Maternal mortality -- how big a problem do I have and how can I measure it?
The original sisterhood method asks respondents how many of their sisters reached adulthood, how many have died, and whether those who died were pregnant near death. For technical reasons, the approach should not be used where the total fertility rate is under 3, where fertility has declined steeply, or where there has been major migration. The method is relatively simple and inexpensive to use. However, one major disadvantage is that the estimate relates to a period 10-12 years before the survey, limiting its use for monitoring recent trends. The direct method is a variation from the original approach and is used in the Demographic and Health Surveys. In the direct method, respondents are asked more detailed information on their sisters, a lengthier, more complex process. The sisterhood method has been adapted to measure maternal mortality. The author discusses when it is appropriate to use the method, preparation of a sisterhood study, using the results, learning about why women are dying, and why an estimate of the magnitude of a given maternal mortality problem will suffice.
Safe motherhood in a refugee setting. Special feature --mothers as refugees.
Kakuma refugee camp in the Turkana desert of northern Kenya is current home to more than 35,000 refugees. Primary health care services in the camp are provided through the International Rescue Committee. Prenatal and postnatal clinics, family planning services, and curative services for children and adults are provided by 4 family health clinics throughout the camp. The clinics also provide a base for community outreach services, including AIDS home care and community-based counseling, as well as for the activities of traditional birth attendants (TBAs) and community health workers. While there is a central delivery unit with prenatal, postnatal, and labor wards, more than half of the deliveries in the camp take place at home, attended by trained TBAs. Emergency obstetric referral services are provided through the Lutheran World Federation (LWF) hospital in the refugee camp and through a mission hospital in Kakuma. TBAs recruited from within the camp, Kenyan midwives, and doctors are the backbone of the excellent maternal health care provided in the camp.
When disaster strikes -- caring for mothers and babies. Special feature -- mothers as refugees.
In many countries, women are poorly nourished and have a high rate of reproductive morbidity. However, during war and other disaster situations, women and children become even more vulnerable. Most of the world's refugees and internally displaced people are women and children. Many women refugees are malnourished and during the emergency and exodus phases, many are starving. Severe malnutrition in a pregnant woman causes fetal malnutrition. Infants born to a malnourished mother are of low birth weight and will grow up malnourished if they stay in the same deprived environment as their mothers. Households headed by women tend to obtain the least food and the children of such households tend to be poorly nourished. Many of the problems and obstacles women face during peacetime and non-emergency situations are simply exacerbated during disasters and war. It may not be possible to head off disasters which result in massive social upheaval, but preparations can nonetheless be made to mollify conditions once disaster hits. Responsible organizations and agencies should research the situation and plan for the worst. This paper discusses how women lose social and economic power during periods of armed conflict, the often lack of even basic reproductive health care during armed conflict and emergencies, coping in an emergency, and living in a refugee camp.
Sexual violence against women is a weapon of war. Special feature -- mothers as refugees.
Rape is recognized as a crime of war. During armed conflict in Bosnia, it was deliberate policy to rape young women to force them to bear the enemy's child. During conflicts in Rwanda, rape was systematically used as a weapon of ethnic cleansing aimed at destroying communities. The national population office in Rwanda estimates that 2000-5000 infants were born as a result of such rape. The general decline in women's health, and in their reproductive health in particular, were two consequences of the wars in Bosnia and Rwanda. Women and girls suffered most from the violence. Systematic rape also has a terrible effect upon women's physical and mental health, including pregnancy-related complications, sexually transmitted diseases (STDs), and death as a result of induced abortion. Fear of social stigma associated with being raped discourages women who have been raped from seeking help or treatment. Moreover, most women who have been raped have difficulty re-establishing intimate relations, while others desire to bear many more children in order to compensate for children lost during the war. Finally, even women who are not raped during times of conflict may find it necessary to have sex with men in order to secure food, shelter, safe conduct, and/or refugee status for themselves and their children. Health services available to people with injuries or STDs need to be better equipped to provide medical care and counseling.
Many women around the world die because, although they were given the correct treatment, they did not receive it fast enough. All hospitals should regularly review how much time elapses between a patient's arrival at the hospital and when that patient receives the needed treatment. Hospitals should work to reduce that time period by identifying and addressing each element which contributes to delay. When looking for delay, the following questions could be considered: whether the gatekeeper sends the patient immediately for treatment, how long it takes for nursing staff to reach the patient and whether they must wait for a doctor before beginning routine first aid, whether the doctor is called immediately and how long it takes for him or her to reach the patient, whether the anesthetist and laboratory technician are always available, how long it takes to prepare the operating theater, and how long it takes the person with the key to arrive. Urgency is a matter of attitude rather than resources. With the same resources, a hospital staff can provide either prompt or delayed treatment depending upon their attitude toward patient care.
FPAN operation area to cover Acham and Illam district.
The Family Planning Association of Nepal (FPAN) began operations during the 1960s in 3 districts. Those activities have since expanded to cover 33 of the country's 75 districts, making it the largest nongovernmental organization working in the field of health and population. Working in line with government policy and expectancy, FPAN has been expanding its projects and programs to remote and unmet need areas. Activities have recently expanded to Acham and Illam districts. Acham is a remote district in the Far Western Development Region with a population of 2 million and a current contraceptive prevalence rate of 6.2%, far below the national level. Only 57.3% of reproductive-age married women in the district know about a family planning method. FPAN's project in the district will cover 10 of the 75 village development committees (VDCs) and a population of 28,617, providing birth spacing methods to 2500 clients and referral services for sterilization to 100 others. Reproductive health education will also be provided to 25% of the district's adolescents and young adults. Illam is a district in the Eastern Development Region with a population of 2.2 million. The contraceptive prevalence rate is 28.2% and the level of knowledge about a family planning method is 95.7%. The project will operate in 8 VDCs and is expected to provide family planning services to 4350 clients and promote reproductive health education among tea estate workers.
UNICEF / Nepal highlights on safe-motherhood.
During the second day of the Family Planning Association of Nepal's (FPAN) 20th Central Council Meeting, and on behalf of UNICEF/Nepal, Indra Lal Singh stressed the importance and implication of the safe motherhood program relative to the family planning program. Singh also stressed the need to promote the two programs together with the aim of ensuring better results. UNICEF/Nepal looks forward to working with FPAN and preliminary talks to that end have already been held. Also at the meeting, a paper was presented upon safe motherhood, government health policy, and different levels of the health delivery system. 40% of pregnant women are not receiving the benefits of the safe motherhood program, indicative of the program's need for both government and nongovernmental organization priority. Other statistics aired during the meeting are that 44% of pregnant women receive only prenatal care services, 92% of deliveries are performed at home, 3% of women are attended by nurses or trained workers, 6% are attended by physicians, 33% of pregnant women receive 2 or more doses of tetanus toxoid, 29% of newly married nonpregnant women use contraception, 539 women out of 100,000 deliveries die due to unsafe motherhood, and 5000 women die each year due to pregnancy-related problems.
NGOCC celebrates second anniversary.
The Nongovernmental Organization Coordination Council (NGOCC) was formed in 1995, conceived by the Family Planning Association of Nepal (FPAN) and supported by the US Agency for International Development and the Asia Foundation. The NGOCC is an informal group of Kathmandu-based national nongovernmental organizations (NGOs) and INGOs working in family planning and meeting regularly to discuss issues of common concern. The FPAN Director General decides upon the mechanism of coordination and arranges the meetings. NGOs and INGOs have responded favorably toward the council, with 29 organizations having thus far actively participated in the council. The NGOCC has organized bimonthly meetings to share experiences and information, and has conducted studies to identify the strengths and weaknesses of member organizations in an effort to consolidate and strengthen programs.
Founder president inaugurates 20th council meeting.
The Founder President, Ex-Minister for Health Mrs. Dwarika Devi Chand Thakurani inaugurated the 20th Central Council Meeting of the Family Planning Association of Nepal (FPAN) held in Banepa-Kavre during April 18-19, 1997. FPAN's president, Sunil Kumar Bhandari, recanted how the FPAN was created in 1959 by several pioneering leaders, before implementation of the government's program in 1965. However, despite decades of program efforts, the gap between the knowledge about contraception and the practice of family planning remains wide and in need of narrowing. That goal can be achieved by providing the proper information and making the appropriate services available throughout the rural areas. A need also exists to promote and repackage family planning as a component of reproductive health. Of immediate concern is making services available to individuals who are already motivated or will be motivated with little persuasion. FPAN expects to contribute significantly toward that end.
HIV-1 diversity in Morocco [letter]
Blood sera were obtained from 200 HIV-1-infected Moroccan and 13 HIV-1-infected European volunteer subjects visiting Morocco in a study to measure the diversity of HIV-1 among subjects. 83% HIV-infected subjects were aged 25-40 years, 5% were under age 25, and 12% were over age 40. 85.5% of HIV infections were acquired through heterosexual relations, 8% through bisexual activity, 4.5% through homosexual activity, 1.6% through drug use, and 1.6% through blood transfusion. 4 of the Europeans were drug users, 2 were homosexuals, and 7 were heterosexuals. Sera were analyzed using a peptide subtype-specific enzyme immunoassay and the corresponding peripheral blood mononuclear cells from 10 subjects were genotyped using heteroduplex mobility assay (HMA). 187 of the Moroccan sera were determined to be of subtype B, 2 as subtype A, and 1 as subtype F. 10 samples were non-typed, but later verified as belonging to group M using specific peptides. All of the European samples were serotyped as subtype B.
Rotavirus infection has been often reported to be responsible for much diarrhea-related mortality and morbidity among children under age 5 years in developed and developing countries around the world. VP4 is one of two rotavirus outer capsid proteins, known to exhibit antigenic polymorphism. Polymerase chain reaction was used to characterize the VP4 types of 39 rotavirus field isolates from symptomatically infected children in Nigeria. Genotype P6 was most frequently identified, occurring in 41.03% of the typed specimens. Genotype P8 was identified as the next most prevalent at 33.3%. Genotype P6 was observed among 68.75% of infected neonates in southern Nigeria, but mixed infection was prevalent among 70% of northern Nigerian children. 4 distinct strains were identified with 4 different P genotypes. Strain G1P8 predominated at 22.22%, followed by G3P6 at 17.8%. Strain G1P8 was prevalent among 70% of infants aged 3.1-9 months, but strain G3P6 was most frequently identified among neonates age 3 months and younger. G1P8 was circulating throughout the country, while 77.8% of G3P6 cases were identified in southern Nigeria. Untypeable VP4 gene also was observed in Nigeria. The occurrence of mixed infection genotype points to the potential for reassortment events among rotavirus genogroups in the country.
Directive counseling should emphasize disease protection, not pregnancy prevention [letter]
The authors disagree with Moskowitz and Jennings that directive counseling upon long-acting contraception can be appropriate and that family planners should develop protocols to that effect. Directive counseling for long-acting contraception is a mistake since almost every woman described as a candidate for directive counseling is also at risk of sexually transmitted diseases (STDs). Such counseling should be considered, but for condoms and other barrier methods rather than for long-acting contraception. While it is important to prevent unwanted pregnancy, women whose birth control fails can still take action to prevent birth. However, women who do not use barrier methods and contract herpes, condyloma, and/or HIV have no second chance to prevent infection. Current value-neutral counseling which encourages women to choose a contraceptive method first and then use condoms to prevent STDs is not working well enough, with far too many women at risk of STDs using nothing to prevent disease. Instead of encouraging at-risk women to use long-acting methods, women need to be encouraged to use the most protective method possible.
Intergenerational redistribution in a small open economy with endogenous fertility.
The literature comparing fully funded (FF) and pay-as-you-go (PAYG) financed public pension systems in small, open economies stresses the importance of the Aaron condition as an empirical measure to decide which system can be expected to lead to a higher long-run welfare. A country with a PAYG system has a higher level of utility than a country with a FF system if the growth rate of total wage income exceeds the interest rate. Endogenizing population growth makes one determinant of the growth rate of wage incomes endogenous. The author demonstrates why the Aaron condition ceases to be a good indicator in this case. For PAYG-financed pension systems, claims can be calculated according to individual contributions or the number of children in a family. Analysis determined that for both structural determinants there is no interior solution of the problem of intergenerational utility maximization. Pure systems are therefore always welfare maximizing. Moreover, children-related pension claims induce a fiscal externality which tends to be positive. The determination of the optimal contribution rate shows that the Aaron condition is generally a misleading indicator for the comparison of FF and PAYG-financed pension systems.
Modeling household fertility decisions with generalized Poisson regression.
Individual household fertility decisions have been modeled in a number of ways. In many empirical studies of fertility, the number of children in a household is modeled as a function of other social and economic variables such as wife's education level and family income. The commonly used models include the standard Poisson and negative binomial regression models, models which accommodate the non-negative number of children in a family. These models are, however, restrictive in some situations. The authors estimate a generalized Poisson regression model of household fertility decisions to accommodate the under-dispersion seen in the new fertility data from the 1989 wave of the Panel Study of Income Dynamics. The generalized Poisson regression model has statistical advantages over both the standard Poisson and negative binomial regression models, and is suitable for the analysis of count data which exhibit either over-dispersion or under-dispersion. The model is estimated by the maximum likelihood method. Approximate tests for the dispersion and goodness-of-fit measures for comparing alternative models are discussed. The empirical results support the 1973 fertility hypothesis of Becker and Lewis.
"I couldn't believe when it happened to me:" the challenge of unintended teenage pregnancy.
While teen pregnancy and out-of-wedlock births have been a part of American society for centuries, unintended pregnancies and births, especially among adolescent girls, have recently gained a great degree of public attention. The proportion of teens having sex by age 18 has increased steadily since the 1930s to reach 61% of males and 58% of females among people born 1963-74. However, only 75% of sexually active teens use contraception, leading almost 10% of all girls aged 15-19 years to become pregnant each year. The current teen birth rate is lower than it was 35 years ago and has fallen slightly over the past 2 years, but it has nonetheless risen markedly since 1980. Teenage pregnancy and motherhood is a national problem, transcending boundaries of socioeconomic class, race, and ethnicity. Evidence suggests that teen motherhood often has negative consequences for both mother and child. Measures must be taken to change young girls' self-perception so that they can delay sexual relations until they are prepared to take responsibility in preventing pregnancy. Support must be given to those young women who do get pregnant.
RU486. Abortion by pill is not as simple as it seems.
Mifepristone (RU-486) is a synthetic steroid which makes it difficult for a fertilized egg to adhere to the uterine lining. When RU-486 is taken with misoprostol, a drug which induces uterine contractions, abortion results. RU-486 has been used by more than 200,000 women in Europe and China since 1988, but has received only tentative approval from US health officials. Such a medically-induced abortion is a noninvasive, nonsurgical way to terminate pregnancy which requires no anesthesia and can be used up to the 63rd day of pregnancy. However, the proper use of RU-486 requires 3 visits to a physician or clinic over a period of approximately 15 days. Moreover, the side effects of a medical abortion may include extensive bleeding, cramping, nausea, and vomiting. On average, women experience varying degrees of bleeding for 8-9 days following medical abortion, compared with 5 days after surgical abortion. The legal fight to get RU-486 approved, clinical trials in the US of the drug's safety and effectiveness, the chronology of RU-486 development, how the pill works, and the planned limited distribution through only physicians are described.
Cool response in Europe [RU-486].
A prescription drug regimen which induces abortion and includes the administration of RU-486 is awaiting final consideration by US health officials. People at meetings in the US expect RU-486 to liberate women by revolutionizing the abortion process. However, experience with RU-486 in Europe suggests that the regimen will most likely not revolutionize access to abortion in the US or make abortion an at-home procedure women can choose. Medical abortion involving RU-486 has become an alternative to surgical abortion over the past decade in France, Sweden, England, and Scotland. However, after experience with 200,000 women choosing abortion by RU-486, the abortion pill in Europe has not replaced surgery as the main mode of terminating pregnancy, has not increased the abortion rate, is not used by the majority of women who could use it, is not offered by the majority of physicians, and has not made abortion a more private affair. RU-486 pills are tightly controlled and given only under medical supervision at designated government clinics and hospitals. A major barrier to the greater uptake of RU-486 is the reluctance of gynecologists to adopt the more complicated routine needed to supervise patient use of the drug. Also, the patient must be actively involved in administering her own abortion when using RU-486.
Indonesia: revolving loan fund for midwives.
Midwives provide 57% of private family planning services in Indonesia. A survey conducted by Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) found that while midwives were interested in establishing or expanding private practices, they had little access to affordable credit. PROFIT therefore initiated, in April 1995, a $1 million revolving low-interest loan fund to help Indonesia's midwives establish or expand private practices which include family planning and reproductive health care services. Serving the provinces of East, West, and Central Java, Jakarta, and Bali, the fund is designed to shift family planning clients from the public to the private sector, to leverage US Agency for International Development funds through the creation of the fund and by obtaining matching funds from a local lending institution, and to sustain lending to midwives on a permanent basis. PROFIT collaborates with Bank Rakyat Indonesia, the Indonesia Midwives Association, and the National Family Planning Coordinating Board to provide maximum loans of $1400 per person with a repayment period of 2 years. As of March 1997, loans had been made to 490 midwives. A typical borrower graduated from midwifery training 22 years ago and has had a private practice for 14 years. Given the continued demand for loans, PROFIT will transfer project oversight to a local foundation which will continue the loan fund beyond the end of the PROFIT project in September 1997.
India: community-based social marketing.
The 1992-93 National Family Health Survey (NFHS) determined that knowledge about modern temporary contraceptive methods is limited in India, with oral contraceptive pills, IUDs, injectables, and condoms used by less than 6% of currently married women. Indian women rely heavily upon sterilization for family planning and more than 80% of sterilization acceptors never used any other method of contraception before sterilization. Knowledge of AIDS is also extremely limited. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) will use a community-based social marketing (CBSM) strategy to support the distribution of modern, temporary contraceptive methods in Madras, Tamil Nadu, India. Specifically, PROFIT will determine whether a CBSM strategy can increase condom use, shift condom users from public to private sources, and enable entrepreneurs to profitably distribute reproductive and sexual health products and messages. International Family Health and the Y.R. Gaitonde Center for AIDS Research and Education are partners in the project approved by the US Agency for International Development in February 1996. Entrepreneur recruitment began in June 1997.
Kenya: managed health care system.
There is significant unmet need for family planning in Kenya despite the increased availability of contraceptives and family planning services. This need exists in the context of dwindling public resources with which to promote family planning services and delivery. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) has been working in Kenya with AAR Health Services of Nairobi since July 1995 to shift the provision of family planning services from the public to the private sector, to increase the number of new family planning users, and to expand the availability of health care services. With PROFIT's support, AAR has developed and opened a managed health care system, Odyssey Plaza Medical Center (OPMC), targeted to employees and their dependents in Nairobi's industrial area. Family planning services began being offered at the center in January 1996, and a media campaign was held in November to showcase the system. The campaign featured the US Ambassador to Kenya. The Kariobangi Outreach Clinic was opened in January 1997 and by April, AAR had almost doubled its membership with signs of continued strong growth.
Philippines: low-cost health care plan.
Since workers in the Philippines' informal sector are not covered by the country's national health insurance program, they have had only limited access to quality health care. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) supported US Agency for International Development goals of providing lower income populations with access to health services, shifting family planning clients from the public to the private sector, increasing the availability of family planning services through the private sector, and increasing the use of modern family planning methods. HealthSaver, a low-cost, pre-paid health care plan, was designed by PROFIT together with PhilamCare Health Systems, Inc., the leading health maintenance organization in the Philippines to offer outpatient and inpatient health care services, including family planning, to members of the Philippines' informal economy. HealthSaver was initiated in May 1994, with services provided at one hospital in Manila and one hospital in Cebu. Premiums are $3.20 per month per covered individual, about half the cost of PhilamCare's least expensive health care plan. HealthSaver is the first private plan in the country targeted to the informal sector and the first to include family planning services. Although 2100 people had enrolled in the plan by August 1996, the PhilamCare Board decided to terminate the plan unless enrollment reached a break-even enrollment level of 4000 since PROFIT could not continue to underwrite the plan.
Philippines: Physicians' Loan Fund.
Access to health care in the Philippines is relatively poor, few economic incentives encourage physicians to establish local private practices, and even fewer incentives encourage doctors to provide primary health care services such as family planning. Lending institutions also often perceive physicians to be poor credit risks. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) began working in the Philippines in March 1995 to increase the availability of family planning services delivered through private practices, to shift family planning clients from the public to the private sector, to help doctors expand or establish private practices, and to help doctors add or increase the level of family planning services. PROFIT established a $300,000 Physicians' Loan Fund which provided credit and training to physicians to establish or expand private practices. To be eligible for a loan, physicians agreed to provide family planning and reproductive health care services. Loans were made through the Bankers' Association of the Philippines Credit Guaranty Corporation (BCGC), with doctors allowed up to 3 years to repay the loans of average amounts of $6800 each. Loan recipients were also given family planning and business management training. The project was terminated in July 1996 due to implementation obstacles, including opposition to family planning in the country, a lack of demand for the loans among the target market of young doctors, and changes in the US Agency for International Development/Manila's strategic objectives. Up to July 1996, loans had been made to 31 physicians, 24 borrowers had attended the family planning training course, and 29 had attended the business training course. 21 borrowers realized increased monthly revenues, and 43% of the borrowers' clients previously received family planning services from the public sector.
Romania: promotion of modern contraceptives and pharmacist services.
The use of contraception in Romania is quite low despite almost universal awareness of modern contraceptive methods. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) is working to teach people aged 15-24 years about modern contraceptive methods, to motivate them to use contraceptives, and to advise consumers about the availability of contraceptive services from commercial pharmacies. To respond to an increase in demand for contraceptive services, PROFIT is training staff members of private pharmacies in sound business practices, contraceptive technology, and ways to provide quality client care. PROFIT has worked with the National Pharmacists' Association, major university departments of pharmacy, advertising and market research firms, and pharmaceutical distributors in urban areas throughout the country since October 1995. In March 1996, PROFIT established an office in Bucharest, then developed a program with pharmacists including family planning and business training in May. During the remainder of 1996, PROFIT collected research data from young adults to design and launch a nationwide media-delivered education campaign on modern contraception and its use; the pharmacists' training curriculum and materials were adapted and translated; and 21 private pharmacists had been trained in Bucharest. In March 1997, the "Contraceptive Technology and Quality Services: Guide for Pharmacists" was finalized, printed, and distributed to 3500 private pharmacists in Romania. 1500 other copies were distributed to university pharmacy departments, nongovernmental organizations, and government agencies. In May 1997, PROFIT conducted a mid-term evaluation of the media campaign and by June 1997, more than 200 pharmacists had been trained throughout the country.
Zimbabwe: private sector initiative.
Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning's (PROFIT) strategy in urban areas throughout Zimbabwe is to increase the number of private providers capable of delivering family planning services while persuading people who can afford to pay for services to use private sector services. Specific subproject goals are to encourage pharmacists to more actively promote and provide family planning products, to increase the use of family planning among those covered by private medical insurance, to increase the provision of family planning services at work sites, to increase the provision of family planning services by private doctors and nurse/midwives, and to motivate consumers to seek family services from private providers. PROFIT works with the Zimbabwe National Family Planning Council, the Retail Pharmacists' Association, Zimbabwe Occupational Health Nurses' Association, Zimbabwe Nurses Association, Zimbabwe Medical Association, Zimbabwe Midwives' Association, the College of Primary Care Physicians, and the National Association of Medical Aid Societies. Activities conducted between January 1996 and March/April 1997 are reported.
Indonesia: PT Bonnys Arsila immucenters.
PT Bonnys was established in 1989 as the first commercial chain of immunization clinics and the leading provider of hepatitis B vaccinations in Indonesia. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning's (PROFIT) goals in Indonesia are to expand the role of the private sector in financing and providing family planning services, to shift middle-income users of public sector family planning to private sector family planning in order to enable scarce public sector resources to be targeted to lower-income groups, and to support the government's goal of improving Indonesia's contraceptive method mix by increasing the use of more permanent contraceptive methods. In keeping with those goals, PROFIT funded the development of a new company management information system to track customers, sales, and service statistics. In January 1994, PROFIT loaned PT Bonnys $650,000 to add family planning to its 6 stationary clinics and 6 mobile units. The funds were to pay for clinic renovations, family planning products and equipment, staffing, and marketing. However, in light of PT Bonnys' financial problems in 1994 and the unlikelihood that family planning objectives would be achieved, an accelerated payback of the loan plus interest was negotiated so that the loan was repaid by May 1995.
With 62,000 physicians and 8 million clients, UNIMED/Brazil is Brazil's largest health maintenance organization (HMO) and physician cooperative. In late 1992, UNIMED/Maceio, a local branch of UNIMED, and Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) negotiated the joint purchase of a hospital in Maceio, the clinic of San Sebastian (CSSS). UNIMED/Maceio agreed to add and operate a family planning (FP) and maternal-child health (MCH) clinic in the hospital. In March 1993, PROFIT and UNIMED/Maceio signed a contract of association and purchased CSSS in June. UNIMED/Maceio directs its HMO members to use the hospital's services in order to better control utilization costs, with cost savings to be used to supply FP/MCH activities. UNIMED/Maceio provides complete medical services to its 32,000 enrollees, with ambulatory services rendered in the private offices of member physicians. Diagnostic and inpatient services are provided either through third paries or in UNIMED's own facilities. In February 1997, UNIMED bought PROFIT's share of CSSS for $1.5 million. In August 1997, PROFIT transferred the divestment contract to Pathfinder International, which will use the funds to promote the US Agency for International Development's objectives in Brazil.
The state of Uttar Pradesh (UP) in northern India has high rates of fertility and low contraceptive prevalence rates, with 84% of rural women in the state obtaining family planning through public sources. Such a high level of public sector services use indicates the existence of considerable room for private sector expansion into the provision of family planning. UP is also a major sugar-producing area, with more than 100 sugar processing plants, each employing approximately 1000 people and interacting with sugar cane growers within a 25-30 km radius. The sugar industry therefore affects the lives of 2 million people in UP. Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) is supporting Mawana Sugar Works (MSW) in establishing a comprehensive, in-house maternal and child health and reproductive health (MCH/RH) program for workers and dependents. The subproject will initially reach an estimated 7500 people, but MSW may later expand the services to 45,000 farmers who regularly supply the company with sugar cane. The goal is to create a model for employer-provided health services in rural UP which could be replicated in other sugar processing plants and to provide access to family planning services through private employers. Shriram Industrial Enterprises Limited (SIEL), owner of MSW, and Parivar Seva Sanstha (PSS), a local nongovernmental organization affiliated with Marie Stopes International, are partners with PROFIT. Program implementation began in May 1997.
Brazil: CEPEO commodities procurement organization.
Since Brazil has achieved a contraceptive prevalence level of 70%, the US Agency for International Development (USAID) plans to stop providing contraceptives to the country by 2000. To facilitate the phase-out process, Promoting Financial Investments and Transfers to Involve the Commercial Sector in Family Planning (PROFIT) established a commercial company, the Contraceptive Procurement Organization (CEPEO), to provide a reliable source of high-quality, affordable contraceptives to the public, private, and nongovernmental organization sectors. CEPEO also sponsors provider training in IUD insertion. PROFIT's objectives were to offer high-quality, affordable contraceptives to public and nonprofit entities in Brazil; to improve Brazil's contraceptive method mix through the promotion and sale of the IUD as an alternative to sterilization; and to make the subproject sustainable over the long term by establishing a financially independent for-profit company which successfully commercializes contraceptives and other health care products. Sales are conducted mainly through mail order and telemarketing. PROFIT collaborated on the project with the Contraceptive Social Marketing (SOMARC III) Project and Pathfinder International. CEPEO sold 142,317 condoms in 1995, 17,087 condoms in 1996, 55,832 IUDs in 1995, and 58,749 IUDs in 1996. Revenue has been higher and losses have been lower than initially projected. As of December 1996, more than 150 private physicians had been trained in IUD insertion through a CEPEO-sponsored training program held at 6 sites in 5 states. In July 1997, PROFIT sold CEPEO to current management through a competitive bid process.
Lymphocyte immunophenotype reference ranges for T, B, and NK subsets were determined for healthy adult Thais in a multicenter study in Bangkok. Subjects were aged 18-50 years and HIV and hepatitis B seronegative. Findings are based upon 217 subject datasets from 131 men and 86 women. Immunophenotyping was through flow cytometry using lysed whole blood, with a standard protocol for flow cytometry instrumentation, reagents, and quality control used to minimize site differences and to facilitate comparison of the Thai reference values to those found for Whites in previous studies. Major differences were found for CD3(T), CD4 (T helper/inducer) and CD16+56(NK) lymphocyte percentages and CD4 lymphocyte absolute counts, with age trends and sex differences also observed. Relative to Whites, Thais, especially Thai males, had lower CD3 and CD4 T lymphocyte percentages and absolute numbers while the percentage of NK lymphocytes was higher. Heterogeneity attributed to the biological variation of CD4 T lymphocyte, but not other immunophenotype subset distributions was also observed in a well-defined geographic population. These study findings demonstrate the importance of ethnicity, age, sex, and possibly environment as factors which influence distribution characteristics of normal lymphocyte immunophenotype reference values.
The success of any health program depends upon efficient communication, a concept which figures prominently in India's 1982 health policy. In health communication, voluntary agencies, developmental agencies, and others must work together toward a common goal. To successfully deliver messages, an appropriate mix of interpersonal approaches, mass media, and folk media must be selected from the vast array of communication possibilities. Efforts should be made to encourage active community participation by involving various community groups. Once a program becomes a people's movement, behavior will be readily changed and health programs will begin to show the desired outcomes. The author discusses the communication process, the information strata, communication strategy, outreach of communication channels, and suggested strategy.
While there have been improvements in India's health status over the past 4 decades, many problems still persist. For example, the infant mortality rate has declined from 114/1000 live births during the mid-1980s to 74/1000 in 1993, and other important parameters such as the crude birth rate, death rate, and maternal mortality rate have also shown downward trends. Smallpox was eradicated 2 decades ago and other important communicable diseases such as cholera, typhoid, diarrheal diseases, respiratory infections, and vaccine preventable diseases have also shown downward trends over the past few years due to the impact of various national health programs. However, not all on the health front has been favorable. For example, there has been a disturbing resurgence of vector-borne diseases such as malaria, kalaazar, and plague in recent years. Falciparum malaria cases and deaths have occurred in some districts of Rajasthan, Manipur, Nagaland, and a few other Indian states as well as in many urban areas, including the metropolises of Calcutta, Bombay, and Delhi. Few ongoing health programs are working well in most parts of the country. The author further discusses the changing pattern of diseases; nutritional problems; problems in urban health care; drug abuse; pollution; health manpower development; health systems research; the involvement of private practitioners and nongovernmental organizations; information, education, and communication; continuing medical education through distance education; and geriatric care.
Healthy cities for better life [editorial]
A growing proportion of the world's population is living in cities. While only 10% of the world's population lived in cities in 1900, more than half of the world's population will be urban dwellers by 2000. Within 15 years, 20-30 cities will have populations of more than 20 million people, slightly more than the combined population of Bhutan, Nepal, and Maldives. However, hundreds of millions of people who already live in cities are living in conditions which are detrimental to their health and even endanger their lives. The health of urban populations urgently needs to be addressed. If cities continue to grow without proper planning, local government authorities will be unable to provide even the most basic conditions of health such as housing, employment, and a safe environment. At a time of explosive urban growth, urban health is a challenge for all concerned with human development, from municipal and national authorities to international health and development organizations. "Healthy Cities," the theme chosen by the World Health Organization for World Health Day 1996, addresses the problem.
Reproductive health: faces old and new [editorial]
India's program of Maternal and Child Health (MCH) underwent nomenclature changes first to the program of MCH and Family Planning, then to MCH and Family Welfare (FW). Short-term policy and management changes produced positive results. However, once the MCH and FW program was launched, it became clear that the survival of mother and child is of high priority. Therefore, under the direction of UNICEF/World Health Organization and the government of India, the MCH and FW program was renamed as the Child Survival and Safe Motherhood (CSSM) program. CSSM included all components and issues of MCH, FW, and survival. However, not included are the early detection of cervical carcinoma, the prevention of infertility, the prevention of AIDS, sex education, the prevention of unwanted pregnancies, breast feeding, referral services, and women development. The name of the program should therefore again be changed to "Reproductive Health."
Substantial progress has been made during the past 18 months within the World Health Organization (WHO) with regard to addressing the issues raised in the renewal of the Health for All process. It is clear that WHO is taking a proactive role in advancing the health for all policy. However, Fiona Godlee's editorial, which focused upon internal and external debates, failed to capture the full scope of the process. Godlee did not note that those debates have been both formally and informally linked to the renewal process, a process which WHO holds to be central to the future course of world health. WHO's views are shared by its member states and governing bodies. Policy renewal was discussed during the 50th World Health Assembly in May and during the subsequent session of the executive board. Fundamental actions suggested during the board meeting include creating a universal Health for All value system which explicitly considers the pursuit of human rights and health security, equity, ethics, and a gender perspective, making health central to development. The complexity of future health demands requires consideration of a broader agenda for global health action, not one which is narrow and disease specific.
Women's health is a global issue.
All over the world, women live longer than men, up to 12 years longer in the Russian Federation. However, while women live longer, they are not necessarily living better, healthier lives. In developing countries, communicable diseases, together with childbirth-related illnesses, account for most morbidity among women. In the developed world, too, women report experiencing higher levels of physical and psychological morbidity. While women risk contracting the same endemic diseases as men, both biological and social factors may increase exposure or worsen the effects. The following are discussed as affecting women more than men, regardless of where they live: poverty, birth rates and aging populations, gender, violence against women, and lack of research about women. Issues affecting women in the developing world and in poorer areas of the developed world include education, lack of autonomy, legal status, preference for sons, traditional practices, lack of access to health care, work and environmental health hazards, and unequal human rights. Women's health in the developed world is also considered.
Speaking out for the aging population: Julia Tavares de Alvarez.
71-year-old Julia Tavares de Alvarez, the Dominican Republic's ambassador to the United Nations, is enthusiastic, intelligent, persistent, and vocal. Long interested in geriatrics and the general concerns of the elderly, Alvarez has become a champion of the rights of older people and an avid campaigner against age discrimination. According to the charter of the United Nations (UN), there is no age at which UN employees must retire from service. However, except for the senior political posts, the UN's mandatory retirement age has been pegged at either 60 or 62 years. Furthermore, Kofi Annan, UN Secretary General, recently expressed his desire to lower the average age of the UN work force from its current level of 49 years. Ambassador Alvarez challenges both Annan's position and the mandatory retirement age. She would like to see a reaffirmation of the Declaration of Human Rights which condemns age discrimination and recognizes the interdependence of people of all ages. Personally promoting such interdependence, Ambassador Alvarez and her husband established the Center on Aging in the Dominican Republic, donating their home to the cause. The center hired retired teachers living in poverty and trained them to teach basic skills such as hand washing and teeth brushing to preschool children. Children in the program were given breakfast and offered some basic medical care, such as oral rehydration therapy for diarrhea. Participation in the center's program has grown from 12 teachers and 200 children to the current level of 1000 children. In addition to the preschool program, a $10,000 grant to the center funds a revolving loan fund which lends small amounts to help older people start small businesses.
There is no such thing as aging. Old age is associated with disease, but does not cause it.
Taking all diseases together, except for deaths from accidents and violence, the total death rate in developed countries is 500 times greater at age 80 years than at age 20. For vascular disease, chronic respiratory disease, and cancers of the digestive or respiratory tract, the ratio is more than 1000:1. Natural selection acts much more strongly against death in early adult life than against death in old age. All major adult diseases will therefore tend to be more common in old age than in early adulthood. Once many different age related phenomena are fully understood, some will probably have part or all of their mechanisms of origin in common, but some may not. In order to avoid confusion, one should accept for now that the underlying mechanisms may be different and refrain from referring too often to an undefined physical concept as the aging of a tissue or an individual. Just because a wide range of adult diseases typically develop in the same part of the life span, it does not necessarily follow that they have similar underlying mechanisms, nor that any one underlying change awaits discovery which could properly be called aging. The many diseases of old age largely share a common teleology rather than a common etiology.
Demographic aging requires major changes across society and in the delivery of health care. Overall, people are living longer than they used to and aging has become an important issue. Only 17% of Britons born 150 years ago reached age 75, while 66% of people born today will reach that age. The proportion of people over age 60 in Britain's population will grow from the current level of 20% to comprise 33% by 2030, and people over age 80 comprise the fastest growing segment of the population. In 1951, Britain had 300 people over age 100; by 2031 it will have 34,000. A comparable growth in the numbers of elderly has been observed in other developed countries. Recently industrialized countries are experiencing a much more rapid transition in their age structure. Much remains to be learned about the impact of population aging upon the developing world. Societies need to change as birth rates fall and life expectancy rises. This paper presents a brief overview of articles in the British Medical Journal's theme issue upon aging.
The "impending" AIDS catastrophe] [letter]
The editor of the South African Medical Journal (SAMJ) should not refer to South Africa's AIDS catastrophe as impending, for it has already arrived. South Africa's public hospitals are already basically AIDS hospitals. Furthermore, it is irresponsible for the editor of SAMJ to claim that South Africa has almost gone beyond the point at which prevention and health education can make a difference. The country's President, Minister of Health, chiefs, religious and community leaders, teachers, editors, and other influentials should send a blunt, belated, mass media message to the public of their need to change lifestyles, practice safe sex, and respect women's rights in the interest of avoiding an early, horrible death due to AIDS. The biggest media effort to date has been a poorly presented play offering questionable advice about the power of the condom. The Minister of Health and researchers are condemned on the Virodene issue, and SAMJ should have commented upon the Sarafina 2 debacle.
Female genital mutilation: international NGOs and advocacy groups active in the field of FGM.
A selected list of nongovernmental organizations (NGOs) and advocacy groups active in the field of female genital mutilation (FGM) is presented. An attempt was made to identify groups with interests and activities which extend beyond their national boundaries. However, since new organizations are rapidly being formed to address FGM and increasing numbers of health and human rights organizations are devoting attention to the subject, this list is not comprehensive. The names and mailing addresses of 20 groups in the US, Europe, Senegal, and Ethiopia are listed. A subsequent roster of inter-African committees, national committees, and other groups and contact persons in Africa is also presented. The names and mailing addresses of 53 committees and contacts are presented, as well as telephone numbers in some cases.
Promoting Women in Development through Advocacy and Research (PROWID).
Aiming to promote the full participation of women in development, the Office of Women in Development funded Promoting Women in Development through Advocacy and Research (PROWID) in 1995, a 4-year grants program to be implemented by the International Center for Research on Women (ICRW) and the Center for Development and Population Activities (CEDPA). PROWID supports gender-related, operations research which promotes policies and programs sensitive to women's development needs; tests innovative pilot projects designed to enhance the economic, political, and social status of women; and supports advocacy programs which offer women the opportunity for greater participation in political, civic, and community life. PROWID will award more than 30 grants over the program period. Funding focuses upon key areas such as economic growth, political participation, violence against women, the environment, and reproductive health and rights. Program implementation is described.
Domestic violence: the cost to society, the challenge to development.
The United Nations defines domestic violence as violence which occurs within the private sphere, mainly between individuals who are related through intimacy, blood, or law. Such violence is a problem which occurs in every country of the world and is perhaps the most insidious form of gender violence. Available data on domestic violence indicate that from 25% to more than half of all women worldwide have been physically abused by a present or former intimate partner, while an even larger proportion have experienced ongoing emotional and psychological abuse. However, even though domestic violence takes place so extensively, societal norms discourage women from speaking out about the domestic abuse they suffer. Shame and the fear of reprisals from the abuser, his family, and the community intimate victims. Moreover, women may accept physical and emotional abuse as a husband's right, causing women to view some violent behavior as less than violent. Some cultures also blame women for provoking a husband's violence. Women may not speak out against the abuser or press charges because they depend upon the man for economic support and their cultural identity. For example, throughout Asia and Africa, women cannot sustain themselves and their children if they disengage from extended families. In many countries, battered women who leave an abusive marriage risk losing their income, children, shelter, land, and social standing. The lack of comprehensive data on the nature and extent of domestic violence, domestic violence as a development issue, and a framework to address domestic violence are discussed.
First International Congress on Population Education and Development.
Resolution 5.3, adopted by the General Conference of UNESCO at its 26th session in 1991, authorized the Director-General to organize, jointly with the UN Population Fund (UNFPA), the first International Congress on Population Education and Development (ICPED). Congress aims were to review trends in population education worldwide over the past 2 decades, to adopt a declaration upon the role of population education in human development, and to devise an action framework in the field. The congress was also held to strengthen the integration of population education into formal and non-formal education systems. At the invitation of the Turkish government, the congress was held in Istanbul during April 14-17, 1993, during which 93 countries were represented and 245 participants attended, including 20 ministers of education and 5 deputy ministers. The 27th session of the General Conference of UNESCO in Paris during October-November 1993 welcomed the conclusions of the first ICPED and endorsed its declaration. Member states, nongovernmental organizations, and governmental agencies are encouraged to implement the principles and activities suggested in the declaration and action framework.
A world's eye view of adolescent issues.
In 1994, governments and nongovernmental organizations met in Cairo to strategize about future population and development. In 1995, governments and nongovernmental organizations met in Beijing to discuss women's status. Adolescents, especially their reproductive health status, were topics of discussion and policy at both conferences. Adolescent sexuality and sexuality education were among the most controversial and debated issues during the 1994 International Conference on Population and Development (ICPD) in Cairo. Despite the consensus reached at the ICPD, many countries remain divided upon the focus, content, and effectiveness of sexuality education, as well as the role of governments in providing sexuality education to youth. This discord of sexuality education affects efforts in the US and developing countries to effectively address adolescent reproductive health. However, the greater acceptance of sexuality education in Western Europe appears to have resulted in lower birth and abortion rates among adolescents in the region. The levels of adolescent pregnancy and approaches to sexuality education in the US, the Netherlands, and Sweden are described.
Rubella, known as German measles, is a mild exanthematous viral infection of children and adults. If infection occurs during gestation, rubella can affect both pregnant mothers and newborn infants. Maternal rubella infection during the first trimester of pregnancy will likely lead to either abortion or the birth of infants with defects. Congenital rubella can affect many organ systems. Immunization against rubella is conducted mainly to prevent high fetal loss, including miscarriages, stillbirths, and the serious malformations which result from maternal infection during the first trimester of pregnancy. Immunization against rubella is usually done as measles, mumps, rubella (MMR) vaccine in the US and other developed countries. The vaccine is administered to young children, prepubescent girls, adult women, and other adults. In India, the Indian Academy of Pediatrics recommends administration of MMR at age 15-18 months. Simple rubella vaccine will be given to girls and women who were not immunized as children. Immunization strategy in Sri Lanka, the US, the UK, and India is discussed.
Blood donors in Brazil have recently begun to be screened for infection with HTLV types 1 and 2. Of 351,639 blood donations screened in Sao Paulo from January 1992 to October 1993, 1063 positive and 2238 indeterminate samples were identified based upon serologic confirmation using the 21e Western blot. Detailed serologic, molecular, and virologic analysis, based upon a laboratory diagnostic algorithm for the characterization of HTLV-1 and HTLV-2 infections, was conducted upon 50 seropositive or seroindeterminate blood donors. 2.3 Western blot serologic assays, which incorporate type-specific recombinant peptides, performed in 29 HTLV 1/2 positive and 21 HTLV 1/2 indeterminate donors with the 21e Western blot identified 25 as infected with HTLV-1, 4 with HTLV-2, 5 with untypeable HTLV 1/2, 15 as HTLV 1/2 indeterminate, and 1 as seronegative. Polymerase chain reaction (PCR) analysis using DNA amplification of proviral pol and tax sequences from peripheral blood mononuclear cells confirmed HTLV-1 and HTLV-2 infections in all 2.3 Western blot seropositive donors. Of the 5 serologically untypeable donors, 3 were found to be HTLV-1-positive, 1 HTLV-2-positive, and 1 negative by PCR. All seroindeterminate donors were also negative by PCR. HTLV-1 could be isolated in cocultures from 10 of 18 infected donors.
Role of private practitioners in tuberculosis control in India [editorial]
Tuberculosis (TB) continues to be one of the most prevalent infections in the world despite efforts to eliminate it. Almost 1.9 billion people are infected with TB worldwide, although 90% of those infected do not develop disease during their lifetimes due to either acquired immunity or immunization with BCG vaccination. There are, however, more than 20 million active TB cases worldwide, with 85% of the burden of TB cases being in developing countries. An estimated 3 million people die annually from TB, with TB deaths outnumbering the annual death toll due to AIDS, malaria, cholera, and other tropical diseases combined. It is estimated that unless TB control programs become more effective, the current estimated annual incidence of 8 million cases of disease could reach 10.4 million by 2000 and 12.1 million by 2005. Half of the TB cases in developing countries are in India, in which private practitioners treat more than half of all TB patients. The National TB Control Program cannot be successful unless it involves private practitioners, as partners in the prevention and control strategy. The Indian Medical Association (IMA) can do much to help control TB in India.
Unchecked perinatal mortality in India -- problems and challenge [editorial]
Levels of perinatal mortality (PNM) are falling in India. To reduce PNM in India, the following measures should be taken: improvements in the socioeconomic conditions and literacy rates, the creation of awareness of the need for universal antenatal coverage at different levels by trained medical staff, referral facilities for high-risk cases at different levels and elective referral to reduce the occurrence of emergency admissions, immunization against tetanus, measures to reduce the incidence of low birth weight with enough antenatal leads in the referral units for high-risk cases, perinatal audits, improved detection and management of medical complications and pregnancy-induced hypertension, better detection and management of intrauterine growth retardation, better surveillance during labor, intensive care of high-risk neonates, training facilities for residents and postgraduates in neonatal pediatrics, and the periodic organization of seminars and workshops to evaluate results.
College students' illusions regarding their vulnerability to risks related to sexual intercourse affect their contraceptive behavior. The authors explored the influence of the illusion of fertility control and attachment tendencies upon contraceptive behavior among 141 male and 251 female self-selected undergraduate students at a small Midwestern university during fall 1993 and spring 1994 semesters. The illusion of fertility control scale (IFCS) was designed to measure the extent to which aspects of the situation present at last intercourse foster an illusion of fertility control. The IFCS attempts to measure the degree to which people believe that they completely control their own fertility, when they are actually taking some degree of fertility risk. 79% of the students were aged 16-24, with the rest older, 90.56% are White, 6.89% Black, 76.3% never-married, 16.6% currently married, and 18.6% had children. Study findings are based upon the analysis of responses from those sexually experienced, never-married, and aged 16-24 years. Multiple regression analyses determined that illusion of fertility control and attachment style were related to contraception, and that 2 subscales of the IFCS were related to contraception. More precisely, a belief in bodily control was associated with less effective current contraceptive use. Females who felt more independence from their partners in making sexual decisions were characterized by a higher contraceptive failure rate. Furthermore, people with a dismissing attachment style reported a history of less reliable contraception.
Surprising decline in Iran's growth rates.
According to Iran's 1996 census, the country's population was 60 million, about 6-7 million people fewer than estimates used by the UN and other international organizations. These findings surprised Iranian demographers and have been examined with skepticism outside of the country. However, if Iran's 1986 and 1996 censuses are comparable and children were not undercounted, these results indicate a remarkable decline in fertility. The proportion of Iran's population under age 5 years fell from 18% in 1986 to 10% in 1996. An Institut National d'Etudes Demographiques, Paris, study published in 1996 estimated that Iran's total fertility rate (TFR) fell from an average of 6.2 children/woman in 1986 to 3.5 in 1993. However, based upon analyses of sample surveys, the Iranian government's health ministry reported that the TFR dropped from 5.0 in 1991 to 3.3 in 1995. Irrespective of questions over the magnitude of Iran's fertility decline, it is clear that the Iranian government is committed to limiting population growth. The UN Population Fund considers Iran's family planning program to be one of the world's best-functioning, with the Ministry of Health Care and Medical Education providing free contraceptives. A bill was passed in 1993 which penalizes couples who have more than 3 children and posters around the country encourage the one- or two-child family. Iran's family planning program is integrated into the national primary health care system and provides a broad range of reproductive health services to women. The program is also the only one in the region which promotes both male and female sterilization.
Africa's culture war: old customs, new values. Human rites.
Ancient Ewe religious custom maintains that for serious offenses such as murder, rape, and theft, the spirits can be appeased only through the enslavement of young virgins from the offender's family in the shrines of traditional priests. The bondage of such girls, including their sexual enslavement to the priests, is a custom more entrenched and longer standing than Western law in Ghana. Recent press reports in Accra, Ghana's capital city, have exposed the tradition to the general public. Legislators are now debating how to eradicate the custom through which as many as 10,000 girls may be enslaved. However, the enactment of legislation will have little, if any, effect upon the practices of the Ewe. Molded over many generations, Africa's traditions will be changed only through gradual persuasion and patient persistence. Throughout much of Africa, practices such as the ritual slavery of the Ewe, female genital mutilation (FGM), polygamy, witchcraft, ritual sacrifice, and demon worship coexist with the modern world and show no sign of being abandoned any time soon. FGM in Sierra Leone is discussed.
The ritual: disfiguring, hurtful, wildly festive. Grafton journal.
Refugees in Grafton, Sierra Leone, will soon be going home. To celebrate the upcoming move, refugee women have been engaging in the ancestral communal ritual of Bondo. Since Christmas, as many as 600 women in one refugee camp have communed in small groups for a week or two at a time to dance, drink, feast, share lessons about womanhood, and have their external genitals cut off. Long practiced, the Bondo ceremony was traditionally part of an exclusive female secret society which, unlike most tribal rites in Africa, brought Sierra Leonian women together across ethnic and religious lines. It has been estimated that in less than 1 month, 4000 or more women in neighboring refugee camps have engaged in the Bondo ritual in preparation for their return to rural homes. Bondo, and the female genital mutilation (FGM) which is part of the ceremony, is deeply entrenched and supported by the overwhelming majority of women in Sierra Leone. By some estimates, as many as 90% of the country's women have undergone FGM. In many other parts of Africa, however, FGM is under siege and in retreat in the face of new legislation against the practice, education targeted to women, and even preaching against the ritual by Muslim clerics.
Man is a tourist town deep in the interior of Cote d'Ivoire. After undergoing female genital mutilation (FGM), pubescent girls in Man receive gifts of money, jewelry, and cloth, and their families honor them with lavish celebrations attended by hundreds of relatives and friends. Among the Yacouba people of Man, FGM is part of a girl's dreams of womanhood, a father's desire to show off with a big party, and a family's way of fitting in with social convention. Men who have not had their daughters excised are not allowed to speak at village meetings and no man in the village will marry unexcised women. News of efforts being made in countries across Africa to eradicate the practice of FGM barely reaches out of the way places like Man. The tradition of FGM is an integral component of the lives of hundreds of ethnic groups in 28 countries across Africa. Most prevalent among Muslims, FGM is also performed by Christians and followers of traditional African religions. The practice is more widespread among the illiterate, but it is also common among the educated. Levels of FGM are slowly being reduced in some areas of Africa.
Woman betrayed by loved ones mourns a double loss.
At age 15, Mariam was dating and having sex with her childhood sweetheart, Idrissou Abdel Razak. Without informing Mariam, Idrissou and his parents obtained the permission of Mariam's family for the two youths to marry. Idrissou and his parents also asked Mariam's parents to have her genitals removed without giving her advanced notice that the procedure would take place. On the day of the genital excision, Mariam was locked in her room by her family, and 6 women were sent in to forcibly cut off her clitoris and genital lips. Mariam was subsequently rushed to a hospital because her wound would not stop bleeding. She developed an infection in the hospital and remained there for 3 weeks. Idrissou and Mariam eventually got married about 7 years later. They both agree that Mariam no longer experiences the sexual pleasure enjoyed during intercourse before the removal of her external genitalia. Mrs. Razak, now age 24, also believes that the excision and the infection it caused are responsible for her inability to bear children. Mr. Razak has nonetheless vowed to remain married to his wife even if she has been rendered infertile. Furthermore, should Mariam become pregnant and bear daughters, Mr. Razak has vowed to send them out of the country to prevent them from being subjected to female genital mutilation.
The common good. The Canadian bishops and the public debate on contraception.
Until 1969, contraception was illegal in Canada. It was, however, permissible for those who could prove that the actions which led to their criminal charge served the public good. Since the Catholic church was known to oppose the use of contraceptive devices, Protestants, Catholics, legislators, and citizens in the early 1960s believed that the Roman Catholic church would oppose all efforts to remove contraception from Canada's Criminal Code. In 1966, however, the Canadian Catholic Conference (CCC) did not oppose an amendment to decriminalize contraception. The author lists members of the Canadian Catholic hierarchy who supported a change in doctrine on contraception. The debate within the Catholic church, the Canadian Catholic hierarchy, and among parishioners over contraception is described. The bill decriminalizing contraception finally received Royal Assent on June 27, 1969. Although Pope Paul VI had issued Humanae Vitae, his encyclical proscribing birth control, in 1968, the public debate in Canada was long over and Canadians were soon to enjoy the legal use of contraceptive methods.
Reproductive health in India's primary health care system.
India's family planning program having reached a dead end, the government of India appointed an expert group to develop a new population policy for the country. While the group's report, submitted in May 1994, proclaimed a new orientation described as pro-poor, pro-nature, and pro-women, the recommendations of the report were criticized as not being serious about gender equity. The government of India, describing a new reproductive health care approach, envisions a paradigm shift in the family planning program strategy. Reproductive health is defined as a state in which people can reproduce and regulate their fertility, women are able to go through pregnancy and childbirth safely, the outcome of pregnancy is successful with regard to maternal and infant survival and well-being, and couples are able to have sexual relations free of the fear of pregnancy and of contracting disease. To further the discussion on the newly initiated reproductive health care approach, the faculty of the Center of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi, organized a workshop for November 4-5, 1996, on the place of reproductive health in India's primary health care. The workshop brought together public health persons, clinicians, and health and women's rights activists. The author outlines the content of papers presented at the workshop.
Western hemisphere leading the way in disease eradication.
National immunization programs in the Americas are fine examples of what mankind can achieve through the appropriate use of technology, global collaboration, and political will for the benefit of all. Over the past 20 years, Western Hemisphere countries have led the world in the war against vaccine-preventable infectious diseases. In September 1985, the 31st Meeting of the Pan American Health Organization's (PAHO) Directing Council established the goal of eradicating the indigenous transmission of wild poliovirus from all countries of the Americas by 1990. Investigations of more than 4000 stool specimens by 1991 identified wild poliovirus transmission in only Colombia and Peru. In September 1994, and following an extensive review of surveillance information, key polio surveillance indicators and laboratory results throughout the region, the International Commission for the Certification of Poliomyelitis Eradication (ICCPE) declared that transmission of wild poliovirus had been interrupted in the Americas. PAHO's recommended measles vaccination strategy has led to the interruption of measles transmission in major geographic areas of the Americas, but the disease still circulates freely elsewhere in the world. Cases of neonatal tetanus (NNT) continue to decline due to PAHO's recommended strategy of vaccinating women of childbearing age with at least 2 doses of tetanus toxoid vaccine, especially in high-risk areas for the disease. NNT is endemic in 16 countries in the Americas.
Orphanhood, child fostering and the AIDS epidemic in rural Tanzania.
HIV prevalence is only moderately high in Kisesa ward, Mwanza Region of northwest Tanzania, but overall adult mortality was probably high during the decades before the AIDS epidemic. The authors present data on orphanhood and child care patterns from that rural area of approximately 20,000 inhabitants, of whom more than 90% belong to the Sukuma tribe, the largest ethnic group in Tanzania. Of the 10,015 children identified in the baseline census, 8.9% under age 18 years and 7.6% under age 15 years were orphans. There was a rapid increase in the proportion orphaned by age: from 3.0% under age 5 years to 18.1% at age 15-17 years. The majority of orphans were paternal orphans, although some were maternal orphans or children with no living parent. Among single parent orphans, it was common for the remaining parent to live elsewhere. Child fostering was very common, with 34.2% of all children under age 18 not living with one or both biological parents. The main reasons for the father not being with the child are premarital child (37.1%), divorce (29.1%), and living with another wife (14.8%). The main reasons for the mother not being with the child are divorce (64.5%) and premarital child (11.4%). Work was seldom a reason for the parent not being present. Differences between households, caretakers, AIDS mortality, schooling, and mortality and migration in the study population are discussed.
Impact of the HIV-1 epidemic on orphan mortality in a rural Ugandan population cohort.
AIDS-related mortality is responsible for the creation of more than 40% of orphans in Uganda's rural populations. The HIV epidemic also contributes directly to childhood mortality. Children under age 15 years in a rural population cohort in southwest Uganda of approximately 10,000 people in 15 neighboring villages were followed from 1990/91 to 1994/95 to establish mortality rates for the period. 4975 children were identified, of whom 10.4% were orphans. 6.3% of all children had lost their father, 2.8% had lost their mother, and 1.3% had lost both parents. Overall HIV-1 prevalence for all ages and among children remained at 5% and 1%, respectively, throughout the study period. 10 of the 32 HIV-seropositive and 110 of the 4562 HIV-seronegative children died over the 4-year follow-up period. 2 of the 10 HIV-seropositive deaths and 9 of the 110 HIV-seronegative deaths were of orphans. Data presented and analyzed indicate the existence of an association between HIV-1 and orphanhood and child and mothers' mortality. However, no convincing evidence was found of increased mortality for orphans after allowing for age and HIV status. The current capacity of this community to cope with its orphans could be overwhelmed if the burden of orphans increases.
Projecting the HIV / AIDS epidemic in southern Africa.
Data are presented from a search of the US Bureau of the Census's HIV database update for 1996. 295 prevalence estimates were found for the countries of southern Africa, with 50 more estimates found for Kenya. The data are presented for Angola, Botswana, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia, Zimbabwe, and Kenya. The search found no national estimates based upon community samples; national-level estimates based upon blood donor samples are available only for Lesotho, South Africa, and Zimbabwe; national-level estimates based upon antenatal samples are available for South Africa and Swaziland; more than 60% of the sources are based upon antenatal estimates of selected clinics which are not representative of the entire country; many studies related only to urban areas; and there has been a shift over time from estimates based upon blood donor samples to antenatal samples. Trends in HIV prevalence in the countries of southern Africa and the percent of HIV deaths from infections after survey are displayed together with a discussion of what is needed to project the future of the epidemic and fitting sigmoid curves to observed prevalence levels. The following are projected for Kenya, Zimbabwe, and South Africa out to 2010: HIV incidence, AIDS incidence, crude death rate, orphan incidence, the proportion of death due to HIV-1 infection, population age structure, and population growth, population size, life expectancy, mean age of working population, and maternal orphanhood with and without HIV-1.
Towards optimisation of the HIV / AIDS modelling process in South Africa.
South Africa is beginning to feel the impact of the HIV/AIDS epidemic in terms of growing morbidity and mortality, health and social welfare costs, productivity losses, and perceived threats to market growth. South Africa will continue to experience increasing prevalence rates already seen in other African countries and previously predicted by a number of HIV/AIDS modelers. The authors consider whether such models are adequate, whether they have been clearly understood, and whether they are being appropriately used. The authors first review HIV/AIDS modelling techniques, then elaborate upon the currently most widely used and accepted South African model. The Doyle model is described in detail, followed by a discussion of modelling beyond the insurance industry. The modelling process can help efforts designed and implemented to control the HIV/AIDS epidemic, and in understanding its potential impact upon market opportunities. The Doyle model appears robust enough to provide the demographic output required and is able to be adapted for many applications.
Projecting the epidemic: policy makers and planners needs.
In general, policymakers and planners in developing countries have not responded to the AIDS epidemic and or its consequences, partly due to denial and partly out of ignorance of the magnitude of the problem and what can be done about it. This inaction is both frustrating and inexplicable. The author considers the implications of the epidemic and how demographers should respond. The implications of the HIV/AIDS epidemic are first described, followed by what planning attempts to do, efforts to put HIV/AIDS into policy making and planning, why issues are not considered, what can be done, and how such action can be taken. The HIV/AIDS epidemic will have demographic, economic, and development effects upon the country. Experiences including AIDS in planning are described for Swaziland and KwaZulu-Natal.
Since the late-1970s, data from large-scale national surveys and decennial censuses have been routinely used to estimate child mortality levels in developing countries. There has been a particularly increased reliance in sub-Saharan Africa during the 1980s and 1990s upon data from the Demographic and Health Surveys (DHS) program for the population-based assessment of changes in rates of infant and child mortality. Almost all countries in the region have experienced substantial declines in the under-5 mortality risk. Periodic sample surveys have performed well in monitoring recent trends in early childhood mortality, but have been less capable of providing a straightforward basis for tracking adult mortality rates. Recently obtained sibling history data from Demographic and Health Surveys in Uganda, Zimbabwe, Central African Republic, Cote d'Ivoire, and Malawi, and birth history data were used to estimate levels of adult and childhood mortality. The study intended to demonstrate that direct mortality estimates from sibling histories provide an additional tool to complement estimates derived from longitudinal and other cross-sectional mortality data in the evaluation of AIDS impact. As for childhood mortality, a survival bias causes an underestimate in the under-5 mortality rate level and tends to mask real declines in mortality or amplify increases if no adjustments are made.
HIV-1 and fertility change in rural Zimbabwe.
This paper considers the demographic effects of HIV-1 epidemics in sub-Saharan African contexts with particular reference to fertility. The authors focus upon identifying possible ways in which an HIV-1 epidemic and responses to it can affect birth rates, through the proximate determinants, and review evidence from a small-scale study in rural Zimbabwe which suggests that early changes are taking place. The net effect of those changes will most likely be an intensification of pre-existing downward pressures upon total fertility. The demographic effects of HIV-1 epidemics upon sub-Saharan African populations can be extensive and complicated. Contemporary fertility trends can have a major influence upon the nature of many of those effects, through population dynamics. Moreover, attitudes and practices related to reproduction can influence the pattern of risk behavior for HIV-1 transmission and the nature of the behavior changes most likely to be adopted. Behavior and biological changes associated with HIV-1 prevention can result in shifts in the proximate determinants of fertility. Additional findings are presented and discussed.
Estimates of the impact of HIV-1 infection on fertility in a rural Ugandan population cohort.
The impact of HIV-1 infection upon fertility was assessed in a rural population of approximately 10,000 subsistence farmers in 15 neighboring villages of Masaka, enrolled in 1989/90 and followed annually. The study involved 3684 women aged 15-49 who experienced 2268 births over the follow-up period, a general fertility rate of 198.6/1000 and a total fertility rate of 6.2 births. Approximately half of the women were under age 25 years, more than 53% were married, 4% were widowed, and 12% were divorced. Definitive serostatus was determined for 78%. 9% of the women were infected with HIV, a higher proportion than the 8% overall prevalence in the adult population. 24% had ever been exposed to syphilis. Highest fertility by age was among women aged 20-24 at more than 300/1000 and among teenagers at 167/1000. Fertility rates declined over the 6-year follow-up from 232/1000 in year 1 to 187/1000 in year 6. HIV prevalence was highest among women aged 20-24 at 21% and among the divorced at more than 20%. HIV infection was slightly more prevalent among women with past exposure to syphilis, a difference of only marginal statistical significance (P = 0.05). The general fertility rate among HIV-seropositive women was 192/1000 women, lower than the rate of 212/1000 among HIV-negative women. The lower fertility among HIV-positive women was seen in every age group except among women aged 15-19. HIV-infected women in this population have 20% lower fertility than uninfected women and the population impact of HIV is approximately 2%. The reduced fertility among HIV-infected women could be due to co-infection with other sexually transmitted disease.
Reduced fertility in women with HIV infection; a population-based study in Uganda.
Pregnancy was investigated among 4813 sexually active women aged 15-49 in rural Rakai District of southwestern Uganda who reported at least one sex partner during the previous year and provided a blood sample for HIV serology. 19.3% were pregnant, with 83.7% of those pregnancies reported by the woman and 16.3% detected by urinary hCG. 953 (19.8%) women were infected with HIV-1. The prevalence of HIV infection varied by age from 7.3% among women aged 15-19, 26.5% in the 20-29 age group, 21.7% in women aged 30-39, and 9.7% in women aged 40-49. The prevalence of active syphilis was 9.3%. 21.4% of women infected with neither HIV nor syphilis were pregnant, compared to 14.2% of HIV-negative women with active syphilis, 8.5% of HIV-positive women with syphilis, and 13.4% of HIV-positive women without syphilis. The age-specific pregnancy rates were lower in the HIV-infected than in the control women in all age groups. However, among the HIV-negative women with active syphilis, the reduction in pregnancy rates was mainly observed in the youngest age group 15-19. These younger women are likely to have relatively recent infections; early syphilis has a severe impact upon pregnancy loss. Among the 953 HIV-infected women, 87.4% had no symptoms or signs suggestive of clinical HIV disease; 14.3% of these asymptomatic subjects were pregnant. Only 7.5% of 120 symptomatic HIV-infected women were pregnant. Pregnancy rates in the symptomatic HIV-positive women were 0% in 5 women with herpes zoster, 5.9% in 34 women with chronic cough, 6.5% in 31 women with oral candidiasis, and 8.8% in 80 women who reported weight loss.
Household composition and the HIV-1 epidemic in a rural Ugandan population.
The authors examined the nature of changes which have occurred in different household structures during the HIV epidemic in rural Rakai District of southwestern Uganda, and which structures have been the most affected by the HIV epidemic. The approximately 10,000 inhabitants spread over 15 neighboring villages were enrolled in 1989/90 and followed annually. A household is a group of people who normally live and eat together, while the head of household owns the house, but is not necessarily the main income earner. An average of 1979 households were sampled per round, of which 26% were female-headed. The average household was comprised of 5.14 persons. 10 household structures were identified in the study area. The study identified a significant increase in the three extended household structures, while the proportion of monogamous households without children decreased significantly. There was no significant change over time in the proportion of female-headed households nor in dependency ratios either overall or for the different household structures. Despite high HIV prevalence, households headed by children remain very rare in the area. Male heads of monogamous households without children and male-headed disrupted households are at increased risk of HIV infection. The HIV prevalence among heads of households at greatest risk did not increase significantly over the study period.
HIV infection in rural households, Rakai district, Uganda.
The authors summarize HIV-related prevalence and mortality data from the Rakai District of southwestern Uganda, and provide information upon selected effects of the HIV epidemic upon households. Findings are based upon annual samplings of 1945 households between 1990 and 1992. Typical of rural African communities, 49.5% of the population was under age 15 years. Women aged 15-49 years comprised 21.3% of the cohort, consistent with 1991 National Census data for Rakai. In 1990, the first year of the expanded cohort study, 34.6% of people aged 13 and over in trading centers were infected with HIV, 21.0% in the trading villages, and 11.0% in the rural, agrarian villages. 47.0% of households in trading centers and 20.3% in villages had at least one resident HIV-infected adult. HIV prevalence was higher among heads of households than in the general adult population, with 43% of trading center household heads infected, 27% in trading villages, and 13% in rural villages. It is concluded that for the district overall, an estimated 27% of all deaths would be averted in the absence of HIV infection. However, the increase in annual mortality which has occurred as a result of the HIV epidemic has not reversed population growth. There are an estimated 29,000 orphans in the district. 7.5% of the district's population is therefore comprised of children who have lost one or both parents. Most of these orphans appear to have been absorbed into existing families.
Five-year HIV-1 associated mortality in a rural Ugandan population.
Findings are reported from a study conducted to measure the impact of HIV-1 infection upon mortality rates in rural Rakai District of southwestern Uganda over a 5-year period. The population of approximately 10,000 inhabitants was spread over 15 neighboring villages, was enrolled in 1989/90, and then followed annually. 8853 of 9777 people resident in the study area in 1989/90 had an unambiguous HIV-1 serostatus; adult HIV seroprevalence remained approximately 8% throughout the period of follow-up. During 35,083 person-years of follow-up, 459 deaths occurred, 273 among seronegative individuals and 186 among those seropositive. This mortality corresponds to standardized death rates of 8.1 and 129.3 per 1000 person-years, respectively. Standardized death rates among adults were 10.4 and 114.0, respectively. The HIV-1 attributable mortality fraction was 41.1% for adults and more than 70% for males aged 25-44 and females aged 20-44 years. Life expectancy from birth among the resident population is estimated to be 42.5 years, lower than the 58.6 year expectancy among people known to be HIV-seronegative.
Levels and causes of adult mortality in rural Tanzania with special reference to HIV / AIDS.
Findings are reported from a study conducted in Kisesa ward of Mwanza Region, Tanzania, to assess the levels and causes of adult mortality related to HIV infection and AIDS. The ward, about 20 km east of the regional capital Mwanza and along the main road to Kenya, has a population of approximately 20,000. Kisesa ward is comprised of 6 villages. A baseline census of all households was conducted in 1994, and by mid-1996, a total of six rounds had been completed. Findings are based upon the analysis of both quantitative and qualitative data. Overall mortality rates for men and women aged 15-59 years were 10.8 and 10.0 per 1000 person-years, respectively, with a comparable age pattern between the sexes. There was, however, slightly higher mortality among men under age 45. Verbal autopsies were conducted for 141 of 160 deaths. Communicable and reproductive conditions accounted for 62.5% of all deaths. HIV/AIDS mortality was associated with 35% of all deaths, and was the leading cause for both sexes (30% of male and 39% of female deaths). Among 50 deaths classified as HIV-associated, there were 30 deaths with clinical AIDS but no tuberculosis (TB), 13 with AIDS and TB, and 7 deaths among HIV-positives with no clinical AIDS. These latter included deaths due to malaria, hepatitis, neoplasm, and 4 deaths with no other diagnosis than a positive HIV test. No cause of death could be determined for 15% of cases. Mortality in Kisesa, with an HIV prevalence of about 6% in 1994-95, has increased by about one-third due to HIV/AIDS, and will likely increase further.
A review of the few studies available on the causes of adult death in sub-Saharan Africa is presented with the goal of identifying the importance of AIDS relative to other causes of death among adults. The author first reviews the available evidence upon the age pattern of AIDS mortality, then focuses upon the magnitude of AIDS deaths. There is a large and growing impact of HIV/AIDS in many African countries. The proportion of deaths attributable to HIV/AIDS appears to be increasing relative to other causes of adult mortality in selected study locations in Africa. There is an urgent need to conduct more research upon causes of adult death in sub-Saharan Africa, for the existing database is weak and ridden with large gaps. No definitive conclusions can therefore be reached about the relative magnitude of HIV/AIDS mortality on the sub-continent. It is, however, clear that in countries of high HIV prevalence, AIDS is increasingly becoming the leading cause of adult mortality.
Reconstructing the dynamics of the HIV / AIDS epidemic in Abidjan, Cote d'Ivoire, 1986-1995.
A major and continuous increase in mortality of adults aged 15-59 years began in Abidjan, Cote d'Ivoire, in 1986, when the first cases of AIDS were documented, reversing the previous declining trend. That increase was ongoing in 1995. Trends in the mortality of children aged 5-14 also reversed at about the same time, but the increase was less marked and stopped after 1989. This increase in mortality was attributed to HIV/AIDS and to related opportunistic infections. A back calculation model using a 5th degree polynomial and data on the series of registered deaths was developed to reconstruct the dynamics of the epidemic among men, women, and children in the city. The first step was to estimate the number of deaths attributable to HIV/AIDS by analyzing the changing death rates over the period 1973-95. Among men, there was a major peak in incidence in 1987-88, followed by a fast decline. Among women, two peaks of incidence were identified, one in 1985 and the other in 1991. Among older children, most of the infections seemed concentrated in 1984-85.
All mainland sub-Saharan African countries and most other developing countries lack complete and accurate civil registration systems. Moreover, most deaths occur outside of the hospital. It is therefore very difficult to measure levels of adult mortality in such populations. A relatively cheap and direct alternative method of generating information upon mortality is to ask questions in a national census or single-round household survey about deaths in the past year. These questions, however, have proved unreliable and often yield incomplete data. Respondents may find it difficult to recall exactly when a death occurred and often have little idea of the ages of those who have died. The deaths of adults who lived alone are unlikely to be reported. Moreover, not everyone is attached clearly to a single household. It is nonetheless important to monitor the levels and trends of such mortality in the context of the large-scale AIDS epidemics which have developed in much of Africa and some other countries. The authors review the existing limitations of methods used to estimate adult mortality in the developing world and the additional obstacles to producing such estimates which arise in populations with substantial mortality from AIDS.
HIV prevalence and life-time risk of contracting HIV / AIDS.
HIV prevalence is the most commonly used index for measuring the scale of the HIV epidemic. In Kenya, the National AIDS Control Program estimated that in 1995, 7.5% of the population aged 15 and over were infected with HIV. One could therefore infer that 7.5% of Kenya's population could expect to contract AIDS during the course of their adult lives. The lifetime risk, however, is much greater than the overall prevalence of infection. The relationship between prevalence and lifetime risk is not straightforward, with other factors involved in determining lifetime risk. The authors explore these factors and develop a method of calculating lifetime risk in Third World countries with limited and defective data. Mortality from causes other than AIDS, age at infection, survival time after infection, fertility, and child and adult risks are discussed. Available data and the developed model suggests that while an estimated 7.5% of Kenya's population was infected with HIV as of 1995, almost 33% of children born in Kenya will die of AIDS, while the remainder will die of other causes.
HIV/AIDS will have a devastating effect upon societies, communities, families, and individuals throughout sub-Saharan Africa. Epidemiological data are needed in order to indicate how many people are affected. This paper focuses upon epidemiological data, such as data sources, target populations, those who collect, types of data, and the range of variables. The authors then consider the usefulness and limitations of the data and make recommendations for improvements to ease their use by decision makers. Data requirements for the type of planning decisions made in selected sectors are described. To compile an overview of data sources and the data available, as well as to clarify data needs for planning purposes, more than 50 publications from Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia, and Zimbabwe were reviewed and key informant interviews were held with representatives from medical aid, insurance, industry, and with researchers. The number of publications ranged from 6 in Namibia to 23 in Zimbabwe. Most epidemiological reports came from respective country ministries of health, while the rest consisted of research papers.
Children rearing children: a study of child-headed households.
Communities with high rates of HIV infection are experiencing a rapid increase in the number of children being orphaned. An estimated 9 million children had lost their mother to AIDS by mid-1996, with more than 90% of affected children living in sub-Saharan African countries. The AIDS epidemic is also reducing the proportion of young adults in the population and the incomes in AIDS-affected households. Changes are therefore taking place in care-giving arrangements for affected children. An increasing proportion of orphans in several countries are now being cared for by the elderly and the very young, with some households headed by children as young as 10-12 years old. Few estimates, however, exist of the prevalence of child-headed households (CHHs). Two World Vision surveys in the Rakai district of Uganda found that 4% of households were headed by children aged 12-16 years and that 2% of orphans were living in households with a care giver who was 18 years old or less. Another survey in the district found that 97% of orphan households had an adult of 17 years or more living in the household. Once CHHs begin to appear in communities, their prevalence and proportion will likely increase as the AIDS epidemic generates orphans at an increasing rate. The causes of CHHs, problems associated with CHHs, coping and survival mechanisms, and the need for community-based support initiatives are discussed.
Most of sub-Saharan Africa experienced serious economic decline or stagnation during the 1980s and early 1990s. Agriculture is sub-Saharan Africa's most important industry. However, agricultural productivity has not kept pace with the growth of population. That productivity has especially been hurt by falling productivity in the export sector and from declining markets and prices. Most sub-Saharan African countries still need to import food. Debt has accumulated, resources are pressured, and evidence exists of environmental deterioration. In this context, efforts to stop economic decline are being questioned with regard to the potential for environmental damage and the consequent inability to sustain either the economy or the resource base upon which it depends. Problems facing sub-Saharan Africa include severe environmental difficulties relating to climatic change, drought, starvation, a deteriorating world market and world financial system, pressures upon international loan capital from non-African sources, declining international investment interest, changes in African societies and political relationships, civil wars, population growth, and rapid urbanization. Environmental issues, resource management, institutional issues, and environment and development in Ghana are discussed. Furthermore, recommendations are presented upon the sustainability of environmental and resource management futures in sub-Saharan Africa.
Poverty, vulnerability, and rural development.
There is a major preoccupation with poverty in arguments about sustainable environments and the management of resources use. Some scientists focus upon poverty as the main concern in the study of developing countries, and that the elimination of poverty or at least the raising of minimal living standards should be one of the main objectives of research and policy formulation. Economic reform together with environmental conservation should always be developed with regard to the poor. The nature of poverty, rural poverty and development in sub-Saharan Africa, aspects of economy and society in sub-Saharan Africa, vulnerability, and poverty and economic reform are discussed. A number of factors came together to exacerbate sub-Saharan Africa's economic and financial problems during the 1970s and 1980s. Price incentives to promote agricultural production and reduce rural poverty will not solve the problems of extremely poor people. Poor people need employment and cheaper food, the latter of which only a more efficient use of inputs in agriculture can provide.
Environmental management and social equity.
People in recent years have become increasingly interested in ensuring that local, national, and regional development is environmentally sustainable. One initiative designed to guarantee the sustainability of development is the creation of a series of strategies, approaches, and techniques to plan, organize, and manage the environment. A body of knowledge and expertise is growing to comprise what is known as orthodox environmental management. The author describes the concepts of sustainable development, environmental management, and social equity; examines the political-economic context of contemporary environmental management; discusses social equity and environmental management with regard to some practices in sub-Saharan Africa; and explores options for sustainable futures.
Introduction to population, resources, and sustainable dekelopment in sub-Saharan Africa.
Sub-Saharan Africa had an estimated total population of 543 million in mid-1992. Like Latin America and the Caribbean, sub-Saharan Africa has a very low population density of 22 people per sq. km, 10% of the population density in South Asia and 20% of that in East Asia and the Pacific. 71% of the subcontinent's population is rural. Sub-Saharan Africa's population is one of the poorest and depends in many subregions upon fragile tropical environments. The author discusses the major subcontinental and regional features of sub-Saharan Africa's demography, introducing the subject as a foundation upon which other more detailed discussions of poverty, development, sustainability, and resource management can rest. Topics relevant to demography such as urbanization, urbanward migration, natural resources, and environmental sustainability are not considered in-depth. Internal and international migration; human resources; population, agricultural land, and food supply; and population, economy, and sustainable development are considered. Land, atmosphere, water, energy, natural vegetation and deforestation, and other primary resources are also discussed.
Urbanization and industrialization: what future for sub-Saharan Africa?
Even though sub-Saharan Africa is the world's poorest, least urbanized, and least industrialized continental region, it has several metropolises with more than 3 million inhabitants and problems comparable in intensity to that typical of other megacities in the Third World. The Pretoria-Witwatersrand-Vereeniging complex, however, centered upon Johannesburg, Lagos, Kinshasa, Durban, Cape Town, Kano, and Ibadan, is the exception. Most capital cities and major industrial centers in sub-Saharan Africa have populations under 2 million. In the smallest states, cities have no more than 100,000-150,000 inhabitants, with the majority of urban Africans still living in relatively small cities, towns, and villages. The continuing rapid rate and scale of urbanization, the urban environment, the limitations of industrialization, the impact of structural adjustment, sub-Saharan Africa as the global periphery, and implications for urbanization and industrialization are discussed.
Urban environmental management and issues in Africa south of the Sahara.
While Africa is the least urbanized continent, it has among the highest rates of urbanization. Africa's rapid rate of urban growth is causing social and economic strains, some of which are manifested in environmental problems. The author reviews a number of environmental problems which occur at varying spatial scales, from the home throughout the neighborhood, the city, to the region. Problems include crowded and cramped living conditions and the presence of pathogens in the human environment because of the lack of basic infrastructure; the dangerous and unhealthy sites of some neighborhoods and the irregular or non-collection of garbage in some neighborhoods; city-wide problems of the disposal of toxic/hazardous wastes, and water, air, and noise pollution; and the more regional problem of energy and vegetation. Causes and factors which contribute to these problems include massive rural-urban migration, poor planning, and ineffective development control, weak urban institutions, and inadequate financial resources. A number of suggestions, including institutional reform, improving financial viability, and reviewing standards, are made to improve the situation. Sections discuss the process of urbanization in sub-Saharan Africa, the nature of environmental problems, causes of the current problems, and the way forward.
Towards sustainable environmental and resource management futures in sub-Saharan Africa.
Sustainable development is defined and its implications discussed. Causative factors of environmental degradation related to development and other activities include modernization; agriculture, including livestock production and fishing; rapid population growth; fuelwood and energy management and associated deforestation; industrialization; poverty and affluence; urbanization; and other varied activities and phenomena. These forces are discussed, followed by sections on the levels of environmental effects of human activities and sustainability concerns, and constraints upon sustainable development in sub-Saharan Africa. Sustainable development in Africa can be achieved only where appropriate policies, strategies, and priorities in research and development are carefully chosen and adhered to with the continuous commitment and allocation of resources and the creation of an enabling environment by governments. The elements of necessary ingredients for such sustainable development are briefly summarized.
Drought, desertification, and water management in sub-Saharan Africa.
Sustainability and sustainable development have become the key terms in addressing the world's general concern over environment and development issues. The development process seems to have reached an impasse in sub-Saharan Africa, food production per person has declined steadily over the past 3 decades, and people in many countries of the region are poorer now than they were 30 years ago. Sub-Saharan Africa's environment remains troubled by desertification and recurrent droughts in the semi-arid lands and high rates of deforestation in the humid eco-zones. The major environmental constraints in sub-Saharan Africa are described, with consideration of their implications for sustainable development strategies in the region and a focus upon semi-arid lands. Sections cover droughts in sub-Saharan Africa and their implications for planning and development, desertification, and land degradation and management of soil and water. The potential roles of agroforestry and a small-scale water-harvesting technique to combat desertification and promote sustainable agricultural production are noted as important to sustainable agricultural development in the region.
Tropical deforestation and its impact on soil, environment, and agricultural productivity.
The humid tropics comprise about 31% of all tropical biomes, 11% of the earth's total surface, 1.5 billion hectares of land area, and are home to about 2 billion people. 45% of the total humid tropical land area is in the Americas, 30% in Africa, and 25% in Asia and Oceania. Within the generic term tropical rain forest (TRF), there are the following main types of forest vegetation: lowland rain forest (80% of the humid tropical vegetation), premontane forest (10%), and lower montane and montane forests (10%). TRF ecosystems are characterized by constantly high temperatures and relative humidity, high annual precipitation, highly weathered and leached soils of low chemical fertility, and high total biomass. The natural vegetation of the TRF is characterized by a high degree of biodiversity. The TRF ecosystem has global importance in terms of soil and climatic interactions and its impact upon several processes. TRF and its conversion, soils of the TRF ecosystem, forest conversion and soil productivity, deforestation and the emission of radiatively active gases, deforestation and hydrological balance, sustainable use of the TRF ecosystem, and research needs are discussed.
Institutional issues on the environment and resource management with reference to Ghana.
There is no common institutional framework for managing environmental resources in African countries because situations differ. Furthermore, the institutional framework for addressing environmental concerns in a particular country may also change with time, depending upon the government's perception of the scope and seriousness of the concerns. Ghana's current institutional arrangements for managing resources and the environment emphasize participatory planning involving local communities and institutions, nongovernmental organizations, and decentralized sectoral organizations. Technical departments will undertake technical implementation, while the Environmental Protection Agency provides coordinating and monitoring functions. Early concerns in Ghana about the land and environmental degradation, the 1972 UN Conference on the Environment in Stockholm, the Environmental Action Plan (EAP), institutional problems and issues, and implementation of the EAP are discussed.
The author discusses the environmental impact and sustainability of plantations in sub-Saharan Africa, mainly upon the basis of Ghana's experiences with oil-palm plantations. Agriculture has traditionally formed the main economic activity in sub-Saharan Africa and currently generates the majority of employment and incomes. Agriculture is the main land-use factor in the region. In Ghana, agriculture contributes half of the gross domestic product and 60% of export earnings, and occupies 57% of the total land area. As the major land-use factor, agriculture can significantly affect the natural environment, especially through vegetation removal. Large-scale plantations comprise one system of agricultural production. An overview is presented of that plantation system in the sub-Sahara, followed by consideration of the evolution of plantations in Ghana, the positive impacts of plantations, and adverse environmental impacts and sustainability.
Growth of the world's megalopolises.
The UN Population Division studies consider an urban agglomeration to be an area with a population concentration which usually includes a central city and surrounding urbanized localities, demarcated without respect to administrative boundaries. A megalopolis refers to an agglomeration which has reached 8 million in population. Changes are noted in the number and regional distribution of cities of 8 million or more, and their past and projected trends of population growth during 1950-90. New York, Tokyo, Los Angeles, Paris, Mexico City, Sao Paulo, Buenos Aires, Shanghai, Beijing, Moscow, Osaka, Rio de Janeiro, Calcutta, Bombay, Jakarta, Delhi, Tianjin, Seoul, Manila, and Cairo are megalopolises. Dating from 1950, New York and London were megalopolises, but London lost that status in 1980 after having shrank to an estimated size of only 7.7 million. Dacca, Karachi, Bangkok, Istanbul, Teheran, Bangalore, Lagos, and Lima are projected to have populations of at least 8 million by 2000. The trend of population growth in these urban centers as projected by the UN is described. The estimated and projected city sizes presented are taken from the 1990 Revision of the UN Population Division's estimates and projections of urban and rural populations and urban agglomerations.
Demographic issues and data needs for mega-city research.
Serious deficiencies related to conceptual issues and data needs continue to confront researchers engaged in demographic research upon megacities. Deficiencies include basic concerns such as the accurate delineation and measurement of the size and composition of megacity populations. Others relate to the demographic processes which affect megacity growth, the dynamics of the labor force, and the linkages between megacities and smaller urban and rural places. Population movement is a key variable related to all of these issues. It is, however, particularly important to refine the concepts related to the urban/rural dimensions of population distribution, especially as they relate to classification of who is to be counted as a resident and functioning member of megacity populations, and the types of population movement which affect short-term and long-term populations of megacities, including permanent in-migration, circular or repeat migration, and commuting. The list of research needs remains long and complex. Data sources and limitations, issues of definition, migration and megacity development, and data collection and analysis are discussed.
Labour force change and mobility in the extended metropolitan regions of Asia.
Asia's urban population is expected to almost double over the period 1980-2020, as an estimated 462 million people are added to the urban population. This growth will result in an overall urbanization level in Asia of almost 50%. Projections of such dramatic growth have fueled concerns over the size of cities which will be needed to accommodate the increase and the problems which will be posed for the creation of urban infrastructure, housing, and the creation of productive employment. However, these projections are based upon certain assumptions of the growth of populations in places defined as urban. The conventional, Western model of urban transition needs to be carefully evaluated in the case of Asia. Such an evaluation involves dispensing with the concepts which are part of the body of urban theory which has grown out of the Western experience with urban transition. The conventional view of the urban transition is inadequate in several respects. Population growth, structural change, labor force absorption, and urbanization in Asia; the emergence of the extended metropolitan region in Asia; features of the extended metropolitan region in Asia; Bangkok as an example of the emergence of the extended metropolitan region; and implications of the emergence of desakota regions for future Asian urbanization are discussed. A model of the spatial economy transition is also presented.
Rapid population growth and heavy rural-to-urban migration in the developing countries during the post-World War II period are among the main determinants of the rapid growth of Third World megacities. Moreover, policies and initiatives to promote economic development and industrialization in the developing countries have been transforming mainly agricultural and rural societies into more industrialized and urbanized societies in a relatively short period. The growth and structural transformation of megacities are integral parts of national development. Global economic integration, increased international trade, capital flows, telecommunication, new technology, and shifts in the comparative advantage of production continue to play a central role in integrating national territories and shaping the spatial organization of national economies at the world level. The interlinkage of megacities and other major metropolises, which form a world city system, are at the center of the global economic integration and structural adjustments. Regionalization of the world economy, the excess supply of commodities and Third World stagnation, changing comparative advantage and new economic configurations, the emerging pattern of a world city system, shifts in successive techno-economic paradigms and the impact upon world cities, and the city system and the shifting techno-economic paradigm are discussed.
The current status of modern cities as highly concentrated centers of services has been made possible by technology. While the potential ability of cities to have direct access to any other city or region in the world through transportation and telecommunications technology gives modern cities unprecedented social and economic power, that power is also changing urban population dynamics. Technology advances are having an ever-increasing impact upon almost all facets of the city. As such, every major city needs a technology policy to guide the most important aspects of its socio-technological interactions. The most important aspect of such policy should be the reshaping of the structure and organization of the city commensurate with its new functions and needs. Urban social problems, technology and the city in the future, redefining the megacity, demography and technology, the city as an ecological device, and technology policies for the city are considered.
The redistributive role of mega-cities.
Large cities, and especially the largest cities, heavily subsidize the other parts of their respective countries through the national budget and many national public services. However, most economic or sectoral policies which were introducing a pro-urban bias, especially in the developing countries, are being abandoned or soon will be. Such policy changes will probably not result in a number of transfers from the urban sector to other parts of given countries which corresponds directly with the number of cities in the country. It is possible that some of the largest cities in some developing countries will become poorer and distribute less to the rest of the country. In developed countries, the evolution of the relative amount of transfer also depends upon economic growth. Decentralization, privatization, and deregulation trends could also have a negative impact upon transfers between the largest cities and the rest of their respective countries. It is more likely that more large cities will finance more transfers mainly in the intermediate-income countries experiencing real economic growth, and less likely in the poorest and richest countries.
Economic impacts of Third World mega-cities: Is size the issue?
The size of megacities and the implications of a given size depend upon how one demarcates the limits of the city. A city could range in area from the traditional core city size of 100-200 sq. km to a region of 2000-10,000 sq. km or larger. Moreover, the growth rates of the constituent parts of these megacities differ widely from one another, with low or even negative growth rates in the densest core and higher growth rates at the low-density periphery. Megacities could therefore be viewed as polycentric clusters