In October 1997, over 200 participants attended the First Mayan Women's Congress in Mexico and called for financial assistance, capacity building, and training to help Mayan women escape poverty. The Congress was initiated by the UN Development Fund for Women in collaboration with the Small Grants Program of the UN Development Program. Traditionally, Mayan women and men have played distinct roles in society, and efforts are underway to increase gender sensitivity and achieve a new balance of power. Mayan women attending the Congress reported that they face daily challenges in gaining their husbands' approval for participation in income-generating activities outside of the home. Eventually, however, some husbands also start working in these enterprises and are learning to assume their share of domestic responsibilities. Mayan women have been forced to reevaluation their role in society by a prevailing agricultural and environmental crisis as well as a high unemployment rate. Crafts that were once produced only for household consumption are now considered for export. Because the women need funds to initiate income-generating activities, the Conference linked women's groups with development practitioners, policy-makers, and donors. The women requested financial aid for more than 30 specific projects, and Congress participants agreed to pursue innovate strategies to support the enterprises with funds, training, and technical assistance. The Congress also encouraged environmental nongovernmental organizations to include Mayan women in mainstream development activities. This successful Congress will be duplicated in other Mexican states.
Year of Safe Motherhood: making pregnancy and childbirth safer.
On World Health Day 1998, an Inter-Agency group, including the UN Population Fund, the UN Children's Fund, the World Health Organization, the International Planned Parenthood Federation, the Population Council, and Family Care International, launched a year-long campaign to promote awareness of what must be done to reduce maternal mortality and to gain commitments for implementing the affordable measures needed to prevent most of the 600,000 annual maternal deaths. To launch the campaign, health officials highlighted what must be done to improve maternal health worldwide, and the US First Lady pointed out the shocking facts that every minute a woman dies, 110 women experience a pregnancy-related injury, and 190 women face an unplanned or unwanted pregnancy because the political will does not exist to remedy this situation. Preparation for the "Year of Safe Motherhood" began with an October 1997 conference that reviewed the results of 10 years of research on safe motherhood. This research revealed that maternal deaths could be reduced drastically by provision of 1) routine perinatal care; 2) emergency care for life-threatening obstetric complications; 3) services to prevent and manage the complications of unsafe abortion; 4) family planning to prevent unwanted pregnancies; 5) health education and services for adolescents; and 6) community education for women, their families, and decision-makers. Maternal and newborn health services would cost as little as US$3/person/year in developing countries.
Progress on youth reproductive health.
The first round table meeting to review progress in implementing the Programme of Action of the 1994 International Conference on Population and Development was convened in April 1998 to consider progress on adolescent reproductive health and rights. The 30 participants from 24 countries concluded that while many countries have made progress, attitudes still need to be changed among those who continue to believe that provision of reproductive health services to adolescents leads to promiscuity. The topics considered during the meeting included: 1) improving accessibility and quality of information and services; 2) creating an "enabling environment" for adolescent reproductive health; 3) enhancing the role of parents and schools in providing sex education; 4) using national laws and policies to protect youth health and rights; and 5) mobilizing private sector and private foundation resources. The round table recommended that adolescent reproductive health programs 1) involve diverse groups of young people in the development of programs, services, and materials; 2) cooperate with a wide variety of other agencies; 3) encourage open discussions of sexuality; 4) train youth as peer counselors; 5) hire youth as paid staff; 6) use a range of quality communication resources; 7) train health care professionals who deal with adolescents; 8) develop evaluation indicators for social and emotional well-being; 9) increase youth access to the formal health sector; and 10) use the visibility of women's groups to promote young women's interests. The round table also asked UN agencies to strengthen their support for youth programs.
Bolivia: views of family planning.
Three studies in Bolivia provide information on women's and men's attitudes towards family planning (FP). A study conducted by the nongovernmental organization Pro Mujer on health service accessibility and use in urban El Alto revealed that migrants face numerous barriers to reproductive health care. To redress this situation, Pro Mujer recommended changing the delivery of its reproductive health services to offer assistance to infertile couples, improve postabortion care, provide adolescent services and psychological counseling, and educate providers about the cultural and psychological barriers uncovered. A study on the psychosocial impact of contraceptive usage on women conducted by Proyecto de Fortalecimiento de Atencion Primaria en el Districto III de la Cuidad de El Alto revealed that women believe contraceptive use enhances their sexuality and that women using modern methods are more satisfied with their lives and family relationships because they are free from fears of pregnancy. A third study conducted among 600 couples by the Cooperazion Internazionale and the University of San Simon determined the impact of men's knowledge, attitudes, and behavior on women's use of contraception. Most men approved of FP and felt men should assume more FP responsibility, but communication between men and women about FP was very poor. These results challenge opinions that men hinder women's FP use. Additional studies are being planned to help improve gender sensitivity among health care providers, determine ethnic differences in FP knowledge and gender roles, and examine the impact of FP on women's paid employment.
A quick history of health communication.
Family planning (FP) health communication has evolved from its emphasis on IEC (information, education, communication), in which top-down sender-focused messages (such as "a small family is a happy family) achieved only limited behavior change, to a new emphasis on the receiver. The new term "behavior change communication (BCC)" reflects this shift, and the BCC strategy recognizes that the intended audience contains active receivers of messages who act only on messages received from trusted sources and perceived as advantageous. The next step is "behavior change intervention," which also recognizes the affect of social policies and economics on an individual's ability to sustain behavior change. Leading theorists have shown how behavior change is a process involving various stages and key factors. Thus, successful communication strategies consider behavioral objectives, audience segmentation, messages appropriateness for each audience, sources, formats, and timing. Values also dictate the approaches and goals of a health communication campaign and can, for example, lead to a shift in emphasis from controlling individuals to helping them make fully informed choices. Value changes lead to new language; thus, the old passive term "FP acceptor" is being replaced with references to "FP users, adopters, and clients."
Changing communication strategies for reproductive health and rights: an overview.
Use of communication strategies that provide information, promote new ways of thinking, and offer rights-based education is essential to promote reproductive and sexual health and rights. While the old IEC (information, education, communication) strategies provided only a relatively static series of messages targeting particular sectors, social changes brought about by the global women's rights movement, the HIV/AIDS epidemic, and the use of participatory approaches by nongovernmental organizations have shifted the focus to "behavior change communication (BCC)." BCC asks what strategies are needed to imbue individual clients with a sense of rights and power and seeks qualitative successes such as an increase in reproductive knowledge and improvements in partner communication and sexual negotiation. Additional analysis is needed to explore how communication strategies can help build political movements, especially in areas where information (and, therefore, rights) is restricted. Many other BCC issues remain to be resolved, and the political will must be created to actualize commitments made at the 1994 International Conference on Population and Development. Studies indicate that obvious answers sometimes fail to offer perfect solutions and that the underlying assumptions of researchers must constantly be examined. Promotion of a culture of reproductive and sexual rights will also depend upon which process is used to develop BCC strategies and the extent to which practitioners are willing to examine their own values.
Philippines: women and decision-making.
In the Philippines, a follow-up to the Cebu Longitudinal and Nutrition Health Survey involved interviews with 2300 women in the original survey and 500 additional women aged 15-25 to determine household decision-making patterns and learn how childbearing affects women's autonomy. Women were asked if they consulted others when making certain minor decisions (buying shoes or clothes), decisions that involved spending more money (buying major appliances or land), and decisions about children (health care and schooling) and family planning (FP). If they consulted others, women were asked how any conflicts were resolved. It was found that most women made minor decisions independently but consulted spouses about decisions involving larger expenditures or traveling away from home. Nearly a third of women made autonomous decisions about working outside of the home, but only 12% used FP without consulting with others (20% of the women consulted other adult females first). The 6% of the sample who were not married were much more likely to make autonomous decisions. Despite consulting spouses, women played a major role in final decision-making: an equal number of women and men prevailed where disagreement arose about working outside of the house, but when women consulted their spouses about FP, the will of the woman prevailed in 25% of cases and that of the man in 7%. In general, the women held sway in minor decisions and the men in major ones.
Mali: views of new contraceptive users.
In Mali, where only 6% of the population uses modern contraceptives, a baseline survey conducted in 1994-95 by the Centre d'Etudes et de Recherche sur la Population pour le Developpement (CERPOD) indicated that most women seek family planning (FP) services after consulting their husbands but that a third hide their decision from their spouses. CERPOD is also tracking 56 new contraceptive users over a 15-month period beginning with their initial clinic visit to determine why contraceptive discontinuation rates are as high as 64% in the country. The first round of surveys indicated that women seek FP to space and limit births and that they enlist the support of sisters-in-law and aunts to win the approval of their husbands.
Adolescents' perceptions. Brazil: views on pregnancy.
An ongoing 3-year study at the Servico de Adolescentes offered by the Maternidade Escola Assis Chanteaubriand in Fortaleza, Brazil is comparing the characteristics and experiences of 375 adolescents seeking prenatal care with 197 who sought emergency treatment for incomplete abortion. Prenatal subjects are being interviewed during their first clinic visit, at week 35 of pregnancy, at 45 days postpartum, and at 1 year postpartum. Abortion patients are being interviewed at hospitalization, 45 days later, and 1 year later. Preliminary findings show that 64% of the prenatal patients perceived nothing bad about the pregnancy, while 41% of the induced abortion group perceived nothing good. While most mothers, friends, and partners were supportive of the pregnancies in the prenatal groups, this was not the case in the abortion group. Most of the subjects would have preferred to delay pregnancy, but 46% of the prenatal clients and 13% of the abortion patients wanted to become pregnant when they conceived. The abortion patients were slightly older and less likely to be in a stable union than the prenatal clients. Both groups became sexually active at about age 15, but the abortion patients had more sexual partners and these partners were older than those of the prenatal clients. Most respondents in both groups had been in a relationship for a fairly long time, and each group reported low use of contraception. Almost 25% of the prenatal group considered abortion, and 39% of these attempted to abort. At least 40% in both groups had a mother or older sister who became pregnant during adolescence.
Adolescents' perceptions. Jamaica: mixed messages on sexuality.
Focus groups involving 56 adolescents conducted by the Fertility Management Unit of the University of the West Indies and the Women's Studies Project in Jamaica revealed that, while boys and girls both viewed sexual activity as a sign of adulthood, the boys viewed the loss of virginity as a source of pride, while the girls saw it as a source of embarrassment. Girls chose to engage in sexual intercourse as a sign of their love, while boys looked for physical pleasure or responded to peer pressure. The focus group participants appeared to be knowledgeable about contraception and to have a positive attitude about family planning (FP). Many mentioned use of condoms to prevent pregnancy and disease, but others noted that they may not be able to afford condoms. Fewer than half of the sexually active participants reported using FP during first coitus. Contraceptive usage was hindered by the belief that sexual intercourse is less pleasurable with a condom and by fears that girls would suffer retribution if their parents found contraceptives in their possession. Both boys and girls believed that adolescent pregnancy would be unwelcome, but few believed it would ruin their lives, and both groups felt adolescent mothers should return to school. Based on these findings, it was suggested that sex education programs begin before puberty and address the gender norms that influence attitudes and behavior.
Egypt: users' views, female employees.
Preliminary findings from focus groups research involving 92 women conducted by the Women's Studies Project (WSP) at the American University in Cairo indicate that while women are knowledgeable about modern family planning (FP) and understand its beneficial impact on women's lives, they may discontinue use as a result of misinformation that creates concern about negative side effects. Of the participants, 47 had attended secondary school or a university, 10 had completed primary school, and 35 were illiterate. Of the 44% who used contraception, more than half relied on IUDs and the rest were equally divided among injectable or oral contraceptive users. The women identified several ways that FP usage enhanced their lives and said they would advise their daughters to use FP. A second WSP study in Egypt is analyzing the FP labor force to determine the role of women as FP employees. Preliminary findings show that most organizations have a high percentage of female physicians working with FP clients and that, in all organizations, more than 50% of the social workers are women. Additional WSP studies in Egypt will examine 1) FP usage among married adolescent women in squatter areas; 2) knowledge, attitudes, and use of FP among youth; 3) the effects of FP use on gender equity among children; and 4) social and behavioral outcomes of unintended pregnancy.
A closer look at client-provider interaction.
The importance of responding to individual needs during the delivery of family planning (FP) services was highlighted by the 1994 International Conference on Population and Development and has been supported by a growing body of research that emphasize the crucial nature of client-provider interactions (CPIs). These results reveal that continuation rates are as much as four times higher among women who receive the methods they request than among women who received other methods. Continuation rates are also higher among clients who have been prepared for potential side effects and who are invited to return for another method if necessary. It is crucial to provide care that is individualized and takes a woman's reproductive situation into account and to inform clients about ways to prevent transmission of HIV infection and sexually transmitted diseases. Helping clients make informed choices is a complex process because clients must be given enough information to make decisions but not enough to overwhelm the decision-making process. Effective CPIs, therefore, entail honoring the client's choice (if safe), respecting the client, maintaining a helpful attitude, ensuring privacy and confidentiality, providing simple and relevant information, and listening to client concerns. Reorienting FP programs to become more client-centered will require eliminating outdated medical procedures and restrictive policies, ensuring availability of a wide range of methods, and training providers to improve quality of care.
Communities learn to take charge of their sexual lives and relationships.
International Planned Parenthood Federation Family Planning Associations (FPAs) in St. Lucia, Guyana, and Belize participated in a process to facilitate community participation in efforts to achieve social and organizational changes so communities could control their own sexual health. The program involved institution building, expansion of clinical services, creation of user friendly services for adolescents, networking, and documentation and evaluation. In order to reorient their services from a top-down flow of information, the FPAs had to 1) listen to the community, 2) engage in a dialogue on sexual and reproductive health, 3) allow the community to take some responsibility for the process, and 4) have faith in the community's ability to know its needs and validate its capacity to devise solutions. The tools for social change included adoption of a participatory approach that facilitated broad-based thinking and a commitment to making sexual health a central focus in the minds of community members. In this case, sexual health was defined as including an understanding of the basic norms and beliefs that influence gender relations, human sexuality, and sexual decision-making. In addition to making a discernable impact on the community, the project inspired the FPAs to engage in institution building, expansion of services, creation of new protocols, peer counseling, networking, and more rigorous evaluation. The project demanded a significant investment of time and requires flexibility and patience, but it is effective, gender sensitive, and sustainable.
Client satisfaction and quality of care: searching for empirical basis.
The first part of this article illustrates the complexity of the family planning client-provider interaction (CPI) and its effect on client satisfaction and quality of health care. This part notes that efforts to understand this effect are hampered because no single element of CPI is linked to client satisfaction, there is no uniform definition of CPI or clear set of CPI indicators, and there is no standard definition of "client satisfaction." Part 2 provides insight into the complexities associated with elements of quality of health care, such as informed choice, which actually can be hampered by providing too much information, and notes that it is rare for clients to be both informed and have a choice in a single counseling session. The third part provides an empirical and programmatic look at quality of health care using three studies as examples. First, a study in Nepal uncovered the role of the client in demanding improved quality of CPI by showing that interventions targeted to providers and clients led to a greater improvement in CPI than did interventions targeted only to providers. Second, studies in Kenya and Indonesia examined provider-caused barriers that limit a client's access to appropriate contraceptive choices and discovered that inappropriate contraindications were being imposed and that a range of process and eligibility barriers limited contraceptive access. Third, a study in Kenya examined longitudinal data to determine whether quality makes a difference in client behavior and found that long-term users are less affected by quality than are drop-outs.
As the 1994 International Conference on Population and Development (ICPD) recommended, the provision of IEC (information, education, communication) and its interface with the community should focus on informing individuals, promoting their rights, and enabling individuals and communities to adopt self-determined behavior changes in response to self-identified needs. This will result in creation of reproductive health communication programs that 1) value the unique needs of women and adolescents rather than demographic or economic concerns, 2) support women in gaining control of their bodies, 3) challenge men to be responsible for their behavior in relation to women and adolescents, 4) seek to eliminate the pressure on women to have undesired sexual intercourse, 5) equip women to assert their right to accept or initiate desired intimacy based on informed decision-making, and 6) stimulate increased equity in gender-power relations. Communities can be empowered to play a critical advocacy role, and donors, national or international agencies, nongovernmental organizations, and governments should act as catalysts to community mobilization. Organizations involved in reproductive health should develop internal consistence between programs and the principles of the ICPD Program of Action, promote facilitation of informed choice rather than target-driven behavior, and incorporate gender sensitivity in communications. After this is accomplished, objectives and measures should be made consistent with the ICPD principles and actions.
Communication strategies for maternal health and rights in Bolivia.
In Bolivia, the MotherCare project is working to help national and regional governments decrease the maternal mortality rate that, at 390/100,000 live births, is one of the highest in South America. A MotherCare study gathered data from five rural and periurban districts through 20 focus group discussions, 205 in-depth interviews, 107 interviews with providers, and observations of service delivery to identify the major barriers and enablers for recognizing obstetrical and neonatal danger signs, making decisions about maternal complications, and accessing health services. It was found that community members recognized danger signs but acknowledged only a superstitious, not a clinical, etiology, so did not seek clinical care in such cases. A different hierarchy of decision-making exists during each stage of pregnancy, with husbands responsible for seeking care for problems near the time of delivery. Health care use is affected by quality of care, by Andean rituals and beliefs, by clinic accessibility, and by socioeconomic status. Evaluation of health services by providers led MotherCare to develop a curriculum to help improve client-provider interactions. MotherCare also developed a project that implemented these research results through programmatic changes in the delivery of health care, created interactive materials for low-literate community members and providers, and initiated a radio campaign to promote reproductive health.
Sex education in Latin America: from Utopia to compromise.
In Latin America in the 1970s, groups that sought social change considered a new form of sex education important because it could address a range of socioeconomic and political issues. The guiding principles of this new approach were 1) avoiding top-down directives; 2) using a democratic, participatory process; 3) being comprehensive; 4) covering ethics and values; 5) viewing sex education as a tool for social change; and 6) acknowledging the positive aspects of human sexuality. Despite political difficulties, successful sex education programs were facilitated by family planning programs and/or national population policies; women's and feminist movements; gay rights movements; expertise, experience, and experts; and government commitment. Then HIV/AIDS linked sex with death and strengthened taboos while increasing the urgency for sexuality education. In Colombia, national policies are helping build a progressive sexuality education program for all citizens from birth through adulthood. Mexico has achieved significant accomplishments without a national policy because nongovernmental organizations have mainstreamed the issue in the media, strong networks have grown from widespread training efforts, and networks have linked programs to government policy. Both countries have developed successful communication strategies. New challenges include finding ways to show sex education works, strengthening the gender approach, ensuring participation of adolescents and children in program development, improving the quality of health care, and reaching underserved populations.
This article, which raises questions about health communication and the politics of sexual health, maintains that shifting the focus to reproductive and sexual health requires 1) a movement from education, motivation, and information towards questioning, understanding, sharing, and planning with the recipients of the services and 2) moving from a focus on the power of individuals to change their own lives to a focus on the possibilities of groups altering societal influences on or acceptances of behavior and human interaction. The issues that must be considered to achieve a holistic approach to reproductive health care are 1) ensuring that this approach is more widely accepted and institutionalized; 2) determining how to show those providing services that they need to raise questions about concerns all community members face; 3) determining how to improve support, supervision, and management in clinics; 4) helping governments and agencies prepare for a holistic approach; and 5) determining why development of programs for provision of service and political mobilization of communities remains so fragmented. After considering the question of acceptance and institutionalization of different approaches to communication, the article reviews some of the things that make it difficult for service systems to establish good communication programs or even good services. The article ends by summarizing the experience of the Caribbean Sexual Health Project and a sexually transmitted disease training program in Malawi and by listing the necessary steps to develop a holistic approach.
Mass media: a powerful tool for social change.
Because of its immense ability to provide access to information, the mass media can play a crucial role in promoting reproductive health and social changes affecting gender, reproduction, and sexuality. An especially powerful aspect of the mass media is its ability to create visual imagery, either directly or, in the case of radio, through projections made as a result of messages heard. In the developing world, mass media communication provides a link to the global village and can play a culturally interactive role. The mass media is one of the most powerful tools that can be used to further the goals of the International Conference on Population and Development (ICPD) because it is the most efficient mode of communication and because of its inherent power. To be most effective, mass media communication campaigns must be submitted to constant and rigorous evaluation. Effective campaigns focus on the consumer and must be based on valid market research. To further the goals of the ICPD, the core objectives of communication campaigns must be assessed, consumers must perceive that the message concerns something that is beneficial to them, the imagery used must be carefully chosen, and the mass media campaign must be created by the most competent and creative professionals available. The ICPD has given the mass media a mandate to promote positive, responsible social behavior and gender equality by truthfully and realistically showing that this is more attractive than its opposite.
This article discusses a 1993 male family planning (FP) motivation communications campaign conducted by the Zimbabwe National FP Council to increase contraceptive usage, especially of long-term methods; promote couple communication about FP; and promote joint FP decision-making. Data were collected from 1) pre/post household surveys of 2052 men and women of reproductive age at five sites, 2) service statistics, and 3) exit interviews at 23 FP facilities. The multimedia campaign included a "FP cup" football tournament, television and radio spots, newspaper advertisements in the sports sections using national sports figures, material distribution at football games, half-time activities at football games, community- level motivational talks, public events, and training of service providers. The campaign resulted in insignificant increases in contraceptive prevalence rates, but increased exposure to campaign messages was positively associated with increased contraceptive usage. Partner communication and joint decision-making increased as more women expressed a belief that FP decisions should be jointly made; however, an unexpected result was that more men expressed a belief that they should make FP decisions alone. Lessons learned include the facts that message content should be considered from the perspective of the audience, appropriate objectives should be set, it is important to understand the target audience, sports events are an effective way to reach men, and gender equity and reproductive health objectives must be balanced.
Marketing the female condom in Zimbabwe: new methods and messages.
In 1997, Population Services International (PSI) began marketing the female condom in Zimbabwe, where HIV prevalence rates are high and women report an inability to control male promiscuity and infidelity. Sales in Zimbabwe to date have outstripped sales in all other related projects combined. Preintroduction acceptability research revealed a high level of knowledge about the product, that women aged 25-35 expressed the most interest in trying it, and that acceptability would depend upon male acceptance. PSI, therefore, attempted to make the female condom nonthreatening to men, dissociate it from the male condom, and create a respectable image for the product using the slogans "the Care contraceptive sheath is for caring couples" and "for women and men who Care." The condom was marketed for its contraceptive rather than disease-prevention aspects to reach women in long-term relationships and is distributed only in pharmacies and clinics to protect its reputation. The communications strategy included a press and radio campaign, advertisements, and posters. Because Care is being sold in record numbers, distribution will be expanded to other sites, interpersonal communications tools will be used to increase product comfort and knowledge, and promotion will focus on lifestyle issues and the dual nature of protection offered by the female condom. Additional research will shed light on the Care consumer and on perceptions about the communications campaign. Constraints are the necessity to subsidize the cost of the condoms, time required for sales, marketing respectability versus accessibility, and funding shortfalls.
One of Nicaragua's largest nongovernmental organizations (NGOs), Puntos de Encuentro (Common Ground), seeks to promote individual and collective autonomy and the empowerment of youth and women by addressing social oppression as interrelated issues. The Nicaraguan context is characterized by a very poor infrastructure, extreme politicalization of issues, a right-wing government, an influential Roman Catholic Church, and a governmental policy that promotes family unity as a social norm. The communications strategy of Puntos calls for clear analysis and proposals, understandable ideas and analyses, destigmatizing controversial issues, modeling values, creating media outlets, and using engaging and attractive messages. Main communication activities include publication of La Boletina, a national feminist women's magazine; creation of a nightly call-in radio show for listeners aged 13-25; production of a socially, relevant, youth-oriented, weekly drama- comedy series; and a national media campaign against family violence. After a negative experience associated with a youth campaign, Puntos conducted research in conjunction with a successful campaign to reduce family violence and learned that 1) behavior change occurs in stages that range from precontemplation to contemplation to decision to action; 2) some violent acts are considered natural, everyday occurrences; and 3) that advertisements had to be simple while not oversimplifying the problem. From its experience, Puntos has come up with nine specific recommendations about the kind of support independent NGOs need from funding agencies.
The need that donor agencies have to measure progress through the use of specific indicators creates a results-driven orientation that is sometimes incongruent with the client-focused, consumer orientation called for by the International Conference on Population and Development and the Fourth World Conference on Women. This tension can be mitigated by the development of measurable indicator and evaluation techniques that indicate that communications goals are worth the investment. It is also a challenge for huge organizations like the World Bank or Ministries of Health to transform their programs to respond to the goals that arose from these conferences, and it is difficult for nongovernmental organizations to overcome governmental politics and corruption to create the kinds of partnerships needed to create change. In order to adopt a reproductive health approach that supports reproductive choice while addressing many neglected reproductive health areas, the World Bank has created a policy dialogue that has successfully moved the policy processes forward in Bangladesh, India, and Indonesia to the point where larger issues, such as gender bias in service delivery, can be addressed. The World Bank also understands that health care systems can not be addressed in isolation from the larger political context.
United Nations Population Fund.
Efforts to implement the goals of the International Conference on Population and Development (ICPD) should entail translation of the ICPD buzzwords that do not exist in some languages. These efforts should consider the cultural context in which terms and concepts are being used and interpreted. It is also important to avoid overdependence on the mass media, because some groups, like adolescents, prefer to receive sex education from their parents. The mass media should be used more actively to counter negative images and to promote concepts of rights, choice, and empowerment. Other service delivery issues that need to be addressed and, in some cases, defined are provider bias, participation of program users, client education, and client satisfaction. Projects and policies must grow out of baseline surveys and needs assessments, and policies must be translated into action, not just established. The role of donor agencies is also expanding from simple funding to concerns with technical competence, relevance, quality of programs, impact, and documentation of experiences. The UN Population Fund has identified the following areas of specific interest: adolescent reproductive health; data requirements, indicators, and research; gender equity; participation of program users; capacity building; innovative strategies; building partnerships with media through co- production arrangements; and expanding service delivery and information points.
United States Agency for International Development.
This document, part of a report from a 1997 meeting on "Changing Communication Strategies for Reproductive Health and Rights," opens with comments on the meeting made by the Chief of the Communication Management and Training Division, Office of Population, US Agency for International Development. The USAID official noted that USAID follows a very complex funding and programming process and that the Office of Population has embraced the goals of the Program of Action of the International Conference on Population and Development while struggling with limited resources. The official commented on aspects of the meeting presentations that dealt with the power of language, the importance of client-provider interaction, the necessity for USAID to use measurable indicators of program success to justify continued funding, the importance of evaluation and replicability, the role of the mass media, the values espoused by USAID, and the root causes of poor health (including domestic violence). The second half of the document summarizes a donor panel discussion that covered the following issues: long-term funding strategies, broadening population policy and funding, rethinking compartmentalized funding, and developing realistic indicators.
Abortion surveillance -- United States, 1995.
This report summarizes and discusses the 1995 US abortion data that were reported to the Centers for Disease Control (CDC). The CDC has collected these data from the 50 states, the District of Columbia, and New York City every year since 1969, and the annual number of abortions in the US has decreased by 15% since 1990. In 1995, 1,210,883 legal abortions were reported to the CDC--a decrease of 4.5% from 1994. This figure also represented the lowest abortion ratio (311/1000 live births) and ratio (20/1000 women of reproductive age) since 1975. Most women undergoing an abortion were young, White, unmarried, and having a first abortion. About half of the procedures were performed at 8 or fewer weeks gestation, and 88% occurred before 13 weeks. About 16% occurred at 6 or fewer weeks gestation, and only about 4% were obtained at 16- 20 weeks (more often by women 24 years old or younger). Most legal abortions were performed in California, New York City, Texas, and Florida, and 92% of women for whom residence data were reported obtained abortions in their home state.
This document contains a collection of declarations and resolutions adopted at seven international and regional conferences spearheaded by the Asian Forum of Parliamentarians on Population and Development, in many cases for the purpose of presenting resolutions to the major UN conferences. The Cairo Declaration on Population and Development was adopted at the International Conference of Parliamentarians on Population and Development in September 1994. The Copenhagen Statement on Population and Social Development was adopted at the March 1995 International Meeting of Parliamentarians on Population and Social Development. The Tokyo Declaration on Gender, Population, and Development was adopted in September 1995 by the International Meeting of Parliamentarians on Gender, Population, and Development. In February 1996, the Twelfth Asian Parliamentarians Meeting on Population and Development adopted the Manila Resolution on Women, Gender, Population, and Development. The AFPPD Statement on Food Security and Population was adopted at the Asian Forum of Parliamentarians on Population and Development's special executive committee meeting on food security and population in Malaysia in May 1995. In September 1996, the Fifth General Conference of Asian Forum of Parliamentarians on Population and Development met in Canberra, Australia, and adopted the Canberra Statement on Food Security, Population, and Development. The last document reprinted is the Geneva Declaration on Food Security, Population, and Development adopted at the November 1996 International Meeting of Parliamentarians on Food Security, Population, and Development.
This document 1) presents the population policies of Australia, China, Indonesia, Malaysia, Singapore, Thailand, and Viet Nam in narrative form following a framework of country reports that outlines the population problems faced by the country (describing the current demographic situation, the underlying concept guiding the population policy, and a brief history of the population policy) and 2) provides information on specific population policies related to fertility, mortality, migration and population distribution, population structure, and any other aspects deemed important. The introduction to the report describes the reasons why it was formulated, provides a comparative profile of the demographic situation in the countries surveyed, including a table comparing selected demographic indicators, and summarizes each of the country reports.
Facts about female circumcision.
In October 1979, the Cairo Family Planning Association (FPA) convened a seminar on the "Bodily Mutilation of Young Females." This seminar examined the issue of female genital mutilation from a religious, health, and social standpoint. Recommendations arising from the seminar included 1) generating interest in the topic in the mass media, 2) inviting women's organizations to participate in efforts to educate people about the harmful nature of the practice, and 3) encouraging schools and universities to include facts about female genital mutilation in their curricula. In addition, the FPA published this booklet containing data collected for the seminar as well as expert opinions on the subject. After the introduction, the booklet describes the motives cited for perpetrating female genital mutilation and the historical and geographical background. The booklet then reviews tenets of Islam and Christianity and notes that Islam holds that male circumcision is commendable because it offers a benefit that exceeds the pain of the procedure but that this is not the case with female circumcision, which is also not required of Christians. A description is then given of the three degrees of severity of mutilation that are common in Egypt as well as the physical, psychological, and social hazards associated with the mutilation. The next sections offer a legal opinion that female genital mutilation can be considered an intentional crime that can lead to criminal and civil liability, the conclusions of a 1959 Egyptian Ministry of Health committee on female circumcision, and the position of the World Health Organization.
This document summarizes the results of a 1989 seminar sponsored by the Ministry of Public Health (MOPH) in Cameroon in collaboration with the Johns Hopkins University (JHU)/Population Communication Services to define the role of IEC (information, education, communication) in Cameroon's population and birth spacing activities. In his opening remarks, the Cameroonian Minister of Public Health noted that birth spacing is indispensable for maintaining and promoting maternal-child health. The seminar recommended that Cameroon's population strategy should define a clear family planning(FP)/birth spacing policy, create a national coordinating agency for birth-spacing activities and IEC, point out the advantages of birth-spacing, address the insufficiency of local IEC resources, address the insufficiency of demographic data, consider increasing use of interpersonal communication and traditional media for IEC, and address the lack of a national infrastructure for birth-spacing IEC. The seminar also recommended that the MOPH make birth spacing a priority issue, create a national FP/birth-spacing coordinating committee, budget sufficient funds for FP promotion, develop a standard data collection system, promote research, and consider adoption of the JHU principles of population communication. The document then details the health and socioeconomic benefits of FP and the demographic consequences of rapid population growth. The report ends by noting that birth- spacing is compatible with Cameroon's stated health policy and pointing out that the government has a crucial role in promoting birth-spacing.
The Working Group on Reproductive Health and Family Planning (FP) was convened by the Health and Development Policy Project and the Population Council in 1994 to help make US-supported international FP programs consistent with the Plan of Action of the International Conference on Population and Development. This document reports on a 1997 Working Group meeting on "Changing Communication Strategies for Reproductive Health and Rights." The first part of the report reviews changing communication strategies and offers a brief history of health communication. Part 2 presents results of a panel discussion about client-provider interactions, community participation, and the interface of client satisfaction and quality of health care. The third part summarizes a panel discussion on community mobilization and reproductive rights education strategies, including communication strategies for maternal health and rights in Bolivia; sex education in Latin America; IEC (information, education, communication), FP, and sexually transmitted diseases interventions; and a methodology for incorporating gender issues into community AIDS prevention programs. Part 4 contains papers from a panel on the mass media and social marketing that consider how to use the media as a tool for social change, a communication strategy to increase male involvement in FP in Zimbabwe, marketing the female condom in Zimbabwe, and the empowerment of women and youth in Nicaragua. The final sections present donors' perspectives, a summary of themes covered in technical group discussions, and appendices.
Female genital mutilation: a report to the Attorney-General prepared by the Family Law Council.
This document contains a report on female genital mutilation (FGM) prepared by the Australian Family Law Council's Child and Family Services Committee in response to a 1993 request of the Attorney- General. The report covers 1) the adequacy and appropriateness of existing laws, 2) Canada's 1993 bill C-126 that seeks to protect children being removed from Canada for intended assault, 3) whether additional Australian legislation is needed, and 4) which Court(s) should exercise jurisdiction. After offering background information on the Family Law Council's examination of this issue, the report explains the practice of FGM and its effects before considering relevant international instruments on women's and children's rights. The report then examines the interface of traditional practices and Western society and offers strategies for the future. The main conclusions reached include 1) pressure to continue the practice will extend for at least one more generation; 2) the incidence of FGM in Australia is unknown, but it is likely that it is practiced in the country; 3) the effects of FGM are damaging; and 4) international agreements require that Australia eradicate FGM. Recommended strategies for eradication include education, creating specific additional commonwealth and state legislation, linking educational efforts with initiation of criminalization, developing child protection protocols, providing counseling and support services, and joining international eradication efforts.
The Women's Sports Foundation report: sport and teen pregnancy.
To determine the influence of athletic participation on adolescent sex behavior and pregnancy risk, this US study analyzed data from the Youth Risk Behavior Survey of the Centers for Disease Control and Prevention (involving 11,000 students in grades 9-12) and from the Family and Adolescent Study conducted by the New York State Research Institute on Addiction involving adolescents from 699 families. Major findings included the fact that female athletes were less likely to get pregnant, were more likely to be virgins, experienced first intercourse later in adolescence, engaged in sexual intercourse less often, and had fewer sex partners. Results for male athletes were mixed, and the only consistent pattern between athletic and nonathletic males was that athletes experienced first coitus at an earlier age than nonathletic males. Athletes of both sexes were more likely to use contraceptives than nonathletes. These results led to the following recommendations: 1) increase athletic opportunities for girls; 2) publicize these findings widely; 3) enlist the help of athletic coaches; 4) recruit elite female athletes for public education; 5) promote gender equity in athletes; 6) use sports as a tool to reach adolescent males; and 7) conduct additional research to assess the causal impacts of athletic participation on reproductive activity, evaluate the effectiveness of pregnancy prevention programs that use athletic participation as a strategy, examine how athletic participation influences gender and sexual identity, and determine the impact of economic factors.
This final report describes the activities of a 1993-95 Provincial Advocacy Project conducted by the Philippine Legislators' Committee on Population and Development Foundation, Inc. (PLCPD) in Pangasinam, Palawan, Ifugao, and South Cotabato. The purpose of the project was to increase the awareness of a group of national and local elected officials and local executives/policy-makers about the interrelationships between population, child survival, maternal mortality, the role and status of women, and sustainable development. The project involved disseminating information on population, development and family planning; holding conferences and workshops; networking with legislators, institutions, and the media; providing funds to the provinces for local advocacy activities; and conducting research and evaluation. Project results included completion of KAP (contraceptive knowledge, attitude, practice) surveys with local influentials in all four provinces, development of linkages among various sectors through meetings that allowed specific project activities to become collaborative efforts, organization of a successful population and development conference in each province, and acceptance of Provincial Population and Sustainable Development Declarations and Calls to Action. Lessons learned included the facts that 1) media attention played a key role in influencing opinions and heightening awareness of population issues; 2) strong political support from local officials (especially the governor) is crucial; 3) effective coordination and implementation of activities requires an organized networking system; and 4) the greatest success was achieved in areas where national legislators played an active role.
Understanding the issues. A democracy and governance booklet for women.
This booklet explains how women and women's groups in Nigeria can work towards having their needs met by participating in the democratic process. After a short introduction that explains why democracy and governance are important to women, the manual offers a definition of democracy and nine major qualities of democracy (multiparty system; organized opposition; rule of law; elections; worldwide agreement on fundamental human rights; one person, one vote; minority rights guaranteed; electoral franchise; and new elections on a regular basis). The next section discusses factors that hinder the successful operation of democracy in Nigeria (abuse of power, reluctance to vote, omission of women in the political process, bribes, lack of freedom, ethnic rivalry, militarization of democracy, and a lack of separation of power). The booklet then covers why women should learn about and participate in democracy and governance, how to learn about and promote democratic practices, how to participate in the electoral process, what is governance, what to do after an election, how to gain support for issues, why the electoral process is important, and how to participate in the electoral process. The manual also explains political parties (with a focus on women's wings in political parties), how to get involved in party politics, and how to influence the party. The remaining sections consider how to increase the number of women active in government and political life and how women can make a difference by voting, forming advocacy groups, working together, talking with others, monitoring elections, and speaking up for others.
Ethical complexities of conducting research in developing countries.
Ethical challenges are posed by attempts to conduct clinical trials in developing countries. Such trials must seek interventions that could realistically benefit the population involved. An inadequate understanding of the complexity of such trials has led to unfair charges that developing country trials of interventions to prevent maternal-infant transmission of HIV are comparable with the infamous Tuskegee study where subjects were deprived of available treatment for syphilis. The system of ethical protection developed after the Tuskegee scandal called for respect for persons, beneficence, and justice in research trials. To apply these principles to research in developing countries requires the support and involvement of the host country as well as an understanding of how conditions in the host country may differ from conditions in the partner country and, thus, may require different types of clinical trials. The current debate hinges on the morality of using a placebo control when the AIDS Clinical Trials Group protocol 076 is being effectively used in other parts of the world. The 076 protocol, however, has not been proved effective in developing country settings, and its per person treatment cost exceeds that which can be assumed by developing countries. The most compelling response to criticisms of the placebo-control test designs is that it provides definitive answers to safety and effectiveness questions in the study setting. Debate on this issue is healthy but should be informed by adequate knowledge of local factors that influence research.
Engendering development: lessons from the social sector programmes in India.
This paper, which considers ways to integrate gender issues in social sector programs in India, begins by evaluating the rationale for developing training programs for gender sensitization and the problems that can limit the impact of gender sensitization training. The next section describes effective training strategies as 1) beginning with creation of an atmosphere where trainees feel free to discuss their work and experiences while the facilitator lists and classifies the information thus gleaned, 2) considering existing situations and identifying areas where immediate action is possible, and 3) promoting collective analysis of information generated by the group. The paper continues with a discussion of the internalization of information to the point where it turns into a conviction for action and the importance of recognizing 1) the need to explore alternative systems that will allow gender issues to be incorporated into an overall development agenda and 2) the role of leadership in creating and sustaining a climate for action. The next section deals with weaving gender into the fabric of development through consideration of the following issues: 1) the organic link between the birth of an idea and its implementation; 2) replication and acceleration of pace; 3) appropriateness of replication; 4) standardization; and 5) management. The paper concludes by exploring the fact that the basic objective of a program should inform all of its segments and by noting that the struggle to engender development must involve seizing every opportunity to initiate change.
Reproductive health in the Baltic Sea area.
This study compared national data on reproductive health indicators from Estonia; Latvia; Lithuania; St. Petersburg, Russia; Finland; and Sweden. The paper opens by defining and discussing the concept of reproductive health, the data sources and reliability, and the legal status of abortion in the study countries. The discussion then covers data presented in tables and figures on 1) the number of abortions and of live births and the abortion ratio in the countries for 1987-96; 2) rates of induced abortion in these countries for 1991; 3) registered pregnancies by type of conclusion for 1992-96; 4) distribution of induced abortions among countries by age groups; 5) legal abortions in Estonia, Latvia, and Lithuania per 1000 women by age group for 1992-96; 6) number of induced abortions per 1000 women aged 15-19 in Estonia, Latvia, Lithuania, Finland, and Sweden for 1992-96; 7) fertility rates per 1000 women aged 15-19 in Estonia, Latvia, Lithuania, Finland, and Sweden for 1992-96; 8) contraceptive usage per 1000 women of reproductive age in Estonia, Latvia, Lithuania, and St. Petersburg for 1990-96; 8) method of family planning in Estonia by birth cohorts for 4-year periods ranging from 1924-28 through 1969-73; 9) registered cases of gonorrhea and syphilis per 100,000 population in Estonia, Latvia, Lithuania, St. Petersburg, and Finland for 1994-96; and 10) registered cases of HIV and AIDS per 100,000 population in Estonia, Latvia, Lithuania, Finland, and Sweden for 1994-96. The reasons for the differences in reproductive health are then discussed, and it is concluded that the positive situation in Finland and Sweden can provide valuable lessons to the entire region.
Drama: an appropriate tool in development support communication.
Because it supports progress, drama embodies development and, thus, can be used to support development communication. In fact, drama is the most appropriate medium for effecting change for development because it 1) involves interpersonal communication; 2) broadens the meaning of development; 3) challenges assumptions, demands accountability, suggests remedies, and evaluates the totality of performance; 4) exploits the politics of possibility; 5) is inherently dialogue; 6) allows the target community to participation during the exposition, the conflict, and the resolution; 7) is easy to assimilate; and 8) provides access to any medium. Drama is especially appropriate in South Africa because children carry on a tradition of play-acting, South Africans exhibit politeness to strangers that makes them passively aggressive in resisting change, it allows the temporary removal of cultural barriers among members of households, and it resembles the oral tradition that was pervasive in the culture. Drama can impart greater legitimacy to topics originating from the community or fuse a totally new concept with local culture. It can be used as a tool to criticize political mismanagement, comment on social problems, question culture, debate religious matters, examine economic society, assist educational programs, assist health efforts, raise people's awareness about conservation, and help spread technological advancements. Drama allows more to be done than said and allows communities to be involved in development efforts.
The emasculation of the population movement.
In the US, public apathy about overpopulation began in 1968 and was fueled by two separate events. After the first UN population conference in 1963 concluded that slowing population growth was important to achieving economic development, the US Congress held a series of hearings on the issue between 1965 and 1968 and earmarked funds for population programs in developing countries. The population issue reached its zenith with the 1968 publication of Ehrlich's "Population Bomb." Population activists received a blow in 1970 when the "Father of the Green Revolution" was given the Nobel Peace Prize for ostensibly making it possible to eliminate hunger and solve the problem caused by overpopulation. Even the timing of this announcement (precisely 6 months after 20 million people demonstrated during Earth Day) seems to have been adjusted to deflate the population issue. The Green Revolution led to increased spending on fertilizer and irrigation and less spending on family planning. The second major event that deflated the population issue in the US was the 1973 Roe vs. Wade decision. After delegates to the 1974 World Population Conference exhibited a lack of urgency about overpopulation, the US pro-life movement was born in 1975. This movement dominated US politics even as the developing world began to see the limits of the Green Revolution. Today, journalists keep the population issue buried, agricultural scientists protect their research funds by failing to issue a call for population stabilization, and right-to-life groups obscure the need to stop world population growth with their eagerness to attack the legality of abortion.
Is Medicaid pronatalist? The effect of eligibility expansions on abortions and births.
From 1987 to 1991, Medicaid eligibility standards were expanded dramatically, expanding the proportion of Medicaid-financed births from 15% in 1985 to 32% in 1991. During this same period, the US fertility rate rose from 65.4/1000 women of reproductive age in 1986 to 69.6/1000 in 1991, and the abortion rate fell from 28.0 in 1985 to 25.9 in 1992. This study examines trends in US birth and abortion rates in 15 states between 1986 and 1992 to determine the effect of changes in Medicaid eligibility on abortion and birth rates among unmarried women aged 19-27 with 12 or less years of schooling. The study is introduced with a literature review that reveals a mixed effect of welfare payments on fertility and a description of the methodology, which is based on data gathered between 1986 and 1992 by the National Center for Health Statistics and on vital statistics from Georgia and Mississippi. Data analysis involved pooled time-series cross-section regressions using the natural logarithm of the state-specific annualized quarterly birth or abortion rate as the dependent variable, with all regressions run separately for race in states with a sufficiently large Black population. The Medicaid expansions were associated with a 5% increase in the birth rate among White women. No effect was found on the birth rate in Black women or on the overall abortion rate. Analysis of a subsample of eight states with the most complete abortion data showed a decline in the abortion rate after the second phase of Medicaid expansions. It is concluded that the Medicaid expansion may have encouraged While women to have more children.
A global review of laws on induced abortion, 1985-1997.
This article provides a brief summary of abortion laws in 152 nations and dependent territories with populations of at least a million and documents changes in these laws since 1985. Classification of abortion laws according to level of restrictiveness (to save the mother's life, to preserve the mother's physical health, to safeguard her mental health, on socioeconomic grounds, and without restriction as to reason) reveals that 41% of the world's population lives in the 49 countries that allow abortion without restriction as to reason. The article then reviews the prevalence of other legal restrictions, such as gestational age, third-party authorization, type of medical facility and personnel, mandatory counseling requirements, restrictions on information, and fees. The review of trends since 1985 shows that 19 countries have reduced restrictions on abortion, and only one country has increased restrictions. This review provides regional summaries and also notes important changes in individual countries. The final section of the article covers factors that affect abortion availability, such as varying interpretations of laws, enforcement, the attitude of medical staff, and responses to the efforts of anti-abortion groups. It is concluded that most of the world's women live in countries where abortion is legal under many circumstances and that the global trend toward liberalizing abortion laws has continued and has enhanced the availability of safe abortion services.
Abortion politics in the federal courts: right versus right.
After an introductory chapter that questions the immunity of federal court judges from the pressures of interest groups, this book examines whether lobbying by interest groups affects judicial outcomes in the US federal courts and explores the political and litigation-related resources of such groups. The second chapter considers whether other political factors affect outcomes in abortion cases and whether judicial decisions in abortion cases are related to the region in which they are heard. In chapter 3, litigation success is analyzed to determine if it is a result of repeat-player status or political clout. Chapter 4 focuses upon the resources and lobbying activities of individual groups, including general public interest groups, civil liberties groups, religious groups, women's rights groups, legal aid groups, and not- for-profit abortion clinics, Planned Parenthood, for-profit abortion clinics, professional associations and unions, and public hospitals. The final chapter provides overall evaluations of abortion litigation and the participants and concludes that the pro-life faction lacks any meaningful organizational representation in federal court litigation, while the pro-choice position has benefitted from numerous coalitions and multiple representation by groups in federal court litigation.
Child health and welfare -- UNICEF. Terminology Bulletin No. 341.
This book contains an list of 3000 terms complied by the UN Children's Fund (UNICEF) that are associated with child welfare. The list provides the term in English, French, Spanish, Russian, Chinese, and Arabic. The list is arranged according to English alphabetical order. Indices are then provided that offer the list in alphabetical order in French, Spanish, Russian, Chinese, and Arabic. Additional indices give the acronym index and display the UNICEF Standard Post Title Scheme.
With the 80 million people added to the world's population in 1997, slightly more than in the previous year, total global population has reached 5.85 billion people. Practically all of those added live in the developing world, already home to approximately 4.7 billion. Approximately 60% of the 80 million people were added to Asia. While the total number of people globally continues to increase, the annual rate of world population growth has slowly declined from an historical high of 2.2% in 1963 to 1.4% in 1997. Developing countries, however, are growing much faster than industrial ones; 1.7% versus 0.3%, respectively. Population size in sub-Saharan Africa is growing at the annual rate of 2.7%. The decline in the number of people added to the world during the 1990s is partly due to falling fertility rates in several developing countries. New data do, however, indicate that fertility rates in some countries are higher than earlier estimated. The UN projects that global population over the next 50 years will reach 9.4 billion, with nearly 60% of the growth expected to occur in Asia. By 2050, China's population is expected to increase from the current 1.2 billion to more than 1.5 billion, while India's population of 930 million should grow to 1.53 billion. The population of the Middle East and North Africa will likely double, while that of sub-Saharan Africa will triple. Controlling population growth depends upon the international community's willingness to make population issues a priority. Developing countries, but not donor countries, are on track with the various population funding expenditures committed at the 1994 International Conference on Population and Development. International population assistance by the US, the largest donor, dropped from $547 million in 1995 to $385 million in 1998.
According to the UN High Commissioner for Refugees (UNHCR), 22.7 million people qualified for and were given refugee assistance between January 1996 and January 1997. 13.2 million of those people had been forced to flee their countries, 4.9 million were internally displaced, and 3.3 million had recently returned to their home countries. The remaining 1.3 million were considered "others of concern." The number of people receiving refugee assistance worldwide reached an all-time high of 27.4 million in 1995, but then declined 2 years in a row, with the drop of 3.4 million between 1996 and 1997 being the largest recorded decline. Afghanistan was the source of the largest number of international refugees, approximately 2.7 million people. Liberia, with 778,000 in exile, and Bosnia and Herzegovina, with 673,000 followed Afghanistan in numbers of refugees. Overall, the number of people who fled their countries declined in 1997, and 10 million have returned home since 1990. Africa provided asylum to the largest number of refugees receiving UN assistance, more than 8 million in 1997. Country-wise, Iran, Germany, and Pakistan hosted the largest number of refugees, with 2 million, 1.3 million, and 1.2 million, respectively. Although the number of international refugees is on the decline, the number of people living in refugee-like situations in their own countries continues to grow. People who are internally displaced can receive international refugee assistance only if their governments allow them to do so. Civil wars and unrest, economic turmoil, and environmental pressures are some factors responsible for the large numbers of displaced people. Finally, as industrial countries tighten their borders, refugees are increasingly being barred from safe havens, especially Europe.
HIV / AIDS pandemic far from over.
Almost 6 million people worldwide contracted HIV in 1997, more than the previous year's record of 5.6 million, and more than 30 million people are now living with HIV/AIDS. More than 40 million people worldwide have been infected with HIV since the beginning of the HIV/AIDS epidemic in the late 1970s, of whom approximately 15 million have developed full-blown AIDS and 11.7 million have died. HIV infection rates and AIDS deaths have either declined or stabilized recently in industrialized countries, but the epidemic continues to grow in the rest of the world. To a large extent, the HIV/AIDS pandemic has become two epidemics. In developed countries, HIV infection and AIDS are treated with expensive drug regimens as a manageable chronic condition. However, in the relatively poor developing countries where more than 90% of all cases occur, HIV infection still means gradual wasting and death. With two-thirds of all the people worldwide who are infected with HIV, Africa remains the most seriously affected region; 7.4% of adults in Africa are infected with HIV. While high HIV prevalence in China and India currently remains limited to high-risk populations, infection could readily spread beyond these groups into the general population. In Latin America and the Caribbean, AIDS is on target to become the leading cause of death among youths. On a positive note, aggressive government campaigns to increase public awareness about HIV/AIDS have led to significant declines in HIV prevalence in recent years in Uganda and Thailand. Although it is essential that steps be taken to prevent the spread of HIV, cultural taboos and paltry resources deny young people access to HIV/AIDS education and condoms, the main means of preventing HIV infection.
750 million people worldwide lived in urban areas in 1950. Now, however, that number has increased to 2.64 billion, with approximately 61 million people added to cities each year through rural-to-urban migration, natural demographic increase within cities, and the transformation of villages into new urban areas. In most countries, the number of city dwellers is growing faster than the national population such that people living in urban areas account for a steadily growing share of world population. UN estimates indicate that more than half of the world will live in urban areas within the next decade. One-third of all city dwellers live in industrial countries. The number of urban areas is also increasing, including the addition of rapidly growing megacities, urban conglomerations with more than 10 million people. The quality of life in many urban centers of the developing world is poorer than that in rural areas due to the overwhelmingly large and growing populations competing for limited available resources. The heavy influx of poor people lured to urban centers in developing countries by the prospects of jobs, better education, and/or improved services tends to lead to high levels of homelessness and unemployment, pollution and congestion, the loss of agricultural land, and the accumulation of nutrients and waste. Massive infrastructure investments will be needed in order to preserve the comparative advantages of cities.
Since human waste is replete with bacteria, viruses, and parasites which can cause widespread sickness if they contaminate drinking water, adequate sanitation is needed to prevent the transmission of such fecal contaminants among humans. Poor sanitation coverage increases the risk of illness. The World Health Organization (WHO) reports that 50% of people in developing countries have one of the 6 diseases associated with poor water supply and sanitation. While the greatest shortage of sanitation is in rural areas, the most urgent need for sanitation is in cities because of the higher potential therein for widespread infections from pathogen-contaminated water. Even though adequate sanitation does not always require flush toilets and underground sewers, the share of developing country populations with access to adequate sanitation fell from 36% to 34% between 1990 and 1994, the last year for which comprehensive data are available. The unserved population in developing countries grew by 274 million people over the period 1990-94, a rapid acceleration of the trend from the 1980s, a period during which the number inadequately covered increased by 50 million. This backsliding runs counter to the goal of the UN-declared International Drinking Water Supply and Sanitation Decade (1981-90), an initiative designed to broaden access to safe water and adequate sanitation. One reason for the inadequate levels of sanitation coverage is its expense, with developing countries spending less than a third of what they should in order to provide adequate sanitation.
Irrigated land is key to agricultural productivity, supplying approximately 36% of the world's food from only 16% of its cropland. With 60% of their rice and 40% of their wheat coming from irrigated lands, developing countries are particularly dependent upon irrigated cropland. However, despite the importance of irrigated land, global irrigated area expanded by less than 0.5% in 1995, the last year for which comprehensive data are available. That increase of 1.4 million hectares brought the world total to 255.4 million hectares, less than 45 hectares of irrigated land per 1000 people worldwide, the smallest area per capita since 1969. The greatest growth in irrigated area occurred in developing countries, with Latin America realizing an increase of 1.2% between 1994 and 1995, 4 times the global figure, and slight expansions in Africa and Asia. In industrial countries, there was a 0.3% loss in irrigated area. Irrigated land area grew sluggishly during the 1990s and is projected to grow far more slowly during the next century. This slowdown in expansion has worrisome implications for growth in the global food supply. In addition to sluggish expansion, some of the world's land continues to be watered unsustainably, while competition for water among households, industry, the environment, and farming will grow together with economic growth. Where water is already scarce, agriculture may be threatened. The expansion of irrigated areas could be helped by an increase in irrigation efficiency, depending upon the use of sprinkler or drip irrigation systems rather than flood irrigation to reduce water wastage on farms.
Sibling models of socioeconomic effects on the timing of first premarital birth.
The increase in premarital birth rates in the US over the past 2 decades has generated interest and research into the causes and consequences of early family formation. This interest stems largely from the perception that births to teens, and especially out-of-wedlock births, are social problems which have undesirable consequences for the mother, the child, and society at large. Data on 1090 pairs of sisters from the National Longitudinal Survey of Youth were used to estimate the effects of observed individual-level factors, common family-level variables, and shared unobserved family-level traits upon the timing of premarital births. Analysis of the data identified important mechanisms through which family and individual attributes affect out-of-wedlock childbearing. The effects of an older sibling's childbearing and unmeasured family-level traits are important components for young White women and Black women. Racial differences in unobserved family traits suggest the importance of the unique familial contexts of premarital births in both the White and Black populations. While only modest racial differences were found in observed and unobserved mechanisms of premarital birth timing, the investigators ignored the possibly important aspect of racial differences in sexual initiation.
Explaining fertility transitions.
Fertility transitions, long-term declines in the number of children from 4 or more per woman to 2 or fewer, are discussed with the hope of stimulating thought and debate among demographers about the process. The 6 most commonly cited theories of fertility transition and the major criticisms of each are presented. The author describes 4 fundamental problems in current thought about fertility transitions and suggests better ways to approach the issues, and describes a perceptual, interactive approach to understanding fertility transitions. An illustrative model of the latter is offered. Most theories of fertility transition have been partially or completely discredited, reflecting a tendency to assume that all fertility transitions share one or two causes, to ignore mortality decline as a precondition for fertility decline, to assume that pretransitional fertility is governed wholly by social constraints rather than by individual decision-making, and to test ideas on a decadal time scale. A perceptual, interactive approach is suggested to explaining fertility transitions which is closely allied to existing theories, but focuses upon conditions which lead couples to switch from postnatal to prenatal controls upon family size.
Health implications for Papua New Guinea of chlamydial infections [editorial]
The increasing incidence of chlamydial infections currently being reported worldwide is possibly due to the greater number of cases being detected through the recent use of more sensitive and versatile methods. Chlamydial infections are well established, widespread, and lie undetected in many communities. Chlamydia trachomatis is the most important of the 3 species of human chlamydial pathogens. Such infections are common in Papua New Guinea, where they pose a significant health problem. A multicenter survey on sexually transmitted diseases (STDs) conducted in 5 STD clinics in Port Moresby, Goroka, Rabaul, Lae, and Daru found a positivity rate for chlamydia infection of 7-47% among males and 17-30% among females. Overall prevalence rates for men and women in the study were 26% and 27%, respectively. A prospective study of endocervical prevalence among 181 antenatal patients at Port Moresby General Hospital between December 1990 and January 1991 recorded a prevalence of infection of 18%. Furthermore, a study recently identified C. trachomatis in 57% of eye swabs collected from children with conjunctivitis and in 26% of nasopharyngeal aspirates collected from children with pneumonia. In Papua New Guinea, consistently high prevalence rates are found in both symptomatic and asymptomatic individuals, together with high transmission rates in studies. Eradicating C. trachomatis in the genital reservoir among infected individuals would control and eventually prevent many of the adverse consequences exacted by the infections. Preventing chlamydia is also extremely important in the face of an imminent HIV epidemic in the country.
Why Italians don't make babies.
Italians have stopped having children and the country is aging rapidly. According to the country's main statistical body, Italy has the lowest fertility rate in the world, with women now bearing only 1.2 babies each over the course of their reproductive lives. The most recent time assessed in Italy, in 1996, there were more deaths than births for 4 years in a row. The increase in Italy's population in 1996 is the result of the 178,000 immigrants who acquired legal residence during that year. There is no definitive explanation for this trend. One potential factor is the growing number of Italian women who work. While women in Northern Europe work just as much, they have more help raising their families in terms of public nurseries, finance, vacations, and husbands who help with housework. In addition, stigma is no longer associated with childlessness and the social pressure to marry and have children is weaker. Another possible explanation is that young Italian professionals want to enjoy the single life for many more years than before, allowing marriage and babies to wait. Contraceptive use is no longer taboo in Italy. Another potential determining factor of current low fertility in Italy is the large proportion of young adults, perhaps even larger than before, which still lives with their parents. Living with parents affects one's relationships with members of the opposite sex.
Fertility and the Easterlin hypothesis: an assessment of the literature.
In his inaugural presidential address to the Population Association of America in 1978, Richard Easterlin challenged the orthodox neoclassical economic model of fertility originally suggested by Becker and subsequently elaborated by Becker and Lewis. While maintaining an economic approach to fertility, Easterlin's model was based upon the notion of material aspirations which changed systematically as a function of income and prices. Easterlin and most sociologists saw the Easterlin model as an attempt to bring sociology into economics, and believed that a discipline of economics which could not accommodate changing preferences was unfeasible. This paper focuses upon the fertility aspects of the Easterlin hypothesis, critically assessing the available fertility literature generated by Easterlin, as well as the complete inventory of data and methodologies in 76 published analyses. An equal number of micro- and macro-level analyses using North American data offer equal, significant support for the hypothesis. While the literature suggests absolute support for the relativity of the income concept in fertility, it is less clear on the sources of differences in material aspirations, and suggests that the observed relationship between fertility and cohort size has varied across countries and time periods due to the effects of additional factors not included in most models.
Family planning clinics provide contraception, pregnancy-related services, abortion, sexually transmitted infection detection and prevention, sexual health education and health promotion, pre-conception advice, youth services, psychosexual therapy, cervical screening and breast awareness, menopause and PMS management, subfertility care, medical gynecology, and vasectomy and sterilization counseling operations. However, not all of these services apply to family planning, reproductive health, and heterosexuals. Family planning clinics therefore need another, more appropriate name which accurately describes the range of services provided. Sex is the main reason people go to such clinics, while sexual health is about enabling people to fulfill their fundamental human need for sex. The promotion of positive sexual health is more than dealing with the consequences of unprotected sex, unwanted pregnancy and disease. Since 95% of sexual activity is recreational rather than reproductive, "reproductive health" is an inappropriate term. Furthermore, use of the term "reproductive" may lead homosexuals and bisexuals to avoid using such services. Changing "family planning" services to "contraception and sexual health" services may be the best way to convey the core business provided by such clinics while indicating the wide range of services offered. Genitourinary medicine physicians and family planning practitioners should work together as colleagues in providing sexual health services.
Looking to avoid giving old-fashioned or judgmental messages to those who need their care, clinicians are uncomfortable with the use of the terms "family planning" and "genitourinary medicine" to describe their services. Existing definitions of sexual health identify its core features as reproductive health, the absence of disease or disorder, and psychosexual well-being. Sexual health is therefore an holistic term which involves taking sex and all of its consequences seriously. That ideal can be achieved through clinicians who understand and adhere to the vision of holistic sexual health care, and agree to work in a professional alliance with colleagues. 2000 young people in East Berkshire were asked what they thought a sexual health service should offer. More than anything, they wanted help answering their sexual health-related questions and concerns. Ideally, an individual could visit one clinical site and have all of his or her needs met in one consultation. The term "sexual health" should be used only when describing the full spectrum of care, including reproductive health care, the management of genital pathology, and psychosexual support.
What are family planning clinics for? [letter]
In the delivery of family planning services, nurses are legally permitted to advise on breast awareness, prescribe emergency contraception, fit caps, take cervical smears, issue the oral contraceptive pill once authorized by the attending doctors, and remove IUDs after having received informed consent. Appropriately trained nurses play a central role in medical abortion and may be responsible for taking client histories, counseling, examining, discharging patients, providing contraceptive advice, and providing follow-up to patients after they have undergone surgical abortion. In subfertility and menopause clinics, nurses may make assessments within agreed protocols, run menopause hotlines, participate in parallel clinics with doctors, and run "nurse only clinics" in which they offer advice upon side effects and the appropriate use of medication. Rather than running "nurse led clinics" or "nurse only clinics," nurses should be encouraged to work with doctors in "nurse and doctor clinic" sessions. Nurses working in such parallel sessions will have less responsibility and pressure, with the assurance that professional back up will be available when needed. Nurse only clinics can, however, function smoothly if established in designated major family planning centers after ensuring that advice from a doctor will be available if and when required.
What are family planning clinics for? [letter]
Family planning nurses bring skills and expertise to family planning and sexual health care services. As such, an informed debate about the role of nurse only community family planning clinics would be welcome. Issues to debate include how nurse only community family planning clinics are defined, how the diverse skills of family planning trained nurses should be acknowledged and fully utilized in community family planning services, issues of referral, and the need to elicit clients' experiences with and preferences for given services. Family planning services face the challenge of how to best use their resources, including the skills and time of their staff. Such services must also be advertised to the general public, and appointments booked in such a manner that clients will be able to make real choices and locate the services which are appropriate to their needs.
What are family planning clinics for? [letter]
Nurse only family planning sessions are better equipped than nurse and doctor general practice sessions to meet the needs of family planning clients. While doctors are not present at nurse only family planning clinics and sessions, community family planning services are able to develop protocols which extend clinic services through the provision of telephone support from a consultant/senior doctor which would keep repeat visits to a minimum, nurses can offer support and counseling even if a client's problem cannot be solved at the initial visit, and a specialist family planning nurse can do more for a family planning client than can a generalist nurse supported by a busy general practitioner. Reliance upon well-trained, specialized nurses to provide family planning services which are commensurate with their skills and expertise free physicians to use their training and expertise appropriately. Women who participated in a recent evaluation of nurse only clinics in Liverpool from both medical and clients' perspectives reported needing few repeat visits to the clinic. The women almost universally expressed their deep appreciation of the quality of counseling provided by the nurses and reported their intention to continue using the nurse only service in the future. Family planning nurses in Liverpool work as a team with their doctors in delivering high quality medical undergraduate and postgraduate training. With proper training and support, the nurses have proven themselves to be excellent research workers.
What are family planning clinics for? [letter]
Family planning clinics exist to serve family planning clients, not just to provide training or conduct research. The rationale for providing such services through both general practitioners and community clinics is to provide the client with a choice of venue for treatment, for patients may have many reasons for needing such options for care. The author offers her opinions on nursing practice, protocolized practice, the provision of general practitioners' (GP) services, cost-effectiveness, and training for the future. If nurses did not use their skills in family planning, doctors would have to manage the problems of general clients in addition to the more complex issues for which they have been specially trained, thereby increasing doctors' workloads. With regard to GP service provision, GPs are not required to be trained in family planning before they offer that service to patients. Moreover, many GPs depend upon their practice nurses to provide family planning services, but in some cases the nurse has little or no training in the field.
Pregnancy while using Norplant [letter]
A 31-year-old woman who had had 4 full-term pregnancies before 1994, including a twin pregnancy, was referred to the author for removal of Norplant. Norplant was inserted in the woman in 1995, after which she had regular monthly bleeds for more than 2 years. Although reassured that conception when using Norplant is very rare and that missed menstrual periods are a common side effect of method use, the subject was convinced that she was pregnant as soon as she missed a period. A positive pregnancy test confirmed the existence of pregnancy, after which the subject and her partner decided to continue with the pregnancy. In seeking to understand why Norplant failed this woman, the author discusses the possible effects of drug interaction with Augmentin and Keflex, non-enzyme inducing antibiotics; that the woman weighed 74 kg; and that her bleeding pattern was regular. Shoupe et al. determined in a 1991 study that women with regular bleeding patterns may be at higher risk of method failure.
The author responds to several issues in the January 1998 issue of the British Journal of Family Planning, agreeing with the points made in the editorial, but adding that the oral contraceptive pill scare should not be underestimated. Many family planning clients do not accept what health professionals say about the pill and are waiting for the next scare. Regarding fertility and induced abortion in the northeast Thames Region of Haringey, cultural and ethnic factors are not mentioned. However, such factors and distinctions are highly pertinent in areas such as Haringey which have a large number of young, fertile, ethnic minority women. Haringey has a considerable number of 30-year-old grandmothers. 30% of clinic patients at Haringey Healthcare NHS Trust in 1996/97 chose to use the condom, 28% oral contraception, 10% the IUD, and 4% Depo-Provera. Family planning clinics exist to serve family planning clients, not just to provide training or conduct research.
The pill -- 25 years ago and today [letter]
Barbara Seaman's book, "The Doctor's Case Against the Pill," deserves a more serious and accurate review than that conducted by Dr. Levinson and published in the Journal of the American Medical Association. It is irrelevant that studies were under way before the original publication of Seaman's book which eventually resulted in changes to the oral contraceptive pill. Seaman's book is important because women read it and subsequently protested publicly. Such protests move corporate manufacturers who, in turn, move medical researchers. Even though Seaman inspired women, corporations, and the government to act, Levinson argues that he cannot recommend her book to the public. The author strongly recommends "The Doctor's Case Against the Pill," especially the updated additions to the newly reissued version, for physicians who do not specialize in contraception and for all women and their partners.
The pill -- 25 years ago and today [letter]
Dr. CJ Levinson strongly criticized the 25th anniversary edition of the author's book, "The Doctor's Case Against the Pill." Levinson directs an endoscopy center at Stanford University which works with corporate partners through a consortium promoting cooperation between academia and industry. That consortium is supported by at least 2 pharmaceutical manufacturers of contraceptive hormones, Syntex and Wyeth Ayerst. Levinson may have undisclosed financial conflicts of interest which influenced his treatment of the author's book. Levinson's sloppy review fails to note that "The Doctor's Case Against the Pill" was the catalyst for US Senate hearings on the pill in 1970, which led to patient labeling for birth control pills. Finally, the author is neither ignorant about nor complicit with Hugh Davis' involvement with the Dalkon Shield.
A cost analysis of family planning in Bangladesh.
A successful supply-side approach has governed the delivery of family planning in Bangladesh for the past 20 years. The heart of the current system is an extensive community-based distribution (CBD) system which provides free door-to-door services and visits almost every eligible couple in the country 6 times per year. However, considerable program overlap and duplication waste resources. The current system is also inefficient because of its reliance upon relatively more expensive re-supply methods and its failure to consider contraceptive demand. With US Agency for International Development (USAID) funding likely to be reduced in the coming years, an impending need exists to improve system efficiency. Findings are presented from a step-down cost analysis using secondary data sources from 26 Bangladeshi nongovernmental organizations (NGOs) which provide family planning services through a USAID-funded umbrella organization. 56% of total expenditures in this 2-tiered umbrella's organizational structure are incurred in management operations and overhead expenses. 88% of the remaining program funds are spent upon the CBD program and 12% are spent upon maternal-child health (MCH) clinic activities. Most CBD program resources are spent providing 4 million contacts which do not involve contraceptive re-supply, with the clinics devoting more resources to providing MCH services than to providing family planning services. Significant savings could be generated through containing administrative costs, improving operational efficiency, and reducing unnecessary or redundant field worker contacts.
Economic and demographic consequences of AIDS in Namibia: rapid assessment of the costs.
Namibia, with a population of 1.6 million people, is one of the countries most severely affected with HIV/AIDS. While more than 28,000 cases of HIV infection have been reported in Namibia since the first case was documented in 1986, some estimate that there are more than 100,000 HIV cases in the country. The AIDS epidemic in Namibia will most likely aggravate poverty and increase levels of social inequity. The government of Namibia recently announced that it plans to provide financial support to people living with AIDS and their family members. However, government budgets are already stretched and funds are still needed for HIV/AIDS prevention. Results are presented from a rapid assessment of the economic costs of HIV/AIDS in Namibia over the next 5 years of the First National Development Plan. The estimates, based upon projections calculated by the DEMPROJ and AIDS Impact Model computer models, include the direct and indirect costs, with the direct costs being the costs to the economy of support payments to people living with AIDS, their families and children orphaned due to AIDS. Government and donor expenditure on national prevention and control efforts are also included. When specific data were unavailable for Namibia, the programs' default values for sub-Saharan Africa were used when deemed reasonable. The HIV/AIDS epidemic in Namibia will affect all sectors of the economy, taxing hospital, public health, and private and community resources.
Maternal-child health in Zimbabwe.
Maternal and child health (MCH) needs in Zimbabwe, existing health care delivery services designed to meet those needs, and the activities and findings of an Earthwatch project to identify and train community peer counselors at Berejena Mission, Masvingo Province, to improve the nutrition and health status of families, especially women and infants, are described. Earthwatch is a worldwide volunteer organization. A longstanding drought has left many women and children in Zimbabwe malnourished. Poor nutrition affects women, pregnancy outcomes, and developing children over both the short and long terms. Major problems which contribute to maternal-child morbidity and mortality in the area include nutritional deficiencies, lack of safe water, and unmet need for family planning. Earlier surveys of maternal nutrition consistently showed iron deficiency, goiters, underweight, and inadequate nutrient intake to be highly prevalent. On the basis of previous assessments, the project focused upon teaching the community health workers how to help families with nutritional deficiencies, family planning, and hygiene needs.
Female condom acceptability among sex workers in Costa Rica.
Costa Rica has an estimated population of 3.2 million people. Contraceptive prevalence in the country was 75% in 1993, 99% of married or cohabiting women have heard about male condoms, and 96% know where to get them, but only 16% use them. Other barrier methods are either not widely used or are unavailable. Barrier contraceptive methods, however, are the only type of contraceptives which can be used to reduce the risk of contracting sexually transmitted diseases, including HIV. Even though female condoms are not yet widely available throughout Costa Rica, a study was conducted to assess short-term female condom acceptability among 51 female prostitutes in San Jose, Costa Rica. Each woman was trained how to use the female condom and asked to use it if clients refused to use male condoms during the 2-week study period. At the first of 2 scheduled follow-up visits, 51% of the women reported that they were thoroughly satisfied with the female condom, while 45% reported liking it somewhat. Similar results were reported after the second follow-up visit. 67% of the participants preferred the female condom over the male condom and the women reported that more than half of their clients liked the female condom either very much or somewhat. The most common problems encountered during the first phase of the study were difficulty in inserting the condom (61%) and discomfort (43%). However, the levels of these problems fell to 22% and 25%, respectively, during the second phase of study, while other use-related problems were noted. Study findings highlight the need to make female condoms more widely available in Costa Rica.
Unlike other health risks such as heart disease and lung cancer, HIV can be contracted through one single act of unsafe sex. If individuals realize this, they may anticipate experiencing considerable regret and self-blame after having engaged in unsafe sex. A prospective study involving 51 male and 49 female undergraduate self-described heterosexual students at the University of Groningen, Netherlands, of mean age 21 years, was conducted to examine how the feelings of regret and self-blame a person anticipates after having unsafe sex affect condom use in new sexual relationships. Of concern is whether self-efficacy perceptions can moderate the relationship between anticipated feelings and actual condom use. 53% of the students reported having more than one new sexual relationship during the preceding year, 72% of whom did not always use condoms in the encounters. Consistent with theories of anticipated regret and social cognitive learning, participants were most likely to use condoms when they anticipated negative feelings as a result of not using condoms and positive feelings after having used condoms, especially when they believed that they were capable of controlling their sexual situations. Implications are discussed for interventions designed to promote safer sex.
Sexuality education and young people's sexual behavior: a review of studies.
Sexuality education for children and young adults is one of the most heavily debated issues facing policy-makers, national AIDS program planners, and educators, provoking arguments over how explicit education materials should be, how much of it there should be, how often it should be given, and at what age instruction should commence. In this context, the World Health Organization's Global Program on AIDS' Office of Intervention Development and Support commissioned a comprehensive literature review to assess the effects of HIV/AIDS and sexuality education upon young people's sexual behavior. 52 reports culled from a search of 12 literature databases were reviewed. The main purpose of the review is to inform policy-makers, program planners, and educators about the impact of HIV and/or sexuality education upon the sexual behavior of youth as described in the published literature. Of 47 studies which evaluated interventions, 25 reported that HIV/AIDS and sexuality education neither increased nor decreased sexual activity and attendant rates of pregnancy and sexually transmitted diseases (STDs). 17 reported that HIV and/or sexuality education delayed the onset of sexual activity, reduced the number of sex partners, or reduced unplanned pregnancy and STD rates Only 3 studies found increases in sexual behavior associated with sexuality education. Inadequacies in study design, analytic techniques, outcome indicators, and the reporting of statistics are discussed.
Malawi -- president supports abstinence education.
A campaign against AIDS was launched in Malawi in January 1995, while an educational program using slides and targeting secondary school students is underway with the approval of the country's Ministry of Education. A survey of students who have taken the courses found that 65% believe abstinence is the best way to prevent the spread of HIV/AIDS, and 25% reported that they would like to be abstinent even though it will be difficult to remain so. Teachers also responded favorably. Once Malawi's president heard about the students' support for abstaining from sexual intercourse, he began promoting abstinence on radio broadcasts. Before receiving the news, the president had been encouraging condom use against HIV/AIDS. Women's Federation members have visited villages in Malawi's provinces to hold slide-complemented lectures. The federation has taught village women how to make lace for export to and sale in Japan, where it is thought that the products will sell well. Also in Malawi, the Women's Federation for World Peace (WFWP) is considering financial aid for students at Malawi University. The university will select grant recipients from among 20 students who show great potential for positively impacting the country's future. Other activities include collecting clothing and food for institutions for the handicapped, street children, and AIDS orphans.
Ophthalmia neonatorum revisited.
Ophthalmia neonatorum (ON), neonatal conjunctivitis, is a major public health problem. Although non-sexually transmitted micro-organisms are involved in 40-50% cases of ON, ON should be considered a sexually transmitted disease (STD) until proven otherwise. That is, unless a case is proven not to be due to a STD pathogen, it should be treated syndromically for both Neisseria gonorrhea (NG) and Chlamydia trachomatis (CT) where microbiologic facilities are unavailable. Materno-fetal transmission occurs during the birth process, mainly of asymptomatic carries of NG and/or CT. The author reviews the microbiology, epidemiology, and pathophysiology of ON with emphasis upon its prevention and management in the developing world. While prophylaxis should be mandatory, no single topical agent can prevent the ocular complications of both NG and CT. However, where levels of resistance to tetracyclines are low, tetracycline ointment can be used for ocular prophylaxis. Eye prophylaxis has a relatively low failure rate. Finally, the management of ON should be syndromic and systemic, with contact tracing being an integral part of that management.
Demographic and sociocultural factors influencing use of maternal health services in Ghana.
The overall level of maternal mortality is twice as high in sub-Saharan Africa as it is in all low income developing countries, and six times higher than in the middle-income developing countries. As such, maternal health services can play an important role in improving reproductive health on the continent. Study findings indicate that access to skilled assistance and well-equipped health institutions during delivery can reduce levels of maternal mortality and reproductive morbidity, and improve pregnancy outcomes, while care during pregnancy, delivery, and the postnatal period can improve overall maternal and infant health. Data from the 1993 Ghana Demographic and Health Survey (GDHS) were used in the investigation of demographic and sociocultural determinants of the use of maternal health services. The GDHS survey yielded a sample of 4562 women aged 15-49 years. The maternal health services considered in the study are the use of a doctor for prenatal care, the solicitation of antenatal check-ups, place of delivery, and family planning. Logistic regression was used to explore the relative importance of age at marriage, number of living children, education, place of residence, occupation, region of residence, religion, ethnicity, and age on the likelihood of using maternal health services. Multivariate analysis found that the use of maternal health services tends to be shaped mainly by level of education, place of residence, region of residence, occupation, and religion. Programmatic implications of these results are discussed.
Adolescent pregnancy and reproductive health in Transkei (rural South Africa).
For more than a century, Black men in South Africa were recruited to work in cities while, by law, women and children had to stay in rural areas. As such, men were unable to establish families and legally move them to South Africa's cities. This policy helped to develop and support the norm of unmarried women in the country and the general acceptance of childbearing outside of marriage. Findings are presented from a study of adolescent unmarried pregnancy in the Transkei, Eastern Cape, South Africa. Quantitative data were collected in a 1994 survey on fertility behavior in the Eastern Cape, including the Transkei subregion, of a representative sample of 2290 married and unmarried women aged 15-49 years. Qualitative data were collected from adolescents, parents, and family planning officials in two June 1995 studies in Caguba and Mtombo villages. Although only 11% of the women surveyed were ever-married by age 19 years, 43% had had children and 51.6% had ever been pregnant by that age. Marriage comes late in the region, with 64% of women aged 20-24 years being never-married.
Safe motherhood: the road from Nairobi [editorial]
While women had long died from complications of pregnancy and childbirth before 1987, it was not until the mid-1980s that several factors converged to prompt the launching of the safe motherhood initiative in Nairobi in February 1987. Data had accumulated which showed that 500,000 women were dying annually due to pregnancy and childbirth, with millions more suffering from severe morbidity. Such suffering need not occur since maternal mortality is largely avoidable and practically nonexistent in developed countries. The increasing status of women also meant that their lives came to mean more and were considered worthy of saving. 10 years later, in October 1997, an international technical consultation was held in Colombo to review progress achieved and lessons learned since the initiative was launched. It is now clear that motherhood can be made safe, with experience indicating that interventions of the following sort can have a positive impact upon safe motherhood: the advancement of women and birth planning, community-based prenatal care and delivery by trained birth attendants, and the provision of essential obstetric care and facilities for referral. The author discusses how with regard to safe motherhood cure is often better than prevention, the need for more than primary health care to make a difference, how poverty and lack of development are only part of the picture determining whether a woman has a safe motherhood or not, and the applicability of the risk approach. Cost-effective interventions are available to make motherhood safe for women worldwide.
Breast feeding: the baby friendly initiative [editorial]
Even though breast feeding is the best way to nourish infants and protect them from infections, a strong culture for bottle feeding exists in Britain. The global baby friendly hospital initiative was launched jointly by UNICEF and the World Health Organization in 1991 with the main objective of making it easier for mothers to breast feed. 10 steps are offered as a standard for good practice, with the Baby Friendly Initiative Golden Award given to hospitals which complete the steps and achieve a 75% rate of breast feeding upon discharge, and the British Baby Friendly Initiative Award given to hospitals which achieve a 50% breast-feeding rate upon discharge. By December 1996, there were only 3 baby friendly hospitals in Britain and another 10 with a certificate of commitment for achieving 3 of the steps. A low level of government involvement, an emphasis upon consumers' right to choose which causes some health professionals to shy away from endorsing breast feeding, and the isolation of some mothers from their extended families when discharged early from the hospital and the accompanying lack of social support to breast feed are some reasons why hospitals in Britain have been slow to adopt the initiative. The initiative needs to be adapted and developed if it is to take hold and make any positive impact in Britain.
Street children in Latin America.
Worldwide, millions of children live on the streets. These children typically have access to neither health care nor education. Sometimes subjected to violence in the home before taking to the street, street children are seen by many as worthless, and many countries have used violent and punitive measures to eliminate them. New approaches have recently been implemented to return these children to society and their families. In the case of South America, children who are on the street are home-based and spend much of the day on the street, but have some family support and usually return home at night. Children of the street are street-based children who spend most days and nights on the street and are functionally without family support. Studies suggest that 80-90% of street children in Latin America have some contact with their families. Surveys also indicate that street children in Latin America are 8-17 years old, with 9 years old being the average age upon entering the street. Girls comprise 10-15% of street children and Black and mixed race children may be over-represented among street children in the region. Both published and unpublished research findings are used to shed light upon the status of street children in South America. The authors consider how many street children there may be, why there are street children, the problems they encounter, and what can be done to help them.
The treatment of falciparum malaria in African children.
More than 80% of all cases of malaria and malaria-related mortality worldwide occur in Africa, due mostly to infection with Plasmodium falciparum. Up to half of all mortality among African children aged 6 months to 5 years may be due to malaria. While prevention measures against malaria infection remain important, the prompt diagnosis and treatment of the disease remain key to reducing the high incidence of malaria-related mortality. It is possible that any patient with a febrile illness in a malaria-endemic area and parasites on the peripheral blood film has malaria. All patients who present with fever and parasites on peripheral blood film need to be carefully clinically assessed, with care given to exclude other causes of fever which could be mistaken for malaria. Both microscopy and the available dipstick tests to detect malaria have limited practical use in diagnosing malaria in febrile African children. First-line treatment, severe malaria, and the future are discussed. A cheap, effective, and safe alternative to chloroquine, Fansidar, and amodiaquine is needed to treat malaria in children in Africa. Multi-drug therapy may be necessary to reduce the emergence of drug-resistant organisms.
Studies across Africa have shown that insecticide-treated materials (ITMs) such as bednets can substantially reduce levels of child mortality through the prevention of malaria. However, while the results of efficacy trials may dictate the need to use ITMs, people in malaria-endemic areas may not recognize and comply with the need. If one wishes to get people to use health technology such as insecticide-impregnated bednets, one must learn about the end-users through clear, simple, formative research, identifying their habits, needs, and wants. Whichever strategy is employed to get ITMs to people in need, the end-users must be committed to obtaining them, caring for them, and using them. All populations in sub-Saharan Africa go to considerable lengths to avoid being bitten by mosquitoes, and see mosquitoes as nuisances rather than as the vectors of a potentially deadly disease. These populations therefore want bednets more to counter mosquitoes as a nuisance than for use as a health technology. In accordance with the population's desires, the authors in Bobo-Dioulasso, Burkina Faso, no longer stress the health benefits of using insecticide-impregnated bednets. They instead promote ITMs as devices capable of giving families peace from mosquitoes and their bites. To repel not only Anopheles gambiae, the vector of malaria-causing parasites, but also Culex, the main nuisance biter in the area, a higher dose of insecticide is now being used to ensure the broad-spectrum repulsion of mosquitoes by ITM users.
Latest developments in the laboratory diagnosis of malaria.
Malaria is the most important parasitic disease worldwide. With the advent of multidrug-resistant strains, it is highly important that the disease be diagnosed both early and accurately. For the diagnosis of malaria parasites, the thick blood film approach remains the gold standard. However, the use of that standard requires a microscope, stains, and a trained microscopist to interpret the films. The author describes the microscopical detection of the malaria parasite through the use of fluorochrome as well as the development of antigen detection tests to improve the laboratory diagnosis of malaria. Histidine-rich protein II (HRPII) is expressed by the asexual stages of Plasmodium falciparum. The detection of HRPII antigen appears to be a useful alternative diagnostic technique when microscopes are unavailable. However, a negative test result may indicate the presence of non-P falciparum malaria or that it is too early in the course of infection to detect parasites. One advantage of a parasite lactate dehydrogenase (pLDH) detection system is its ability to detect all 4 species of malaria and to diagnose both P. falciparum and P. vivax infections.
HIV, STDs, anal sex and AIDS prevention policy in a northeastern Brazilian city.
Brazil has since the beginning of the AIDS pandemic consistently reported the second or third highest number of AIDS cases in the world. As of June 1996, most of the 82,852 officially reported AIDS cases were concentrated in the southeastern regions of the country, with the majority of Brazilian AIDS and HIV cases continuing to belong to the higher-risk groups of men who have sex with men, and IV drug users. By February 1995, 325 AIDS cases had been reported in Maranhao state. The incidence of AIDS cases in Maranhao state was 6.9/100,000 population, far lower than the 120.6/100,000 in the state of Sao Paulo. The majority of these cases were located in Sao Luis, the state capital. Data were collected in Sao Luis on HIV/AIDS, other sexually transmitted diseases (STDs), related sex practices, and AIDS prevention measures during May-July 1995 through participant-observation field work, face-to-face interviews, archival research, updated by correspondence in 1996-97, and a brief visit in February 1998. Public health statistics and findings from public HIV testing recently conducted in the city suggest that HIV infection has remained largely concentrated among men who have sex with men, with a few, but growing number of cases of women apparently infected by such men. The other STDs endemic to the region could facilitate the spread of HIV infection. Although AIDS prevention education programs have begun in public schools and elsewhere in the city, greater attention needs to be given to preventing and treating other STDs. As in other regions of Brazil and Latin America, the common practice of anal sex among heterosexuals is a significant risk factor for HIV transmission.
Condom use among aboriginal people in Ontario, Canada.
A number of studies have found higher rates of sexually transmitted diseases (STDs) among Canada's populations of native peoples relative to rates for the country's general population. More than 63,400 native peoples live on-reserve in Ontario. A survey was conducted of 658 First Nations native men and women living in 11 of Ontario's reserve communities in an effort to identify prevailing patterns of condom use. The 400 people who had experienced vaginal and/or anal intercourse during the previous 12 months were included in the analysis. Study participants were age 15 years and older; 15.8% of the total sample of participants was age 40 years and older. 47.5% were married; 7.3% separated, divorced, or widowed; and 45.3% were never married. 1% reported engaging in homosexual sexual relations during the previous 12 months. 8% of the sample reported always using condoms during the preceding 12 months, 31% used them sometimes, and 61% never used them. Condom use rates varied according to the number of sex partners during the last year, age, gender, whether or not a person had a steady sex partner, and marital status. According to multiple logistic regression, the people most likely to use condoms were under age 30 years, male, without a long-term steady sex partner, with more than one sex partner, worried about pregnancy, knowledgeable about HIV/AIDS, and not embarrassed to obtain condoms. Condoms users who were knowledgeable about HIV/AIDS and who knew someone with HIV/AIDS were more likely to always use condoms. The most common reason cited for not using a condom was because the individual was having sex with his or her steady sex partner.
Surveys of risk behavior depend upon the accurate reporting of respondents about their sensitive and possibly illegal behaviors. An audio computer-assisted self-interviewing (audio-CASI) technology for measuring such behaviors was tested with 1690 respondents aged 15-19 years in the 1995 National Survey of Adolescent Males (NSAM). Audio-CASI's computer-driven technology can administer complex survey questionnaires in an audio format and record respondents' answers without the direct participation of a survey interviewer. This approach allows respondents to listen over headphones to spoken questions which have been digitally recorded and stored on a lap-top computer. Answers are input by the respondent via numbered keys on the computer keyboard. The audio survey questions are also displayed in written form on the computer screen. The audio-CASI method allows interviewees to respond to questions in complete privacy, even if their reading ability is limited. The sample of NSAM respondents were randomly assigned to answer questions using either audio-CASI or a more traditional self-administered questionnaire. Estimates of the prevalence of male-male sex, ever use of IV drugs, and ever having sexual contact with IV drug users were higher by factors of 3 or much greater when audio-CASI was used. Increased reporting was also found for alcohol, marijuana, and crack/cocaine use; being drunk or high when having sex; and being subject to or a participant in acts of violence within the past 30 days or 1 year.
Technology, experimentation, and the quality of survey data.
Computers have expanded researchers' capacity to collect, process, and analyze data. Computers can also improve the quality of data collected. For example, researchers routinely have computers check data consistency by identifying out-of-bounds and internally inconsistent answers. Rather than clean their data, researchers can use computers to perform immediate and relevant checks, and probe for clarifications which lead to the collection of more clear and accurate data. Moreover, through automating skip patterns, computers can ask more questions in a given amount of time while following researchers' intended logic. The use of audio computer-assisted self-interviewing (audio-CASI) technology is discussed, followed by sections on data accuracy and the future use of experimental techniques in designing surveys.
Family planning's role in reducing health risks.
A safe and effective method of family planning exists for every woman. Providing all women with the opportunity to make voluntary and informed choices about which family planning method(s) they will use can improve reproductive health. The risk of dying from the use of modern methods of family planning is far less than the risk of death associated with pregnancy and childbirth, especially in developing countries, where women have comparatively less access to obstetric care. Family planning can prevent at least 25% of all maternal deaths by allowing women to delay motherhood, prevent unintended pregnancies and unsafe abortions, protect themselves from sexually transmitted diseases, and stop childbearing when they attain their reproductive goals. Spacing births by at least 2 years can prevent an average of 25% of infant deaths in developing countries. Adequate birth spacing can also improve the survival of the next older sibling. Although an estimated 150 million women in developing countries have an unmet need for family planning, the need for family planning continues to grow. Meeting just the existing demand for family planning could reduce the number of maternal deaths and injuries by up to 20%.
Men matter: additive and interactive gendered preferences and reproductive behavior in Kenya.
Interest has grown during the 1990s in men's involvement in reproductive decision-making in sub-Saharan Africa. Some study findings suggest that husbands and other male family members are a major reason for the nonuse of contraception among women who would otherwise consider contracepting. Recent evidence supports arguments that cultural bases explain why male preferences may prevail over those of females in Africa. In an attempt to causally link men's fertility preferences to reproductive behavior, the author investigated the relative strengths of men's and women's preferences in determining reproductive behavior. Additive and interactive preferences are examined, because while fertility decisions may be jointly determined, comparing estimates of interactive and additive preferences provides a better indication of the relative influence of males' and females' preferences. The study also examines 9 categories of joint preference proposed by Dodoo and van Landewijk in 1996, which include spacing and allow a comparison of the effects of various types of agreement and disagreement, as well as the relative contributions of gendered preferences to explaining differences in behavior across time. Further improvements upon prior research are the inclusion of monogamous and polygamous couples and the assessment of current contraceptive use, a temporally more proximate behavioral outcome of preferences. The analysis of data from the 1989 and 1993 Kenya Demographic and Health Surveys found a significant effect of men's preferences upon contraceptive use, which may overpower women's preferences. The implications of these findings are discussed.
HIV - STDs. Making integration work.
The Bulgarian Family Planning and Sexual Health Association (BFPA) has adopted a holistic approach to promoting reproductive health, with its clinics combining obstetrics/gynecological (OB/GYN) consultations with sexually transmitted disease (STD) services and family therapy. Service statistics indicate that this approach has been welcomed by women. In the Sofia clinic, the number of total visits increased from 2892 in 1995 to 5880 in 1996, while the number of contraceptive consultations increased from 1718 in 1995 to 4068 in 1996. The number of clients using OB/GYN services, STD services, sexual counseling, and psychiatric counseling also increased. Countrywide, there were 6921 visits overall in 1996. In addition to integrating STD prevention into other reproductive health activities, for the past 3 years, the BFPA has arranged sex education sessions in schools for youth. STD and AIDS information is a major aspect of the information provided through brochures, leaflets, and other forms of communication. BFPA's promotions in the printed media and upon radio and television also give STD prevention priority attention.
Campaign to back "morning-after" pills.
An estimated 700,000 couples in the US have unprotected sex daily despite not wanting a pregnancy. These deliberate acts of unprotected intercourse, together with the times when contraception fails, result in quite a number of pregnancies, many of which end in induced abortion. More than 1.5 million abortions are performed annually in the US. While many physicians and women have known for years that multiple-dose oral contraceptives, taken in the appropriate dosages and within 72 hours after an act of unprotected intercourse, will most likely prevent pregnancy, most young women and some doctors in the US are unaware of the method. Oral contraceptives have been used for emergency contraception in Europe and New Zealand for almost 15 years, but have been approved by the US Food and Drug Administration for such use in the US only since February 1997. National and state family planning organizations are launching a major campaign to inform women about emergency contraception through the use of "morning-after" doses of ordinary birth control pills. The campaign is underway in 5 cities and advertises the national Emergency Contraception Hotline, which refers callers to the nearest clinics and/or physicians who will prescribe the pills. Gynetics of Somerville, NJ, recently announced its intention to begin marketing the pills for the purpose of emergency contraception in 1998. The broader use of emergency contraceptive pills in the US should lead to a decrease in the incidence of induced abortion.
Hotline informs women of option.
Every year, about 3.5 million pregnancies in the US are unintended. Approximately half of these pregnancies are due to contraception failure such as condom breakage or diaphragm slippage. While physicians have known for 20 years that a 2-stage dose of ordinary birth control pills taken within 72 hours after having unprotected sexual intercourse can significantly reduce a woman's chance of getting pregnant, there is widespread ignorance of the method in the general public. A national campaign is therefore now underway to inform people in the US about such emergency contraception, something to be used as a last-resort strategy when other birth control methods have failed or have not been used. There are 3 possible ways in which contraception can be afforded following unprotected sex. One way is for the woman to take 1 dose of ordinary oral contraceptives containing estrogen and progestin in normal strength within 72 hours after unprotected sex and a second dose 12 hours later. Other ways consist of either taking 1 dose of progestin up to 48 hours after sex followed by a second dose 12 hours later, or through the insertion of a copper-T IUD up to 7 days after sex. The pills either delay or prevent ovulation that month so that a sperm cell cannot fertilize the egg. The pills can also prevent a fertilized egg from nesting in the uterine lining, thereby blocking the formation of a fetus. The national information campaign advertises the national Emergency Contraception Hotline, which refers callers to the nearest clinics and/or physicians who will prescribe the necessary contraceptive pills.
The effect of chemoprophylaxis on the timing of onset of falciparum malaria.
The clinical pattern of falciparum malaria which occurs while taking chemoprophylaxis may be modified. That is, Day and Behrens have suggested that a regimen of mefloquine prophylaxis may be associated with the delayed onset of disease. Findings are reported from a retrospective study conducted to determine whether 477 nonimmune cases of falciparum malaria who were using mefloquine or chloroquine-proguanil (C-P) experienced a delayed onset of disease compared to cases who had not used chemoprophylaxis. 56 cases had used mefloquine, 90 C-P, and 331 no chemoprophylaxis while travelling. For short-term travellers using mefloquine, the time between arrival in the UK and diagnosis with malaria was significantly longer than for chloroquine and proguanil users or for those who had not used prophylaxis at all. The delay in diagnosis was mainly due to a later onset of symptoms. C-P use was not associated with delay in the onset of symptoms or diagnosis when compared to those who did not use prophylaxis. Possible reasons for these findings are discussed. Clinicians and travellers need to be aware that mefloquine prophylaxis may delay the onset of falciparum malaria and its recognition.
Missing the boat on pregnancy prevention.
In the past few years, new national efforts have been implemented which are designed to reduce the large numbers of unintended pregnancies among US teenagers. However, most unintended and unwanted pregnancies occur among adults, not among teenagers; adults account for about 75% of the 3.1 million unintended pregnancies which occur in the US annually. The 60% unintended pregnancy rate in the US has remained largely unchanged since the early 1980s and is by far the highest among developed countries. Unintended pregnancies burden individuals, families, and communities. In order for the level of unintended pregnancies to decrease, Americans must dispel the belief that unintended pregnancies among adults are common and inevitable. Instead, it is high time that the country adopt the norm that all pregnancies should be intended, consciously and clearly desired at the time of conception. The author considers the high costs of unintended conceptions, sex education for adults, and the need for a national campaign to improve public knowledge about sex, contraception, and reproductive health, increase access to contraception, guide couples in the effective use of contraception, expand and evaluate local pregnancy prevention programs, and stimulate research on new contraceptive methods.
Exogenous testosterone (T) treatment reduces sperm counts in men through the suppression of gonadotropin levels. Such treatment is a promising reversible contraceptive which induces azoospermia in approximately 70% of subjects and oligospermia in the rest. However, the basis of this variable response to treatment is unclear. Findings are presented from an investigation of that variable response through the examination of the spermatogenic process and the counting of germ cell numbers in men after T-induced gonadotropin withdrawal. 10 normal fertile men aged 31-46 years, already planning to undergo vasectomy, either received 200 mg of T enanthate (TE) intramuscularly weekly for 19-24 weeks or went directly to surgery, at which point a unilateral testicular biopsy was taken, while germ cell numbers were estimated using the optical dissector stereological method. Study findings suggest that TE treatment neither adequately nor consistently withdraws hormonal support for spermatogenesis, leading to variable between- and within-individual patterns of germ cell suppression.
The use of insecticide-treated nets (ITNs), such as bednets and curtains, can reduce rates of morbidity and mortality from malaria in endemic areas. 4 recently completed large-scale randomized controlled trials have assessed the impact of insecticide-treated bednets and curtains upon overall child mortality in Africa. The results of those trials, conducted in Gambia, Kenya, Ghana, and Burkina Faso, have fomented discussion among implementing agency representatives and researchers about their public health significance. Protective efficacies ranged from a reduction of 29% in overall mortality in Kenya to a reduction of 14% in Burkina Faso. There is, however, an apparent trend for protective efficacies to decrease with increasing entomological inoculation rate (EIR). While most arguments upon the interpretation of intervention impact have been based upon this observed trend, an analysis of the absolute measure of impact revealed a different pattern. The impact of interventions is 3.8-6.9 lives saved per 1000 children protected per year, with no significant trend and with equally high values in both low- and high transmission sites. It is important to consider both relative and absolute decrease in risk when assessing the public health importance of interventions.
Although the standard method for diagnosing malaria in primary health care settings is through the microscopic examination of hemolyzed blood smears stained with Giemsa (GTS), the accurate speciation of malaria parasites is difficult because the morphology of infected red blood cells cannot be assessed after hemolysis, and the parasite shape is affected. Recently, alternative diagnostic methods such as PCR and acridine orange (AO) fluorescence microscopy have been developed. Field surveys using these methods have revealed high proportions of mixed infections, including P. malariae and P. ovale in Africa, South-East Asia, and Oceania, most of which had previously been missed using GTS. The prevalence of the 4 human malaria parasites among malaria patients at northern, central, and southern towns in Thailand along the border with Myanmar between September 1995 and May 1996 was assessed using the AO-thin smear method and PCR. Many mixed infections with 2-4 species, including P. malariae and P. ovale, were detected using thin smears obtained from 548 Thai and Burmese patients subjected to the AO staining method. These diagnostic results were then compared with 2 PCR-based diagnoses, microtiter plate hybridization (MPH) and a nested PCR method, both of which targets the same, species-specific regions in the 18S rRNA genes. Many P. malariae and P. ovale were identified in both PCR diagnoses. These results indicate that the prevalence of P. malariae and P. ovale along the Thai-Myanmar border may be much higher than previously reported.
The provision of appropriate water, sanitation, and hygiene education, especially in schools, is very weak in some areas of South Africa. Inadequate education is one of the biggest obstacles to providing sufficient water in the country. The South African Hygiene Education Project (SASHEP) will be implemented during 1996-98 with the goal of developing a child-oriented sanitation and hygiene education curriculum informed by the perceptions of children and adolescents in primary schools. In the first phase of the project, researchers and educators in the Western Cape, Eastern Cape, Northern, and possibly KwaZulu Natal Provinces will investigate children's perceptions of water, sanitation, and hygiene practices. Child-friendly research approaches, such as the draw-and-write method and focus group discussions, will be used. The perceived needs for water, sanitation, and hygiene education among primary school students will later be used in the development, implementation, and evaluation of the school hygiene education curriculum and extracurricular activities. Curriculum activities will use methods such as the child-to-child approach.
UK pledges money for WHO malaria initiative.
Leaders of the world's 8 major government powers who met at the Group of Eight (G8) Summit in Birmingham, UK, during May 15-17, endorsed an international initiative to control malaria and other parasitic diseases. The leaders agreed to improve mutual cooperation on infectious and parasitic diseases, and offered support for the new World Health Organization (WHO) initiative "Roll Back Malaria" to reduce levels of malaria-related mortality by 2010. UK Prime Minister Tony Blair was, however, the only leader to pledge new funding, in the amount of US$100 million, for the initiative. The other G8 countries fought the inclusion of specific targets in the final joint G8 document and made no new commitment to fund the malaria initiative. The Japanese government's report on global parasite control for the 21st century outlined 4 strategies for controlling malaria, soil-transmitted nematode infections, schistosomiasis, filariasis, and other parasitic infections. The strategies include international cooperation for implementing parasite control and research to provide a scientific basis for such control. Roll Back Malaria will begin in Africa. G8 support was less enthusiastic for France's Therapeutic Solidarity Initiative to establish a fund for HIV treatment regimens which are appropriate to conditions in the developing world.
World Health Assembly winds up on a sober note.
Proposals at the 51st World Health Assembly (WHA) in Geneva, Switzerland, during May 11-16, 1998, to switch a proportion of World Health Organization (WHO) funding, especially from southeast Asia to Africa, with some funds going to Eastern Europe and the former communist states, were strongly opposed by developing countries. The assembly finally agreed that funding for the 28 least-developed countries would not be affected, and that the reduction for any region would not exceed 3% per year over a 6-year period. The WHA president discussed the considerable work which remains to be done against disease, the promotion of health universally, and in reducing existing disparities between the rich and the poor. Delegates from the 191 member states earlier adopted a declaration calling for "Health for All for the 21st Century" to replace WHO's previous goal of "Health for All by the Year 2000." Giving priority to tobacco and malaria, the reorganization of WHO will initially focus upon the following 4 areas: monitoring, reducing, and where possible eradicating communicable diseases; combatting non-communicable diseases; helping countries build sustainable health systems, with focus upon women and mothers; and ensuring that the WHO will advocate for health. Judging by the applause, the WHA's favorite guests were US First Lady Hillary Rodham Clinton and Cuban President Fidel Castro. President Castro noted that only 3% of the $800 billion currently devoted worldwide annually to military expenditures would cover the cost of universal access to basic healthcare services.
The demographic impact of the HIV epidemic in Thailand [editorial]
Relative to other developing countries experiencing major AIDS epidemics, Thailand has some of the best public health data about its HIV epidemic. Scientists from Chulalongkorn and Oxford Universities have applied a deterministic mathematical model to epidemiologic data on the HIV/AIDS epidemic, sexual behavior data, and demographic data from Thailand to predict the future impact of the epidemic upon the size, age, and sex structure of the Thai population by 2014. The model predicts that about 1 million Thais will be infected with HIV by 2000 and an equal number will have died by 2014. The demographic effects in the northern region follow the same pattern, but is approximately twice as severe, with a population deficit of 400,000 people by 2014. Most developing countries with rapidly spreading AIDS epidemics involving the general heterosexual population have high rates of population growth. However, Thailand had almost reduced its population growth to replacement levels by the late 1980s, just before the beginning of the HIV epidemic. Thailand may therefore be one of the few countries to experience population shrinkage as a result of the AIDS epidemic. The HIV/AIDS epidemic in Thailand will likely have serious and growing economic consequences upon the healthcare system and the economic well-being of hundreds of thousands of families, especially in the northern part of the country. It is essential that Thailand's HIV prevention program be maintained. One particular public health challenge is preventing the transmission of HIV between HIV-discordant married partners.
Demographic impact of the HIV epidemic in Thailand.
A deterministic mathematical model was applied to epidemiologic data on the HIV/AIDS epidemic, sexual behavior data, and demographic data from Thailand to predict the future impact of the epidemic upon the size, age, and sex structure of the Thai population by 2014. Partial differential equations express the relationships between biological, behavioral, and demographic variables. Permitting the evaluation of different sexual mixing patterns, variable transmission probabilities, and incubation times, the model predicts that about 1 million Thais will be infected with HIV by 2000, there will be 550,000 AIDS deaths by 2000, and 1 million deaths after 2014. Without the HIV epidemic, the population would have grown at the estimated annual rate of 1.2% during 1985-95, after which a decline to 0.9% would have occurred by 2005. The HIV epidemic began to affect the population growth rate by 0.026% per year in 1991, and the difference is projected to increase to approximately 0.12% per year during 1995-2000, to decline to 0.06% in 2005, then disappear. While mainly people aged 15-35 years were affected by HIV in the mid-1990s, younger and older age groups have become affected through perinatal HIV transmission, a decline in fertility, and the aging of the 15-35 year old birth cohort. Because of HIV, there will be 612,000 (1%) fewer people than otherwise expected in 2000, and 1,140,000 fewer (1.6%) by 2010. The HIV/AIDS epidemic will be more severe in the northern part of the country.
FPAN committed to encompass a wider section of the community in its programme.
Various organizations working in the field of family planning have been concerned since the 1994 International Conference on Population and Development with adopting the holistic life-cycle process and integrating sexual and reproductive health issues and program needs into their programs with the goal of expanding their scope of involvement in reproductive health. In 1997, the South Asia Region of the International Planned Parenthood Federation (IPPF) organized a regional workshop in Colombo upon sexual and reproductive health in an attempt to develop a common understanding of the concept, to introduce and discuss several components of sexual and reproductive health relevant in the region, and to help family planning associations integrate sexual and reproductive health components into their existing programs. The workshop served as a forum in which successful field experiences could be shared. A similar workshop was organized for family planning association branch managers.
Policresulen vaginal suppositories are a condensation product of metacresolsulfonic acid and formaldehyde manufactured and distributed mainly for the treatment of vaginitis through a process involving intravaginal mucosal coagulation and subsequent elimination. The authors investigated the use of such suppositories in a sample of female prostitutes in Thailand and whether that use could facilitate HIV transmission. The effects of self-administration of a single suppository by each of 6 women were also directly observed; 3 women were HIV-seronegative and 3 were HIV-seropositive. Of the 200 prostitutes interviewed, 32% had used policresulen vaginal suppositories in the preceding year and 46% had ever used them. Many used them to ends not listed on the package insert, such as for improving their male partners' sexual pleasure, and most did not abstain from vaginal sex after use. Among 36 brothel-based and 67 non-brothel-based prostitutes with known HIV infection status, the use of the product was not associated with HIV-1 infection. Exfoliation of the vaginal and cervical mucosa was observed in each of the 6 prostitutes directly observed 1 day after product use. An increase in genital HIV-1 RNA shedding was also detected in each of the 3 HIV-seropositive women directly observed. The disruption of genital mucosa caused by the use of policresulen vaginal suppositories may facilitate the transmission of HIV.
Surviving until five: child survival program keeps Delhi's children healthy.
Children under age 5 years comprise only 14% of India's population, but 45% of overall mortality in the country each year. The children who live in the shanties and shanty neighborhoods of Delhi are among the most vulnerable. PLAN International provides funding and technical resources to help make sustainable community-based health programs possible. In Delhi, PLAN funds health clinics, trains health volunteers, provides supplemental food for malnourished children, and provides families with access to safe sanitation and potable water facilities. A 1990 study by PLAN and its partner agencies in Delhi found that half of the children under age 5 were malnourished, with 10% acutely malnourished. Under 10% of children under age 2 years had been fully immunized and most children under age 2 years had experienced diarrhea within 2 weeks of the survey, but only 20% of parents knew how to prevent dehydration and weight loss from diarrhea. Parents in one western slum have since adopted the child survival strategy with the help of the Deepalaya Education Society and PLAN. Child survival programs encourage exclusive breast feeding during the first 4-6 months of life and continued breast feeding until age 2 years. Volunteer health associates are at the core of the child survival program in the city. Program activities include the monitoring of children's weight, growth, and immunization status. PLAN also incorporates lessons in child health in adult literacy classes targeted to parents.
Combatting AIDS in Burkina Faso.
Official Burkina Faso Ministry of Health figures indicate that approximately 4% of Burkina Faso's population is infected with HIV. There is, however, most likely a higher proportion of HIV-infected people in the country. PLAN International combats HIV/AIDS in Burkina Faso by disseminating AIDS education in villages; promoting and selling condoms; giving local hospitals what they need to test for HIV infection; counseling patients, their families, and relatives, including widows, widowers, and orphans; and mobilizing others to fight against AIDS. Regarding AIDS education at the village level, the PLAN medical team first trains social workers in AIDS and AIDS education who, in turn, train men, women, boy, and girl volunteers in villages, who subsequently teach other villagers about the dangers of AIDS and how to prevent it. The workers also sell condoms, keeping part of the proceeds. Drama is an integral component of the project. Radio and films are also used to spread AIDS prevention messages, with specific risk groups receiving extra attention. AIDS tests will be distributed in 1998. PLAN's project, covering Kongoussi, Boulsa, and Koupela, has positively affected HIV/AIDS-related knowledge and practices. In 1992, no one surveyed in Bonam, a small village in Burkina Faso's interior, could define AIDS, 9% used condoms, and 41% had casual sex. However, by 1993, after having been exposed to PLAN's interventions, 80% of people surveyed could define AIDS, 18% used condoms, and 4% had casual sex.
Development of immunocontraceptives: an introduction.
The global eradication of smallpox through vaccinations led people to believe that a contraceptive vaccine could be developed and used to help solve the problem and pressures of excessive population growth. A pioneer in the field, the government of India, through its Department of Biotechnology and the Indian Council of Medical Research, mounted a major effort in the mid-1970s to develop birth control vaccines which would be effective in both men and women. However, the B human chorionic gonadotropin (HCG) vaccine developed by Talwar in 1997 was the first contraceptive vaccine to be clinically tested in the world and found to be safe for use in women. The heterologous follicle stimulating hormone (FSH) vaccine developed by Moudgal et al. in 1997 is the first ever contraceptive vaccine to be tested in men. FSH vaccine has since been shown to cause infertility in monkeys, and phase I trials have clearly shown that the vaccine causes no ill effects in men and that some important semen characteristics are changed in a manner commonly seen in infertile men. Adiga (1997) has used an evolutionarily conserved vitamin transport protein as a contraceptive vaccine because the protein is essential for the survival of the fetus. Animal studies have shown that the vaccine effectively reduces fertility in mice and monkeys of both sexes. Gupta (1997) explored the possibility of developing a vaccine by using the zona pellucida proteins as the antigen with encouraging results. However, none of these vaccines is effective in all individuals.
A highly cost-effective program which improved local health facilities' ability to diagnose and treat sexually transmitted diseases (STDs) in rural Tanzania reduced the incidence of HIV-1 infection by 40% during a 2-year trial period. The intervention was conducted during the early 1990s in 6 rural communities with a total population of approximately 150,000, which were compared with 6 communities matched for location, type, and rates of STD presentation at health units. Primary health care workers in the program communities' health units were taught to diagnose and treat STDs using simple decision-making flow charts based upon readily detectable signs and symptoms, and were also given basic diagnostic instruments and kept supplied with drugs and other necessary materials. Supervisors visited the health units regularly to monitor the quality of care provided and to offer informal training when needed, while health education teams visited the villages. Annual program costs totaled $59,060, or $0.39/person in the communities served by the intervention. The annual cost per HIV infection prevented was lower than the likely cost of treating someone infected with HIV, while the cost of averting the loss of 1 healthy life-year because of HIV-related disability or death compared well with other costs associated with other public health programs in low-income countries.
What have we learned from studying changes in service guidelines and practices?
A group of researchers in 1992 observed that, while family planning methods have been made safer over the past several decades, many contraceptive prescribing practices remain based upon outdated scientific data or were produced for contraceptives which have since been reformulated. Noting that providing quality care to clients may be hindered when providers base service delivery practices upon guidelines developed from outmoded data, they argued that rather than preserving women's health, some practices impede quality contraceptive access. Others, however, argued that focusing narrowly upon medical procedures as barriers would reduce the quality of care for clients. This debate over medical barriers broadened the focus upon service delivery practices. Improving service practices is part of the US Agency for International Development's Maximizing Access and Quality (MAQ), an initiative of which separating necessary service practices from medical barriers is a fundamental element. To evaluate how research can help program decision makers, the authors examined the methodologies used in service practice research and recommend directions for future research upon the subject. Advances in practice research, decision-makers' concerns, service guidelines and practices, and service safety, access, and quality are discussed.
Diarrhoea in children in Papua New Guinea.
The incidence of diarrhea tends to vary among Papua New Guinea's various populations and it remains unclear to what extent the country's children are plagued by such diseases. Controlling diarrheal diseases in children involves early and appropriate treatment, as well as prevention. Breast feeding, good nutrition, immunization, the early treatment of childhood illness, and maintaining proper sanitation and hygiene all help prevent the development of diarrheal disease. Fluid intake must be increased in children with diarrhea in order to prevent dehydration. This increase in fluid consumption is the most important part of the early management of acute diarrheal disease. While UNICEF's glucose-based oral rehydration therapy is widely available to manage dehydrated children, it is inadequately used. The use of locally prepared, cereal-based oral rehydration solutions should be encouraged. Furthermore, breast feeding should be continued during episodes of diarrhea unless there is a specific contraindication of lactose intolerance. The child's nutritional intake should nonetheless be maintained and, if possible, increased during episodes of diarrhea. Antibiotics should not be used to treat diarrhea in children unless there are specific indications for such use. Diarrheal episodes which last more than 14 days are associated with high mortality and severe malnutrition. It is therefore important for children with diarrhea of longer than 7 days to be managed appropriately according to standard guidelines.
Killing an estimated 2.9 million children annually, diarrheal disease is the second leading cause of child mortality worldwide. Diarrheal disease is also the second leading cause of child mortality in Papua New Guinea (PNG), killing an average 193 inpatient children per year over the period 1984-90. However, despite the high level of diarrhea-related mortality and the proven efficacy of oral rehydration therapy (ORT) in managing diarrhea-related dehydration, standardized ORT has been underutilized in PNG. The current glucose-based oral rehydration solution (ORS) does not reduce the frequency or volume of a child's diarrhea, the most immediate concern of caregivers during episodes of illness. Cereal-based ORS, made from cereals which are commonly available as food staples in most countries, better address the short-term concerns of caregivers while offering a superior nutritional profile. A sample of guardians of children brought to the Port Moresby General Hospital's Children's Outpatient Department complaining of child diarrhea were asked about their preferences on glucose-based versus rice-based ORS in order to determine the acceptability of a rice-based ORS. More than 60% of the 93 guardians interviewed preferred the glucose-based solution for its mixability, appearance, and taste. 65% initially reported that their children preferred the taste of the glucose solution. However, after a 30-minute trial, only 58% of children still preferred the glucose solution.
Gastrointestinal nematodes: the Karkar experience.
Findings are reported from the author's research into the hookworm Necator americanus in the village of Kabasob, Karkar Island, Papua New Guinea, beginning in 1988. N. americanus was determined to be the most prevalent of the identified gastrointestinal nematodes, infesting almost all of the adults with an intensity of 40 worms/host. The intensity of infection was related to host age and to the development of iron deficiency anemia, which occurred at a much lower infection intensity than had been previously reported. Results of an assessment of the immune response to infection initially suggested that antibody responses and eosinophilia do not protect the host against infection. However, the authors have since found a negative correlation of IgE and eosinophilia with the weight and fecundity of N. americanus and that immunity is dependent upon thymus-derived helper 2 lymphocytes. Patients were treated with single 10 mg/kg doses of pyrantel pamoate. However, after 2 years, the prevalence of N. americanus infection had returned almost to pretreatment levels, with the rate of acquisition of adult worms being independent of host age. A highly significant correlation was observed between individuals' pretreatment egg counts and worm burden and those acquired after reinfection. The prevention of infection with N. americanus will come from measures to reduce the transmission and intensity of infection, and can be achieved through improved sanitation or by vaccination. For now, vaccination is not an option because too little is known about protective immunity.
The new problem of typhoid fever in Papua New Guinea: how do we deal with it?
Few cases of typhoid fever were reported in Papua New Guinea (PNG) before 1960 and only sporadic cases were reported during the 1960s. However, typhoid fever has now become a major public health problem in the country, endemic throughout the Highlands Region and in some of the larger coastal towns such as Port Moresby. In 1993 and 1994, there were 4485 and 4551 people, respectively, reported to have been admitted with typhoid fever throughout PNG, with 87% and 73% of these cases, respectively, occurring in the Highlands Region. The vast majority of the remainder of patients were in the National Capital District, Central, or Morobe Provinces. No data are available on the number of outpatient cases. The transmission of typhoid fever in PNG appears to be mainly from person to person, with little evidence of water-borne transmission. Problems posed by the prolonged convalescent excretion of Salmonella typhi are discussed. Typhoid fever will be prevented over the long term by improvements in hygiene and sanitation, although more immediate control could be achieved through vaccination with an appropriate vaccine.
A review of the current status of enteric vaccines.
Enteric infections, including diarrheal diseases, dysenteries, and enteric fever, disproportionately affect less developed countries, in which up to 7-10 episodes of diarrheal disease occur per child per year during their first 2 years of life. However, since relatively few etiological agents cause pediatric diarrheal disease in developing countries, the development and dissemination of safe and effective vaccines against rotavirus, enterotoxigenic E. coli, enteropathogenic E. coli, Shigella and Vibrio cholerae O1 would reduce to a considerable extent the burden of diarrheal disease. Two new vaccines against typhoid fever, oral Ty21a and parenteral Vi polysaccharide, have been licensed in many countries. Newer, more sophisticated typhoid vaccines undergoing clinical testing include recombinant attenuated Salmonella typhi strains and Vi polysaccharide-carrier-protein conjugate vaccines. Two inactivated oral cholera vaccines, consisting of inactivated Vibrio cholerae O1 bacteria alone or in combination with B subunit of cholera toxin, each conferred 50-53% protection over 3 years in a field trial in Bangladesh where subjects were immunized with a 3-dose regimen. Furthermore, an engineered live oral cholera vaccine, strain CVD 103-HgR, has been shown in clinical trials to be well-tolerated by children and adults in less developed countries and highly immunogenic following the administration of a single oral dose. Several candidate vaccines against Shigella and enterotoxigenic E. coli are in clinical trials, while a multivalent rotavirus vaccine is in extensive field testing in both developed and less developed countries.
The protective effect of condoms and nonoxynol-9 against HIV infection.
The authors reanalyzed data from a longitudinal observational study of the efficacy of spermicides and condoms among a sample of female prostitutes in Cameroon. Two earlier reports from the study presented data indicating that spermicides are effective in preventing HIV transmission. Data upon 224 women HIV-seronegative at admission were used in the analysis. All participants were given 100 mg nonoxynol-9 suppositories and nonspermicidal condoms and were followed up monthly for up to 12 months. Their sexual activity and barrier method use were recorded in coital logs. The Pearl index, and maximum and marginal likelihood approaches were used to measure the barrier methods' efficacies. Condoms plus nonoxynol-9 were used in 39% of 27,432 reported sexual contacts, condoms alone in 25% of cases, nonoxynol-9 alone in 24%, and no barrier method in 11%. A strong protective effect was observed for spermicidal suppositories in all 3 of the assessment methodologies. While the Pearl index indicated that spermicide alone is effective, the efficacy per contact cannot be quantified using the approach. Maximum likelihood estimates for the efficacy of nonoxynol-9 alone and condoms, with or without nonoxynol-9, were 100% and 92%, respectively. These data therefore suggest that nonoxynol-9 may be efficacious in reducing the risk of HIV transmission.
Infection with genital ulcer disease (GUD) facilitates the transmission of HIV. However, granuloma inguinale (GI), an endemic sexually transmitted disease (STD) in India, has been ignored as a cause of GUD. In the context of increasing prevalence of HIV infection among patients with STD at a clinic in Mumbai, a study was conducted to determine the clinico-epidemiologic features of GI and HIV, with the goal of identifying any possible interaction between the two. 21 consecutive cases of GI in HIV-seropositive individuals and 29 controls, HIV-seronegative individuals with GI, participated in the prospective follow-up study to determine how long it takes for GUD to heal. Healing was considered complete when total re-epithelization of the ulcer(s) was observed. All cases and controls received a standard treatment regimen of erythromycin under supervision until healing occurred. While the GI ulcers at recruitment were not significantly larger among HIV-seropositive individuals compared with those among HIV-seronegative individuals, the former took longer to heal completely; an average of 25.7 days compared to 16.8 days, respectively. The former ulcers also tended to produce greater tissue destruction. Slow-healing GI ulcers with underlying HIV infection can lead to the increased transmission of both infections.
High seroprevalence of human herpesvirus-8 in pregnant women and prostitutes from Cameroon [letter]
The recently isolated human herpesvirus-8 (HHV-8) is thought to be the etiological agent of Kaposi's sarcoma. The prevalence of HHV-8 was determined in blood sera collected between 1993 and 1996 from 353 pregnant women from Yaounde, Cameroon, and 214 female prostitutes from Douala. 25 sera from classic, endemic Kaposi's sarcoma originating from East Africa, French Guiana, or France served as HHV-8-seropositive controls. In addition, 300 consecutive sera samples from blood donors collected during April/May 1997 from the Blood Transfusion Center of Laennec Hospital in Paris were included for comparison purposes. The seroprevalence of HHV-8 was detected by an immunoperoxidase test technique. 274 (45.6%) sera from Cameroon exhibited a clear nuclear staining upon BCBL1 cells and were considered HHV-8-seropositive. 6 other samples were sero-indeterminate and not included in the analysis. The 25 sera from classic Kaposi's sarcoma reacted positively to the test on BCBL1 cells, and negatively when using B-jab cells, while 1 blood donor from Laennec Hospital was found to be HHV-8 seropositive. HHV-8 seroprevalence increased significantly with age, from 39% among women under age 25 years to 57% among women over age 35. HHV-8 seroprevalence was significantly higher among HIV-seropositive women than among HIV-seronegative women. Being a prostitute was also associated with an increased risk of HHV-8 seropositivity. After adjusting for age, only HIV seropositivity remained a risk factor for increased HHV-8 seroprevalence, and after logistic regression, only being over age 30 years remained significantly associated with HHV-8 seropositivity.
The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia.
It is important that community-acquired pneumonia be diagnosed in a timely fashion, especially when bacterial etiology and children under age 5 years are considered. However, the clinical presentation of such pneumonia can be deceptive, and both laboratory and X-ray investigation misleading. The World Health Organization (WHO) recommends that the screening of pneumonia be focused upon the assessment of respiratory rate and chest in-drawing. Findings are presented from an assessment of the value of various clinical signs and symptoms in diagnosing pneumonia in young children. 153 children, aged 1 month to 7 years, at the University of Sao Paulo Teaching Hospital, including 51 pneumonia cases and 51 non-respiratory and healthy controls matched by age and sex were submitted to a standard protocol to investigate clinical symptoms and signs, with the diagnosis of pneumonia supported by X-ray images. Univariate data analysis comparing pneumonia and non-pneumonia subjects suggested that the best pneumonia indicators would be chest auscultation, history of breathlessness, history of cough, chest in-drawing, and fast respiratory rate, in descending order. A multivariate approach including X-ray data was then applied using multiple discriminant analysis to study the separation of pneumonia cases, non-respiratory cases, and healthy children. The performance and value of individual symptoms and signs change when many items of information are considered; the best predictors of pneumonia were identified as chest in-drawing, chest auscultation, X-ray, history of breathlessness, and toxemia. Any attention to X-ray should be secondary to clinical investigation, while WHO guidelines could benefit from the inclusion of at least history of breathlessness.
There is only limited transmission of malaria in Zimbabwe's high plateau region, but malaria can nonetheless occur during the rainy season and be imported from lower areas. The areas of the country below 900 m are endemic for malaria, while the areas at 900-1200 m have malaria of low endemicity. Findings are reported from a cross-sectional study conducted to assess the extent of malaria prevalence among primary and secondary school children at various elevations in Zimbabwe and during the dry and rainy seasons. Participating children were approximately age 8 and 13 years. 103 children were examined in Chitungwiza in November 1992, 94 in Gokwe, and 96 in Sasame. In April 1993, the numbers of children examined were 86 in Chitungwiza, 78 in Gokwe, and 81 in Sasame. Findings are based upon indirect fluorescent antibody test (IFAT) levels, and parasite and spleen rates. No splenomegaly was detected in children in schools at elevations higher than 900 m. Parasitemia was not detected in children in schools above 1200 m, but was identified in 1 child at 900-1200 m and in 37 children under 900 m. IFAT levels were lowest in children in areas higher than 1200 m and increased significantly with decreasing altitude. The parasite rate during the rainy season was significantly higher than that during the dry season. No significant differences were observed in the IFAT levels and spleen rates between the dry and rainy seasons. 65% of all children in schools above 1200 m visiting rural areas used no protective measures against malaria, while all children in schools under 900 m reported that their homes were sprayed, but very few other prophylactic measures were reported.
Through the Zimbabwe Expanded Program of Immunization (ZEPI) introduced in Zimbabwe in 1982, children are vaccinated with the Schwarz-strain vaccine at age 9 months. Through the ZEPI, measles immunization coverage has increased from 56% in 1981 to 82% in 1995. Nonetheless, measles remains one of Zimbabwe's most important public health problems. The number of reported measles cases has declined, but there is still an unacceptably high level of cases and outbreaks continue to be reported regularly throughout the country. The efficacy of the measles vaccine used in the ZEPI was evaluated near the end of a measles outbreak which occurred between June and November 1996 in Mbare suburb, with an estimated 1995 population of 120,000. The retrospective study was conducted through interviews with caregivers of 7 or more children aged 9-35 months from each of 30 randomly selected neighborhood clusters. A total 294 children were considered from the clusters, of whom 83% were vaccinated and 9.5% had measles during the outbreak period. The attack rates for the vaccinated and unvaccinated were, respectively, 6.9% and 22%. Vaccine efficacy was therefore determined to be 68%. Clinical measles cases identified during outbreaks should be serologically confirmed to achieve a more accurate diagnosis. Moreover, the Mbare Health Team should conduct a comprehensive evaluation of its measles vaccination program.
Facilitating condom use with clients during commercial sex in Nevada's legal brothels.
In March 1988, in an effort to prevent HIV transmission, the Nevada legislature enacted a law requiring condom use during all brothel sexual activity. Therefore, prostitutes who work in the state's legal brothels have legal support for their insistence upon condom use with clients. Prospective clients are made aware of the state's mandatory condom law well before the initiation of sexual activity, both through a public health notice posted upon entrance gates and inside over the bar. Even so, brothel workers have reported that some clients still resist using condoms. 40 female prostitutes in 2 of Nevada's brothels were interviewed about client resistance to condoms and techniques used to facilitate condom use. 90 (2.7%) of the women's 3290 clients during the previous month were reluctant to use condoms. Of those 90, 72% eventually used condoms, 12% chose nonpenetrative sex without condoms, and 16% left the brothels without receiving sexual services. 38 prostitutes reported having a lover in the past year, of whom 14 had multiple nonpaying lovers. Overall, the women had 1-10 nonpaying lovers, an average of 1.9. All but 3 lovers were male. Only 7 of the 38 women (18%) used condoms consistently with lovers. These findings suggest that brothel prostitutes may be at greater risk for acquiring HIV and other STDs from lovers than from clients.
Alcohol consumption, strength of religious beliefs, and risky sexual behavior in college students.
Relationships between alcohol consumption, strength of religious beliefs, and risky sexual behavior were examined among 210 students at East Carolina University, North Carolina, a large public university in the US's "bible belt." The study sample largely reflected the overall composition of the student body: 61% of the respondents were women and 39% were men; 9% were Black, 86% were White, and 4% were other; and they were aged 18-36 years, of mean age 21 years. 84% reported having had sexual intercourse, with 34% of the entire sample reporting a frequency of 1-3 times per week, and 27% reporting a frequency of 1-2 times per month. 27% reported the consistent use of condoms, 60% reported inconsistent use, and 13% reported never using condoms. 48% of respondents reported having sexual intercourse with multiple partners during the past year. 60% of respondents believed in attending church or attended church on a regular basis, 78% believed that God operated in their daily lives, and 80% believed that they would go to heaven when they died. 66% did not believe that premarital sex was a sin and 77% did not believe that alcohol drinking was a sin. 35% reported being intoxicated more than 5 times in the past month and 33% reported drinking so much alcohol that they passed out at least once during the past month. The women with strong religious beliefs consumed less alcohol and were less likely to engage in risky sexual behavior than were female participants with weaker religious convictions. Among the men, religious conviction was not significantly related to alcohol consumption or risky sex behavior, but the inconsistent use of condoms and having multiple sex partners were significantly positively correlated with alcohol consumption. Men had higher rates of alcohol consumption and unprotected sexual activity than women did, although the two groups did not differ in the overall frequency of sexual activity.
The nutrition challenge in the twenty-first century: what role for the United Nations?
United Nations (UN) agencies can play a key role in raising awareness upon the problem of malnutrition and encouraging policy changes which support effective programs. To such ends, the UN Administrative Committee on Coordination's Sub-Committee on Nutrition (ACC/SCN) decided at its recent annual meeting in Nepal to establish a small, but high-level International Commission on Nutrition. The proposal was prompted by recent evidence of slowdown in rates of nutrition progress, the absolute deterioration of nutrition in sub-Saharan Africa, and marked progress made over the past 5 years against micronutrient deficiencies, especially with regard to iodine and vitamin A. The SCN proposed that the commission review the situation and make recommendations upon goals and objectives for accelerating progress in the field of nutrition over the next decade or 2, especially in protein energy malnutrition. The commission should include 3-4 distinguished international experts, including a senior economist.
Meeting the nutrition challenge: a call to arms.
Recent data points to a slowdown in the rate of nutritional advance in many regions of the world and a downturn in some countries, especially in sub-Saharan Africa. This slowdown, however, is unnecessary. Even over the past 5 years, major advances have been made in some areas of nutrition, particularly in reducing by 1.5 billion the number of people at risk from iodine deficiency disorders. The world, working together as an international community, can make progress in nutrition. In 1992, the governments of 159 countries adopted the World Declaration and Plan of Action for Nutrition, declaring their determination to eliminate hunger and reduce all forms of malnutrition. By adopting the declaration and plan of action, governments agreed to develop national plans of action, using the technical expertise of UN agencies. As of 1996, 106 countries had prepared national plans of action for nutrition and most countries in which the national plan has been endorsed by the government are actively pursuing its implementation. Several countries, however, especially the poorest, lack the human and financial resources needed for implementation. Now, almost 5 years after the adoption of the plan, the global impact upon almost all forms of malnutrition falls far short of that required to meet the goals for the year 2000. If current trends continue, no region except Latin America and the Caribbean will achieve the 1992 International Conference on Nutrition and 1990 World Summit for Children goals to reduce levels of child malnutrition by 2000. A holistic, international approach is needed to prevent malnutrition.
Although recent estimates of trends in malnutrition show some improvement worldwide, that improvement has occurred at a far slower rate over the past few years than during the 1980s. The prospect of ending hunger and malnutrition is receding further into the future. Goals from the 1990 World Summit for Children and the 1992 International Conference on Nutrition of halving the prevalence of malnutrition between 1990 and 2000 are becoming increasingly less likely to be met. Urgent action is needed. Adverse economic conditions in many countries and drought in many parts of Africa and Asia are 2 reasons why the slowdown in progress has occurred. Furthermore, continued progress will be slower now that the beneficial effects of child health interventions have almost attained maximum impact and population coverage. Trends in underweight prevalence describe progress in nutrition and, more generally, in human development. The global prevalence of underweight children was 29% in 1995, with more than half being in South Asia. Trends on underweight children aged 0-60 months are presented by world region for the period 1985-95.
Clinical and experimental data indicate the possible existence of a causal link between fetal and infant growth and diabetes, cardiovascular disease, and possibly obesity later in life. An experiment using rats was conducted to explore the long-term consequences of fetal protein malnutrition upon the biology of the pancreas and the outcome in terms of glucose intolerance in offspring. Pregnant rats were divided into 2 groups, an experimental group fed a low protein diet and a control group fed a normal protein diet. Both groups had equal energy intake. The offspring of the 2 groups were subsequently raised until reaching the adult age of 84 days. The experimental group was then further divided into 2 groups, one which continued with a low protein diet throughout life and a recovery group fed a diet adequate in protein from birth. The control group continued with a normal diet throughout life. Study results show that the lack of adequate protein availability during gestation induces developmental disabilities with consequences in adulthood in organs responsible for diabetes and causal for vascular disease and hypertension.
Prevention and the role of nutrition.
As the less developed countries develop economically, their populations will increasingly adopt many lifestyle traits of Western society commonly understood to be causally linked factors in non-communicable diseases. The expected increase in the incidence and prevalence of non-communicable disease has major implications for health care resource demands and the distribution of available resources; resources will be diverted away from lower income groups. Problems of excess and those associated with development need to be addressed. The author considers changes in lifestyle and nutritional factors which affect individual health and development with regard to heart disease and diabetes, and discusses research reports, including the issue of fat intake taken up in a FAO/World Health Organization report. The implications of early malnutrition and environmental factors upon human health and well-being are considered, with a reminder to address the difficult questions of preventing protein-energy malnutrition, to view child and adult problems as population problems, and to develop and implement holistic solutions.
Effective programmes in Africa for improving nutrition.
The general nutrition situation in Africa is deteriorating due to extreme poverty, severe drought, and conflict. The quality of diets in many parts of the continent is poor and inadequate, and there are underlying problems of chronic malnutrition due to marginal access to food, seasonality problems, and the chronic lack of basic services in many countries. A symposium on effective programs in Africa for improving nutrition held at the UN Administrative Committee on Coordination's Sub-Committee on Nutrition's (SCN) 23rd session in Accra, Ghana, in February 1996, coincided with the launch of Ghana's National Plan of Action for Nutrition. A summary and main conclusions of the proceedings are presented. The major theme of the symposium, effective programs in Africa for improving nutrition, focused mainly upon household food security, a problem of major concern to African countries. The overall goal was to develop conclusions which will help Africa's search for suitable solutions to ensure food security and improved nutrition for all.
Vaginal drying agents and HIV transmission.
Biological, social, and economic factors all affect a woman's risk of HIV infection. Certain sexual practices, such as the use of vaginal drying agents, may also increase women's HIV risk when such practices result in genital irritation and inflammation. Stones, leaves, powders, herbs, water, dry cloth, antiseptics, pharmaceutical products, and tissue or toilet paper are some of the items which may be inserted into the vagina to make it more dry and tight when a cultural preference exists for dry vaginas during sexual intercourse. The use of vaginal drying agents has been reported in South Africa, Senegal, Zaire, Cameroon, Malawi, Zambia, Kenya, Zimbabwe, Saudi Arabia, Haiti, and Costa Rica. The international health community, however, knows little about the prevalence of the practice, whether it increases the risk of HIV infection, or how to implement culturally sensitive and effective educational interventions which address the potential health consequences of use. Vaginal drying practices are part of a complex web of biological, economic, and cultural factors which may affect women's risk of HIV infection and other sexually transmitted diseases. Health promotion and disease prevention initiatives can be effective only if they understand and account for the interrelated factors affecting the practice. Qualitative data are needed on the impact of such agents upon reproductive health initiatives for women.
Where have all the vaginal foaming tablets gone? Program statistics and user dynamics in Ghana.
During the early 1980s, a condom gap was detected in Bangladesh, a situation in which program statistics indicated a far higher level of condom use than did national survey data. If both data sources were correct, many more condoms were being distributed than were being used. A large-scale study eventually determined that much of the gap could be explained by underreporting of method use. Years later, Ghana had a similar problem. Available data upon the distribution of vaginal foaming tablets did not reflect data on the prevalence of the product's use. A short survey of family planning providers and tablet users was therefore conducted to assess the extent of misuse in the country and if such misuse could explain the gap. Tablet misuse was just one of many possible explanations for the observed gap. No evidence was found to indicate that the discrepancy was due to widespread tablet misuse. Efforts should be made to improve data collection. Researchers, however, are likely to spend considerable time and resources conducting large-scale surveys to evaluate various possible explanations for divergences between program statistics and survey data, without drawing any clear programmatic implications. When a country has a contraceptive gap like those experienced in Bangladesh and Ghana, one needs to consider whether the product is being misused and if products are either expiring in the distribution pipeline or not being used by consumers. Answers to these queries can usually be obtained quickly and at minimal cost.
Back to basics: the shift to primary health care.
Understanding that the incidence and prevalence of disease are related to economic and social factors, and not just biological and physical factors, the founders of the World Health Organization (WHO) stressed that health should be seen from as broad a perspective as possible. WHO followed a global health service approach during its first 3 decades of existence even though the agency was instead established to help countries develop their own health care systems. Mass campaigns were launched against a number of major diseases. In 1973, WHO Director-General Marcolino Candau argued for a shift in focus to more directly address the priorities of health care consumers and small communities. The notion of "health for all" was adopted at the 1977 World Health Assembly, with primary health care (PHC) chosen in 1978 at the International Conference on Primary Health Care, in Alma Ata, as the strategy by which WHO goals would be met. Since PHC refers to health care provided at the first point of contact with the health care system, it is more related to the communities in which people live than with high-technology hospitals. 20 years after Alma Ata, even though PHC has had a major global impact, far too many people still have no access to basic health care. PHC backed by specialist care for those who need it will likely be seen in future health care systems.
Malaria currently occurs in about 100 countries or territories, with 90% of cases being in sub-Saharan Africa. Malaria also occurs in parts of Asia, the Western Pacific, and Central and South America; there has been a resurgence of the disease in Tajikistan and Azerbaijan, where it had been eradicated; and epidemics have also occurred in Turkey and Iraq. Worldwide, about 2 billion people are at risk. The World Health Organization (WHO) has met with varying degrees of success and failure helping countries control malaria. A new strategy for the global control of malaria was adopted in 1992 at a Ministerial Conference in Amsterdam which involves the early diagnosis and treatment of malaria, selective and sustainable preventive methods, prevention or early response to epidemics, and strengthening local capacities to analyze the malaria situation, especially with regard to the relevant ecological and socioeconomic factors involved. A new WHO global action plan stipulated that by 1997, at least 90% of malaria-endemic countries should have appropriate control programs in place and that by 2000, deaths from malaria should be at least 20% lower than in 1995 in at least 75% of countries affected. Efforts to ensure the early diagnosis and treatment of malaria have been supported by a new WHO training program, while the World Bank/UNDP/WHO Special Program for Research and Training in Tropical Diseases is leading the drive to develop new methods of preventing and controlling malaria.
Promoting health locally, nationally and globally.
A supportive environment for health is one in which the physical, economic, and social surroundings are conducive to good health. Increasing attention is being focused upon models of disease, curative services, and the consumption of medical care, as well as the health potential inherent in the social and institutional settings of daily life. A wide range of measures can be taken at all levels to make various environments more supportive of health. There are, however, many obstacles to the creation of health-supporting environments, including the fragmentation of sectoral responsibilities at the national level. Such intragovernmental fragmentation together with the separations between government and nongovernmental organizations, and between the public and private sectors, impede the development of strategies and policies informed by an awareness of health and health needs. Fragmentation can reduce the impact of health-promoting activities, especially those at the local level. While integrated action is needed, too complex interaction and international interdependence can also frustrate the creation of supportive environments for health. The World Health Organization and other international agencies are beginning to have some success getting health put onto the agendas of all policy-makers and decision-makers and encouraging them to address health issues through an integrated approach. Education, empowerment, and equality are discussed.
DOTS: a breakthrough in TB control.
Directly Observed Treatment, Short-course (DOTS) is the World Health Organization (WHO)-recommended strategy for detecting and treating tuberculosis (TB). The most effective way of preventing the spread of the disease and the last line of defence against an increase in multidrug-resistant TB, DOTS is considered by some to be the biggest health breakthrough of the decade. The strength of DOTS is its combination of 5 key components which work in concert: detection of infectious cases through sputum smear microscopy, a dependable supply of powerful anti-TB medicines, observing patients take their medicines for at least the first 2 months of treatment, a reliable management and record-keeping system to track treatment progress, and political and financial commitment. Inconsistent or partial treatment is one of the major causes of multidrug resistance. DOTS is designed to prevent the development of resistance to any one of the essential drugs. DOTS is a proven, inexpensive treatment strategy which can prevent millions of deaths over the next 10 years.
Human rights and maternal-fetal HIV transmission prevention trials in Africa.
The first effective intervention to reduce the perinatal transmission of HIV was developed in the US in 1994, in AIDS Clinical Trials Group (ACTG) Study 076. 6 months after stopping the trial, the US Public Health Service recommended the regimen as the standard of care in the US. In June 1994, the World Health Organization (WHO) convened a meeting in Geneva at which it was concluded that the 076 regime was not feasible in the developing world. Subsequent to that consensus, at least 16 randomized clinical trials, of which 15 used placebos as controls, were approved for implementation in developing countries, mainly in Africa. The trials involve more than 17,000 pregnant women. 9 of the studies are funded by the US Centers for Disease Control and Prevention (CDC) and the US National Institutes of Health (NIH). The authors consider the ethical grounds for whether or not these trials should be conducted. Since the adoption of the Universal Declaration of Human Rights by the UN General Assembly in 1948, the countries of the world have agreed that all people have dignity and rights. However, there is concern that developed countries which use research subjects in developing countries are exploiting developing country populations for the benefit of the more developed world. The only way to prevent a research population from being exploited is to insist not only that informed consent be obtained from study volunteers, but also that should an intervention be proven beneficial, it will be provided to the population from which the research subjects were recruited. Neither NIH, CDC, nor any host country currently has a plan to make the interventions they are studying available in Africa, where more than 66% of all HIV-infected people worldwide live.
Placebo controls in HIV perinatal transmission trials: a South African's viewpoint.
Researchers should not conduct research in poor countries that would be unethical in their own countries, except under justifiable extenuating circumstances. In South Africa, 0.76% of pregnant women in 1990 and 14.07% in 1996 were infected with HIV. An urgent need therefore exists to find practical and affordable ways to reduce the vertical transmission of HIV. To that end, two large HIV perinatal transmission trials are currently underway in South Africa, one to assess the effect of vitamin A supplementation and the other to determine the effects of a combination of zidovudine and 3TC given for a short period before, during, or after delivery. Both trials are double-blind, randomized control trials with placebo arms, and scrutinized by ethics committees. While any appropriate and effective intervention eventually developed for use in South Africa need not be as good as the ACTG 076 regimen of therapy, its impact upon HIV vertical transmission must be known, because that information will be the basis of policy to protect hundreds of thousands of infants from becoming infected with HIV. The placebo control arm of these 2 studies is ethically justifiable given the current context of HIV epidemic conditions in South Africa and the HIV/AIDS prevention central goal of the trials.
The preferred standard of care for preventing the transmission of HIV from HIV-infected mothers to their fetuses, the ACTG 076 regimen consists of giving zidovudine to pregnant HIV-infected women during their last 2 trimesters of pregnancy, an intravenous bolus of zidovudine during delivery, and zidovudine to the newborn infant for 6 weeks. Due to its high cost, this treatment approach is affordable and widely available in only industrialized countries, where vertical HIV transmission is a small problem relative to HIV conditions in many other developing countries. 16 placebo-controlled trials were therefore launched in selected developing countries to determine whether far cheaper alternatives to the ACTG 076 regimen could reduce vertical HIV transmission to at least some extent. Considerable controversy ensued over whether the trials were ethically justified. An effective method of preventing maternal-fetal HIV transmission already exists, but it simply unaffordable for the HIV-infected masses in developing countries. The ethical dilemma should therefore not be so much over whether or not the trial research design is appropriate, but rather whether the inequitable distribution of wealth inherent to the current world economic order which necessitates finding a cheaper prophylaxis is morally sound.
Informed consent to partake in a research study implies that the researcher and subject have entered into a voluntary agreement of the subject's participation with no element of coercion and that the subject is fully aware of the implications of participation. Since 1991, first-time antenatal clinic attenders at King Edward VIII Hospital had been invited to participate in a study of perinatal HIV transmission. Findings are reported from a study conducted to determine whether study participants gave truly informed and voluntary consent to being tested for HIV. 56 first-time antenatal clinic attenders randomly selected from those enrolled in the perinatal HIV study answered questionnaires before and after counseling. A sensitization control group comprised of 56 other participants completed only a post-counseling questionnaire. Study participants had an average of approximately 10 years of education. The women's already high knowledge of HIV transmission and prevention was little improved after counseling. While 88% of the study group and 93% of controls agreed to be tested for HIV, 88% of the women reported that they felt compelled to participate in the study, despite assurances that participation was voluntary. Consent was truly informed, but not truly voluntary.
A biocultural perspective on health and household economy in southern Peru.
Using research upon the relationship between health and household economy among small-scale farmers of the Nunoa District in the southern Peruvian Andes, the author developed and presents a biocultural approach to human health which integrates perspectives from anthropological political economy, ecology, and human adaptability. Poor health and nutrition in the local population reflect the social and economic history of the region, in which illness is both a symptom and a catalyst of poverty and change. Compared to healthy households, households crippled by illness plant half as many fields at twice the labor cost. Among poor households, the effects of illness upon farming production are exacerbated by their inability to adequately supplement family labor with non-household workers. The consequences of illness can lead to changes in access to resources and production strategies, shaping household health and economy in the future.
Globalization and public health: a new challenge for WHO?
Globalization and global change will likely be major challenges for the World Health Organization (WHO) in the 21st century. Although globalization means different things to different people, the concept of globalization with regard to public health refers to the threats and opportunities for health which transcend national borders. Since these phenomena are so international, they cannot be adequately addressed through only national policies. While not a new problem, the international spread of infectious disease is the most commonly cited example of a transnational health threat. However, over the past 200 years, the average distances travelled and the speed of travel have increased by a thousandfold. The massive volume of international traffic, with more than 1 million people crossing national boundaries each day, facilitates the globalization of infectious agents. Global trade liberalization; the international trade in psychoactive drugs, tobacco, and alcohol; trade in health services; and structural adjustment policies are also associated with transnational public health risks. On the positive side, however, globalization facilitates the exchange of modern technologies and ideas between countries, offering the chance to improve global health in the future. Current and future cross-border issues confronting the world can be resolved only through global cooperation. WHO could play an important role in facilitating action on transnational policy issues in the 21st century.
Using a spreadsheet to develop population pyramids.
Demographic analysis lies at the heart of most planning studies, with data on the existing population, as well as recent and anticipated future population trends, helping to inform planning decision-makers. Most planning offices use both spreadsheets and population pyramids. While the former are often used to prepare population graphics on trends, averages, totals, and projections, few planners know that it is also possible to develop population pyramids using a spreadsheet. Among those planners who are aware that population pyramids can be created in such a manner, few know how to do it. Even the documentation which comes with spreadsheet programs does not explain how to create pyramids. Population pyramids are, however, readily created on spreadsheet programs with only a little guidance. This paper explains through a step-by-step procedure how to create population pyramids using spreadsheets.
More on the myths that population and immigration are no longer problems.
American Enterprise Institute (AEI) Senior Fellow Ben J. Wattenberg predicted toward the end of 1996 that the expected crisis of global overpopulation is not developing and that instead, many countries will experience declining population size. He further believes that global population will reach a maximum size of 7.7 billion, then decline. While it is true that the rates of total fertility and population growth in many countries have declined in recent decades, one must ponder the long-term effects of the already large global population with regard to the environment, political stability, and overall quality of life. The 27 developing countries which have below replacement level fertility did not achieve that fertility on their own, they had help from family planning programs. Wattenberg fears having too low levels of fertility and also supports the immigration of low cost laborers to the US. The US government spends too little on international population programs and that money which is spent is controlled by restrictions to such an extent that its effectiveness is limited.
FPAN 21st Central Council meeting emphasises on sustainability.
Nepal's Minister of Health at the 21st Central Council Meeting of the Family Planning Association of Nepal (FPAN) noted that Nepal was experiencing major migration problems due to its open borders between China and India. Migration problems have been exacerbated by both refugees from Bhutan and the forced return migration of Nepalese-origin Indians from some Indian states. Internal migration from the hills to the teral region is also aggravating population-related problems in the country. FPAN needs to educate and provide family planning services to the rural poor population which is in need of services, yet can neither support nor educate itself. With family planning already effectively practiced among the educated and affluent, focus should be upon reaching the rural poor with the family planning program. The FPAN president urged the government of Nepal to integrate population into development programs and stressed that program success and sustainability depend upon the level of community involvement. The council meeting was held to review progress made in 1997, and to decide upon policies, programs, and directives for the future.
"Deukis" servants of gods: a challenge for the project.
Deukis are girls offered by parents to serve the temple God and Goddesses in the hope of receiving salvation. Deukis live on temple premises and are dependent upon offerings made to God and Goddesses. In addition to being exploited by the priest and the general community, Deukis are not eligible for marriage and are treated as second-class citizens. To earn enough money to survive, many Deukis work as prostitutes outside of the temple premises, unwittingly becoming infected with and spreading HIV and other STDs. Since children born to Deukis cannot identify their fathers, they eventually work as prostitutes like their mothers. Vision 2000: Challenges for Change Project in Baitadi is teaching approximately 40 Deukis about sexual and reproductive health issues, while also using them to promote safe motherhood, family planning, and an end to the tradition of offering Deukis. Using Deukis as health and condom promoters, Vision 2000 has tried to raise their social status and recognition while also finding them alternative employment opportunities.
Study of immunisation: knowledge, attitude and practice.
Immunization is a key component of the fight against certain childhood diseases. The workers of Durgapur Steel Plant, Durgapur, in the district of Burdwan, West Bengal, and their family members who attended the local health unit were interviewed to learn about their preventive health care-related knowledge, attitudes, and practices. Study findings are based upon interviews conducted with 1378 people between November 1987 and October 1988, with a follow-up period of 3 months. Triple antigen, double antigen, and oral polio vaccines were considered. 110 (7.98%) of the industrial workers were unaware of the preventive aspects of health care. Most of these latter individuals were illiterate, rural in origin, and with monthly family incomes of less than Rs1000. Female children and third and fourth children in households were relatively more neglected, the mass media was the main source of preventive health care-related knowledge, and trade unions played no role in health education. Seasonal variation was observed in the numbers of immunization and drop-out cases. Reasons for dropping out included child illness, being out of station, not knowing the necessary number of doses and time or both, and parental negligence. Of the 640 parents who brought their children for immunization and understood the preventive aspect of health care, 7 believed in other than a scientific system of medicine.
The Baby Friendly Initiative in Zambia.
88% of mothers in Zambia breast feed their newborn children for longer than 6 months. However, in the UK, only 66% of mothers start breast feeding, and by 4 months, only 42% are still breast feeding. This difference in breast feeding prevalence exists even though UNICEF is running a Baby Friendly Initiative in both countries to encourage the practice. The maternity unit of Queen's Park Hospital in Blackburn, UK, has photos of breast feeding, no promotional material from baby formula manufacturers, side rooms where mothers have absolute privacy, and 3 midwives on duty. The maternity unit of Chikankata Mission Hospital outside of Lusaka is more modest, with only 1 midwife, but extremely clean. Mothers seen at the unit in Blackburn have no intention to breast feed, in large part due to the social stigma attached to the practice. It is therefore a considerable challenge to convince the women in Britain to breast feed at all. In contrast, mothers in Zambia expect to breast feed, especially since bottle feeding is not affordable for most of them. The major challenge is to convince them to do it exclusively for 6 months. Central to the programs is the training of health professionals in the UK and volunteer health workers at the community level in Zambia. Efforts are made in Zambia to not withdraw breast feeding or end exclusive breast feeding when they become pregnant with another child, if their baby gets diarrhea, and during the hot winters. Commonalities in practice between both hospitals and the burden of AIDS in Zambia are discussed.
The tuberculosis epidemic: scientific challenges and opportunities.
Tuberculosis (TB) as a public health problem was considered resolved once effective antibiotics were introduced during the 1940s to the 1960s. However, by the late 1980s, the number of cases was on the rise and new antibiotic-resistant strains were emerging. Spread through the air, TB threatens everyone. In this context, the US Congress increased the National Institute of Health's (NIH) budget for TB research from approximately $3.5 million in 1991 to approximately $35 million in 1996. In 1996, the US experienced its fourth consecutive year of declining TB rates, recording 21,337 cases, the fewest since 1985. However, by 1996, the TB case rate had either remained the same or increased in 23 states and the District of Colombia relative to 1995. Globally, the incidence of TB was recently estimated to have been approximately 7.3 million cases in 1995, causing approximately 3 million deaths annually. 33% of the world's population is thought to be infected with the bacterium which causes TB, and TB has become the leading cause of death in people infected with HIV. This paper discusses how TB is spread; active and latent TB; the diagnosis of active pulmonary TB; directly observed treatment, short-course (DOTS); multidrug-resistant TB; the development of diagnostic assays, drugs, and vaccines; and the genomics of TB.
Acute respiratory infections: the forgotten pandemic.
Although acute respiratory infections cause 19% of all deaths in children under age 5 years and 8.2% of all disability and premature mortality, acute lower respiratory infections receive only 0.15% of the research and development budget for health. A major international conference, co-sponsored by the World Health Organization and held in Canberra during July 7-10, 1997, to discuss the prevention and treatment of acute respiratory infections was attended by experts from all over the world. The conference included 35 workshops and 27 plenary sessions. It was resolved at the conference that in developing countries, too many children continue to die from pneumonia. Children in such countries should be immunized immediately with H. influenzae type b vaccine, while conjugate S. pneumoniae vaccine should be made available soon. Furthermore, the role of unconjugated S. pneumoniae vaccine needs to be defined and antibiotic treatment for pneumonia provided to all children. Drugs have little effect in developed countries upon viral upper respiratory infections. Evidence on respiratory infections should be studied, guidelines developed and promoted for antibiotic prescribing, and the use of influenza and pneumococcus vaccines increased. Globally, as US$8 billion annually is wasted upon symptomatic treatment, more money needs to be invested in researching acute respiratory infections.
Commentary: malaria control in the 1990s.
The global malaria eradication campaign adopted by the 8th World Health Assembly in 1955 was based upon the widespread use of DDT against mosquitos and of antimalarial drugs to treat malaria and eliminate the parasite in humans. While eradicating endemic malaria by 1967 in all developed countries and parts of tropical Asia and Latin America, the approach employed in the campaign was both unsustainable and not feasible for implementation globally. In 1992, a Global Malaria Control Strategy was endorsed by a ministerial conference on malaria control and confirmed by the World Health Assembly in 1993. This new strategy is based largely upon the primary health care approach and requires flexible, cost-effective, sustainable, and decentralized programs based upon disease rather than parasite control, adapted to local conditions and responding to local needs. The implementation of this strategy is beginning to have an impact in several countries, such as Brazil, China, Solomon Islands, Philippines, Vanuatu, Vietnam, and Thailand. Its success demonstrates that malaria can be controlled by locally and currently available tools. This new control approach now needs to be brought to populations experiencing high levels of malaria-related morbidity and mortality, especially in sub-Saharan Africa.
Indonesia loses family planning advocate.
Professor Masri Singarimbun, a much lauded Indonesian demographer, died on September 25 at age 66. During the 1970s, the government of Indonesia promoted family planning in a bid to check the high rate of population growth. Although condoms were then highly unpopular as a contraceptive method, Singarimbun took the lead in popularizing demography and promoting condom use. His perseverance helped to reduce Indonesia's population growth rate. In 1973, Singarimbun established the Center of Population Research and Studies at Gadjah Mada University, now known as the Center for Population Research. Singarimbun headed the center for a decade after its founding, training demographic researchers and scientists who are now found across the country. He volunteered with the Indonesian Planned Parenthood Association until his death. The government of Indonesia also awarded Singarimbun the Cipta Karya medal of merit in 1995.
Is your condom on upside down. The surprising things people don't know about condoms.
The use of latex condoms when having sexual intercourse is the best way to protect oneself from sexually transmitted diseases. While latex condoms come in a variety of different shapes, Lifestyles condoms, manufactured by Ansell Personal Products, are available in only three slightly different sizes. A condom should be used before the expiration date noted on its package. Condoms with spermicide have a shelf life of 3 years, while nonspermicidal versions are good for 5 years after manufacture. It is better to carry a condom in one's shirt pocket than in one's rear pocket. Lengthy exposure to heat can break down latex and sharp objects commonly found in a purse can damage condoms. The condom should be handled gently once it has been removed from its package. The condom should then be rolled onto the penis, taking care not to apply it inside out. A small amount of air should be left at the tip of the condom and only water-based lubricants should be used. If the condom breaks, the penis should be withdrawn immediately and another condom applied before re-engaging in sexual intercourse.
Can Africa meet the goal of eliminating iodine-deficiency disorders by the year 2000?
While Africa ranks third among all regions of the world most affected by iodine-deficiency disorders (IDDs), the continent is moving rapidly toward eliminating IDDs by 2000 mainly because of the availability of affordable, cost-effective technology and an unprecedented alliance among governments, the private sector, and international agencies. Remarkable progress has been made toward achieving universal salt iodation. By the end of 1995, there were IDD control programs, using iodated salt as the long-term strategy, in almost all countries on the continent where the World Health Organization estimates that IDDs are a problem of public health significance. As of February 1996, an estimated more than 50% of all salt consumed in Africa was iodated. If trends continue, the mid-decade goal of universal salt iodation could be achieved by the end of 1996 and IDDs may be eliminated throughout Africa by the beginning of the next century. Major obstacles do, however, remain to achieving universal and sustained salt iodation.
Chagas disease: Central American initiative launched.
An initiative to interrupt the transmission of Chagas disease in Central America was launched at a meeting held October 22-24, 1997, in Tegucigalpa, Honduras. Sponsored by the UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases (TDR), the meeting was attended by government delegates from Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama. The initiative was launched within the framework of Resolution 13 of the Meeting of Ministers of Health of the Central American Countries, held in Belize in September 1997. Detailed plans of activities were prepared for each country for the period 1998-2001, for approval by the various ministries of health, while operational, epidemiological, and entomological research priorities were also agreed upon. Research projects to help improve disease control will be sponsored by TDR. The first meeting of the Technical Intergovernment Commission established to meet annually to assess progress in control activities will occur in October 1998 in Guatemala. Vector and infection rate data are briefly presented on each country represented at the meeting.
Mahidol University's Faculty of Tropical Medicine, Bangkok, Thailand, established in 1960, is one of 14 faculties, 5 institutions, 5 centers, and 2 colleges within Mahidol University. It consists of the following departments: Helminthology, Medical Entomology, Microbiology and Immunology, Protozoology, Social and Environmental Medicine, Tropical Hygiene, Tropical Medicine, Tropical Nutrition and Food Science, Tropical Pediatrics, Tropical Pathology, and Tropical Radioisotopes. The UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases (TDR) has been associated with the Faculty since 1977, collaborating mainly upon malaria research, but also in filariasis, leprosy, and schistosomiasis research. Early TDR support was directed at research training and institutional strengthening, although by the early 1980s, the Faculty played an increasingly important role in TDR's research and development program. In recent years, the Faculty has focused upon researching malaria, parasitic and bacterial diseases, nutrition and food sciences, and environmental health. The Faculty's malaria-related research is described. The Faculty also conducts research in many other areas of tropical medicine outside of those of interest to TDR.
Multilateral perspective on malaria begins to take shape.
13 funding bodies collaborated in January 1997 to create the Africa-targeted Multilateral Initiative on Malaria (MIM). African scientists have been deeply involved in the MIM from its inception in Dakar, Senegal. The immediate goal of the initiative is to facilitate collaboration between governments, control programs, scientists and supporting agencies. Both the public and private sectors are actively involved. It is possible that in the long term the MIM will function as a global forum for malaria-related discussions, creating political awareness and a political context for concerted action by parties which usually work separately. With follow-up meetings held in the Hague in July and in London in November, the MIM is moving ahead quickly with a varied and full agenda of research objectives. In the short term, improvements will be sought in the way existing tools are used, while results from studies of epidemiology, pathogenesis, the malaria genome project, and the genetic engineering of mosquitoes will be applied over the medium and long terms. The UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases (TDR) will help assess the scientific needs and strengthen the research capacities of malaria endemic countries in Africa, providing approximately US$3 million annually to support 10-15 projects for periods of 1-3 years. Training will be a component of all research.
Haemophilus influenzae group b (Hib) is an important cause of meningitis. Compared to early-generation Hib vaccines, more recent Hib vaccines activate the relevant macrophages and T-helper cells to induce greater amounts of antibodies and permit booster responses. Their use in developed countries has led to a major reduction in the incidence of meningitis and invasive infections. Findings are reported from an assessment of the immunogenicity of the Haemophilus influenzae-diphtheria CRM197 protein conjugate vaccine (HbOC) in a randomized clinical trial of Arab children living in Tripoli, Libya. The vaccine was given to 90 infants as part of a 3-dose series at ages 2, 3, and 4 months together with hepatitis B, OPV, and DPT. Anti-H. influenzae antibody levels in these infants were compared with those of 81 infants receiving hepatitis B, OPV, and DPT, but not HbOC. The immunogenicity and safety of HbOC in this study were as high as that observed in industrialized countries. No major complications were observed, while fever and temporary local discomfort occurred in less than approximately 2% of infants. The level of Hib antibodies increased in infants after having receiving only 1 dose of HbOC vaccine. The geometric mean anti-Hib antibody levels were 0.41, 1.36, and 2.91 mg/ml after 1, 2, and 3 doses, respectively. After 2 doses, all children had antibody levels higher than 0.20 mg/ml, while the lowest antibody concentration was 0.80 mg/ml. Since antibody levels among these study subjects are similar to those in Europe and the USA, HbOC will likely provide good clinical protection in the study population.
Editorial: The next century of Tropical Health.
Since one of the publications involved in the merger which created Tropical Medicine and International Health began publication in 1898, it is fair to report that the journal has reached its 100-year mark and can now look back to gain insight into possible salient issues for the 21st century. A very high rate of growth is anticipated with regard to information and the understanding of the basic biology of disease in developing countries. There will also be some improvement in humans' ability to intervene biomedically, with a longer life expectancy at birth, but little reduction in some of the more important tropical infections, as well as a far poorer performance regarding the understanding and action to improve the social and economic standing of the majority of developing country residents. The pattern of disease has changed radically, but not universally during the century. However, human responses have changed repeatedly and at an increasingly rapid rate. The advent of HIV/AIDS has, nevertheless, shown us that we must remain vigilant to future health hazards with hopes of either preventing or controlling them. Environmental experts have begun to consult on such potential threats.
Malaria is a considerable health burden on the Kenyan coast, accounting for 39% of admissions to the Kilifi District Hospital (KDH) pediatric ward. A study was conducted to calculate the costs at KDH and Malindi Sub-district Hospital (MSH) of treating pediatric malaria admissions including cerebral malaria, severe malaria anemia, and malaria-associated seizures; and to estimate the implications for hospital expenditure of a reduction in pediatric malaria admissions. Findings are based upon patient data from hospital records. In 1992, there were 3047 admissions to KDH's pediatric ward and 1698 admissions to the pediatric ward at MSH in 1993. Unit recurrent costs per admission in KDH ranged from US$57 for "other" pediatric malaria to US$105 for cerebral malaria, and in MSH from US$33 to US$44 for the same categories. The annual recurrent cost of treating all pediatric malaria admissions to KDH before the trial was an estimated US$78,900. During 1993-95, a community randomized controlled trial of insecticide-treated mosquito nets (ITMNs) conducted in a population of approximately 56,000 in Kilifi district demonstrated that the intervention could reduce pediatric malaria admissions to KDH by more than 40%. That reduction in admissions resulted in an estimated savings of US$6240 in the cost of treating pediatric malaria admissions from the intervention area.
1997 salary survey results. Salaries stay steady as managed care moves into town.
Contraceptive Technology Update's 1997 salary survey recently found that even though the family planning arena continues to be rearranged by the introduction of managed care, salaries for reproductive health care providers remain steady. 5% of the 181 respondents to the annual survey indicated that their salaries decreased, 23% indicated no change in salary, 41% reported a 1-3% increase in the last year, 20% received a 4-6% increase, and 5% a 7-10% increase. 51% of respondents reported no change in the number of employees in their department, while others saw either increases or decreases in numbers. Physicians who responded to the survey reported a median salary of $87,500, up from the 1996 level of $67,500. Salaries increased from $37,500 to $42,000 for health educators and from $37,500 to $40,000 for physician assistants. Certified nurse midwives, registered nurses, and administrators maintained their respective 1996 levels of $57,500, $32,500, and $42,500. The only group which saw a decline in pay were nurse practitioners, with their median salaries dropping from $47,500 in 1996 to $42,500 in 1997. While salary and personnel levels are largely unchanged, some clinicians are concerned about their job security.
Health promotion and health education in Puerto Rico: an overview.
Puerto Rico, the smaller of the Greatest Antilles in the Caribbean Region, is a commonwealth of the US, and as such, economically and politically dependent upon the US. According to the 1990 census, approximately 3.5 million people inhabited the country, of whom more than 71% live in urban areas. The Department of Health provides a 3-tier system of regionalized health services. Formal health education began in Puerto Rico during the 1940s. Milestones in the development of health education are noted for the period 1944-81. 700 health educators have graduated from the University of Puerto Rico since 1948; the institution offers bachelor and master degrees in health education. The government of Puerto Rico is now seeking health sector reform in an attempt to achieve health for all by 2000. 5 years after implementing changes in the health sector, various sectors of society are asking for evidence of the effectiveness and efficiency of the changes. Chief concerns relate to the lack of control over the quality of private sector health services, especially regarding health education and prevention services.
World Population Day: FPAN committed to promote reproductive health and rights.
On July 11, 1997, World Population Day, the Family Planning Association of Nepal (FPAN) organized a talk on the reproductive rights of adolescents and integrated reproductive health in Nepal. The event was attended by 60 participants from the various nongovernmental organizations (NGOs), international NGOs, government officials, parliamentarians, and representatives of the local UNFPA. FPAN is committed to promoting adolescents' reproductive rights as basic human rights. Indeed, the future and success of FPAN's population program depends upon young people. Nepal is also committed to implementing the recommendations of the International Conference on Population and Development held in Cairo and the Beijing Declaration. The long-term objective of HMG/Nepal is to ensure the universal availability of reproductive health information and services to all men, women, and adolescents. The government has focused upon an integrated approach to health service delivery and also plans to provide reproductive health services in an integrated manner. Papers presented and remarks made at the July 11 conference are briefly discussed.
The health consequences of FGM.
There are both immediate and long-term consequences of female genital mutilation (FGM), depending upon the type of procedure undertaken, the skill of the practitioner, the nature of the tools, the environment, and the physical condition of the girl upon whom the mutilation is exacted. The physical side effects are better understood than the effects upon girls' mental and sexual health. The short-term effects of FGM include severe pain resulting from tissue injury, bleeding, shock and death in cases of severe bleeding, the development of scar tissue which may lead to acute urine retention, and possible tetanus infection, failure of the wound to heal, and fractures and dislocations caused by restraining the struggling girl. Long-term complications can include painful menstruation and problems with menstrual flow, difficulty passing urine and recurring urinary tract infections, pelvic infections and infertility due to deep infections, and prolonged labor and subsequent vesico-vaginal or recto-vaginal fistulae. Successful efforts to eliminate FGM require sensitivity due to the intensity with which cultural beliefs are held regarding the practice. Suggestions are offered on how to end FGM in Nigeria.
Reproductive tract infections: challenges for international health policy, programs, and research.
With often devastating health and social consequences for women and their children, reproductive tract infections (RTIs) are extremely common in resource-poor settings around the world. RTIs refer to sexually transmitted diseases (STDs), endogenous infections caused by the overgrowth of organisms which can be present in the genital tract of healthy women, and iatrogenic infections associated with medical procedures. All of these infections are preventable or treatable causes of infertility, ectopic pregnancy, cervical cancer, fetal wastage, low birth weight, infant blindness, neonatal pneumonia, and mental retardation, and also facilitate the transmission of HIV. However, due to sociocultural factors and social barriers to care, the incidence and impact of RTI sequelae are likely to be especially major in the Third World. RTI syndromes also have major implications for the success of key health-related development programs such as those dealing with family planning, child survival, women's health, safe motherhood, and HIV prevention. In turn, each of these initiatives offers opportunities to prevent and control RTIs. The authors consider the demographic, societal, biomedical, and technological developments related to addressing RTIs; summarize the human and socioeconomic costs of RTIs in the developing world; and discuss program and policy implications.
Sexually transmitted diseases: current and future dimensions of the problem in the Third World.
An overview of sexually transmitted diseases (STDs) in developing countries is presented, with an emphasis upon STDs in women. Women appear to be more susceptible to acquiring infection and are more likely to experience complications which develop from primary infections. The emphasis given to women in this paper also reflects the greater abundance of epidemiological data on the prevalence of STDs in women than in men. Where available, data are provided on STD prevalence among high-risk men. Drawing from the literature and research upon pregnancy-associated STDs at a maternity hospital in Nairobi, Kenya, the authors first present a summary of STD prevalence rates among defined populations of women at varying risk of STDs, together with an estimate of the impact of maternal STDs upon maternal and child health. The potential demographic effect of HIV and gonococcal infections upon population growth rates are discussed, while a conceptual model of STD transmission dynamics is also presented in order to rationalize the projected changes in STD rates. Finally, the implications of the information summarized in the paper are discussed in terms of future research needs.
Upper reproductive tract infections (RTI) and their consequences are major health problems for women worldwide, especially in resource-poor settings. Pelvic inflammatory disease (PID) is due mostly to sexually transmitted infections which start in the lower reproductive tract and ascend into the upper reproductive tract. Cervical cancer is also usually the result of sexually transmitted infection, with human papilloma virus (HPV) apparently the causal agent. These conditions can be effectively controlled and prevented through relatively simple and inexpensive methods. One now need only commit the necessary human and financial resources for activities to prevent and treat RTIs. PID is discussed in terms of PID risk, the extent of the problem, postpartum infection and sepsis, postabortal infection and sepsis, the sequelae of PID, PID-related infertility, the extent of infertility, PID and ectopic pregnancy, the impact of ectopic pregnancy, and programs, policy, and research. Cervical cancer is discussed in terms of cervical cancer risk, HPV infection and infectious agents other than HPV, other factors, program recommendations and policy implications, and research needs.
Family planning: the responsibility to prevent both pregnancy and reproductive tract infections.
While the use of contraceptives can prevent both unplanned pregnancy and reproductive tract infections (RTI), technology development, policy emphasis, and service delivery have focused almost solely upon the pregnancy prevention merits of contraception. The contraceptives with the best track records in preventing pregnancy provide minimal protection against RTIs, while some contraceptive methods may even increase the risk of certain infections. Decisions about contraception by individuals, communities, and policy-makers should involve balancing the relative need to prevent both RTIs and unplanned pregnancy. At the personal level, contraceptive use by couples is affected by the perceived risks and costs of either RTIs or pregnancy, while at the community level, contraceptive acceptance is affected by the social norms of particular cultures. At the policy level, contraceptive emphasis by policy-makers is affected by the aggregate risk and costs of RTIs and unplanned pregnancy in the particular society. This paper explores similarities and differences between the fields of RTIs and unplanned pregnancy, examines the scientific evidence of contraceptive influence upon RTIs, presents estimates of the relative effectiveness of different contraceptive methods in preventing unplanned pregnancy and RTIs, and recommends areas where sexually transmitted disease (STD) control and family planning programs may build upon each other's efforts.
Human immunodeficiency virus infection prevention: the need for complementary STD control.
The advent of the AIDS epidemic in the 1980s called attention to the importance of sexual transmission in spreading infections, as well as the lack of control programs for sexually transmitted diseases (STDs) in many parts of the world. Before AIDS, STDs were largely ignored internationally. However, since 1988, AIDS professionals have begun to consider possible connections between AIDS and other STDs as they attempt to explain the HIV epidemic in some parts of the world. The sexual transmission of HIV may be facilitated by the presence of other STDs, which most likely partly explains the differing rates of HIV's spread around the world. At the same time, the natural history, diagnosis, or response to the treatment of STDs may be changed in HIV-infected people. Several modes of interaction between HIV and STDs have been postulated. This paper examines the available data from around the world on whether STDs enhance the sexual transmission of HIV by increasing susceptibility in HIV-negative individuals or by increasing infectivity in HIV-positive persons, and if HIV infection and consequent immunodeficiency changes the natural history, diagnosis, or response to treatment of other STDs.
HIV / AIDS in a Brazilian prison [letter]
Several research studies have reported high levels of HIV infection in prison institutions in Brazil. During November 1993, the authors interviewed 631 prisoners from South America's largest prison about their HIV risk-related behavior. Study participants were also tested for infection with HIV, hepatitis C virus (HCV), and syphilis. The prison population at the time of the study was approximately 4700 inmates. 16% of the inmates were infected with HIV, while 2.5% of assays yielded indeterminate Western blot results. Antibodies against hepatitis C were found in 34.1% of the population, and against syphilis in 18.1%. Only 13 individuals fulfilled the 1993 CDC criteria for AIDS. Acknowledged sexual risk behavior included homosexuality, bisexuality, and sexual promiscuity involving sexual relationships with more than 1 nonregular sex partner, and without using a condom during the past 6 months. No parenteral exposure other than IV drug use and blood transfusion was reported. Study results, when compared with previous research findings, suggest a stationary situation of overall HIV prevalence over the past few years in this prison. A strong correlation was identified between HIV and HCV seroprevalence among the inmates, even in the absence of acknowledged use of IV drugs. Multivariate analysis indicates that HIV is most likely being transmitted parenterally in this population. The prevalence of HIV infection in this prison is 75 times higher than in the general community at large, and the average inmate spends only 2.78 years in jail. As such, these inmates could spread HIV to the broader community once released.
Progress toward elimination of measles from the Americas.
In 1994, the Pan American Health Organization (PAHO) established the goal of eliminating measles from the Western Hemisphere by 2000. To reach that goal, PAHO developed a measles-elimination strategy comprised of 3 vaccination components and integrated epidemiologic and laboratory surveillance. The strategy aims to achieve and maintain high levels of measles immunity among infants and children, and detect all chains of measles virus transmission through surveillance. This paper updates measles surveillance data through February 1998 and summarizes the impact of elimination strategies upon measles in the Americas. Each country in the Americas except the US, the French Antilles, and the Netherlands Antilles conducted measles "catch-up" campaigns during 1987-94. Vaccination coverage achieved during these campaigns was 94% region-wide, while country-specific coverage was 71-99%. Since 1994, 26 of the 47 countries and territories in the region have also conducted "follow-up" vaccination campaigns. In 1996, a record low of 2109 confirmed measles cases was reported from the region, with most of the region free of circulating measles. However, provisional data from January 1997 through February 1998 indicate that 88,485 suspected measles cases were reported in the region, of which 31% have been confirmed, 37% have been discarded, and 31% are being investigated. Brazil and Canada, with 26,348 and 570 confirmed cases, respectively, accounted for 97% of all confirmed cases region-wide. Details on the outbreaks in Brazil and Canada, as well as the presence of measles in the US are reported.
Progress and problems in the fight against AIDS.
The provision of double-nucleoside therapy against HIV/AIDS in Europe and North America is most likely responsible for the observed marked declines in AIDS-related morbidity and mortality in 1995 and 1996, while the addition of protease inhibitors resulted in further benefit in late 1996 and 1997. The number of inpatients with AIDS has decreased while the number of outpatients has increased, reflecting major improvements in the treatment of HIV infection. However, simpler treatments are needed and much remains to be learned about how to safely apply these new biomedical tools against HIV/AIDS, including the nature of therapy-related long-term complications. Furthermore, funds are still needed for ongoing research and prevention. For the average AIDS patient in developing countries, highly active antiretroviral therapy is an inaccessible dream, and merely a diversion for developing country health ministries from more pressing concerns which threatens more cost-effective programs against HIV, such as the targeted distribution of condoms or the treatment of sexually transmitted diseases which facilitate the spread of HIV. Since nothing will likely bridge this gap between poor and rich countries, only prevention and a vaccine will likely make a real difference for the poor in the battle against HIV/AIDS.
Progress toward poliomyelitis eradication -- African region, 1997.
In 1988, the World Health Assembly established the goal of eradicating poliomyelitis worldwide by 2000. The World Health Organization (WHO) has since promoted the implementation of specific strategies to achieve that goal. Eradicating polio from Africa is one of the remaining major challenges to achieving global eradication by the target date. This report summarizes progress in WHO's African Region in 1997 with the implementation of polio eradication strategies, with data indicating that polio eradication by 2000 remains a feasible target. While reported routine coverage with 3 doses of oral poliovirus vaccine (OPV3) is low in the region overall among children under age 1 year, coverage has increased from 47% in 1993 to 54% in 1996. In 1996, 12 countries reported that less than half of children were routinely vaccinated with OPV3. Of the largest and most populous countries, only Ethiopia improved routine coverage, from 54% in 1995 to 67% in 1996. Coverage levels were 42% in Angola, 36% in DR Congo, and 26% in Nigeria. All 24 countries of central and western Africa reported OPV3 coverage levels of less than 60% in 1996, except Algeria (77%), Benin (80%), The Gambia (97%), Senegal (80%), and Togo (82%). During 1997 and the first quarter of 1998, 36 countries in the region conducted national immunization days (NID); NID coverage data are presented. A total 1949 polio cases were reported in Africa in 1996, with Nigeria, Ethiopia, DR Congo, Uganda, Chad, and Angola accounting for 88% of cases.
Mega-cities and the urban future. A model for replicating best practices.
Urban problems are growing more serious and threatening all societies. Given the magnitude of such problems, new methods need to be developed to support, adapt, and replicate innovative solutions, as well as to accelerate the process of incorporating new approaches into public policy. One key challenge is how to reduce the time-lag between urban innovation and its implementation. Based in New York City, the Mega-Cities Project is an international network of urban leaders including 18 city coordinators worldwide. Locally, the coordinators identify, distill, and disseminate positive approaches among sectors, and strengthen the capacity of urban leaders and groups by finding sources of support for them. On the intercity or international levels, coordinators can serve as transfer agents among cities by coordinating with their city coordinator counterparts in the other cities. The achievement of active linkages within and between sectors or cities is facilitated through a 4-part strategy. The project has thus far initiated the transfer of 37 innovations. The authors describe lessons learned, challenges, and opportunities from the Zabbaleen Environmental Development Program first implemented in Cairo, then applied to situations in Manila and Bombay.
Turkey: uncertain emblem of the future? Taking a path, finding a role.
While Turkey has undergone major changes over the past 15 years, the possibility of equally wide-ranging changes is on the horizon for the near future in terms of the country's economic, social, and political positions, as well as its international role. In 30 years, Turkey's population has doubled, while that of Istanbul has increased by fourfold, reflecting the rapid pace of urbanization in the country. Istanbul produces about 40% of the country's total gross national product. However, infrastructure is lacking in Turkey's cities, particularly in terms of public transport and environmental protection. With agriculture, industry, and tourism concentrated along coastal areas, the Ministry of Tourism launched the Atak Project in 1989 to address the currently intense property development in such areas. Water pollution is of particular concern. Turkey may either seek closer ties to the European Union or develop itself as a bridge between East and West. This latter international role is discussed in some detail.
People used to perceive and sometimes fear nuclear war, environmental collapse, criminal conspiracy, and social disintegration as potential threats to civilized living in cities. It has, however, become apparent during the 1990s that the prospect of chronic civic disorder caused by the build-up of tension leading to violence produced by conflict between groups of diverse cultural identities should be added to the list of dangers faced by urban societies. Just like the collective cultural conflict which rages in Sarajevo and has attracted the peacekeeping efforts of the global community, internecine conflict could erupt in a number of cities as a result of national, ethnic, racial, and/or religious differences which exist between groups which share the same space. In the context of the global increase in urban violence and destruction, people must be encouraged to be open and appreciate the range of cultural diversity found in cities working together in the spirit of intercultural collaboration toward a common secure and prosperous future.
Denizli is a city of almost 300,000 in southwest Turkey which has experienced unprecedented growth over the past 2 decades. Until the 1970s, the only important development in Denizli was the establishment of a new textile factory in 1953. The first substantial measures supportive of industrialization emerged in the 1970s, with the State Planning Organization in 1973 designating the province as a priority area for industrialization. The 1980s were a turning point for Denizli initiated by local textile producers who took advantage of the export-oriented transformation in Turkey as well as the global restructuring of textile and related production. Trade firms played an important role in the process. At the beginning, a small number of medium-sized firms entered subcontracting agreements especially to produce towel and bath rope. This early entrepreneurship fueled the growth of other small producers and medium-sized firms to the extent that Denizli operations generate almost 10% of the rapidly growing Turkish textile exports in the 1990s. The transformation experienced in the city has produced some large-scale changes in the structure and nature of local alliances and conflicts. This paper describes the local transformation process which Denizli has undergone over the past 2 decades, with emphasis upon the emerging forms of inequalities and strategies of resistance upon the part of the excluded masses.
Sex education and young people.
Young people comprise up to 60% of Belize's total population of more than 200,000. Many of them have dropped out of school and simply loiter on the streets with little or nothing to do. The only nongovernmental organization in Belize providing family planning and sexual and reproductive health care services, the Belize Family Life Association (BFLA) is well aware of the many problems facing youth, such as AIDS, teen pregnancy, sexually transmitted disease, poverty, and gangs. In an effort to improve conditions for youth and to address their problems, the BFLA established a successful teen center in the Mesopotamia Area and the Belizean Youths with an Aim for Prosperity (BYAP), a project designed to foster and support entrepreneurship among a group comprised mainly of out-of-school at-risk youths. Population Concern is helping to fund reproductive health projects for youth in South Africa with the goal of reducing the prevalence of unwanted pregnancy, sexually transmitted diseases, and unsafe abortion through reproductive health services and education. Young people are helping design the project by explaining their perceived needs to the project team. In Trinidad and Tobago, controversy followed the Family Planning Association of Trinidad and Tobago's (FPATT) recent launch of its annual Family Life Education Training program for teachers, while 2 recent hurricanes, unemployment, and illicit drug sales and use are some of the problems facing the Dominica Planned Parenthood Federation and Dominica's youth.
Reconciling opposites -- the vision and the work [editorial]
The Children's Vaccine Initiative (CVI) was initially tasked with developing a supervaccine against a broad spectrum of childhood diseases. 5 years after its inception, the CVI has made progress toward developing new and better vaccines and, for the first time, has a full-time coordinator. There has also been a shift in the conceptual framework within which people in the disease prevention community work and think. The CVI has gained a broader governing base and a more clearly defined mandate regarding the global vaccine community in general and the World Health Organization's Global Program for Vaccines and Immunization (GPV) in particular. Progress has also been made in fostering consensus and stimulating support for work upon vaccines and immunization. In support of and as part of the CVI, researchers and other experts from diverse areas of the vaccine development field have joined forces to work on specific objectives, such as the single-dose tetanus toxoid vaccine. Progress made in developing vaccines against a range of diseases and funds allocated for vaccine research are described.
AIDS as a political issue: working with the sexually prostituted in the Philippines.
An estimated 200,000-500,000 men, women, and children work in prostitution in the Philippines in a variety of venues, including brothels, nightclubs, pubs, massage parlors, and other legitimate entertainment establishments. Few, however, are voluntary prostitutes. Many people who work as prostitutes have been recruited from the provinces, kept in conditions similar to slavery, and forced to earn money from prostitution to pay for their transportation, board, and lodging. Many prostitutes work in urban centers and tourist resorts in the countryside. During the 1970s, then President Ferdinand Marcos promoted tourism as a major industry, effectively marketing attractive Filipinas to tourists. Sex tourism has flourished in the country ever since. Thousands of prostitutes are also located in Olongapo and Angeles, 2 cities north of Manila, from where they serve the sexual desires of US military personnel. The presence of US military personnel in the Philippines has always been associated with prostitution. The country's social hygiene centers, prostitutes in Manila and Davao, and AIDS education are briefly discussed.
Migration and population replacement.
Although the net reproduction rate for Canada has remained well below replacement level for the past several decades, there is no sign of imminent population decline in population size. The rate of population growth instead exceeds 1% and has remained largely stable in the recent past. This trend in population is occurring because the prediction of population trends implied by the conventional stable population model does not correctly describe population change, for the model is closed to migration, and Canada is not. Three stable population models are described and exemplified with current data for Canada. The first two are closed to migration, with fertility fixed at the current level and at replacement, while the third model has fixed amounts of migration, with fertility at the current level. Analysis focuses upon the comparative age distributions, as well as the role of migrant age. Limitations are assessed with regard to the applicability of such study for policy.
Census coverage evaluation and demographic analysis in Canada.
While Statistics Canada is charged with maintaining highly accurate population figures, some degree of coverage error always exists in population censuses. Statistics Canada must therefore correctly adjust population figures for the census undercount of those people overlooked in the census-taking process. For the first time, following the 1991 Census, Statistics Canada directly incorporated into its population estimation program census counts adjusted for coverage error. Quarterly estimates of population produced since then by the Population Estimates Section of Demography Division have also been fully adjusted for population undercount. The authors review the range of procedures developed by demographers and statisticians which have helped in evaluating the coverage of census data in Canada. Most methods can be grouped as involving either demographic analysis or case by case matching procedures and record linkage techniques. Possible avenues for future research are suggested. Much could be gained by giving greater emphasis to demographic analysis in estimating census coverage, especially in improving estimates for specific age and sex groups.
Family migration and the economic status of women in Malaysia.
Recent literature suggests that family, rather than work considerations, are more important for women when making migration decisions. The author explored the employment consequences for women when they migrate with their spouses and whether they incur a cost to their economic status when doing so. Findings are based upon the analysis of data from the second round of the Malaysian Family Life Survey, which took place in 1988. Detailed life history data were available for 2904 couples and 637 never married and formerly married women. Using a lifetime perspective and the retrospective migration histories of husbands and wives, it was found that family migration has a significantly negative influence upon women's likelihood of working. Controlling all other factors, each additional experience of family migration decreases the odds of a woman working by about 15%. However, the effect of each additional instance of solo migration is positive, though nonsignificant. For working women, family migration has a negative but nonsignificant effect upon their socioeconomic standing. Solo migration, however, has a positive and significant effect.
In 1991, the University of Nairobi launched an HIV/STD project to strengthen community-based control activities and improve health facility-based STD management. With an eye toward ensuring sustainability, all activities were integrated into the existing infrastructure and implemented through local personnel. Serving a population of approximately 400,000, the project initially operated in Nairobi in 5 city health centers and their catchment areas, and in all 5 municipal health centers, the provincial hospital, and their catchment areas in Nakuru. Within a few years, 10 model clinics had been strengthened in the 2 cities and 497 health workers had been trained and organized into multidisciplinary teams of health professionals. High quality and accessible HIV/STD-related health services are now available at the clinics. In Nairobi and Nakuru, 2500-3000 clients are treated monthly for STD syndromes, over 1000 women are screened for syphilis, almost all syphilis-seropositive women and 60-70% of partners are appropriately treated, and more than 20,000 condoms are distributed. An evaluation of project impact in Nairobi found an impact upon risk perceptions, sex behavior, and the prevalence of STDs over the course of the project. Lessons learned are described.
With the broad selection of modern contraceptive methods currently available, there is no valid excuse for unwanted pregnancy or AIDS, especially for those people who are literate. The condom is one particularly attractive contraceptive option since it protects against not only unwanted pregnancy, but also AIDS and sexually transmitted diseases (STDs). Moreover, everyone can use a condom. Although they are not 100% effective, condoms, when used correctly, still provide a high degree of protection during sexual intercourse. Sexually active people at risk of contracting a STD or having an unwanted pregnancy should therefore get used to condom use and depend upon condoms as a normal component of sexual intercourse. Young people fail to use condoms because they think that sex using a condom is inferior to sex without one, while men believe they will be considered less manly if they cover their penis with a condom. Both men and women should carry condoms, for it is no longer the man's exclusive responsibility to produce one when needed. Finally, it is important to not let oneself be pressured into having unprotected sex.
Adolescents, vital in population control.
There are approximately 1.5 billion people aged 10-24 years worldwide, almost 30% of the overall global population. In Zambia, 3.3 million people are aged 10-24, about 34% of the total national population. According to the 1996 draft Demographic and Health Survey, the median age for first sexual intercourse in Zambia is 16 years and the majority of women become mothers by age 20 years. In the revised National Population Policy of December 1996, the government of Zambia recognized the potential problems faced by adolescents, especially HIV/AIDS and pregnancy. To address their needs, the revised policy aims to improve the population's access to appropriate, affordable, and quality reproductive health services, including family planning, and promoting the incorporation of population and gender education into schools at all levels. Furthermore, the Ministry of Health urges all people who have contact with adolescents to have a supportive rather than negative attitude toward them.
Designing an effective immunocontraceptive.
Gamete immunocontraception refers to the immunological inhibition of fertilization. In order to achieve such contraception, a gamete-specific antigen target must first be defined. In addition, the presentation of the immunogen to the immune system must be clearly understood in order to elicit a defined immune response which will target the native gamete molecule. Owing to the application of molecular biology techniques, the goal of defining gamete antigens has progressed considerably over the past decade. While molecules unique to testis and spermatozoa are the best choice, many partially specific antigens could also be used as targets and immunogens. Hyaluronidase is a well-studied sperm antigen whose native, membrane-bound form (PH-20) is a successful immunocontraceptive in female guinea pigs. However, it remains to be demonstrated that a successful native antigen can be a successful synthetic or recombinant gamete immunocontraceptive (GAMICON). The problem of converting a successful native contraceptive antigen into an effective synthetic or recombinant GAMICON is at the heart of the problem of GAMICON design. GAMICON design and haplotype recognition are discussed.
UN statistics indicate that youth comprise up to 30% of the world's population. As almost one-third of humanity, youth deserve to actively participate in debates which will influence the future of their world. Accordingly, a large group of youth has been working with the Habitat II Secretariat, governments, and nongovernmental organizations to create channels for youth participation and involvement in Habitat II. Youth can also bring a great deal more to the Habitat process than just sheer numbers, both now and in the future. Their energy, commitment, and ability to do much with few resources can bring vitality to the process of creating and implementing the Habitat Agenda and Global Plan of Action. Youth bring unique perspectives which need to be taken into account. The key youth issues in need of action of Habitat II include sustainable approaches to the environment, including education; children and adolescents living in poverty; the provision of adequate shelter; employment opportunities; and access to resources, especially for rural youth. A lack of access among adolescents to essential resources such as shelter, education, and employment can prevent youth from developing into contributing members of society. Youth participants at the Istanbul conference are expected to make a commitment to taking responsibility for their own development, fostering youth awareness, and becoming involved in the implementation of Habitat II.
Withdrawal use in Pakistan: data and issues for decision making.
According to 6 studies conducted in Pakistan between 1990 and 1997, coitus interruptus (withdrawal) is used as a contraceptive method in 1.2-12.7% of cases. As a percentage of the overall contraceptive prevalence rate, withdrawal is practiced 10.2-40.6% of the time. Before the 1994-95 Pakistan Contraceptive Prevalence Survey (PCPS), little use of withdrawal was detected in surveys, possibly due to insufficient probing by survey interviewers. During the late 1990s, however, withdrawal is a major part of fertility regulation practice in Pakistan. According to the 1994-95 PCPS, coitus interruptus is practiced more than twice as often in major cities as in rural areas, and more than 3 times as often among women with secondary education and higher than among women with no schooling. Among provinces, its use is highest in Punjab, both proportionally and absolutely. Fear of side effects from other methods is the major reason why people use withdrawal. Other reasons for method use include convenience, privacy, and overestimation of the risk of failure of modern methods. Provisional data from the Council's User Satisfaction and Longevity Study show life table continuation rates of withdrawal of 78% after 1 year and 55% after 3 years. Practitioners of the withdrawal method seem generally satisfied with the method. Use-effectiveness, aspects of use, and policy implications are discussed.
Bibliometric analysis of AIDS literature in Latin America and the Caribbean.
The preliminary results of a bibliometric analysis of AIDS literature produced in or about Latin America and the Caribbean during 1980-96 are reported. Findings are based upon a literature search on AIDS and Latin America/Caribbean conducted in the US National Library of Medicine's database on AIDS (AIDSLINE), the Institute for Scientific Information's Science Citation Index (SCI), the Pan American Health Organization-supported database on Latin American Literature in the Health Sciences (LILACS), and the National University of Mexico's Latin American Literature on Sciences (PERIODICA). Two international and two regional secondary sources were therefore used to obtain comparative analyses on the comprehensiveness of AIDS literature coverage and local/main frame visibility. The following numbers of records were retrieved from the respective databases: AIDSLINE, 966; LILACS, 765; PERIODICA, 272; and SCI, 82. The overlap of records has yet to be explored. Leading countries in AIDSLINE were Haiti, Brazil, Mexico, and Puerto Rico, while the distribution by year of publication showed a decrease in Haiti records from 54 in 1983 to 4 in 1995. The other countries either increased or maintained an average production of literature throughout the years. The regional secondary information sources were less current and comprehensive in the field.
The socio-economic and cultural context of the spread of HIV / AIDS in Botswana.
HIV infection has spread rapidly in Botswana since it was first identified in the country in 1985. The 1994 Sentinel Surveillance study estimated that the number of people infected with HIV rose from 60,000 in 1992 to more than 125,000 by 1994, while the 1995 Sentinel Surveillance Survey found that approximately 13% of the general population was infected with HIV. Focus groups discussions held with healthcare workers from the maternity wards of 8 hospitals in different districts, and men and women in the villages of Bokaa and Sikwane of Kgatleng district indicate that multipartnered sexual activity is prevalent in Botswana. The distance between sex partners, the search for a partner, women's economic position, the non-use of condoms during sexual encounters, and the lack of parental control over children are likely to increase the pace of HIV spread in the country. A need exists to strengthen the HIV/AIDS educational program in Botswana to stress that AIDS is not a myth, but a social reality with which the population must cope. A growing number of people are becoming ill and dying due to AIDS in Botswana. Women's bargaining power must be increased to afford them the strength with which to make independent decisions. Evidence was also found of sex being forced upon women. People need to stop engaging in behavior which puts them at risk of contracting STDs, including HIV/AIDS.
A series of 15 open-ended interviews was conducted among 7 men and 8 women in rural Hlabisa district, KwaZulu/Natal, South Africa, seeking care for sexually transmitted diseases (STDs) at Hlabisa district hospital in an attempt to identify constraints to communication among sex partners and prevailing patterns of sexual networking. The men were more likely than women to discuss having multiple partners. However, both men and women believed that they should tell one partner about their STD, most often a steady partner. Study respondents made strong distinctions between regular and casual partners, emphasizing the role of trust in a steady relationship. Men and women were both concerned about telling their partners of their illness, but the women were more often afraid of disclosure while the men were more often embarrassed. Multipartnered sexuality is common in this population and widely accepted for men. While both men and women value regular partnerships as important, existing sexual relationships were highly unstable. Stronger health promotion messages could help to facilitate communication among partners. The patterns of communication and sexual networking observed in this study have major implications for the STD epidemic.
HIV / AIDS and sexual behaviour among youth in Zambia.
Zambia is reportedly the worst hit country in Africa by HIV/AIDS, with HIV transmitted in the country mainly through unprotected heterosexual intercourse. 1994 study findings indicate that 21-27% of Zambia's urban population and 10-13% of the rural population were infected with HIV. 200 focus groups were held during January-February 1995 in Lusaka, Kabwe, Kitwe, and Ndola with in-school and out-of-school boys and girls aged 12-25 years to determine how sexual behavior among young people may influence the course of the AIDS epidemic with an eye toward developing appropriate HIV/AIDS prevention and control policies. Subjects were divided into the following age groups: 12-14, 15-18, and 19-25 years, and each focus group was comprised of 6-12 participants. It was found that sexual matters are discussed with close friends of the same sex and peer group, or with cousins of the same age. Grandmothers are also sometimes asked for advice by coresident granddaughters. Boys and girls engaged in sex or thought about engaging in sex at an early age, while girls discussed their intentions about sex with their close friends. The youths do not appear to take STDs seriously mainly because most STDs are curable and many young people perceive AIDS to be a threat to neither their lives nor their sexual encounters. Policy recommendations are offered.
Since students in Tanzania are at risk of contracting and transmitting HIV, much of TANESA's anthropological research is designed to better understand the nature of sexual risk behavior among adolescents with a view to provoking positive change. This paper presents the dominant themes of sexual discourse among adolescent primary school students in Magu district along the southeastern shores of Lake Victoria in Tanzania. 11 primary schools are situated in the study area, Kisesa ward. 15 girls aged 13-15 years and 16 boys aged 5-18 years from 6 of the schools participated in a narrative research-based study conducted in workshops over the course of 2 days. The majority of students in the higher classes first experienced sex at age 12 years. The dominant themes which presented from the students' discourse upon sexual relationships are love and sex, sexual desire, money and rewards, deception, and the fear of pregnancy. These themes dominate in that the students spent most of their time discussing them and also in the sense that students' perceptions of sexual relationships are formed and informed by them. By age 15 or 16, many adolescents are regularly involved in sexual relationships or one-time sexual encounters. Due to the nature and extent of their sexual relationships, students in the study population will be increasingly exposed to the risk of HIV and STD infection. That risk is exacerbated by the lack of condom availability and the proscribed nature of sex and condom use among the students.
In conducting field work on a large commercial farm in southern Zambia to learn information which could contribute to the design of an HIV prevention program for farm workers, the author learned about the disproportionate number of men to women on the farm, and the existence of sexual contact between some local girls under age 17 years and older migrant male workers. In 1994, 21% of all farm workers were females aged 8-45 years, 67% under age 25, and 69% unmarried. Recognizing that the young girls who were sexually involved with the men on the farm could be at risk of HIV and other sexually transmitted diseases, the author voiced her concerns, before completing her field work, to management. The next day, the company fired 81 seasonal workers who looked under age, mostly female workers. Some members of the local community, including local research assistants, some managers, and some workers welcomed the decision to terminate under-age employees. Others, however, were angered. The author regrets having disclosed her research findings to management. It was a mistake to let personal distress over conditions found in a research setting cloud her judgment as a researcher. The researcher's actions also jeopardized the successful continuation of her research.
Many of Tanzania's youths aged 10-24 years, who comprise about a third of the country's population, have unprotected premarital sexual intercourse, experiencing adverse health consequences. Current reproductive health information sources for Tanzania's young people are largely informal. Youths face a range of reproductive health problems, including exposure to unprotected sex, low levels of reproductive health knowledge, poor awareness of the potential consequences of unprotected sex, and a lack of counseling services upon reproductive health issues. The available literature is reviewed upon youths' exposure to premarital sexual intercourse, followed by a discussion of youth's current and preferred sources of reproductive health information, as well as the contexts of acquisition of such information and exposure to sexual intercourse. Sections also discuss what is known about the consequences of unprotected premarital sexual intercourse among young people and barriers to reproductive health information and services as well as potential approaches to solutions.
The prevalence of HIV in KwaZulu/Natal, South Africa, is almost twice the national average, and increasing rapidly. In 1995, the prevalence of HIV among women attending antenatal clinics was 18.2%, up from 4.5% in 1992. HIV in South Africa is not limited to an urban population. In Hlabisa, a rural district in northern KwaZulu/Natal, HIV prevalence among women attending antenatal clinics increased from 4.2% in 1992 to 25.9% during the first 4 months of 1997. Even though laws restricting population migration in South Africa have been lifted, circular migration remains a way of life for several million Black South Africans. This paper examines the social and epidemiological implications of widespread circular migration from the perspective of a rural South African Health District. Findings from a school-based study and a household study are reported on the patterns and prevalence of migration in and out of the Hlabisa Health District, and the patterns of sexual networking of migrants and their rural partners. The implications of patterns of migration and sexual networking are considered with regard to the spread of HIV and other STDs.
Migrant labour, sexual networking and multi-partnered sex in Malawi.
Using findings from interviews with 163 returned migrants to 4 districts in 3 regions of Malawi, the author discusses the possible links between migrant labor, multipartnered sexual activity, sexual networking, and the spread of AIDS in Malawi. The interviews were conducted in two separate studies in 1989-90 and 1993-94. The paper focuses upon the economic, social, cultural, and mobility factors of HIV/AIDS, and their effect upon the spread of the disease. Migrant laborers, like truck drivers, itinerant traders, and prostitutes should be seen as high-risk groups both at their places of work and in their areas of origin. The author also discusses the difficulties of research on HIV and AIDS among returned migrants. The sensitive nature of HIV/AIDS and the political context in which it is often understood in Malawi hinder its objective and effective analysis. Another limiting factor is the consideration of human rights issues when interviewing actual or potential HIV patients.
The Workshop on Multipartnered Sexuality and Sexual Networking in Southern and Eastern Africa transpired at the University of Natal, Durban, South Africa, during February 7-8, 1997. 22 young researchers involved in behavioral and cultural studies related to the spread of HIV/AIDS from 9 countries in the region met to assess the current state of research upon multipartnered sexuality and sexual networking in the region; discuss the significance of regional dynamics of multipartnered sexuality and sexual networking in relation to HIV/AIDS, sexual and reproductive health, fertility, and gender; and consider how to coordinate a regional program of research and support for junior African scholars working on such topics. Conference organizers noted that an inadequate amount of social research is being conducted upon AIDS in Africa, while workshop participants created SafeSexNet, a facilitating body designed to maintain open communication among regional scholars conducting behavioral and cultural studies on sexuality and risk in the context of AIDS.
Transmission of genetically diverse strains of HIV-1 in Pune, India.
HIV-1 viral subtypes were determined for homologies in the V3-V5 region by heteroduplex mobility assay (HMA) in 46 patients with sexually transmitted diseases (STDs) in Pune, India. Proviral DNA from the peripheral blood mononuclear cells (PBMCs) of 20 recent seroconverters and 26 HIV-seropositive individuals were analyzed. 44 of the samples analyzed were HIV-1 subtype C, 1 sample was subtype A, and 1 sample was subtype B. 29 of the subtype C samples had maximum homology to the C3-Indian reference strain, while 15 were most homologous to the C2-Zambian strain. 80% of the seropositive subjects were infected with the C3 genotype. Most C3 strains observed were closely homologous to each other, while greater nucleotide sequence divergence was seen in the C2 samples. A higher quasi-species complexity was observed in the samples collected from seropositive individuals. These study findings may have important implications for the design and testing of effective candidate HIV-1 vaccines for India.
Condoms. Barriers to bad news.
Millions of Americans are infected with sexually transmitted diseases (STDs) annually, of which hundreds of thousands become seriously ill or die as a result. According to the US Centers for Disease Control and Prevention, someone is infected with HIV in the US every 13 minutes; 65% of AIDS cases can be attributed to sexual contact. The best way to protect oneself against contracting STDs is to not have sex or to have a mutually monogamous relationship with someone who is known to be uninfected. However, for people who are sexually active, studies have shown that the proper and consistent use of latex condoms is the best defense. Using a latex condom during every sexual encounter can significantly reduce the risk of HIV and other STDs, while also protecting against pregnancy. Male and female versions of polyurethane condoms are available as alternatives to latex condoms. Condoms should be seen as commonplace, necessary personal hygiene commodities, like toothpaste and toilet paper. In the current context of HIV/AIDS, wearing condoms is just something you have to do, like brushing one's teeth.
The authors explored whether the available epidemiological data could quantify the risk of cardiovascular disease among non-smoking users of currently available, low-dose oral contraceptives under age 35 years, without medical conditions known to increase the risk of vascular disease. To that end, they reviewed all relevant published studies identified from the library of references held by the Royal College of General Practitioners' Manchester Research Unit, the reference lists of each paper, and conducted a computerized literature search of the MEDLINE database. 74 papers were identified on the relationship between the current use of combined oral contraceptives and cardiovascular disease. 23 papers reported the risk of venous thromboembolism, 22 reported data on ischemic stroke, 13 on hemorrhagic stroke or subarachnoid stroke, 13 on all stroke, and 33 on myocardial infarction. 5 papers provided information which directly address the clinical question and 14 discarded papers could have probably answered the clinical question. These findings demonstrate that much of the epidemiological data on the risk of cardiovascular disease in users of combined oral contraceptives is not useful to clinicians, although some of the discarded data could be made more useful to clinicians through reanalysis.
Diarrhea ranges from a mild and socially inconvenient illness to a major cause of malnutrition among children in developing countries and causes 4-5 million deaths worldwide annually. The people of the Khatra region of Bankura, West Bengal, India, use parts of various plants to treat and cure diarrhea. The region has a dense forest with a formidable number of medicinal plants which have been used by the local people for many years to treat illnesses. Ethanol extracts of Ficus bengalensis Linn., Eugenia jambolana Lam., Ficus racemosa Linn., and Leucas lavandulaefolia Rees from Khatra region were evaluated for anti-diarrheal activity against different experimental models of diarrhea in rats. The concoctions showed significant inhibitory activity against castor oil-induced diarrhea and PGE(2)-induced enteropooling in rats. The extracts also showed a significant reduction in gastrointestinal motility in charcoal meal tests in study subjects. These results attest to the efficacy of these plant materials as anti-diarrheal agents.
Seattle pilot project makes emergency contraception available directly from pharmacists.
In February 1997, the US Food and Drug Administration (USFDA) endorsed the use of certain oral contraceptives for postcoital emergency contraception (EC). The board of pharmacy, Washington State Pharmacists Association, University of Washington School of Pharmacy, PATH, and a public relations firm are now collaborating upon a 2-year pilot project launched in the Seattle area which enables pharmacists to provide EC under protocol. State legislators, insurers, physicians, pharmacists, and other health care groups are represented on the project's advisory board. Patients in need of EC can locate pharmacy providers, physicians, and clinics by telephoning the national hotline or through the World Wide Web. More than 200 pharmacists, mostly from chain community pharmacies, have been trained for the project. While individual pharmacists may choose not to participate, they are required to refer patients to other providers. Health system providers have thus far not applied for protocols for EC. The University of Washington School of Pharmacy will participate in evaluating the project's effect upon access to EC and reducing unintended pregnancies.
Levels and patterns of intrauterine growth retardation in developing countries.
Intrauterine growth retardation (IUGR) is defined as being born with a birth weight under the 10th percentile of the birth-weight-for-gestational-age reference curve. It is a status which applies to approximately 30 million newborns annually. of whom almost 75% are in Asia, mainly in South-central Asia, 20% in Africa, and 5% in Latin America. A large proportion of newborns in most developing countries suffer some degree of IUGR. This paper quantifies the magnitude and describes the geographical distribution of IUGR in developing countries. At least an estimated 13.7 million infants are born annually at term with low birth weight (LBW), 11% of all newborns in developing countries. This rate is approximately 6 times higher than that experienced in developed countries. LBW, being born under 2500 g, affects 16.4% of all newborn infants, or approximately 20.5 million infants annually. Many developing countries currently exceed the internationally recommended IUGR and LBW cut-off levels for triggering public health action. As such, population-wide interventions designed to prevent fetal growth retardation are urgently needed. The data presented in this paper on LBW were obtained from an updated version of the World Health Organization database on LBW compiled by the Maternal Health and Safe Motherhood Program. The database contains data published from 1980 onward.