ovulation in the majority of cycles. Anovulation and luteal insufficiency did, however, occur in some animals during prolonged treatment. The contraceptive effect in the ovulatory cycles seems mainly related to the retardation of endometrial development resulting in the inhibition of endometrial receptivity. The authors find it likely that a dose or treatment regimen of onapristone which will inhibit endometrial receptivity and prevent implantation without affecting the menstrual cycle even on prolonged treatment could be identified.
Risk and vulnerability reduction in the HIV / AIDS pandemic.
An estimated 13.2 million men, 10 million women, and 2.7 million children worldwide have been infected with HIV since the beginning of the pandemic, and more than 10,000 people daily acquire HIV infection. 67% and 19% of these infections have occurred in sub-Saharan Africa and Southeast Asia, respectively. Even though the annual number of new HIV infections appears to have reached a plateau in Western Europe and the Caribbean and may be approaching one in sub-Saharan Africa, and the rise of new infection seems to be on the decline in North America, Oceania, and the southeastern Mediterranean, the HIV/AIDS pandemic has not been controlled anywhere in the world and its major impact has yet to come. Prevention activities undertaken by individuals, communities, nations, and international bodies have shown that the spread of HIV can be effectively reduced. Public health interventions against HIV/AIDS emphasize risk reduction strategies through the provision of HIV/AIDS-related information about safe behavior and the promotion of prevention methods. Exclusive reliance upon risk reduction strategies, however, fails to address the contextual issues in which the pandemic is rooted. In order to significantly affect the pandemic, short-term risk reduction interventions must be expanded considerably, adapted to local needs, and replicated worldwide. An expanded response to the pandemic also calls for medium- and long-term risk reduction interventions, including the linking of HIV/AIDS prevention, care, and support work with other actions in the health and social sector, and the remodeling of services to respond more effectively to growing needs. Until recently, such interventions have been neglected or misconstrued as the process of spreading thinly and irresponsibly HIV/AIDS actions within health and social programs. The sustainability and eventual success of HIV prevention will depend upon the capacity of health systems to integrate HIV/AIDS-related activities with other initiatives, while retaining the ability to track the epidemic and account for what is done about it. The influence of contextual factors on vulnerability to HIV/AIDS is discussed.
Impact of health education during pregnancy on behavior and utilization of health resources.
Health education during pregnancy may improve pregnancy outcome. The authors investigated whether reinforcing pregnant women's social network and emotional support, improving knowledge about pregnancy and delivery, and reinforcing adequate health services use could improve pregnancy outcome. The randomized, controlled trial was conducted between January 1989 and March 1991 in Rosario, Argentina; Pelotas, Brazil; Havana, Cuba; and Mexico City, Mexico among pregnant women at risk. The control group was comprised of 1120 pregnant women at risk who received routine prenatal care. 1115 others received a home intervention of four-six visits providing psychosocial support and education about health-related habits, alarm signs, hospital facilities, anti-smoking and anti-alcohol programs, and a reinforcement of adequate health services utilization for the pregnant woman and a support person. The distribution of risk factors and demographic, obstetric, and psychologic characteristics at baseline was similar in both groups. Women in the intervention group showed a statistically significant better knowledge of seven of the nine alarm signs considered and of two of the three labor-onset signs required. No differences between groups were, however, observed with regard to improvement on diet, cigarette and alcohol consumption, maternal physical strain, lactation at forty days postpartum, and health facility use. The intervention therefore failed to show any benefit upon perinatal outcome, health-related behavior, or health facility use.
Editorial: beyond population statistics [editorial]
If the size of the world's population continues to increase at its present rate of growth, it will not be long before their will be neither sufficient resources nor space on the planet. It will be increasingly necessary to ration scarce resources as we move forward into the 21st century. In the meantime, the public health community has the responsibility to see what moral and humane steps can be taken. Morrow and Bryant have suggested a modified triage approach toward a social strategy for health and population policy in which they assign a standard for judgement in the rationing of health resources in an index to reach those most in need. The index, through an economic analysis of illness and the burden of disability, suggests what is needed and what can be accomplished. It is one of few efforts taking into consideration local expectations and is not based exclusively upon the donors' analysis and decisions. More needs to be done in conjunction with larger issues, such as the application of a burden-of-disease index to the wealthy countries, more prudent management of resources there, and the protection of the global environment.
Health policy approaches to measuring and valuing human life: conceptual and ethical issues.
In order to achieve the most cost-effective and equitable use of health resources, health care decision makers need better ways to define disease burdens and guide resource allocations. Resource allocation decisions in sectors other than health are based upon benefits obtained per dollar expended. During the last two decades, composite indicators which combine losses due to disability and premature mortality have been developed as a measure of disease burden and as an outcome indicator for health status in economic analyses. With the increasing use of these indicators, it is timely to examine potential conceptual and ethical issues related to the measuring and valuing of human life. The authors review the healthy life approach of the Ghana Health Assessment Team, the quality-adjusted life year approach, and the World Development Report disability-adjusted life year approach. The review covers conceptual and ethical issues generic to the use of composite indicators for measuring and valuing life, highlights issues specific to the methods used in the World Development Report, and provides suggestions to refine the approach for developing tools to assist in more rational resource allocation decisions. Further refinement of the tools is needed to incorporate national and local values into weighting, elaborate methods for disaggregating calculations to assess local disease patterns and intervention packages, and develop guidelines for estimating the marginal effects and costs of interventions. It is of the utmost importance that equity be ensured during the attempt to achieve reasonable efficiency.
Abortions in rural Idaho: physicians' attitudes and practices.
94% of nonmetropolitan counties in the US have no legal medical provider willing to provide abortion services. This means that even though a woman's right to undergo a first-trimester abortion is protected by the US constitution, abortions are virtually unavailable in rural America. The considerable distances that most rural women must travel to find a provider willing to perform abortions effectively deny access to the medical procedure in many cases. All family physicians, obstetrician-gynecologists, and general surgeons practicing in rural Idaho in 1994 were surveyed to gain insight into why rural physicians are unwilling to provide abortions. Idaho is a conservative state with the second lowest abortion rate in the country. Rural physicians were defined as allopathic and osteopathic physicians working in nonmetropolitan counties and in communities of fewer than 20,000 people. A survey was sent to each of the 251 physicians identified as eligible for the study; 138 responded. 86% were family physicians, 91% male, and in practice for a mean period of fifteen years. Less than 4% of the respondents performed abortions. Most rural Idaho women seeking an abortion must therefore travel long distances for the procedure, with the average travel distance to the nearest abortion provider being 85 miles. The doctors reported having chosen to not provide abortion services because of both their own moral objections and local community opposition to the procedure. Younger, residency-trained physicians were more likely to have personal moral objections than their older colleagues. 26% of the respondents did, however, indicate interest in using RU-486 for abortions when it becomes available. This intention to use RU-486 suggests that the development of acceptable medical abortifacients may improve access to abortion even in very conservative rural areas.
Subdermal levonorgestrel implants: three years' experience in Cairo, Egypt.
Findings are reported from a three-year, advanced phase III clinical trial assessing the efficacy, safety, and acceptability of levonorgestrel implanted subdermally as a long-acting, low-dose, progestin-only contraceptive method for women. The prospective, observational study was conducted through the family planning clinic of Ain Shams University Hospital in Cairo, Egypt. There was a 0.98% net three-year cumulative pregnancy rate among the 350 women in the study. Menstrual disturbances, present in 25% of women during the third year, were the major side effects and ranged from amenorrhea to menorrhagia. The disturbances resulted in 28 removals, 19 due to amenorrhea. Medical complications, including headaches, hypertension, and non-insulin dependent diabetes; desire for pregnancy; and complications at the insertion site were the principal reasons for another 57 implant removals. No gynecologic or breast lesions have developed, and weight changes were not noted. The continuation rate after three years was 65.5%.
Vitamin A deficiency in the South Pacific.
Vitamin A deficiency is a major cause of morbidity, mortality, and blindness among children in many developing countries. Until recently, however, data have been lacking on the magnitude of the problem in the South Pacific region. Five cross-sectional surveys for vitamin A deficiency were conducted during 1989-1992 in the Republic of Kiribati, Tuvalu, the Republic of Vanuatu, Solomon Islands, and the Cook Islands, covering 10,673 children aged 6-72 months. The prevalence of xerophthalmia was 14.76% in the Republic of Kiribati, 1.55% in Solomon Islands, 0.59% in the Cook Islands, 0.28% in Tuvalu, and 0.11% in the Republic of Vanuatu. Bitot's spots were the most common clinical findings followed by nightblindness. Xerophthalmia was more common among boys and tended to occur in older preschool children.
Hearing loss: a possible consequence of malaria.
More than 200 million people worldwide contract malaria from mosquito bites. In sub-Saharan Africa, 100 million clinical cases of malaria are reported every year, resulting in almost one million deaths. Malaria has been implicated in the causation of deafness in several studies in the West Africa subregion. This paper examines the association between malaria and deafness, and considers which factors may be involved in the causation of deafness. Although age, immunity, the type of malaria parasite, fever, complications of malaria, and complications resulting from the drug treatment of malaria may contribute to the development of deafness in malaria, the actual mechanism of causation is not clearly understood. Deafness in malaria is associated with P. falciparum parasitic infection. The author is certain that the high fever in malaria, leading to febrile convulsions and cerebral involvement, can result in deafness. Further investigation is needed to determine whether the presence of untreated malaria parasites in the blood causes deafness.
The HIV / AIDS epidemic in Thailand: addressing the impact on children.
Within the space of a decade, the level of HIV infection in Thailand has grown to epidemic proportions. With regard to children, 16,000 had been born with HIV by the end of 1994, while tens of thousands of child prostitutes and street children are at risk of infection. By the year 2000, more than one million Thai children will have at least one HIV-infected parent. Many of these children will therefore become either orphans or abandoned by their infected parents. The magnitude of these problems over the course of the lives of HIV-affected children depends heavily upon actions taken now. This paper summarizes the joint report of the Thai Red Cross Society and the East-West Center's Program on Population on the impact of HIV on children in Thailand. The current situation, projected impacts, and policy recommendations are described. No other country has had as complete a monitoring system or as early a warning of the problems ahead. Some recommended approaches are familiar and simply need to be strengthened and expanded to the regional or national level, while others require field testing. The authors stress the need for shared commitment, ideas, resources, and efforts of all sectors of society to plan for the future needs of children affected by HIV, to protect them from infection, and to provide them with the social and economic support, medical treatment, and legal protection they need.
Fistula -- a disaster for teenage mothers.
Obstetric fistula is one of the most severe childbirth-related complications. The small size and physical weakness of many young pregnant girls makes it extremely difficult for them to give birth to a child. Delivery is therefore often prolonged. During childbirth, girls' perineum often tears, leaving holes between the bladder and/or the rectum and the vagina. The young mothers from then on lose control over their bladder and bowels, are unable to bear more children, and find sexual intercourse painful. Such fistula are common in Somalia, Ethiopia, most Sahelian countries, Zambia, and Zimbabwe, but particularly so in Niger. 23,000 girls and women in Niger have the condition, or 1% of all women of child-bearing age. Obstetric fistula can, however, be cured by a simple operation. France recently announced a $400,000 aid project to help teenage girls in Niger with fistula and to discourage parents, village elders, and women's groups from marrying girls at too young ages. Doctors in Niger will be trained to surgically repair fistula, cured women will be helped to reintegrate into society, local health workers will be trained to recognize the early signs of fistula, and female genital mutilation will be discouraged because of its role in increasing the likelihood of fistula development.
High society lacks knowledge of epidemic. Focus: South Africa.
The attitudes, prejudices, and knowledge of 1500 leaders of South Africa's politics, academia, agriculture, military, bureaucracy, business, media, and churches were assessed through a mail survey between July and September 1994. AIDS is a major public health issue in South Africa and one of the most hotly-debated political problems. The survey found that these opinion leaders have a surprisingly low level of knowledge about HIV and AIDS, which may explain the relatively low position of AIDS issues in public policy. Overall, opinion leaders with right-wing affiliations are intolerant toward people with AIDS, it is commonly felt that people with AIDS should be treated in public hospitals, opinion leaders believe that the entry of illegal aliens is making the AIDS problem worse, it is widely considered that the state cannot afford to fund medical research on AIDS at the cost of primary health care services, it is widely felt that regular AIDS tests for all South Africans should not be compulsory, and most opinion leaders believe that employees who test HIV-positive should inform their employers. The author posits that this level of ignorance of the full implications and dimensions of HIV/AIDS may cause institutions to fail to adapt to the growing crisis.
After more than a decade of AIDS, prevention programmes begin to prove their worth.
The first reports of AIDS, then an unidentified new disease, surfaced in the US in 1981. HIV was identified as the causal agent in 1983, and a diagnostic test for the presence of HIV antibodies was developed shortly thereafter. The investment of millions of research dollars since then has yet, however, to lead to a cure or vaccine against HIV/AIDS. Millions of people have been infected over the past decade with HIV, many have died due to AIDS, and many continue to be infected daily. HIV and AIDS are truly global in scope, but they will not annihilate entire populations as predicted during the 1980s. On the one hand, it has been demonstrated that the appropriate prevention and control measures can contain the spread of HIV. On the other, we now know that the prevalence of HIV infection will peak at different levels depending upon the country. Extensive blood screening, the prevention and control of sexually transmitted diseases, and education interventions designed to bring about changes in sex and related risk reduction behaviors have helped to control HIV in selected populations and countries around the world. Examples of such success are noted in Thailand and Zimbabwe. Although AIDS has become a major cause of death among young adults, people are coping with their loss. Cost-effective ways to help these affected individuals, families, and communities adapt to HIV/AIDS are needed. Finally, efforts aimed at stopping the epidemic must continue, with attention also given to understanding and changing the conditions which allowed HIV to spread.
Improved STD treatment: a message of hope. Special report: Tanzania.
The overwhelming majority of adult HIV infections in Africa are acquired through heterosexual sexual intercourse. Many studies, however, report a close association between HIV and long-standing sexually transmitted diseases (STD) such as syphilis, gonorrhea, and chancre. It may be that these latter STDs enhance the transmission of HIV by causing breaks in the skin or by increasing the number of HIV-infected inflammatory cells in the genital tract. STDs are common in many parts of Africa, but appropriate treatment services tend to be poor or nonexistent. It may be assumed that were STDs promptly and appropriately treated, a decline in the incidence of HIV transmission may result. A HIV/STD intervention program in Mwanza region, Tanzania, was established to determine whether improved services for STD treatment would reduce the incidence of HIV infection, and if so, by how much. Twelve rural communities were selected in different parts of the region. Six were randomly chosen to receive the intervention at the beginning of the study, while the remaining six received it at the end. Designed to be effective and affordable, the program was integrated into the Tanzanian primary health care system. Existing health care staff were trained to diagnose and treat STDs using the syndromic approach recommended by the World Health Organization, and supplied with effective drugs. Regular supervisory visits were made to the health units to check drug supplies and to make sure that the staff was treating STDs correctly. Moreover, the project campaign visited the intervention villages regularly to publicize the improved services and to motivate villagers to come for treatment of STDs without delay. In the six communities with improved STD services, there were 48 new HIV infections, giving an incidence rate over two years of 1.2%. In the six other communities, there were 82 new cases for an incidence of 1.9%. Allowing for other important risk factors, the investigators estimate that the intervention reduced the incidence of HIV by 42%. This study has therefore shown that an affordable and replicable program can have a substantial effect upon the spread of HIV. Policy implications are discussed.
South Africa steps up fight against HIV and AIDS.
As of the end of 1993, 4.3% of the population in South Africa was infected with HIV. The proportion of infected individuals in the country grew to 7.6% by the end of 1994. Estimates based upon department of health statistics indicate that one million people may have been infected with HIV in South Africa by the end of 1994. In South Africa's most populous region, Guateng, which contains Johannesburg, Pretoria, the Witwatersrand, and Vaal Triangle, 6.4% of the population is estimated to be infected with HIV. KwaZulu-Natal is the worst-affected province with 14.4% of the population affected. An estimated 6.5% of teenagers are infected with HIV, 8.9% of 20-24 year olds, 9.6% of 25-29 year olds, and 6.4% of 30-34 year olds. The belief among some men that having sex with a virgin will rid them of HIV is cause for concern. Money has been set aside by South African health authorities for HIV/AIDS prevention and education campaigns, with almost two million condoms already imported for free distribution at clinics. A publicity campaign using celebrities is planned as well as propaganda films on state television and a possible play targeted to urban and rural youth.
Talking about a revolution. The politics of population.
5.7 billion people currently inhabit the Earth, but 100 million individuals are added each year. As population size increased over the past fifty years, there has been a range of political thinking, strategies, and policies to address the issue of and need for population stabilization. Governments have pursued either pro-natalist or anti-natalist policies depending upon their individual perceptions of what should be the ideal rate of domestic population growth. Women have been the primary targets of population policies, strategies, and programs. Women, however, have had only limited roles in making policy, with men holding the reins of power over whether and when women bear children. Much was changed at the 1994 International Conference on Population and Development (ICPD). For the first time, population stabilization went beyond family planning and was considered in the context of sustainable development. The 180 countries' representatives realized that only through the empowerment of women can economic development and population stabilization be realized, and worked out a plan to stabilize population. The author reviews some of the history of the population debate since the early 1960s, the role of nongovernmental organizations, and the program of action resulting from the 1994 ICPD.
Contraceptive methods and the risk of Chlamydia trachomatis infection in young women.
Chlamydia trachomatis infection is among the most prevalent of sexually transmitted diseases in young women in the US. Approximately 2.6 million women are estimated to be infected annually in the country. The authors investigated the relation between contraceptive methods and cervical Chlamydia trachomatis infection in a population-based sample of 1779 nonpregnant women aged 15-34 years attending two primary care clinics at Group Health Cooperative of Puget Sound between January 1988 and June 1989. 3.8% of the women were infected with C. trachomatis. Cervical chlamydial infection occurred more often in women younger than age 25 years, of black race, low income level, single marital status, in nulliparous women, women having douched during the preceding year, and those having two or more sexual partners in the preceding year. Overall, the risk of cervical C. trachomatis infection among barrier method users was lower than among all other women. Condoms, diaphragms, cervical caps, spermicidal sponges, foam, and vaginal spermicidal suppositories are barrier contraceptives. The greatest protective effect among barrier method users was found in women aged 25 years or older. Overall, there was no association between the use of oral contraceptives and chlamydial infection. These findings therefore suggest that present patterns of use of barrier methods differ by age and afford only selective protection against cervical infection with C. trachomatis.
Natural infections by Vibrio cholerae 01 are known to confer substantial protection against recurrent infections in populations where cholera is endemic. This suggests that it may one day be possible to develop a highly effective oral vaccine against cholera. It is, however, curious that cholera continues to occur into adulthood in populations which have endemic cholera. This phenomenon could be the result of an inability among some individuals in endemic populations to mount suitable immune responses to natural infections. If such immune hyporesponsiveness is truly at work, it may be an important barrier against the development and use of an effective oral cholera vaccine. The authors evaluated whether deficient immune responses to natural infection were associated with the risk of vaccine failure among recipients of killed oral cholera vaccines in a field trial in Bangladesh during 1985. Their findings support the hypothesis that immune hyporesponsiveness, even after the vigorous stimulus of natural infection, may have limited the protection conferred by the vaccines studied in the trial.
Follow-up bias develops in epidemiologic cohort studies when the incidence rate among individuals who do and do not return for follow-up differ. The authors estimated the rates of HIV incidence in India using a new method which accounts for follow-up bias. This new method combines data on the prevalence of p24 antigenemia among all individuals initially screened together with the longitudinal follow-up data on the subset of patients who return for follow-up. The current annual rate of HIV incidence among patients attending sexually transmitted disease clinics in Pune, India, was found to be 18.6%. The study found that follow-up bias can lead to significant underestimation in HIV incidence rates, perhaps by as much as 60%. These incidence estimates, together with findings from other HIV seroprevalence studies, suggest that the HIV epidemic in India is growing rapidly.
Stopping female genital mutilation. An update.
There is widespread consensus among many individuals, countries, and organizations that female genital mutilation (FGM) is a human rights abuse. France, Britain, Sweden, and Switzerland have passed legislation forbidding medical personnel from performing FGM, eighteen African countries have made official statements against FGM, and FGM was an issue in the 1993 World Health Assembly, the 1993 World Human Rights Conference, and the 1994 International Conference on Population and Development. True change, however, depends upon a transformation in the informal economic, social, and political structures which perpetuate women's dependency upon marriage and men. The Research Action Information Network for the Bodily Integrity of Women (RAINBOW) and the Development Law and Policy Unit of the Columbia University School of Public Health introduced the Global Action Against FGM (GAAFGM) Project in June 1994. The project is designed to integrate action against FGM into existing health and human rights programs and to pool available resources against FGM. GAAFGM has also coordinated an interagency working group comprised of international agencies, in-country grassroots organizations, and women's groups, which met for the first time in November 1994. The project should provide considerable information and leadership on the issue. On another front, participants in the most recent preparatory meeting for the upcoming Beijing Conference noted the existence of a strong recognition that FGM is a problem upon which the international community should act. The author notes recent litigation brought by the Egyptian Organization for Human Rights against the grand sheik of Al-Azhar University for issuing a fatwa declaring female circumcision an Islamic duty. In addition, a Ghanaian may be granted refugee status in Canada on the basis of her efforts to avoid mutilation if deported to her country of origin.
What the U.S. Constitution says. The law and abortion.
The US Supreme Court in its January 22, 1973, decision on Roe v. Wade abolished virtually all abortion restrictions previously imposed at the state level in states across the country. That decision marked the beginning of an ongoing national debate on a woman's right to choose to have an abortion. Some Americans think that abortion should be permitted at some stages of fetal development and in certain circumstances, while others strongly oppose abortion under any circumstances. Americans enjoy certain fundamental liberties which are protected by the US Constitution. The right to abortion is not one of these freedoms. The Bill of Rights balances individual rights and majority rule by allowing the majority to pass legislation through its elected representatives. The decision in Roe v. Wade is an example of such legislation passed by pro-choice Supreme Court judges. As such, the author stresses that a conservative Supreme Court could one day enact legislation denying women in the US the right to abortion on demand. It is clear that many states will pass legislation regulating abortion if the Roe v. Wade decision is ever overturned. Pro-choice supporters therefore want US President Bill Clinton to select pro-choice judges for the Supreme Court.
Malawi uses games to educate the young.
Recent figures suggest that Malawi has the highest rates of HIV infection in the world, with at least 12% of the sexually active population estimated to be HIV-seropositive. In urban areas, 30% of women attending antenatal clinics are infected with HIV. By March 1995, more than 37,000 AIDS cases had been reported. Adolescents and children about to enter adolescence in Malawi are at particular risk of contracting HIV. Attempting to avoid exposure to HIV, many men have spurned mature female prostitutes in favor of young girls. In exchange for school fees and other gifts, girls as young as eight years old have sexual intercourse with mature Malawian men. These men are often infected with HIV. It therefore follows that five out of six youngsters with HIV in Malawi are female. Since their female peers are involved with older men, boys are increasingly having sex with the older women rejected by mature men. Studies suggest that 55% of school pupils have experienced sexual intercourse, 76% of whom first had sex when they were younger than age 15. "AIDS Challenge" is a board game developed for distribution to all secondary schools in Malawi with the purpose of educating students about AIDS. It is played on a modified snakes-and-ladders board, using a pack of 100 cards, each with some true or false statements about AIDS. 36 boys and 35 girls aged 13-20 years from a government secondary school participated in the first trial. Four weeks of playing the game had a significant effect upon pupils' knowledge of HIV. While some of the statements on the cards are specific to Malawi, the game can easily be adapted for use in other African countries. The game is available from UNICEF Malawi at Box 30375, Capital City, Lilongwe 3, Malawi.
Viewing the human cost at Leopard Hill.
Recent data on Zambia indicate that the AIDS epidemic may have peaked in urban areas. The epidemic nonetheless continues to exact an enormous level of human suffering for both those who are infected with HIV and their friends and families. Leopard Hill cemetery is the main burial ground for the city of Lusaka. The author on a recent visit to the city found the site to be rapidly filling up and busy all the time, even Saturdays and Sundays. The intelligentsia and youth of Lusaka are being decimated. While grave plots are free, buying coffins, hiring transport, and covering other incidental expenses must drain the resources of most families. All government ministries are, however, involved in the AIDS control program, and the program's staff is dynamic and imaginative in its response. The country also is trying to accommodate the needs of a growing population of orphans.
The impact of HIV: a closely-guarded secret.
More than ten million people in sub-Saharan Africa, almost 3% of the subcontinent's population, are infected with HIV. Some countries in the South of the subcontinent report prevalence rates of 9%. Many industries have hired analysts and forecasters to help guide them through the epidemic, while police and armed forces have conducted detailed investigations into the impact of HIV. Intelligence agencies routinely hire consultants to analyze and forecast the impact of HIV in selected regions. The results of these studies and forecasts, however, are closely guarded. The many studies on the health care costs of AIDS concur that the HIV/AIDS epidemic is expensive in economic terms. There are virtually no published studies on how the African epidemic of HIV will affect the supply, demand, and quality of healthcare. The demand for care has received the greatest attention. The authors discuss how the AIDS epidemic in sub-Saharan Africa may affect health care personnel.
Prospects for global health: lessons from tuberculosis.
Preventable diseases continue to afflict billions of people worldwide in both rich and poor countries. With regard to tuberculosis (TB), much has been learned over the past century about Mycobacterium tuberculosis, the responsible infectious agent, and its medical treatment and cure. TB is, however, an old disease currently making a resurgence at the global level. An estimated one third of the world's population is infected with M. tuberculosis and HIV infection is increasing the proportion of those in whom infection will progress to TB disease. HIV and M. tuberculosis infections co-exist most extensively in the poorest parts of the world. TB control programs are inadequate, the degree of multidrug resistance is growing, and infections are increasingly transmitted freely across international borders. The combination of these factors suggests that scientific progress and humanitarian aid to developing countries may not be enough to avert the potential tragedy of untreatable TB. The author discusses the history of TB, the present situation, and the future.
Subdermal contraceptive implants.
Subdermal contraceptive implants deliver progestin from polymer capsules or rods placed under the skin. Diffusing slowly from the polymer containers at a stable rate, the hormone provides contraception for 1-5 years, with the period of protection conferred dependent upon the specific progestin and type of polymer employed. Once inserted, the device allows a woman to have sexual intercourse over a certain period of time without any significant risk of becoming pregnant. Protection is ensured with a low drug dosage and no estrogen, and fertility is readily reversible once the implants are removed. The levonorgestrel implant Norplant R is the only subdermal contraceptive implant system approved for distribution. Annual pregnancy rates using Norplant are extremely low. Menstrual problems are the main reason why women discontinue using Norplant. Research is ongoing to reduce the number of implanted units and to introduce other progestins which may minimize side effects. Norplant-2 was designed to release the same dose of progestin from only two covered rods. Nestorone, 3-Keto-desogestrel, and Uniplant are single implants under development which are expected to be effective for 1-2 years. Completed phase II clinical trials with Nestorone found no pregnancies in 1570 woman-months of use, although bleeding irregularities occurred in 20-30% of women. A multicenter study is ongoing with a newly-designed 3-keto-desogestrel implant named Implanon, as well as another multicenter study with Uniplant, an implant which releases nomegestrol acetate with a one-year duration of action.
Transdermal application of steroid hormones for contraception.
The transdermal delivery of steroids (TD) is gaining ground in hormone replacement therapy during menopause. This approach to treatment, however, has only recently been envisaged for contraception. Delivered in the appropriate solvent, both estrogens and progestins can penetrate the skin. Approximately 10% of any total dose applied topically is actually absorbed systemically. Currently available TD systems (TDS) are either of the reservoir type or of the matrix dispersion type in which the drug is dispersed into a polymer matrix. Estradiol is the most appropriate steroid for TD and can be combined with progestins to ensure a contraceptive effect. The use of potent progestins allows effective plasma levels to be reached with low doses through application over a small area of skin. TDS changed weekly and delivering both estradiol and levonorgestrel at daily dosages of 38.4 and 28.8 mcg per 10 sq. cm daily, respectively, was found to suppress ovulation. ST 1435, a synthetic progestin derived from 19-norprogesterone, has also been shown to penetrate the skin when suspended in acetylated lanolin or dissolved in a hydroalcoholic gel and to suppress ovulation at a dose of 2 mg per day in a small number of cycles. TD systems should be perfectly adhesive, well-tolerated locally, and nearly 100% effective.
Childhood diarrhea and malnutrition in Pakistan, Part II: Treatment and management.
Diarrhea and malnutrition are the leading causes of morbidity and mortality among children younger than age 5 years in developing countries. The prevention and management of diarrhea and malnutrition are frequently affected by local customs and vary from country to country. This paper reviews the treatment and management of diarrhea and malnutrition in Pakistan. Discussion of the management of diarrhea is divided into sections on rehydration, oral rehydration solution, the use of antibiotics and antidiarrheals, and the administration of foods and diet. The management of both moderate and severe protein-energy malnutrition is considered. Most mild cases of diarrhea can be managed on an outpatient basis. The authors note that physicians in Pakistan often treat children with diarrhea who are not severely dehydrated with expensive medications and intravenous fluids which lead to serious complications. Children who do, however, show clinical signs of severe dehydration require intravenous fluids and should be admitted to a hospital.
International Union against the Venereal Diseases and the Treponematoses: an overview.
Founded in Paris in 1923, the International Union Against the Venereal Diseases and the Treponematoses (IUVDT) is the oldest international organization focusing upon the control of sexually transmitted diseases (STD). The union was founded to coordinate activities on both medical and social aspects of the control of venereal diseases. The principal aims of the IUVDT are to coordinate and assist in disseminating information about STDs; to stimulate research into the scientific, medical, and sociological aspects of STDs; to compile information on trends of incidence of STDs worldwide; to organize meetings and conferences and to participate with other national and international organizations to study problems related to the understanding and control of STDs; to provide information and materials for health education about STDs; and to maintain a comprehensive list of all organization members. The 36th General Assembly of the IUVDT will be combined with the IUVDT World STD/AIDS Congress and the 9th IUVDT South East Asian and Western Pacific Regional Conference in Singapore during March 19-23, 1995.
Responsibility and irresponsibility: young women and family planning.
Until the 1930s, the medical profession deemed the issue of birth control to be unworthy of its attention. Clerics, politicians, and social commentators avoided any direct association with the promotion of family planning, even if they privately supported its use, while practitioners of family planning were equally reserved. The history of medical opposition to the free provision of contraception regardless of marital status and age is well-documented. Seven doctors and seven nurses, all White females in their mid-twenties to mid-fifties, employed at six inner city family planning clinics in Northwest England were interviewed in an open, structured conversation framework. The interviews were conducted outside of clinic hours in either the clinic or respondents' homes. The research was undertaken to assess the extent to which the value-free appearance of professional practice masks underlying professional ambivalence about the desirability and efficacy of such practice, especially with regard to young single women. The author describes how these women handle the issue of age when providing contraception to young service users.
How teen pregnancy has become a political football.
More than half of all high school students are having sexual intercourse and approximately one million teenagers become pregnant each year. Teens are therefore responsible for 12% of all births in the US, a rate higher than in any other developed country. High rates of teen pregnancy are not new to the US. Indeed, birthrates among teens were actually higher during the mid-1950s than they are today. More of those teens, however, married and even the income of a non-high school graduate could support a family. Rates of teen pregnancy in the US declined quite steadily during most of the 1980s, but they have increased in recent years. This increase comes at a time when poverty, sex, sexual and reproductive freedom, abortion, the breakup of the traditional family, and welfare reform are hot button issues in the US. To satisfy their need for scapegoats, politicians have seized upon the largely disenfranchised and impoverished population of pregnant teens as an easy target. These politicians are exploiting the issue of teen pregnancy to sidestep difficult decisions and advance their own agendas. Teen pregnancy, closely associated with poverty and sexual control, plays well into the welfare reform debate. Fifteen states have or are considering proposals to limit the amount of money welfare mothers receive and the length of time they are eligible to receive it. It is expected that teens will be discouraged from having babies if welfare support is harder to get. Numerous empirical studies, however, have found that girls and women are generally not motivated by welfare payments when they decide to have babies. Giving women real life options to pregnancy and motherhood is the fastest way to reduce the number of children women have. Moreover, instead of punishing teens for becoming pregnant, politicians should fight against sexual predators, violence and incest at home, and merchandizing which capitalizes upon sex.
Population growth threatens nutritional status of up to one billion people. Press release.
The global fish catch peaked in 1989 at 89 million metric tons and has remained near 85 million tons ever since. The UN Food and Agriculture Organization (FAO), however, estimates that 60 million tons is the maximum sustainable harvest of wild fish which can be captured for human consumption. Globally, protein from fish comprises slightly more than 5% of the average person's protein intake from animal and vegetable sources. For at least 640 million people in 39 countries, fish consumption accounts for an average of more than 10% of their total protein intake, while at least 950 million people rely upon fish for more than one-third of their animal protein. The FAO estimates that almost 70% of the world's conventional fish species such as cod, hake, and haddock are already fished up or beyond sustainable limits. Demand for fish, however, increases as the population grows. Population growth has already reduced the average human consumption of fish to 13 kg per capita in 1993 from a peak of 13.5 kg in 1989. The UN projects world population to reach between 7.9 billion and 11.9 billion people by the middle of the next century. On the one hand, burgeoning global population will demand larger quantities of fish for consumption. On the other hand, the larger number of people on the planet will generate more waste and pollution to contaminate the coastal waters upon which fish depend. The supply of fish will therefore be increasingly threatened in the face of higher demand. Aquaculture, fish farming in either marine or inland waters, cannot long compensate for the declining availability of fish caught in the wild. In addition to working to stabilize population growth, governments are urged to reduce bycatch, the throwing away of unwanted fish, by encouraging methods which discriminate between target and non-target species; improve storage and distribution technologies to reduce post-catch losses; eliminate subsidies which support overcapacity in the fishing industry; and protect coastal and other fishery habitats by controlling development and pollution. It is nonetheless clear that in the next century, many species of fish will become luxuries which only the well-to-do can afford.
The current status of family planning as a component of CBHC / FP projects in Kenya.
Family planning activities began on a small scale in Kenya during the early 1950s. These activities have been national in scope since 1967. Up to 81% of respondents in the 1984 Kenya Contraceptive Prevalence Survey were aware of at least one method of family planning. The contraceptive prevalence rate was, however, only 15%. The cost of modern contraceptives, travel distances to clinics, fear of young nurses, and poor clinic services have been noted as obstacles to the more widespread use of modern contraception. Community-based distribution (CBD) of family planning services began to develop in the mid-1960s. The author discusses the beginning of CBD and family planning through community-based health care (CBHC/FP), resistance to community-based services, spearheading CBD and CBHC/FP strategy, improving access, community-based delivery of other services, the community health worker, remaining issues, and lessons learned. Many questions remain to be answered on the implementation of CBHC/FP. It is nonetheless certain that the multidisciplinary nature of CBHC/FP programs will promote the overall health of Kenyans and play a major role in enhancing the birth rate and population growth rate.
The long overlooked Latin man.
Men play a very big role in determining whether contraception will be used during sexual intercourse and, if so, which form of contraception. That role merits the inclusion of men in family planning programs. Family planning programs in Latin America, however, have long overlooked the importance of informing and motivating men. Program developers and implementors have erroneously assumed that men in Latin America are too macho to pay attention to family planning. The Johns Hopkins University Population Communications Services has enjoyed considerable success in involving men in the development of radio, print, and video materials aimed specifically at men with local family planning agencies in Bolivia, Brazil, Colombia, Costa Rica, Honduras, and Mexico. When given the chance and approached correctly, men in Latin America are eager to participate in family planning. Successful male family planning clinics in Latin America also demonstrate that men are very interested in family planning. Accordingly, and especially given the need to control AIDS and other STDs, men should be given higher priority in family planning programs.
Males' use of public health department family planning services.
The family planning service of the Winnebago County Public Health Department in Rockford, Illinois, long focused almost exclusively upon female clients, consistent with national trends. A condom distribution service for males was implemented, with condom availability advertised in brochures and the newspaper. Males had to be at least 13 years old to receive condoms. All males requesting condoms or visiting with their partner over a six-month period of data collection were asked to complete a questionnaire or be interviewed. 207 males responded, 74% of condom acceptors and 78% of males visiting with their partner. Condom acceptors were younger than males in the other group, more likely to be single, of lower educational level, and lived nearer to the health department. They reported a younger age of first intercourse, 12.7 years compared to 14.4, with more than 47% of condom acceptors being sexually active by age 12 compared to 26.2% of males accompanying their partners. At first sexual intercourse, 60% of all males reported using no contraception. Almost 66% of condom acceptors were repeat visitors to the service, more than 40% had visited within one month, and almost 42% reported the service as their sole source for condoms. The free provision of condoms, a friend's suggestion, and that no questions were asked by service providers were cited as the main reasons for using the service. 60% of males visiting the clinic with their partner did so for the first time, and 25% had used the condom distribution service. 72-77% reported they would buy condoms from the service if necessary or share in expenses for services. Both groups reported being satisfied with health department services. Finally, more than 55% of the respondents expressed interest in additional services including medical examinations, STD programs, and support for adolescent fathers.
Depo-Provera is a contraceptive drug which contains a synthetic hormone similar to the natural hormone progesterone. When injected into the muscle of the arm or buttock, the drug is gradually released into the bloodstream to prevent pregnancy for a period of three months. Depo-Provera was developed in the 1960s and has been approved for contraception in many countries. The Upjohn Company first submitted it for approval in the US in the 1970s. The US Food and Drug Administration (FDA) approved the drug for use in the US on October 29, 1992. Depo-Provera is more than 99% effective. It is available in 150 mg single dose vials from doctors and clinics and must be given on a regular basis to maintain contraceptive protection. If a patient decides to become pregnant, she simply discontinues the injections. As with any such products, however, the FDA advises patients to discuss the benefits and risks of Depo-Provera with their doctor or other health care professional before making a decision to use it. The most common side effects are menstrual irregularities and weight gain, while some patients may also experience headache, nervousness, abdominal pain, dizziness, weakness, or fatigue. The drug should not be used by women who have acute liver disease, unexplained vaginal bleeding, breast cancer, or blood clots in the legs, lungs, or eyes. Furthermore, doctors are advised to not prescribe the drug in pregnant women due to concerns about low birth weight in babies exposed to the drug. Recent data also indicate that long-term use may contribute to osteoporosis.
Nationalism, race, and gender: the politics of family planning in Zimbabwe, 1957-1990.
Nationalists in Zimbabwe opposed family planning when it was introduced in 1957, on the notion that it was a conspiracy to control the Black population. An official policy to reduce African fertility emerged eight years later in 1965 following the unilateral declaration of independence by the White settlers under Ian Smith. Nationalists used propaganda to fight the policy, while the facilities which were established under the policy, as well as their personnel, became military targets during the guerilla war in the late 1970s. The nationalists held their pronatalist position after independence in 1980, but a postwar baby boom during the early 1980s made it clear to officials in charge of economic and social development that society could not sustain such high fertility. The pronatalist policy was therefore reversed and by 1990 Zimbabwe had become an internationally recognized leader of family planning among developing countries. The author notes that these changes occurred without any real input by African women who were generally excluded from power.
This paper presents preliminary findings on the levels and causes of infant mortality from rural areas of Balochistan province and three districts of Hazara division of NWFP. 20,486 households were interviewed in Balochistan and 959 infant deaths were reported during the past year. In the Hazara division, 7500 households reported 208 deaths during the same period. Verbal autopsy interviews were conducted on infant deaths reported in the past year to identify the major causes of death. The infant mortality rates (IMR) in the four districts of Balochistan are as follows: 172 deaths/1000 live births in Loralai, 142/1000 in Khuzdar, 121/1000 in Pishin, and 112/1000 in Lasbela. IMR in Hazara was 82/1000. Diarrhea was the most common cause of death in the two regions followed by acute respiratory infections (ARI), birth asphyxia, low birth weight, and neonatal tetanus. IMR was significantly related to the availability of clean drinking water and proper toilet facilities, birth spacing, and the death of a previous child under five years of age in the family during the past five years. Study findings suggest that a significant reduction in levels of IMR can be achieved by providing safe water and sanitation facilities in rural areas, accessible family planning services, active follow-up and support to mothers who have experienced a previous child death, an aggressive promotion of oral rehydration solution, and the case management of ARI.
Maternal and infant mortality policy and interventions. Conference summary.
Greater effort needs to be made to reduce levels of maternal mortality. Strong commitments to improving women's social status; strengthening health services to provide equitable, universal coverage; incorporating social and epidemiological oversight of the population to ensure that people at risk and in need will not be overlooked by the health care system; university development of education, research, and health services, and cooperation with policy makers, government health personnel, nongovernmental organizations, and communities in building and sustaining effective programs; and encouraging others toward global commitments to support the roles of women and protect them from unnecessary risk, disability, and death are needed to lower levels of maternal, perinatal, and infant mortality. Participants at a conference on maternal and infant mortality policy and interventions discussed health policy reform, the complexity of the issue, factors contributing to maternal and infant mortalities, and what needs to be done.
Interventional strategies to reduce infant mortality rate.
The Aga Khan Health Service (AKHS) is a non-profit organization which provides primary and curative health care in Pakistan, India, Bangladesh, Kenya, Tanzania, and Syria. The organization began working in Pakistan in 1924 with the establishment of the Jan Bai maternity home in Kharadhar, Karachi, followed by a maternal and child health center in the same area. These facilities were opened to address an urgent need for good quality maternal and child care in the area. AKHS now has five maternity homes, 212 health care outlets, and one medical center in Pakistan. The maternal and child health center is the basic unit of service, with the Lady Health Visitor (LHV) being the basic provider of service. The LHVs are supported by local health committees and supervised by a team of field directors and LHVs. Infant mortality in Karachi is 17 deaths/1000 live births, 42/1000 in the North, 48/1000 in Sindh and Punjab, and 63/1000 in Chitral. AKHS has offered immunization and growth monitoring in the attempt to reduce infant mortality. Breast feeding up to two years, early weaning, proper nutrition of children and mothers, oral rehydration therapy against diarrhea, personal hygiene, and child spacing are also promoted.
Development and trial of interventions for infant survival: the Chandigarh experience.
Despite declines, levels of infant mortality remain high across most of India. This paper describes the strategy adopted by the Community Medicine Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, in establishing a demonstration project for trial of the following interventions for reducing infant mortality: the ongoing training of primary health care workers, a safe care cord kit, diarrheal diseases control, case management of pneumonia, universal immunization, domiciliary care of low birth weight babies, case management of birth asphyxia, and home-based maternal and child record. The community project was started in collaboration with Haryana State Health Services in Raipur Rani Community Development Block in 1975. Each block covers approximately 100,000 population, with health services comprised of a community health center, approximately four primary health centers staffed by doctors, and twenty sub-health centers each manned by a male and female health worker. Each village has traditional birth attendants supported by the community. The interventions were implemented through the existing primary health care infrastructure of these government health services. Drugs, equipment, and training support were provided by the Community Medicine Department.
The experiences of the Islamic Republic of Iran in reduction of maternal and child mortality.
Before the Islamic Revolution in Iran, and despite an acceptable level of GNP, access to health services in Iran was generally inadequate. As may be expected under such circumstances, health indicators were poor. After the revolution, however, primary health care was chosen as the model by which health and treatment services would be provided through the health network. Manpower training and community participation were adopted as central to the provision of health services. Priority was given to rural and deprived areas over urban areas, prevention over treatment, outpatient treatment over hospitalization, and general medical treatment over specialty treatments. A 1974 survey found the level of maternal mortality to be 120 and 370 per 100,000 live births in urban and rural areas, respectively, declining to 77 in urban and 233 in rural areas in 1985. Following the expansion of health houses in rural areas and expansion of the family health programs in cities, a 1988 survey found rates of maternal mortality to have declined to 41, 138, and 91 per 100,000 live births for urban, rural, and the whole country, respectively. Maternal mortality rates in 1991 were 26, 53, and 40 per 100,000 live births for urban, rural, and the whole country, respectively, having declined even further than in 1988 due mainly to the expansion of health houses in rural areas and the increased frequency of the presence of trained personnel during deliveries. The 1988 survey on 10% of the total population found that the deaths of children under age five years accounted for 55% and 32% of total deaths in rural and urban areas. The study indicated that 26% and 24% of deaths in the under-five age groups were due to infectious diseases, mainly respiratory infections and diarrheal diseases. A 1991 survey found a declining trend of mortality among neonates, infants, and under-fives from 1975-91. Despite the Iran-Iraq war, economic sanctions, and natural disasters, Iran has made inroads against maternal and child mortality.
Following the Alma Ata conference on Health for All using primary health care as the key approach, traditional birth attendant (TBA) training and use programs were accepted by almost all governments of Southeast Asia. Training programs were launched in many countries. Since 1960, Lady Health Visitors (LHV) working in Basic Health Units and Rural Health Centers in Pakistan have been responsible for training two TBAs per year. Although not necessarily practicing TBAs, the women chosen from nearby villages for the training were interested in learning midwifery. They received hands-on training for one year and were expected to complete 15-25 supervised deliveries in order to qualify for certification as a trained TBA. Many certified TBAs were then employed at the health facility, while others worked in their own villages. The Government of Pakistan in 1982 implemented the Accelerated Health Program, a program to address the major causes of maternal and infant mortality and morbidity. The program was comprised of immunization, diarrheal diseases control, TBA training, and health education. The TBA is the only health worker who is available and is in regular contact with women in rural communities in Pakistan. The focus of the TBA component was upon upgrading the skills of practicing TBAs and on greatly increasing the number trained. TBA training in Pakistan is described.
Faisalabad obstetric flying squad: a four year study.
The obstetric flying squad is an emergency ambulance equipped with medicines and trained staff first established by Bellshill in Lancashire in 1935 as a way of managing obstetric emergencies. The squad rushes to patients' homes in response to complications during pregnancy, labor, and puerperium in domiciliary practice, resuscitates the patient, then transfers her to the hospital for further management. Even with the best antenatal care, unexpected complications can arise at home, although the patient has been booked for hospital delivery. Flying squad service was started in Faisalabad, Pakistan, on March 16, 1988, but the first call was not until nine months later. Indications for calling the Faisalabad Obstetric Flying Squad include abortion, ectopic pregnancy, pregnancy-induced hypertension, eclampsia antepartum hemorrhage, postpartum hemorrhage, retained placenta, ruptured uterus, inversion of uterus, obstructed labor, malpresentation, primigravida, and grand multigravida. The level of maternal mortality in the city subsequently declined over the past five years to 0.77 deaths per 1000 live births, 215 maternal deaths for 276,171 total births over the five-year period. The squad received 394 calls during 1989-92, saving many lives. Relatives, traditional birth attendants, and lady health visitors are the primary callers of the flying squad.
Studies have been conducted since 1980 to assess the levels of maternal mortality in various parts of Egypt. Maternal mortality ratios have been in the range of 150-299 per 100,000 live births. Since different methodological approaches were used in the studies, no national rate could be calculated. The Child Survival Project of the Ministry of Health therefore conducted a broad-scale survey of maternal mortality in the country. 122 randomly selected health bureaus reported all deaths of women aged 14-50 years weekly for one year starting March 1, 1992. Maternal deaths were identified through screening questionnaires by the trained health bureau directors. The study covered 21 governorates, with the remaining five frontier governorates excluded from consideration due to their atypical nature compared to the rest of the country. The report of survey findings is in publication. The author defines maternal mortality and its causes, then describes the survey design. It already seems apparent, however, that better care by medical professionals and less delay among women and their families in seeking antenatal care and medical advice could lead to reductions in the level of maternal mortality.
Government policies on maternal mortality: theory and practice.
National health policy in Pakistan as