A number of studies have shown that glucose tolerance declines with decreasing birth weight and that people with low birth weight and high body mass index (BMI) as adults are at the highest risk of developing type II (non-insulin-dependent) diabetes mellitus. The authors explored the relation between glucose tolerance and birth weight in a group of 7-year old Black South Africans for whom longitudinal anthropometric data were available. Oral glucose tolerance tests (OGTTs) were conducted on 152 subjects and inverse correlations were found between birth weight and the total amount of insulin secreted during the first 30 minutes and last 90 minutes of the oral glucose tolerance test, and also between birth weight and the 30 minute glucose concentrations. Children born with low birth weights, but who had high weights at age 7 years had higher insulin concentrations and indices of obesity compared with those with low birth weights and low weights at age 7 years. Positive correlations were also found between weight velocity and BMI, and weight velocity and insulin resistance as measured through homeostasis model assessment. Therefore, low birth weight together with rapid childhood weight gains, especially in subcutaneous fat, produces poor glucose tolerance in 7-year old children and can make them susceptible to the development of type II diabetes later in life.
Newborn infants were studied longitudinally to assess their serum copper (Cu) and ceruloplasmin (CLP) status. All infants were born between July 1, 1991, and June 30, 1992, at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Preterm infants (PI) of a maximum gestational age 36 weeks were divided into sick (A) and stable (B) cohorts, beginning with 30 in each of the 2 groups. The groups were matched with respect to gender, gestational age, birth weight, Apgar scores, and socioeconomic class. Cu levels were also determined in 30 stable, full-term infants. Sick PIs had significantly lower mean Cu and CLP levels at birth, while Cu level was significantly increased by 4 weeks in cohort A and approached levels of the stable PIs. With regard to CLP, catch-up of levels was delayed until 8 weeks, and a triphasic pattern of linear rise in Cu and CLP was discernible by 24 weeks. Sick PIs had mean serum CLP levels of 0.5 mcmol/dl, 5.9, 15.2, 17.3, 21.2, 25.1, and 23.7 mcmol/dl at birth, 4, 8, 12, 20, and 24 weeks, respectively, and were similar from 8 weeks in cohort B. Generally, CLP paralled serum Cu levels. Cu levels in the full-term infant (FI) were higher at birth and became similar to PIs from 12 weeks, but were overtaken by levels in PI at 24 weeks. FIs' Cu was significantly elevated by 8 weeks. Decreased growth rate, nonpitting pedal edema, exaggerated physiological anemia, and chronic lung disease were morbidities noted in association with very low Cu and CLP levels. Newborns with serum Cu and CLP higher than 0.2 mcmol/ml and 2.3 mcmol/dl, respectively, did not have a poor outcome.
Seasonal pattern of morbidities in preschool slum children in Lucknow, north India.
Findings are reported from a study conducted to quantify the burden of common morbidities in each month in 1 year among preschool children at 32 randomly chosen anganwadi centers in urban Lucknow, India. Overall, there are 153 anganwadi centers in the city. All eligible children registered with the anganwadi worker were enrolled over a period of 6 months from July 1995 to January 1996, and then contacted again 6 months later. Findings are based upon the study of 549 boys and 512 girls aged 1.5-3.5 years. The annual incidence rate (IR) per 100 child-years for respiratory, diarrhea, and skin diseases, and pneumonia were 167, 79.9, 30.6, and 9.6, respectively. When compared to other seasons, the IR of pneumonia was lowest during October-February, the winter months, while those of diarrhea and skin diseases were the highest during March-June and July-September, respectively. Season-specific diseases were measles in summer, and fever as the isolated symptom in monsoon season. The IR for combined morbidities was the highest during the monsoon season. These findings warrant the consideration of season-specific intensification of existing health care resources for such morbidity.
Prevalence of malnutrition and intestinal parasites in preschool slum children in Lucknow.
Findings are reported from a study conducted to assess the prevalence of intestinal parasites and their association with malnutrition in a sample of preschool children from 32 randomly chosen anganwadi centers in urban Lucknow, India. Overall, there are 153 anganwadi centers in the city. All eligible children registered with the anganwadi worker were enrolled. Findings are based upon the study of 549 boys and 512 girls aged 1.5-3.5 years. 67.6% were underweight, 62.8% were stunted, and 26.5% were wasted. Parasites were detected in 17.5% of children by a single direct fecal smear examination. Of those, Ascaris lumbricoides was found in 124 (68.1%) and Giardia lamblia in 60 (32.9%). There was no association between weight or height and parasite positivity. The mean hemoglobin levels for children who were smear positive rather than smear negative for ascaris or giardia were 9.1 g/dl and 9.6 g/dl, respectively. Urgent steps are needed in this setting at the community level to improve children's nutritional status and control parasite infestation.
A prospective cohort study on the survival experience of under five children in rural western India.
Findings are presented from a prospective study conducted in 45 villages in Shirur Development Block in Pune District, Maharashtra, to gain insight into the role of birth weight, nutrition, immunization, and other medical and social factors in determining child survival. 4129 children were followed from birth until age 5 years, with child weight and length/height measured at birth and at 3 monthly home visits. Information was also obtained on common childhood morbidities, immunization status, and other biomedical factors, and the cause of death was ascertained through verbal autopsy. The neonatal, infant, and under-five mortality rates were estimated to be 37, 60, and 79 per 1000 live births, respectively. Diarrhea and acute respiratory infections (ARI) contributed to the major mortality burden. The Kaplan Meier Survival curve showed a sharp fall in the neonatal period, a less rapid decline during the post-neonatal period, followed by a marginal fall in the post-infancy period until age 5 years. Girls had a better survival during the early neonatal period, but the trend reversed during the late neonatal period. Normal birth weight children had better survival curves compared to low birth weight children. Survival improved with increasing birth order. Multivariate analysis found that birth weight, immunization status, and mother's and child's nutritional status influenced infant and under-five mortality. Since birth weight continues to influence survival and mortality even up to age 5 years, strategies to improve child survival should include immunization and breast-feeding.
A phase 1, double-blind, placebo-controlled trial was conducted in Longchuan County, China, to evaluate the safety and immunogenicity of a prototype HIV-1 synthetic peptide vaccine in a sample of 26 IV drug users and 4 of their sex partners, and to establish the infrastructure for future large-scale HIV vaccine efficacy trials. 29 subjects of mean age 27.2 years completed the full 3-immunization regimen, with 12 subjects receiving a 100 mcg dose of the vaccine, 12 receiving a 500 mcg dose, and 5 receiving placebo. Each subject was given 3 injections on an accelerated 0-, 1-, and 2-month schedule. The vaccine was well tolerated with no significant local or systemic reaction observed in any subject. 55% of 100 mcg dose and 64% of 500 mcg dose subjects who received the vaccine produced binding antibody to the immunogen as determined by ELISA. However, HIV-1 neutralizing antibody was detected in only 23% of subjects with detectable HIV-1-specific binding antibody. This prototype vaccine was therefore well tolerated, safe, and immunogenic, but the 0, 1, and 2-month schedule was not as effective in stimulating HIV-1-specific neutralizing antibodies as were previous trials using a 0, 1, 6-month schedule. This clinical trial site in Yunnan should be considered for conducting larger trails of candidate HIV vaccines.
Towards evaluation of the quality of care in health centres.
In accordance with Spanish and Portuguese conditions, a strategy was designed to implement quality assurance in health centers on a voluntary basis, with particular attention to internal involvement. The main elements of this project, which became known as the Iberian Program of Training and Implementation of Quality Assurance Activities in Primary Health Care, were training, involving problem-solving, a phased approach, and the use of real cases; internal commitment; professional leadership; teamwork; external support; and intrinsic professional incentives. Training was the most important strategic factor. Also probably significant was the adequate ad hoc implementation of the principles of planned change. A high degree of reliance was placed upon the intrinsic motivation and self-determination of professionals. The complete training program reached 213 professionals attached to 203 health centers. Program elements are described.
Willingness to pay for district hospital services in rural Tanzania.
Health sectors are being restructured in many parts of the world to shift the financial burden of health care away from the public sector onto individual citizens. This paper describes a study conducted to investigate the willingness of patients and households to pay for rural district hospital services in northwestern Tanzania. Surveys conducted included interviews with 500 outpatients and 293 inpatients at 3 district-level hospitals, interviews with 1500 households, and discussions with 22 focus groups within the catchment areas of the primary health care programs of these hospitals. Information was collected on the willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The surveys found a considerable willingness among respondents to pay for district hospital services. However, most respondents favored a local insurance system over user fee systems, a finding which applied at all places and in all of the surveys. More female respondents favored a local insurance scheme. The conditions needed to introduce a local insurance system are discussed.
Regulating the private health care sector: the case of the Indian Consumer Protection Act.
The private sector provides an important proportion of overall health care delivery services in India. As such, efforts must be made to ensure that such services are of acceptable to high quality. With professional organizations such as the Medical Council of India and local medical associations unable to influence the behavior of private providers, the recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step toward regulating the private medical sector. The author surveyed the views of 130 private health care providers from the city of Ahmedabad on the legislation. Data were also analyzed on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. While respondents believe that COPRA will reduce the levels of malpractice and negligent behavior among private practitioners, they envision an increase in physicians' fees, a greater number of prescriptions made and diagnostic tests conducted, and an adverse effect upon emergency medical care. Medical associations have argued that introducing COPRA will foster expensive and needless litigation. Other concerns have been raised by consumer forums.
Applying medical anthropology in the control of infectious disease.
Anthropological interest in infectious disease control is relatively recent. Now, however, anthropology plays 2 roles in controlling infectious disease. First, anthropologists can identify and describe concerns and understandings of disease, including local knowledge of cause and treatment relevant to disease control. Second, local concerns can then be translated into appropriate health interventions by providing information to be incorporated into education and communication strategies for disease control. Problems arise in infectious disease control programs with competing knowledge and value systems. Anthropology's role has traditionally been in translating local concepts of illness and treatment, and adapting biomedical knowledge to fit local etiologies. Medical anthropology, however, can be applied to better understand the local context of disease diagnosis, treatment, and prevention, as well as the structural and conceptual barriers to improved health status. National and international public health goals which respect local priorities are uncommon, and generic health goals rarely coincide with specific country and community needs. The success of interventions and control programs is moderated by local priorities and conditions, and sustainable interventions need to acknowledge and address country-specific social, economic, and political circumstances.
Incorporating gender in the anthropology of infectious diseases.
Over the past 2 decades, increasing attention has been given to the impact of gender upon health status, outcomes, and health-seeking behavior. This paper examines how a gender-sensitive perspective can influence our understanding of the nature and epidemiology of disease and guide the design and evaluation of interventions for its control. The author focuses upon key issues in the research and control of infectious diseases to stress the utility of combining a gender perspective with anthropological investigation. Gender-sensitive research is essential to the understanding of the nature of the disease, its prevalence, distribution, determinants, and consequences. Examples are drawn from anthropological studies on infectious diseases, including research on urinary schistosomiasis, malaria, leprosy, leishmaniasis, and onchocerciasis. Defining and conceptualizing gender are discussed.
This paper considers the following issues of broad relevance to the role of medical anthropology in infectious disease control: the nature of interdisciplinarity, the role of rapid assessment methodology, and data interpretation. Focus is given to the tensions created by the inherent conflict between the need for the rapid production of apparently relevant data for use in disease control projects and the development of truly valuable anthropological insights. Rapid assessment procedures informed by anthropology are increasingly being used in the formulation of a range of international disease prevention and control strategies. However, the refinement of these rapid procedures has narrowly focused upon their methods, compared with the broader potential scope of context-based anthropological contributions. The control of HIV and other sexually transmitted diseases (STD) in India is used to describe the potential role of anthropologically informed insights and investigations in the development of effective interventions, with particular reference to the examples of syndromic management, symptom presentation, and treatment provision. Anthropological, epidemiological, and clinical studies need to be properly integrated.
Onchocerciasis is known for both its ocular and dermatological effects. Although the former effects have received more attention in efforts to control the disease, more than half of the 17 million affected persons in Africa live in forest areas where onchocercal skin disease (OSD) is common, but onchocercal blindness is rare. For onchocerciasis-affected people, the most severe complication of infection is intense itching. Findings are reported from a multicenter, double-blind placebo-controlled trial conducted among 4072 residents of rural communities in Ghana, Nigeria, and Uganda to determine the effects of ivermectin therapy in annual, 3-monthly, and 6-monthly doses upon OSD and severe itching. Baseline clinical examination categorized reactive skin lesions as acute papular onchodermatitis, chronic papular onchodermatitis, and lichenified onchodermatitis. The presence and severity of itching was assessed through open-ended questions. Clinical examination and interview took place at baseline and each of the 5 subsequent 3-monthly follow-up visits. While the prevalence and severity of reactive lesions decreased for all 4 arms, those receiving ivermectin maintained a greater decrease in prevalence and severity over time. The difference between ivermectin and placebo groups was significant for prevalence at 9 months and for severity at 3 months. The differences between ivermectin and placebo groups were far more pronounced for itching; from 6 months onward, the prevalence of severe itching was reduced by 40-50% among those receiving ivermectin compared to those receiving placebo.
While the blackflies' innate immune system is unable to encapsulate and melanize intruding parasites, blackflies are nonetheless capable of killing and clearing Onchocerca microfilariae. Using the bovine species Onchocerca ochengi as a model for human onchocerciasis, the authors have been investigating the immune response of Simulium damnosum s.l., the main vector of human onchocerciasis in sub-Saharan Africa. The parasite is naturally transmitted by S. damnosum s.l. and occurs throughout the cattle-breeding areas of Africa. This study explored how to kill Onchocerca parasites inside the vector and the hypothesis that apoptosis is one of the main causes of death among Onchocerca parasites in the vector insect. The injection of female S. damnosum s.l. with 5 microfilariae of noncryopreserved microfilariae of O. ochengi and the protease inhibitors z-VAD.fmk and boc-D.fmk led to significantly increased survival of the parasites. Subsequent in situ apoptosis detection assays demonstrated that in the case of boc-D.fmk, enhanced survival was due to a diminished apoptosis level of the microfilariae in vivo. Additional assays using O. ochengi microfilariae coinjected with serine protease inhibitors into S. damnosum s.l. revealed that certain serine protease inhibitors can reduce the level of apoptosis. Study findings clearly demonstrate that apoptosis is involved in eliminating Onchocerca parasites in blackflies.
The Health Behavior in School-Aged Children (HBSC) study was implemented by 3 European countries in 1982, and has since been adopted by more than 25 countries, including Canada and Australia. It is generally expected that African and Asian countries will follow suit. The 1996 HBSC study in Indonesia was conducted to collect information on the health-related behaviors of Indonesian youth, and to provide recommendations for the further adaptation and use of the HBSC in non-Western countries. This paper reviews some methodological constraints in adapting the HBSC study in Indonesia. While the international HBSC team reported methodological problems in the cross-national study, no attempt to extend the original European study to Southeast Asia has been described before. Cultural, religious, economic, and social differences create specific obstacles and challenges in such an adaptation. Structural problems in preparation and implementation were experienced. Efforts are needed to assess the validity of the HBSC study in non-Western countries, while specific strategies need to be elaborated to accommodate the future participation of developing countries in the study.
Quality of care in sexually transmitted diseases in Zambia: patients' perspective.
Sexually transmitted diseases (STD) are the most common infectious diseases in Zambia, affecting mainly adolescents and young adults across society. Zambia, with a total population of about 8 million people, experiences approximately 125,000 cases of STD annually. Findings are reported from a study conducted to describe Zambian STD patients' response to treatment and compliance with partner notification, as well as their satisfaction with health care received. 92 male and 87 female patients were interviewed twice at an urban health center 5 km outside of Lusaka. The men and women were aged 17-55 and 15-37 years, respectively, of mean ages 26 and 23. 48% of the men and 78% of women were married. Most of the patients were unsatisfied with the care received. Their response to treatment and compliance with partner notification were unsatisfactory. For example, lack of funds prevented 13 patients from buying medicines, and 125 patients had asked 134 sex partners to come for treatment, but only 60% of them had actually done so and been treated. The most important factors defining good quality STD care noted by study participants were the provision of free medicines, privacy, injections rather than tablets, pre-treatment examinations, and information about their diagnoses. Health care providers must improve their communication and counseling skills to better understand patients' needs.
A tension exists between the aim of health policy-makers to achieve high quality standards of care on the one hand and the district multi-crisis reality in sub-Saharan Africa on the other. Disintegrating health services together with deteriorating living conditions adversely affect the population's health status and contribute to an increase in health inequalities both nationally and internationally. Constraints and some examples of achievements in district health management in Mporokoso and Kaputa districts in Northern Province, Zambia, are presented. A strong focus should be given to community-based health care, partnership with communities, and accelerated health system support through the strengthening of on-site supervision. Decentralization and self-reliance can help in flexible crisis management, but demand continuity in human resource development and appropriate care for carers. To increase operational efficiency, there is a need to conceptualize a practical approach of minimum primary health care.
The provision of zidovudine drug therapy to pregnant women has been shown to reduce the vertical transmission of HIV in non-breast-feeding study populations. However, many women in developing countries have little to no option but to breast-feed their infants. Findings are presented from an assessment of the acceptability, tolerance, and 6-month efficacy of a short regimen of oral zidovudine in African populations practicing breast-feeding. The randomized, double-blind placebo-controlled trial was conducted in public clinics of Abidjan, Cote d'Ivoire, and Bobo-Dioulasso, Burkina Faso. Eligible participants were women aged 18 years or older, with confirmed HIV-1 infection and pregnancy of 36-38 weeks duration, and who gave their written consent. Exclusion criteria were severe anemia, neutropenia, abnormal liver function, and sickle-cell disease. Subjects were randomly assigned to receive either zidovudine or placebo. The 214 women who received zidovudine did so in a 300 mg dose twice daily until labor, 600 mg at the beginning of labor, and 300 mg twice daily for 7 days postpartum. 217 women received placebo. The women were enrolled between September 1995 and February 1998. The Kaplan-Meier probability of HIV infection in the infant at age 6 months was 18.0% in the zidovudine group and 27.5% in the placebo group. Adjustment for potential confounders did not change the treatment effect. A short-course regimen of oral zidovudine given during the peripartum period is therefore well accepted and well tolerated, and provides a 38% reduction in the level of early vertical transmission of HIV-1 infection despite breast-feeding.
Many developing countries have not implemented the AIDS Clinical Trials Group 076 zidovudine regimen to prevent perinatal HIV-1 transmission because of the regimen's complexity and cost. In a randomized, double-blind, placebo-controlled trial, HIV-1-infected pregnant women at 2 Bangkok hospitals were randomly assigned either placebo or zidovudine therapy of 300 mg twice daily from 36 weeks' gestation and every 3 hours from the onset of labor until delivery. Mothers were given infant formula and asked to not breast-feed. Between May 1996 and December 1997, 397 women were randomized, of whom 393 gave birth to 395 live-born babies. The median duration of antenatal treatment was 25 days, with a median of 3 doses given during labor. 99% of women took at least 90% of scheduled antenatal doses. Adverse events were similar in the 2 study groups. Of 392 babies with at least 1 PCR test, 55 tested positive; 18 in the zidovudine group and 37 in the placebo group. Estimated transmission risks were 9.4% on zidovudine and 18.9% on placebo. Between enrollment and delivery, women in the zidovudine group had a mean decrease in viral load of 0.56 log. About 80% of the observed treatment effect was explained by reduced maternal viral concentrations at delivery. This short course of zidovudine was safe, well tolerated, and capable of reducing the risk of vertical HIV-1 transmission by half.
Given the high risk of vertical HIV-1 transmission in Africa, the authors assessed the safety and efficacy of a regimen of short-course perinatal oral zidovudine among HIV-1-seropositive breast-feeding women in Abidjan, Cote d'Ivoire. From April 1996 to February 1998, all consenting, eligible HIV-1-seropositive pregnant women attending a public antenatal clinic in Abidjan were enrolled at 36 weeks' gestation and randomly assigned placebo or zidovudine (300 mg tablets), 1 tablet twice daily until the onset of labor, 1 tablet at the onset of labor, and 1 tablet every 3 hours until delivery. HIV-1 DNA PCR was used to test the infection status of babies at birth, 4 weeks, and 3 months. The study was stopped on February 18, 1998, when efficacy results were available from a study in Bangkok, Thailand, in which the same regimen was used in a non-breast-feeding population. 280 women were enrolled in the study. The median duration of the prenatal drug regimen was 27 days and the median duration of labor was 7.5 hours. Treatment was well tolerated with no withdrawals due to adverse events. All babies were breast-fed. Among babies with known infection status at age 3 months, 30 of 115 (26.1%) in the placebo group and 19 of 115 (16.5%) in the zidovudine group were identified as HIV-1 infected. The estimated risks of HIV-1 transmission in the placebo and zidovudine groups were 21.7% and 12.2% at 4 weeks, and 24.9% and 15.7% at 3 months, respectively. Efficacy was 44% at age 4 weeks and 37% at 3 months. Short-course oral zidovudine therapy was safe, well tolerated, and decreased mother-to-child HIV-1 transmission at age 3 months.
Control of malaria vectors: cost analysis in a province of northern Vietnam.
The cost of permethrin-treated (twice yearly) bednets was compared to the cost of annual residual spraying with lambdacyhalothrin in Hao Binh, a mountainous province in northern Vietnam. Calculations of the amounts of insecticides needed were based upon national guidelines, cross-sectional survey data, and district activity reports. The actual cost of insecticide required per person per year for impregnation was US$0.26, lower than the US$0.36 required for spraying, although the total cost for impregnated bednets per person per year was US$0.90, compared to US$0.47 for spraying. The determining factor for the large difference in overall cost was the cost of the net, amounting to US$0.58/person/year, assuming a 5-year net life. Other materials, labor, and transport combined accounted for only 17% of the impregnation cost and 23% of spraying expenses. However, for the National Malaria Control Program of Vietnam, the cost per person per year for impregnated bednets was only US$0.32, because most nets are bought by the population. For spraying, the program had to bear the entire cost.
While some herald the growth monitoring (GM) of children in developing countries as the cornerstone of the child survival revolution, others see it only as an ineffective and useless ritual. Findings are presented from a prospective cohort study designed and conducted to assess the value of anthropometric, clinical, biological, and dietary indicators in predicting the short-term morbidity of young children in rural central Africa. The population-based follow-up study was conducted in Northern Kivu, Congo, involving 842 children under age 2 years who completed weekly follow-up interviews and health examinations during a 3-month period. Anthropometric indicators appeared to be poor predictors of morbidity. In contrast, however, nonanthropometric variables such as growth as judged by the caregiver, child's diet at the time of examination, and the occurrence of disease during the month preceding the interval of observation were useful. In the context of the Sick Child Initiative, simple tests and diagnostic tools to improve the quality of prevention and cure in first-level facilities need to be identified. Focus upon nonanthropometric variables should be encouraged to most comprehensively evaluate child health status.
Syndromic management of sexually transmitted diseases: is it rational or scientific?
Sexually transmitted diseases (STD) are of major public health importance since they mainly affect young adults, carry stigma, facilitate the transmission and acquisition of HIV, and can have costly complications. The World Bank estimates that for people aged 15-44 years, STDs excluding HIV are the second most important cause of healthy life lost among women after maternal mortality and morbidity. However, despite the importance of preventing and controlling STDs, they are of only low priority in many developing countries. Indeed, many such countries do not even have an effective STD control program. The control of STDs improves the reproductive and sexual health of afflicted individuals and lowers the community burden of HIV. Preventing STDs or their complications requires health education, condom promotion, and effective case management. Since clinical diagnosis is often incorrect and laboratory-confirmed etiological diagnosis is expensive, the syndromic management of STDs makes sense in resource-poor countries which lack trained personnel and laboratory facilities. Although the approach is simple in design, it nonetheless requires the regular monitoring and evaluation of protocols as well as the supervision and training of clinicians.
More than half of all cases of onchocerciasis reported in the Americas are recorded in Mexico and Guatemala. Mass ivermectin administration and nodulectomy campaigns are conducted in these countries in an attempt to alleviate the clinical manifestations of the disease and interrupt transmission. Mass ivermectin treatment efficiency is typically evaluated by assessing the apparent prevalence and intensity of infection as measured by numbers of microfilariae (mf) in skin snip biopsies. There are, however, obstacles and limitations to this approach. This study compares the utility of an ELISA using 3 recombinant antigens with that of the skin biopsy to estimate the incidence of infections in a sentinel cohort of individuals living in an endemic community in southern Mexico during a set of 11 subsequent ivermectin treatments. The apparent community prevalence of infection and microfilarial skin infection before and after 11 treatments with ivermectin plus nodulectomy were 78% and 13%, and 0.68 mf/mg and 0.04 mf/mg, respectively, as measured by skin biopsy. Of 286 individuals participating in all surveys, a sentinel cohort of 42 mf and seronegative individuals were followed since 1994. The annual percentages of subjects becoming seropositive in the cohort was 24%, 28%, 0%, and 4.3% in 1995, 1996, 1997, and 1998, respectively. Likewise, the incidences in children aged 5 years and younger were 15%, 18%, 0%, and 11%, respectively. All subjects became positive to both tests simultaneously, indicating that seroconversion assessed infection incidence as accurately as skin biopsy in the sentinel group.
Facing the challenge: household responses to HIV / AIDS in Mumbai, India.
With an estimated 3 million adults infected with HIV, India is a major epicenter of the AIDS pandemic. How households and families in India will respond to AIDS is of key importance when it comes to designing programs and interventions to provide support and care to people living with HIV/AIDS. Where household and family responses are negative, different kinds of interventions may be needed from those where responses are more supportive. Based upon data collected in individual and couple interviews, findings are presented on household and family responses to HIV and AIDS in India. Participant responses were greatly influenced by prevailing gender relations, with men responded to more positively than women, as well as other variables such as social status. The quality of responses is also influenced by pre-existing patterns of support and discord within the family. Where trust is high and spousal conflict minimal, HIV and AIDS are reacted to more positively than when there is mistrust and interspousal conflict.
Ethnic minorities and their vulnerability to AIDS in a border state of India.
The social vulnerability of ethnic minorities, indigenous, or aboriginal populations to HIV infection is an area of concern for AIDS policy-makers, researchers, and program managers. Findings are presented from a study conducted to document aspects of community response to HIV/AIDS in Churachandpur town, Manipur, India, where a high rate of HIV infection is reported among IV drug users (IVDUs). The authors also sought to identify any gaps in existing HIV/AIDS prevention programs. Interviews were held with 635 opinion leaders from 8 tribal groups in the community, including teachers, students, and community leaders. 67% of respondents were male, and 31% were married. 81% of respondents were aged 15-19 years. Most respondents were generally aware of how HIV/AIDS is transmitted and supported HIV/AIDS, sex, and drug education in schools. 76% believed AIDS education could reduce the transmission of HIV among young people. A great majority of the respondents were willing to help with AIDS education in the study area. More than half of respondents were willing to care for relatives if they were infected with HIV. However, also about half of the study population believes that people with HIV/AIDS should be identified and isolated from the community. Almost half of the study population was worried about becoming infected with HIV, but only 7% were aware of their own personal vulnerability. Students were the most concerned about the threat of AIDS.
Prevalence of HIV infection among hospital patients in north west Tanzania.
A study was conducted to assess the prevalence of HIV infection among patients at Bukoba regional government hospital in the Kagera region of Tanzania, the economic impact of AIDS upon health care, and the implications of HIV testing upon clinical suspicion of AIDS. 1471 consecutive admissions were recruited into the study, of whom 1422 completed questionnaires and had their blood sera tested for HIV antibodies. The overall age-adjusted HIV-1 prevalence among the hospitalized patients was 32.8%, with no statistically significant difference in the age-adjusted, sex-specific HIV-1 prevalence rate. The highest HIV-1 prevalence of 53.3% was found among people aged 25-34 years, as well as in the gynecological and medical wards (41.2% and 40.4%, respectively). HIV-1-infected patients were more likely to have a history of previous hospital admissions, and were at an increased risk of developing tuberculosis (TB). The diagnostic categories with the highest HIV-1 infection prevalence were clinical AIDS (88.5%), herpes zoster and other HIV-1 skin manifestations combined (85.7%), and pulmonary TB (58.3%). The prevalence of HIV-1 infection was high among these patients, indicating that the major cause of illness leading to admission to the hospital may have been underlying HIV-1 infection. However, since the diagnostic category of clinical AIDS was only 11.3% sensitive, only 11.3% of the HIV-seropositive cases would have been HIV tested on the clinical suspicion of AIDS. These findings indicate that in a high HIV-1 prevalence area, testing for HIV infection on the basis of clinical suspicion of AIDS alone is insufficient to provide rational care to the majority of HIV-infected patients.
Data on health-seeking behavior were collected in Vihiga and Homa Bay Districts of western Kenya, as part of formative research for a sexually transmitted disease (STD) control and HIV/AIDS home care project with the main goal of securing information to guide project design and implementation. Community-based, ethnographic research methods were used from January 1995 to June 1996, including key informant interviews, focus group discussions, and in-depth interviews. Illness narratives of STDs provided the basis for an analysis of sequential steps in health-seeking behavior, namely recognizing, classifying, overcoming stigma, identifying treatment options, and selecting a course of therapy. A range of terms were used to identify STDs, including multiple terms referring to "women's disease." Stigma associated with STDs was based upon a set of beliefs of the causes, contagiousness, and sequelae of STDs, and resulted in treatment seeking delays. 5 commonly used treatment options were identified, with multiple sources of care often used concurrently. The desire for privacy, cost, and belief in the efficacy of traditional medicines strongly influenced health-seeking behavior. The belief that STDs must be transmitted in order to achieve cure was held by several respondents and promoted by a traditional healer. Implications for STD control strategies are considered, including the development of educational messages and clinic design.
As HIV has spread throughout sub-Saharan Africa, persistent diarrhea has become a major problem in hospitals and communities in severely affected areas. Antiprotozoal therapy, however, has been shown to reduce diarrhea in AIDS patients in urban Zambia. Findings are presented from a randomized, placebo-controlled trial conducted in the home care service of Ndola Central Hospital, Zambia, to determine whether the clinical response to albendazole can be improved by oral micronutrient supplementation. 106 HIV-seropositive patients with persistent diarrhea were randomized to receive either albendazole plus vitamins A, C, and E, selenium, and zinc orally, or albendazole plus placebo, for 2 weeks. While serum vitamin A and E concentrations before treatment were powerful predictors of early mortality, supplementation did not reduce time with diarrhea or mortality during the first month, even after considering initial vitamin A or E concentrations, CD4 cell count, or clinical markers of illness severity. Serum concentrations of vitamin A and E did not increase significantly in supplemented patients compared with those given placebo, and there were no changes in CD4 cell count or hematological parameters. No adverse events were detected except those attributable to underlying disease. Short-term oral micronutrient supplementation fails to affect diarrhea-related morbidity or mortality in such patients.
Infection with M. tuberculosis is the most common bacterial infection in humans, and HIV infection is the strongest risk factor for tuberculosis (TB). The World Health Organization estimates that more than 4 million people, mostly in Africa, are coinfected with both organisms. Randomized controlled trials, however, have demonstrated that isoniazid (INH) prophylaxis may reduce the incidence of TB in HIV-negative populations at high risk of developing active disease. The efficacy of INH in preventing TB in tuberculin skin test-positive and negative individuals with HIV infection was assessed through the meta-analysis of 7 randomized controlled trials from Mexico, Haiti, the US, Zambia, Uganda, and Kenya. Findings are based upon 2367 subjects treated with INH and 2162 in control and placebo groups. The mean follow-up of trial participants varied between 0.4 and 3.2 years. Pooling all 7 trials, the risk ratio (RR) of INH versus placebo for TB was 0.58, and 0.94 for death. In groups of tuberculin skin test-positive and -negative subjects, the RR of TB was 0.40 and 0.84, respectively, and the difference in the effectiveness of INH versus placebo between the groups was statistically significant. Consistency of results was found across trials for all comparisons. Prophylaxis with INH therefore reduces the risk of TB in HIV-infected individuals. However, the effect is limited to tuberculin skin test-positive persons.
The treatment of tuberculosis in HIV-infected persons.
Tuberculosis (TB) is one of the most important infections affecting HIV-infected individuals in the world. Rates of HIV-related TB have risen in countries in Europe, the US, and South America, and so rapidly in India and the rest of Asia that they may equal those in sub-Saharan Africa by 2000. Globally, 1 in 11 cases of TB are attributed to HIV, with the proportion expected to rise to 1 in 7 cases by 2000. The authors review the evidence from clinical trials of the efficacy of rifamycin-based short-course regimens for TB when rifamycin is used for the entire treatment period or only in the intensive phase. The authors also examine the drug-drug interactions between anti-TB and antiretroviral drugs, and consider possible TB regimens which could be used in HIV-positive patients on or beginning antiretroviral therapy, and suggest best practice treatment strategies.
The transmission of HIV-1 infection from an infected mother to her infant is estimated to be 15-40%, with more than half of transmission probably occurring late in pregnancy or during labor and delivery. Nevirapine, a non-nucleoside reverse transcriptase inhibitor, is an excellent candidate for a single-dose antiretroviral intervention administered during labor. Findings are presented from a study assessing the safety, pharmacokinetics, tolerance, antiretroviral activity, and infant HIV infection status following the administration of 1 dose of nevirapine to HIV-1-infected pregnant women during labor and their newborns during the first week of life. 200 mg of nevirapine were given as a single dose during labor to 21 HIV-1-infected pregnant women in Kampala, Uganda. 8 of their infants did not receive the drug, while 13 infants received 1 dose of nevirapine, at 2 mg/kg, at 72 hours of age. Nevirapine was well tolerated by both the women and infants, with no serious adverse events related to the drug observed. Median nevirapine concentration in breast milk 1 week after delivery was 103 ng/ml. Plasma nevirapine concentrations remained above 100 ng/ml in all infants from both cohorts tested at age 7 days. Maternal HIV-1 RNA levels decreased by a median of 1.3 logs at 1 week postpartum, and returned to baseline by 6 weeks postpartum. Detectable plasma HIV-1 RNA was observed in 1 of 22 (4.5%) infants at birth, 3/21 (14%) at 6 weeks, and 4/21 (19%) at 6 months of age. This regimen has promise as a prophylaxis against intrapartum and early breast milk HIV transmission in a breast-feeding population.
A sterilization outreach program camp for minilaparotomy was established in December 1996 in Bajura, one of India's least developed rural districts. A vasectomy camp was also organized. This paper describes the reproductive behavior and morbidity among women who came to receive sterilization services. Such family planning camps can play a major role in addressing some of the burden of reproductive health problems. The camp was organized at 2 sites in the district, offered services including counseling, screening, and surgery over a 3-day period at each site. Potential clients were identified over several months by community-based health or social workers. The main criteria for preliminary selection in the communities were that the women wanted to bear no more children and that they were currently not pregnant. The sparse distribution of villages demanded that many women walk for several hours or days to visit the camp sites. The profile of women visiting the camps and morbidities of women during the 3 months preceding their interview are presented.
Aedes aegypti is the only known vector of dengue, dengue hemorrhagic fever, and dengue shock syndrome in the Caribbean. Since the virus and its vector threaten the well-being of people in the Caribbean, public health authorities in the region support efforts to manage the mosquito vector. During an outbreak of dengue fever in Jamaica during October-December 1995, a study was conducted to assess the impact of aerial ultra-low volume malathion treatment upon adult Aedes aegypti. Researchers monitored oviposition rates of the vector in 3 urban communities in Kingston and exposed caged mosquitoes directly and indirectly to the aerial treatment. The insecticide was delivered at a rate of 219 ml/ha between 7:10 a.m. and 8:45 a.m. This intervention failed to interfere with Aedes aegypti oviposition, and adult mosquitoes held in cages inside dwellings were largely unaffected. This type of intervention therefore seemed to have little impact upon arresting or abating dengue transmission.
Efficiency of hospital cholera treatment in Ecuador.
The efficiency of cholera treatment was assessed in 3 hospitals representative of the Ecuadorian public health system to provide hospital directors, administrators, and health service policy-makers with information to plan responses to future epidemics, as well as to reduce the general costs of cholera treatment. Total and excess cholera treatment costs were calculated using hospital files and statistics, and an in-hospital surveillance system of cholera cases. 45% of cholera treatment costs were excessive, with the most important contributor being excess recurrent costs, including extended hospital stays, the disproportionate use of IV rehydration solutions, and unnecessary laboratory tests. Excess capital costs from land, buildings, and hospital equipment represented 10% of the total excess treatment costs. While no significant relationship was found between treatment costs and the severity of illness, nor between costs and a patient's age, patient's sex seemed to be an important variable, with the cost of treating women notably higher than for men. An inverse relationship was found between treatment costs and the complexity of the hospital.
Effectiveness of nutrition centers in Ceara state, northeastern Brazil.
Childhood malnutrition has been a major, longstanding health concern in northeastern Brazil. Therefore, during 1992-94, the state government of Ceara, with financial support from the World Bank, established 34 new nutrition centers. During 1996, these centers were evaluated to assess their operational effectiveness and identify weaknesses in the system and possible solutions. Also evaluated were the adequacy of resources, admission and discharge criteria, staff training, and community satisfaction. Each center was visited for 3-5 days during January-April 1996 for observation and the collection of relevant data. The level of effectiveness was found to be low, with treatment procedures failing to conform with World Health Organization recommendations. Rates of weight gain were inadequate, and the mean 8.7 months of rehabilitation was too long. Case fatality levels in 2 centers were too high, at 40% and higher, while entry and exit criteria for rehabilitation were ill-defined. Few staff were adequately trained; knowledge was weak, especially about case management; and mothers were not effectively instructed. Objectives should be set for these centers, referral systems improved, entry criteria standardized, case management improved, and performance indicators established.
Findings are described from the epidemiological surveillance of influenza virus in Mar del Plata and Cordoba, Argentina, during 1987-93. Data are presented on disease notification, the serologic characterization of influenza virus isolates, and the sequence of the HA1 subunit in 5 isolates of type A subtype H3N2 from the epidemics of 1990 and 1993. Clinical samples were obtained and processed in the National Institute of Epidemiology in Mar del Plata and the Institute of Virology in Cordoba. Patients providing samples were being treated for acute respiratory infections in hospitals and health centers in the 2 cities. Some samples were also worked up from employees of an automobile factory serving as a sentinel surveillance site. The incidence of illness, type of viruses isolated, and H gene sequences were similar to what has been reported from other parts of the world during the same period. The H3 strains isolated in the 1990 and 1993 seasons were somewhat removed in their molecular characteristics from the strains of the World Health Organization recommended for vaccines for those years, and appeared closer to the strains recommended for vaccination in subsequent seasons.
A new vision for adolescent sexual health.
US adults are generally uncomfortable with the subject of adolescent sexuality. As such, they either pretend that teenagers do not have sex or try to control and limit the information which young people receive about sex and contraception. Sexual abstinence until marriage is the US Congressionally mandated message to students. In contrast, adults, and society in general, in the Netherlands, France, and Germany are comfortable with adolescent sexuality, and understand that teens have sex as a natural part of growing into sexually healthy adults. Perhaps paradoxically, adolescents in these 3 countries have first intercourse 1-2 years later than do US teens. The US also has a higher teen birth rate than the Netherlands, France, and Germany, as well as Morocco, Albania, Brazil, and more than 50 other developing countries. The teen birth rate in the Netherlands is almost 8 times lower than that of the US. Adolescent HIV and STD rates are also higher in the Netherlands, France, and Germany than in the US. At the heart of these 3 European countries' success in achieving low teen pregnancy and HIV/STD rates is a cultural openness and acceptance of adolescent sexuality which respects young people's rights and responsibilities as sexually maturing members of society. Rather than following the American model of trying to prevent young people from having sex, the Dutch, Germans, and French teach and empower their youths to behave responsibly when they decide to have sex. The US could learn from the Dutch, French, and German experiences with adolescent sexuality in developing and implementing a more balanced approach to adolescent sexuality.
The health care services of African countries are coming under increased stress due to limited budgets and growing demands for services. To address this situation, some African countries are adopting quality assurance and quality improvement approaches. A range of quality assurance and improvement approaches are being combined and integrated to meet particular needs based upon circumstances and available resources. Quality improvement activities in Ghana, Kenya, and South Africa are described. While a number of programs implemented in the 3 countries are showing promise, the challenge will be to use the growing body of knowledge and expertise being developed to improve all facilities and services, including rural services which are severely deprived, to ensure that patients who enter health care facilities will receive acceptable care with minimum risk. The problems of low use of public health services and substandard health care will continue until all governments seriously commit themselves to improving the quality of care. National level policy is required.
Hits for Hope. Delivery of Improved Services for Health (DISH) Project, Uganda.
Delivery of Improved Services for Health (DISH) Project, a joint project of the US Agency for International Development and the Uganda Ministry of Health, was developed to teach in-school and out-of-school youths about healthy sexual and reproductive behavior, and increase the demand for and use of integrated reproductive health services. 12-45-year olds in 10 urban and rural districts were expected to be exposed to the project's activities and messages. The project disseminated the following key messages: youth can prevent HIV infection by practicing safe sex; young men need to make their own decisions; young people who have not had sex should abstain until finding a monogamous partner; the best way to avoid HIV/AIDS is to abstain from sex; condoms should be used if having sex; and condoms are the only way to protect oneself when having sex. District and national level campaign activities and materials are described, as well as follow-up survey findings on the target audience's exposure to various mass media sources and related knowledge and behavioral change.
Short-course zidovudine for prevention of perinatal infection.
In 1994, the Pediatric AIDS Clinical Trials Group (PACTG) protocol 076 showed that a 6-week course of zidovudine, given to the mother during pregnancy and labor, and then to the neonate for 6 weeks, reduced HIV transmission rates by almost 70%. The adoption of this regimen in the US and Europe has caused perinatal HIV transmission rates to decline to 6% or less, while transmission rates of 2% have been reported when zidovudine prophylaxis is combined with elective cesarean delivery. However, in absolute terms, the impact of perinatal HIV transmission prevention measures will be greater in developing than in industrialized countries, in part because the overall level of HIV infection among pregnant women in developing countries is far higher than the overall level in industrialized countries. While trials must continue to identify simpler and more cost-effective HIV prevention measures, effort must still be given to implementing the already proven effective regimens in developing countries. To implement short-course HIV prophylactic regimens requires available and accessible antenatal care, HIV testing and follow-up for pregnant women, available and affordable zidovudine, and patient compliance with the drug regimen. To ensure intrapartum zidovudine administration, deliveries must be attended by professional birth attendants. Then, to prevent postpartum HIV transmission, there must be a safe and effective strategy for reducing the risk of HIV-1 transmission through breast milk.
Cameroon and Chad: cost recovery.
African Ministers of Health adopted the Bamako Initiative in 1987 to ensure sustainable and efficient primary health care (PHC), with an eye toward decreasing levels of morbidity and mortality in Africa. The initiative has made local communities largely responsible for identifying problems and distributing and managing local health care resources. Cost recovery is a key component of the Bamako Initiative. The adoption of a policy of decentralization in which the immediate providers and users of PHC services are responsible for the recovery of costs was recommended. Chad and Cameroon decentralized its health services in 1990 and 1992, respectively. With onchocerciasis one of these 2 countries' most important public health problems, the 2 governments decided to base onchocerciasis control efforts upon the mass distribution of Mectizan (ivermectin, MSD) integrated into the local PHC systems and including cost recovery. Community participation must now be developed to ensure the sustainability of treatment programs in both countries. In both Cameroon and Chad, studies have found that the introduction of cost recovery has had no significant effect upon treatment coverage in hyper- and meso-endemic communities. In fact, those charged for Mectizan treatment often believe that the drug must be worthwhile because they have to pay for it.
The challenge of establishing community-directed treatment with Mectizan in Uganda.
Onchocerciasis is a major public health problem in Uganda, affecting 17 of the country's 39 districts. 1995 data indicate that of the 19 million Ugandans, 1.8 million were at risk of infection and 1.36 million were already infected. 1.3 million Ugandans in 2255 villages are currently being targeted for annual treatment with Mectizan (ivermectin, MSD). 74% of the targeted villages are hyperendemic and 18% are meso-endemic for the disease. The control of onchocerciasis in Uganda through the mass distribution of Mectizan began in the early 1990s, as a result of collaboration between the Ministry of Health and 4 nongovernmental development organizations. With the aim of eliminating onchocerciasis as a public health problem in Uganda, the national program now reaches all communities known to be affected by the disease in all but 1 district, and achieved a mean treatment coverage of 75% in 1995 and 1996. However, with results of a 1996 World Health Organization study suggesting that community-directed treatment should be the main method of onchocerciasis control in Africa, Uganda's national onchocerciasis task force must now reorient its current program from community-based to community-directed treatment. This latter approach gives communities a greater role in distributing Mectizan.
HIV infection in children: the widening gap between developing and industrialized countries.
The HIV/AIDS pandemic began approximately 20 years ago. Since then, there has been considerable progress in research on the mother-to-child transmission of HIV with regard to its epidemiology, immunology, transmission-associated factors, clinical syndromes, and prevention. While much of this research has taken place in developing countries with international support, HIV/AIDS-affected mothers and children in these countries have thus far benefitted little from their involvement in research efforts. This is especially so with regard to the administration of antiretroviral drugs during pregnancy, the early diagnosis of HIV infection in children, prophylaxis against Pneumocystis carinii pneumonia (PCP) in early infancy, and facilities for the general support of affected families. In industrialized countries, the heterosexual spread of HIV occurs mainly among the poor and minority populations. However, in developing countries, HIV affects all levels of society. The author reviews the epidemiology of perinatal HIV infection, antenatal clinic HIV surveillance, vertical transmission, breast-feeding by HIV-infected mothers, clinical factors of HIV infection, social aspects of HIV infection, and preventing the vertical transmission of HIV from mother to child.
Prevention of congenital syphilis in X: the "supposed to" syndrome.
Syphilis is a systemic, chronic infectious disease transmitted through sexual intercourse, from mother to infant during pregnancy, and through the transfusion of infected blood. Untreated maternal syphilis infection may lead to abortion, stillbirth, infant prematurity, or congenital syphilis. However, syphilis infection is easy to detect and fully curable, at least since the advent of penicillin in the 1940s. Antenatal screening for syphilis serology is a national health policy in country X, with pregnant women found to be seropositive for syphilis referred to a STD clinic for treatment. However, a survey conducted in 10 MCH clinics found that an adequate syphilis screening had been conducted in only less than 10% of pregnant women. Efforts were subsequently taken to strengthen the syphilis control program in the country's capital. Findings are presented from an evaluation of the program in 13 MCH clinics across the city. 3-4% of pregnant women in the capital of country X are seroreactive for syphilis. Furthermore, approximately half of the antenatal attenders do not undergo blood screening, despite optimal logistic support, and alternative approaches such as screening and testing at antenatal clinics followed by prompt treatment, or mass treatment from a certain prevalence rate, should be considered.
Findings are presented from a community-based study of experiences with modern contraceptive methods in urban and rural Cambodia, and user preferences for various technical attributes, including effectiveness, mode of administration, secrecy, and the rapid return of fertility. Findings are based upon 12 focus group discussions held with 95 poor, reproductive-age, married women; 3 focus groups with 25 urban, married men; and 2 group discussions with 15 urban female prostitutes. Women who use modern contraceptive technologies want highly effective methods of birth control. Cambodian women are mainly interested in longer-acting methods, perceive weight gain positively, and are less concerned about a rapid return to fertility upon method discontinuation or secrecy from their partners. The women reported a high level of method side effects and considerable variation between side effects and each modern method used. The data also indicate that women may switch from a modern method associated with negative side effects to a less effective traditional method, to either take a break from unwanted side effects or discontinue modern method use altogether in the absence of an alternate, acceptable method. Efforts therefore need to be made to develop and provide a broad array of modern contraceptive methods, together with improved information on how methods function in vivo and the expected side effects of use.
Bangladesh has considerable national experience promoting and providing family planning services through home visits to reproductive-age married women by paid female community workers. Since 1978, the government has trained and employed 24,000 such workers, known as Family Welfare Assistants (FWA), while nongovernmental organizations (NGO) have trained and employed an additional 7000 field workers to carry out similar activities. NGO field workers are considered to be part of the national family planning program. Findings are presented from an assessment of the quality of family planning services provided by community-based field workers in zone 3 of Dhaka City, Bangladesh, and are based upon a large household survey of a representative sample of clients, direct field worker observation, and interviews with field workers and clients. Areas in greatest need of improvement include the frequency of contact with clients who are nonusers or who have special needs, client education about family planning methods, and counseling about side effects and warning signs.
Determinants of childhood mortality in slums of Karachi, Pakistan.
Pakistan has an infant mortality rate (IMR) of 90.5/1000 live births, and the country's child mortality level of 117.5 is worse than in other South Asian countries. Rapid population growth combined with rural-to-urban migration has led to the creation of urban slums in which morbidity levels are usually higher than in rural populations. A study was conducted in January 1993 in 6 slums of Karachi where the Aga Khan University has operated primary health care programs since 1985. Researchers recorded the deaths of 347 children under age 5 years old due to diarrhea and acute respiratory infections (ARI) during 1989-93. 235 mothers of these children were interviewed. The following are discussed as risk factors for under-5 child mortality: the use of traditional healers, poor nutritional status, incomplete or no immunization, the quick change of healers, inappropriate child care arrangements, mother's literacy, who decides about outside treatment, short birth interval, bottle feeding, and nuclear family structure. Maternal autonomy, appropriate health-seeking behavior, and child-rearing processes identified in the study point to the need for intervention strategies which go beyond the usual primary health care initiatives and involve communities in developing social support systems for mothers.
Knowledge of HIV / AIDS among migrants in Delhi slums.
Over the past decade, there has been a sharp increase in the reported and estimated numbers of HIV/AIDS cases in India. The UNAIDS estimates that up to 3 million people in India may be infected with HIV, of which 70-80% were infected through unprotected heterosexual activity. Findings are presented from an assessment of HIV/AIDS-related knowledge and awareness among slum dwellers in Delhi, India, and which factors affect that knowledge. To explore the links between socioeconomic, health, and migrant status generally, a survey was conducted in 1996 among 150 slum households from different parts of the city. The slum dwellers were all migrants from other states, living for at most 15 years in Delhi. All 361 adults in the selected households were interviewed. Despite significant investment in IEC activities by the State AIDS Cell over the past decade, respondents were found to be poorly informed about HIV/AIDS and how it is spread. The probability of having better knowledge about HIV/AIDS was higher among younger, more educated individuals, as well as among those who owned televisions and lived in certain zones.
Improving family planning program performance through management training: the 3Cs paradigm.
Action research was conducted in Bangladesh to determine whether a high level of fertility control behavior can be attained in a country of very low socioeconomic status, including very low levels of literacy and women's status, and if management training help can improve the performance of service delivery systems. 20 family planning officials participated in a 14-week, non-degree, management training program conducted in Dhaka. The research found that competently executed determined effort is a far faster and more effective alternative to socioeconomic development-led contraception in a developing population. A carefully designed and executed intervention can achieve a high level of contraceptive use, and thereby control fertility, without waiting for significant improvement in a country's socioeconomic indicators. For example, in the 19 experimental thanas, the contraceptive prevalence rate increased by an average of approximately 10 percentage points within 12 months of training. These findings demonstrate how a task-focused, well-designed, and properly conducted management training, backed by well organized and managed follow-up, can effect major improvement in a system's effectiveness and productivity, even if that system is staffed by a demoralized and apathetic work force.
Feasibility of local condom production examined.
Despite Africa being the world region worst affected by the HIV/AIDS pandemic, there is only 1 condom manufacturer on the continent, in Johannesburg. Hundreds of millions of condoms are donated and imported annually. For example, 500 million units were donated in 1996, of which 212 million came from the US Agency for International Development. A recently released study commissioned by the European Union's HIV/AIDS Program for Developing Countries determined that it would be technically viable to manufacture condoms in not only South Africa, but also in Mauritius, Cote d'Ivoire, and Kenya. All that is required is a factory, work force, water, and electricity, with the raw materials to be imported from Malaysia or Thailand regardless of where the factory is located. The financial returns of such an operation would depend upon the cost of labor, the type of factory and its output, and market demand. Benefits would include employment creation, potential exports, and foreign exchange savings. A typical condom plant, operating 24 hours a day with 2 production lines, can produce 160 million condom units per year. However, should such a factory be built and put into operation, managers must ensure that any condoms produced are of high quality.
Voluntary HIV counseling and testing (VCT) is an entry point to a range of HIV prevention and care interventions. Given recent breakthroughs to help people with HIV/AIDS, there is considerable reason to promote such services. However, despite the particular need for VCT in developing countries with high prevalences of HIV infection, VCT is rarely available. One exception to this general lack of HIV testing and counseling services in Africa is the AIDS Information Center in Uganda, where more than 450,000 people have received VCT. Zambia's first VCT center, Kara Counseling and Training Trust, was established in November 1992, and offers a range of support services outside the workplace or medical center. Fear, the lack of available medical help for HIV-infected people, and stigma associated with having HIV are discussed as some of the reasons why people decline to be tested for HIV infection.
In summer 1999, the Religious Consultation on Population, Reproductive Health, and Ethics will host a meeting of international scholars in Philadelphia for the first of 2 conferences on the right to family planning, contraception, and abortion in 10 world religions. The project is being funded by a grant from the David and Lucile Packard Foundation. The Consultation project hopes to uncover and disseminate the neglected resources within religious traditions which can justify, on religious grounds, the moral right to family planning, including contraception and abortion. The project's aim is to foster the introduction and consideration of more progressive religious views on family planning, contraception, and abortion in ongoing international debates. A list of attending scholars is presented. Academic papers developed from the consultation will be published first in an academic volume, then in a popular volume targeted to policy-makers, population workers in the field, and the general public. Chapters of the popular volume will be translated into several non-English languages, and the project's scholars will maintain a permanent task force to present briefings, engage the media, and contribute to policy debates in the US, at the UN, and abroad.
U.S. moves forward on international promises.
The United Nations Population Fund (UNFPA) is wholly funded by voluntary contributions from UN members to improve the quality and accessibility of voluntary family planning services in the most poor regions of the world. In 1997, UNFPA provided support services to 168 countries for reproductive health, including family planning, the prevention and treatment of sexually transmitted infections, HIV/AIDS, infertility, and maternal and child health care. In 1997, extremist US Representative Chris Smith, a Republican from New Jersey, led a movement in Congress to defund US contributions to UNFPA, citing China's coercive reproductive health practices even though no UNFPA funds were used to support coercive practices and UNFPA strongly opposes them. In March 1999, a bipartisan group of Senators introduced a bill in the US Senate to restore UNFPA funding. The bill, which has already passed the House International Relations Committee by a vote of 23-17, authorizes the appropriation of $25 million to UNFPA for fiscal year 2000 and $35 million for the following year, while also addressing important public health and human rights concerns.
Gender, refugee status and permanent settlement.
The size of the world's refugee population has grown considerably during the past 25 years due to social, economic, and political instabilities associated with factors such as the formation of new nation-states after the end of colonial rule, the end of the Cold War, and the legacies of earlier military action and foreign policies of industrial countries. In many cases, women outnumber men in these forcibly displaced populations. Yet, the over-representation of women in refugee flows reverses to under-representation in claims and/or settlement in the world's industrial countries. Women are also under-represented as asylum claimants. This paper examines how gender is implicated in the stages of defining a refugee, the refugee determination process, and the act of final settlement. After a general overview of the situation, specific relevant details are presented for Canada. Canada admits refugees for permanent settlement, and has been the first country to develop gender-sensitive guidelines and to participate in the resettlement of women at risk of harm. However, the available data indicate that women are under-represented in humanitarian-based flows to Canada. When they enter Canada, they are more likely than men to be married and to enter as spouses rather than as principal applicants.
Bringing order to chaos. A framework for understanding and treating female sexual abuse survivors.
This article presents a framework that can help clinicians treating survivors of sexual abuse understand the interactions among the past abuse, the survivor's present symptoms, and the treatment process. After an introduction sketching the problems faced by therapists who treat survivors of abuse, the article focuses on specific difficulties caused by the fact that therapists often exhibit a strong countertransferential response to survivors of abuse. The next section gives an overview of the framework that uses four boxes to describe effect, general symptoms, symptoms of transference, and symptoms of countertransference. This framework is then fleshed out for the following effects of sexual abuse: stigmatization, early sexualization, and lack of trust. It is concluded that the framework offers therapists a way to control the very intense feelings and dynamics that are present during sexual abuse therapy. Thus, therapists can better understand their clients' feelings and their own countertransference tendencies. This will help therapists avoid retraumatizing their clients.
Working toward freedom from violence. The process of change in battered women.
This article proposes using the transtheoretical model of behavior change to improve understanding of how battered women change their lives so that eventually these changes can be systematically and quantifiably measured. After a brief introduction, the article reviews currently applied outcome measures and notes that they fail to measure the internal changes that allow battered women to change. The next section reviews what is known about the process of change, pointing out that it is no easier for a battered woman to leave her abuser than for a person to adopt any other seemingly simple health-giving behavior (cessation of smoking, exercise, dietary change). This section notes that some agencies for battered women have intuitively developed programs that respond to the stages the women must go through when changing their lives. The article continues with a description of the transtheoretical model of behavior change, which assumes that behavior change is dynamic and is constructed with a recognition of stages of change, processes of change, decisional balance, and self-efficacy. Each of these constructs is discussed and applied to the situation faced by battered women. The article concludes that, while the model as it exists addresses many of the issues that battered women face in their attempt to overcome abuse, to be as useful as possible, researchers must determine what must be added to or changed in the model to make it completely relevant to this application.
Public health targets teens' private acts.
During the 1998 annual meeting of the American Public Health Association, most of the research on adolescent health focused on ways to reduce risk behavior. One researcher reported that when physicians discussed abstinence and condom use with boys 12-15 years old undergoing general examinations, condom use increased, but 8% of the respondents noted at follow-up that they believed the physicians thought it was acceptable for them to engage in sexual intercourse. Selection bias due to only 50% participation by eligible respondents may have skewed these results. Other researchers underscored the difficult but essential task of involving adolescents in research. In a study involving longterm follow-up of adult-led and peer-led risk-reduction interventions for 659 Black adolescents at risk of contracting HIV, one intervention stressed abstinence, one stressed condom use, and one dealt with nonsexual health behavior. The abstinence education led to respondents being less likely to report engaging in intercourse at the three-month follow-up, but this effect disappeared by six months. Condom promotion had a consistent positive effect. There were no differences among groups facilitated by adults or by peers. A survey of the television habits of 240 Black adolescent females 14-18 years old revealed that the viewing of television shows depicting women as sexual objects and those depicting violence was associated with adolescent pregnancy and sexual behavior that placed the adolescents at risk of becoming infected with HIV.
A battered woman needs more than biological help.
Violence against women can take many forms and is widespread, but incidences are difficult to quantify because women suffer in silence or fail to realize that the violence they experience is unacceptable. In India, a survey of 1842 rural women of reproductive age revealed that both men and women consider wife beating acceptable and that 40% of all wives have been beaten by their husbands. Indian women who have a good education, are married at later ages, and have control over economic resources are less likely to experience domestic violence. Females can suffer from violence throughout their life cycle. Fetuses may be aborted just because they are female; infants may be killed because they are female; girls may be neglected or subject to various other types of abuse; adolescents may be raped; married women may be beaten, raped, or killed by their husbands; and widows may be neglected and abused. The health effects of this violence, thus, range from death to psychological trauma. In response to this situation, women's organizations have focused worldwide attention on violence against women as a human rights violation and are beginning to hold accountable governments that were party to the Convention on the Elimination of All Forms of Discrimination Against Women. Training medical personnel on how to deal with women who are obvious victims of domestic violence will be an important strategy.
Are newspapers a viable source for intentional injury surveillance data?
This study sought to determine the accuracy of previous reports claiming that newspaper accounts were a reliable adjunct to surveillance of the prevalence of unintentional injury. Data were collected through an in-depth analysis of every issue of the two largest daily newspapers published in Alabama in 1991. Published accounts of 422 assaults, homicides, suicides, and rapes occurring in Jefferson County were compared with data available from the coroner's office and the justice system. It was found that the newspapers underreported cases of suicide, rape, and assaults. While 88% of the assaults covered in the newspapers involved firearms, firearms were actually used in only 23% of all assaults in the county. While 18% of homicides and 20% of assaults occurred with knives, the newspapers only reported 7% and 6% of these incidences, respectively. It was concluded that editorial policy leads to exclusion of much information of potential value for injury surveillance purposes, and newspapers are neither a valid nor a reliable data source for injury surveillance.
Third trimester abortion: is compassion enough?
One comprehensive ethical framework that can be applied to cases of third trimester abortion is based on the following notion: patient trust depends upon physicians developing specific virtues and basing their professional actions on these virtues. One such virtue, as described by Dr. John Gregory in 1772, is sympathy for the distress of others that overcomes self-interest. This application of sympathy and desire to relieve suffering can justify late term abortion in some cases. The compassionate response to sympathy forwarded by Gregory, however, must be properly regulated by reason, as Gregory himself recognized. Thomas Percival (1740-1803), author of the classic text "Medical Ethics," charged physicians with uniting "tenderness" (Gregory's "sympathy") with "steadiness." This combination of virtues reoccurs in the contemporary work of bioethicists Edmund Pellegrino and David Thomasma. The intellectual component of compassion requires physicians to exhibit compassion towards their patients, and this includes fetal patients. Thus, third trimester abortion is only justified in cases where fetal abnormalities are associated with the certainty or near certainty of early death or of a complete absence of cognitive developmental capacity. Most anomalies fail to meet these criteria, and physicians must exhibit the virtues of self-effacement and integrity to make rigorous, clinical, ethical judgements and properly balance the interests of the pregnant woman and the fetus.
Investing in the World Health Organization [editorial]
The World Health Organization (WHO) has been at the forefront of efforts to promote global health since its inception. The US has always considered that its support of the WHO promotes humanitarian goals and national self-interest. Under the new leadership of Gro Harlem Brundtland, the WHO is revamping its programs so that it will be even more effective in setting priorities and meeting goals. However, as of May 1999, the US was more than $35 million in arrears in assessed dues to the WHO and has taken a position of resistance to even nominal increases in its assessment. The WHO is funded through its assessments and through extrabudgetary contributions. The agency's ability to function has been jeopardized by the fact that its purchasing power has declined approximately 20% in the past decade. In 1998, the US gave the WHO $46.1 million in extrabudgetary contributions, but the US ranks eighth in contributing nations when its contribution is calculated on both a per capita basis and as a share of gross domestic product. A mere 3.7% increase in assessments would allow the WHO to cover price increases and exchange rate fluctuations. The WHO has been exemplary in adopting reforms to increase efficiency; this year, it reduced administrative costs by 15%. The US must pay its arrears and enlarge its financial commitment to this important institution.
Ensuring students' well-being as they learn to support victims of violence.
As medical schools in the US incorporate domestic violence into their curriculum, they must also create mechanisms to assist medical students who have personal histories of domestic violence. In addition, all students must receive the support they will need to confront the psychological difficulties of working with survivors of domestic violence. It is only within the past decade that the extent of domestic violence and its effects on health have been recognized. The few surveys that have examined the prevalence of a history of domestic violence among health care providers have revealed that figures for this population mirror those for the general population. One reason for this is that more women are becoming medical students, and significantly more women than men have violence in their histories. Because it is a caring profession, medicine also attracts those who were exposed to family violence. Some of these individuals become high achievers to alleviate their pain but find it impossible to maintain perfectionism in medical school. When survivors are ultimately unable to feel good about themselves, they are unable to deal with patients objectively. As patients begin to discuss experiences of violence with medical students, the students may react by withdrawal, denial, or "intrusive" actions such as rescue attempts or boundary violations. These situations may be particularly problematic for medical students who have survived violence. Medical schools, therefore, should offer self-care training as they address the presence of family violence experiences among their students.
The disastrous results of condom distribution programs.
Distributing condoms to adolescents in an effort to protect them from pregnancy and HIV infection is a prescription for disaster because adolescents are too impulsive and undisciplined to use condoms properly. A 1988 survey showed that 27% of never-married, low-income, adolescent females became pregnant in their first year of depending upon condoms for birth control. A program of condom distribution in San Francisco's Balboa High School led to nearly double the number of sexually active students using condoms and a 25% increase in the school's overall pregnancy rate, despite graphic demonstrations of proper condom use. A school-based program of condom distribution in St. Paul, Minnesota, resulted in a 33% increase in pregnancy rates (from 22/1000 to 29), while condom distribution at an inner-city school in Dallas, Texas, resulted in an 11.2% pregnancy rate, a 47% increase from the rate of 7.6 in a control school. Studies have shown that even among adults with HIV-positive partners, counseling on proper condom use is not always effective. With this evidence that condom distribution only worsens the consequence of adolescent sexual activity, another approach must be found to protect adolescents from pregnancy, sexually transmitted diseases, and HIV infection.
The Church Partnership Program.
In 1996, Black religious groups in the US acknowledged that adolescent pregnancy is a serious problem for Black churches and that the churches have a responsibility to address reproductive health concerns. These statements bolster the collaboration between clergy and faith communities and Planned Parenthood of Metropolitan Washington (PPMW) that began in 1992 when PPMW entered into a partnership with the Mt. Airy Baptist Church to prevent HIV infection. As new congregations entered the Church Partnership Program, the focus changed to the prevention of adolescent pregnancy. The program offers to ministers and lay leaders training workshops that incorporate a curriculum adapted for multiple denominations. PPMW also holds a series of monthly ministerial breakfasts to reach additional clergy and congregations. During the training and breakfasts, ministers are introduced to short-term programs offered by PPMW, such as parent-child communication workshops, forums for teenagers and younger children, and use of PPMW's resources. Longterm programs include an adolescent pregnancy prevention program, called the "Sursum Corda Youth Program," that provides life skills to 62 children from ages eight to 18. Other longterm efforts include establishment of a church-based reproductive health clinic and incorporation of an educational youth theater troupe. PPMW is currently producing a video describing this innovative partnership in order to promote its replication nationwide.
Handling information in public health planning [editorial]
This editorial highlights two papers that focus on the challenge of coordinating the flow of information between neighboring countries in southeastern Asia in order to enhance public health. One paper uses geographical mapping to display data on malaria control in China's Yunnan Province that are of relevance to bordering Myanmar, Laos, and Viet Nam. The other paper addresses data collection issues related to disease dispersal in the Greater Mekong Subregion caused by international migration. Both papers illustrate the need to extend data collection beyond standard sources, especially since such sources have evolved to document stable populations with predictable disease patterns. The effect on health of increased population movement is both positive, from resulting economic development, and negative, due to increased pressures on health systems and disease dispersal that can trigger epidemics. This public health context highlights the essential role of effective, continuous data collection and of displaying data in ways that are readily interpretable by planners. Geographic information systems that allow data to be mapped on macro and micro scales are a powerful tool. While the maps are only as valuable as the data on which they are based, it is important to begin the process with available data to stimulate the development of improved data collection systems.
Japanese experts positive on Vietnam.
During a study meeting of the Japan International Cooperation Agency's Viet Nam Project, two experts reported on recent visits to the reproductive health project in Nghe An Province, Viet Nam. Dr. Shoko Nagaya made advisory visits to the project in June and November 1998. He observed activities in 7 of the 8 districts covered and 1 of the 11 districts not covered. He was especially interested in the effects of project training on the staff of the 244 Commune Health Centers (CHCs) who oversee prenatal care and delivery. He found that the training of the mobile team members of the District Health Centers (DHCs) resulted in positive supervisory support to the CHCs. He also spoke to key personnel at the provincial Maternal and Child Health and Family Planning Center (MCH/FPC) to encourage them to achieve project sustainability. His overall impression was that the project should be expanded nationwide. Dr. Michiko Chosa made three visits to the project to transfer hospital management techniques to the MCH/FPC. In particular, he taught personnel a five-point Japanese system of making priorities, putting things in order, practicing self-hygiene, cleaning, and creating habits. Chosa found that his efforts were increasingly accepted by the staff, which was eager to become a model for the DHCs and CHCs.
Regional Technical Committee meeting.
In January 1999, the 7th Regional Technical Committee of the Asia Regional Project, which seeks to strengthen community-based delivery of reproductive health (RH) care and family planning (FP), met at JOICFP. The 15 participants from Bangladesh, Laos, Nepal, the Philippines, the UN Population Fund, and the International Planned Parenthood Federation (IPPF) reviewed project activities during 1996-98 and finalized a work plan for 1999, reviewed evaluation outcomes, drafted a set of guidelines for the implementation of community-based RH programs, and consolidated plans to ensure program sustainability beyond 2000. The delegates from each country reported on their accomplishments and future challenges, and these experiences will be incorporated into manuals that will be useful tools for policy-makers and grassroots activists alike. A representative of the IPPF recommended continued sharing of accumulated project experience, sharing IEC (information, education, communication) materials with other nongovernmental and governmental organizations, fostering site visits to expand projects, and involving local governments to raise local resources. She noted that the IPPF would explore ways to continue project support. The UNFPA representative called for increased regional activities in the areas of adolescent sexual and RH education and services, quality of care training, advocacy, and furthering male involvement.
To highlight the advantages that can be gained by distinguishing between anger and hostility in attempts to understand domestic violence, this article analyzes the literature on anger and hostility exhibited by men who commit acts of domestic violence. After a brief introduction that notes the complexity of the relationship between the experience of anger and hostility and the expression of aggression, the review opens by defining hostility and anger and the relationship between the two. The next section considers methods that are commonly used in marital violence research to assess hostility (the Buss Durkee Hostility Inventory, the Hostility and Direction of Hostility Questionnaire, and the Hostility Scale of the Brief Symptom Inventory) and anger (the Novaco Anger Scale, the Multidimensional Anger Inventory, the State Trait Anger Expression Inventory, single-item rating scales, and affect/verbal content coding systems). The article continues with a review of empirical studies that have used these assessment tools to investigate anger and hostility in maritally violent men. The analysis concludes that theoretical inconsistencies, measurement confounds, and methodological inadequacies in the studies prevent sound conclusions about the role of anger and hostility that can be used to devise interventions. The conclusion also explains the advantages of differentiating between anger and hostility and the necessity of improving the assessment of anger through the use of instruments, such as a spouse-specific anger scale, derived from a theoretical model of anger.
Date and acquaintance rape. Development and validation of a set of scales.
Increasing recognition of the prevalence of date/acquaintance rape (DAR) in the US, especially among college women, has led to an understanding that the techniques needed to fend off attacks from friends and acquaintances differ from those used to prevent rape by strangers. This study developed and tested the reliability and validity of the following DAR constructs: perceived vulnerability (underestimation of vulnerability discourages adequate self-protection), self-efficacy, relational priority (neglecting self-interest to save a relationship), rape myth acceptance (subscribing to myths about rape allows women to avoid facing their own vulnerability), and commitment to self-defense. These constructs were also correlated with scales measuring masculinity, self-esteem, and degree of belief in a "just world." Data were gathered to test these constructs via a questionnaire administered to 800 female undergraduate dormitory residents (47% response rate). Analysis of the data allowed refinement of 50 items into 25 items that constitute reliable scales of perceived vulnerability, self-efficacy, and self-determination and a marginally reliable scale of victim-blaming (rape myth). Support was found for 5/6 predicted correlates between DAR scales and 3/5 hypothesized correlations between DAR scales and convergent/discrimination validity scales. Research into this rape prevention tool will continue.
The Massachusetts-based Women's Rights Network (WRN) was founded in 1995 in response to the need to develop collaborative, crosscultural, and international strategies to eliminate domestic violence. The WRN initiated meetings with local advocates to identify the most pressing issues facing the US battered women's movement and then began to contact advocates for battered women throughout the world. To date, the WRN offers a resource center documenting strategies used around the world to end domestic violence, gives workshops and presentations to increase public education and awareness about domestic violence, organizes international strategy sessions between women's advocates in Massachusetts and those in other countries, facilitates one-on-one partnerships between groups for battered women in Massachusetts and sister organizations in other countries, and participates in the annual "16 Days of Activism Against Gender Violence." The WRN also plans to publish a biannual journal.
"The war against women". Media representations of men's violence against women in Australia.
This article analyzes how a newspaper in Victoria, Australia, represented violence against women in a special series entitled, "The War Against Women." True to the series title, the series appropriated all of the metaphors of war and dealt with violence against women in much the same fashion as it would report a war, speculating as to its causes, mapping its prevalence, reporting deaths, and referring to "explosions" of violence. As in war coverage, the series included findings of a poll of public opinion, told a story of contrition from an enemy who surrendered (a man in counseling), and offered editorials. While it drew attention to one of society's most pressing and intractable social problems, the paper ignored its own previous reports on domestic violence to gain the shock value of the "new" and, therefore, perpetuated a pattern of "discovery, forgetting, and rediscovery" of violence against women. The paper also failed to apply the feminist notion of a continuum of male violence or to breach the chasm between feminist and public understanding of male violence. Finally, the paper used editorial disclaimers to minimalize men's responsibility and distance itself from feminists. Thus, it placed its critique of men's pervasive violence against women within the hegemonic narratives of gender relations, which hold that women acquiesce in domestic violence, feminists vilify men, and men are a much-maligned group not responsible for the bad behavior of a minority. The paper, thus, conveys that idea that this war will not be won.
This article analyzes how religion influences the way in which the medical profession, legislators, and the public in Latin America think about assisted reproductive technologies (ARTs). Opposing views consider ARTs, and indeed most technology, to be either an artificial form of life or an expression of nature based in culture (and, therefore, something people have a right to use as a tool that can be considered a gift from God to be used to make God's work more effective). The dilemmas that ARTs pose are based on the myriad of choices available and on the need of some social actors to impose their own views and moralities on the rest of society, in effect attempting to exercise a moral dictatorship. The reproductive mandates of Catholicism have been specifically directed to legislators, who then refuse to implement laws that would respect moral diversity while individual citizens follow their own consciences instead of church dictates. The 1995 Latin American consensus offers minimal ethical guidelines on the various aspects of ARTs in the absence of legal regulation. It is important that ARTs be officially accepted, even if this entails restrictions. For the foreseeable future, access to ARTs in the region will, unfairly, be restricted to those who can afford private treatment.
The "illegitimacy bonus" and state efforts to reduce out-of-wedlock births.
In 1996, the US Congress responded to a dramatic increase in out-of-wedlock births (now a third of all US births annually, mostly to women not receiving welfare) by mounting a nationwide campaign against "illegitimacy." The hallmark of the campaign is a program that divides an award of up to $100 million annually among as many as 5 states for 5 years beginning in 1999 for achieving the greatest declines in out-of-wedlock births and abortions. While some states are making formal efforts to win the award, others are attempting to reduce these births despite their acknowledgement that they have little chance of winning the bonus. State programs and policies are attempting to: 1) increase contraceptive usage among low-income women by promoting family planning (FP) and expanding FP access, 2) prevent adolescent pregnancy, and 3) reach adults and adolescents. Funding for many programs is coming from "Temporary Assistance to Needy Families" (TANF) welfare block grants, which can be used for this purpose. In some cases, states are passing on small and substantial grants to communities to encourage local initiatives to reduce out-of-wedlock fertility. Initiatives undertaken since the illegitimacy bonus was announced will likely have no effect on the winners in the first or even the second years. Even when the results of the new efforts are in, it may be difficult to establish cause and effect. It is clear that the incentive has sparked activity, especially given the flexibility of available TANF funds to support this activity.
AIDS now world's fourth biggest killer.
In May 1999, the World Health Organization released figures indicating that AIDS is now the fourth leading cause of death in the world (moving up from seventh in 1998 rankings). The previous first three causes, ischemic heart disease, cerebrovascular disease, and acute lower respiratory disease, remain the same. In Africa, AIDS is the number one killer and was responsible for 1,830,000 deaths last year, twice as many as were caused by malaria. The change in AIDS ranking was partially due to improved methods of estimating the mortality caused by diseases, but the new figures vindicate UNAIDS warnings in 1998 that the epidemic is still out of control. UNAIDS estimates that 6 million more people are infected with HIV each year, but the international community is only investing $150 million each year to prevent and control HIV in Africa.
Why men like or dislike condoms.
In a double-blind, crossover study to determine how men decide if they like a specific type or brand of condom, 194 men rated 3765 condoms as 61% favorable, 31% neutral, and 8% unfavorable. The men found less favor with condoms that were too loose, too tight, too short, or too hard to apply. Unfavorable ratings were also given if the condom slipped or broke. In general, men with larger penises rated condoms less favorably. Condoms that seemed to be well-lubricated throughout use found more favor. The study concluded that resistance to adoption of consistent condom use could be reduced through better condom design and manufacture.
Public health issues in Hong Kong and China [editorial]
The 1997 return of Hong Kong to Chinese jurisdiction has created public health opportunities and challenges. Public health problems attendant upon industrialization and urbanization on the mainland include environmental pollution, food contamination, and increasing occupational injuries and traffic accidents. Major problems in Hong Kong have included outbreaks of infectious diseases and food poisoning. Chronic diseases in both areas have been caused by socioeconomic changes that led to lifestyle changes, such as increased tobacco use. With smoking rates already over 30% in China and 15% in Hong Kong, there is concern that multinational tobacco companies will attempt to increase their market in developing countries to compensate for losses at home. A further concern is the increase in incidence of sexually transmitted disease. The reunification of Hong Kong and China, however, presents opportunities for joint research in areas of medicine and public health of common interest; joint training of health care workers; and cooperation in the prevention, control, and surveillance of infectious diseases and in environmental protection. Challenges include securing the necessary government support and resources to implement new activities, mobilizing the community to improve community health, enlisting the support and cooperation of other sectors, and revamping the outdated organizational structure of government agencies dealing with public health issues.
French-led therapy fund kicks off in Africa.
The antiviral drugs used to treat HIV infection successfully in developed countries are priced out of the reach of most infected individuals in the most effected areas of the world. To reduce this global inequity, in 1997 the Minister of Health and the President of France created the Fund for International Therapeutic Solidarity to subsidize the cost of anti-HIV therapies in developing countries. The Fund's first project will be to provide about $1.7 million over 4 years to help prevent maternal-child transmission of HIV in the Ivory Coast. To date, the only contribution to the fund has been $4 million in seed money donated by France. There is hope for an additional $3.3 million from the European Commission, and talks are underway with the World Bank. The Ivory Coast project will subsidize "bitherapy" for 500 patients and will support testing and therapeutic follow-up for 20,000 pregnant women and their families in Abidjan. The women who test positive for HIV will be offered a "short course" of antiviral drugs to prevent maternal-child transmission, and mothers in advanced states of HIV will be offered triple therapy. Health officials in the Ivory Coast welcome the project but point out that it will have only a small effect. UNAIDS officials counter that it is better to begin than to wait until the perfect intervention is available. Meanwhile, other African nations are seeking assistance from the Fund, and new programs will soon start in Uganda and Morocco.
A future free from violence: a world where all women enjoy their human rights.
The executive director of the UN Development Fund for Women (UNIFEM) opened her address to the 42nd session of the UN Commission on the Status of Women by affirming a vision of hope for creation of a world where women can enjoy their human rights. To further this vision, UNIFEM is working at the national level to: 1) help women's organizations increase their capacity and develop networking, leadership, and advocacy skills; 2) focus attention on needed changes in pivotal criminal justice and legal systems; and 3) explore ways that governments, international agencies, and civil institutions can create conditions that will foster peace. UNIFEM administers the UN trust fund in support of actions to eliminate violence against women, which has supported 45 innovative initiatives in 40 countries, and coordinates the Latin America and Caribbean Campaign on Women's Human Rights: A Life Free of Violence. In addition, UNIFEM has developed an array of initiatives to encourage universal ratification of the Convention on the Elimination of All Forms of Discrimination against Women. UNIFEM's work in the area of peace-building and conflict resolution includes the African Women's Crisis Program, which enables UNIFEM to support women who have been victimized by armed conflict and other emergencies, the launching of the Federation of African Women Peace Networks, and help in establishing the Mogadishu Peace Market initiative. These efforts reflect UNIFEM's understanding that without peace and women's human rights there can be no sustainable communities or development.
A Safe Space Created by and for Women: sexual and gender-based violence program phase II report.
This report covers the second phase of a Sexual and Gender-Based Violence Program being implemented by the International Rescue Committee among Burundian refugees in Tanzania. This phase involved applying the findings of a needs assessment survey so that the refugee community could be engaged in reducing the incidence of sexual and gender-based violence. The report is introduced with an overview of the history of the conflict in Burundi and an update of the Tanzanian context. The next section summarizes the methods used and results obtained during the first phase of the project. Then the report describes the community mobilization effort undertaken as the second phase of the project moved through the steps of disseminating survey results, establishing drop-in centers, building the capacity of women leaders, and involving block leaders and security leaders. The report then reviews efforts to deal with emerging topics such as managing staff stress, expanding the program's focus to include children under 18 years of age, dealing with violence against men, and creating interagency networks. The report concludes by noting that the program depends upon the existence of trust between survivors and staff and that the program will continue to progress with the lessons learned in one camp transferred to work done in the others. The guiding principles of this program are that it is community run and owned (and, therefore, sustainable) and that the experience gained by the women will help them improve their overall position in society.
Clandestine abortion in Latin America: provider perspectives.
This report details in-depth interviews with 10 clandestine abortion providers in Latin American cities. The introduction notes that unsafe abortion is thought to cause 24% of maternal deaths in Latin America and is known to strain public health resources. Because most of the abortions occur in women with children, the high mortality rate causes adverse effects in surviving children. Efforts to redress this situation have focused on reducing the number of unwanted pregnancies by providing high quality contraceptive services, improving postabortion health care, and changing the legal prohibition on abortion. The article continues by discussing the factors that led the abortion providers to begin their clandestine work, such as experiencing a sense that they were called to help women in this way, a personal experience with abortion, and a commitment to social change. Next, the article considers the major difficulties this work causes in the personal and professional lives of providers as they deal with a lack of medical support; the need for secrecy; and threats of violence, extortion, and prosecution. Finally, the article reviews what gives the providers satisfaction in their work, such as the feeling that they are saving women's lives and empowering women while meeting a challenge.
The Musasa Project, in collaboration with the University of Zimbabwe and the London School of Hygiene and Tropical Medicine, conducted action research to document the magnitude and health consequences of violence against women (VAW) and to explore strategies for action. In 1997, they reported their findings at the Musasa Project Workshop, held at the Monomotapa Hotel in Zimbabwe. This report contains the text of speeches and papers delivered at the workshop and excerpts from discussions. The first day of the workshop was devoted to an analysis of the current situation in Zimbabwe. It featured an opening speech by the Deputy Minister of Health, who described VAW as an emerging health issue in Zimbabwe. Papers showed VAW to be a global health problem, sketched the magnitude and health consequences of violence against women in Zimbabwe, presented community attitudes that perpetuate VAW in Zimbabwe, and presented Musasa's experience in meeting clients' counseling needs. On day two, papers were given on the following topics: options for community action in confronting abuse, strengthening Zimbabwe's health sector response to address violence, lessons learned from the establishment of victim-friendly courts, community intervention strategies dealing with gender issues, and counseling women who are experiencing violence. Workshop participants then made specific recommendations calling for appropriate responses to domestic violence and additional research into the effectiveness of interventions.
Philippine migration policy: dilemmas of a crisis.
Philippine migration policy is traced from the early 1970s to the present. The main migration trends in the 1990s are described. An assessment is made of the efficacy and appropriateness of present migration policy in light of the economic crisis. A regional approach to migration policy is necessary in order to encourage placing migration as a greater priority on national agendas and in bilateral agreements. In the Philippines, migrants are considered better paid workers, which diminishes their importance as a legislative or program priority. Santo Tomas (1998) conducted an empirical assessment of migration policies in the Philippines, but refinement is needed. Although migration is a transnational experience, there is little dialogue and cooperation among countries. Philippine migration policy defines its role as an information resource for migrants. Policy shifted from labor export to migrant management in the public and private sectors. Predeparture information program studies are recommending a multi-stage process that would involve all appropriate parties. There is talk of including migration information in the education curriculum. There are a variety of agendas, competing interests, and information resources between migration networks and officiating agencies. The Asian financial crisis may have a mild impact, but there are still issues of reintegration, protection, and employment conditions
The Singapore state's response to migration.
Migration trends in Singapore are traced since 1819. Immigration has been encouraged to advance economic development. Local and international factors fuel migration to Singapore. Singapore depends upon foreign labor. Population growth has been mainly due to migration from China, India, Malaysia, and countries surrounding Singapore. Independence in 1965 led to policies aimed at controlling high population growth. Policies became pronatalist after 1987. Foreigners in 1998 were over 18% of the total population, which was six times the number in 1970. About 2000 Singaporeans per year emigrated during the 1990s. Singapore is encouraging overseas industrial development. In 1997, the Prime Minister called for recruitment of foreign talent in order to meet the challenges of an increasingly globalized world, low fertility, and an aging society. Economic planners recommend short-term migration of unskilled foreign workers who would be a revolving pool to fill jobs natives do not want. Singapore is promoting arts and culture in order to keep people in Singapore. The government has issued assurances that natives will have first priority on jobs, education, and training. Singapore's ability to absorb workers will depend upon its economic performance.
The Malaysian state's response to migration.
This paper aims to provide a profile of migration trends in Malaysia since 1970 and to analyze public policy on migration in the context of economic growth and the labor market. The discussion centers on the impact of the Asian financial crisis. There is long history of immigration to Malaysia. The development strategy of the 1970s and 1980s was to create more jobs and restructure employment to meet equity goals. Labor shortages on plantations and construction booms led to a more organized, sustained effort to import labor. Recession in the mid-1980s led to unemployment, but many Malaysians were unwilling to work on plantations, in construction, or in low paying jobs. Economic growth during 1987-96 was very high, and labor shortages spread to service and manufacturing sectors. Migration policy has shifted over the decades. Both the market and the government's promotion of export-based industrialization require access to low cost migrant labor. Public and official recognition of the large number of migrants was not made until 1995. The financial crisis in 1998 led to enforcement of a new migration policy on illegal migrants and greater outflow of migrants. The economic crisis has increased job and income inequities in the region; this encourages continued migration. It is argued that it would be best for Malaysia to maximize short-term gains while minimizing long-term economic, social, and political costs.
Thailand's responses to transnational migration during economic growth and economic downturn.
This paper gives an historical overview of immigration to Thailand since the 1970s and emigration since the 1960s. It describes migration policies since the 1930s. Final discussion focuses on the impact of economic contraction on migration. Immigration to Thailand dates back to the 1760s when a huge wave of Chinese emigrated to Thailand. The flow continued until about 1850 and resumed during 1905-17. The next big waves of immigrants were after 1975, when refugees fled Indochina, and in the 1990s, when migrants flocked from neighboring countries drawn to the booming economy. Thai professionals left in the 1960s for the USA. During the 1980s, many left for work in the Middle East. During the 1990s, Thai migrants moved within the East and Southeastern Asian countries and the USA or Europe, and they included many women and illegal migrants. Emigrants leave as arranged by the government, by employers, by recruitment agencies, and as trainees. The first official act was in 1950 and revised in 1979. Many work permits were approved in the 1990s, especially for unskilled labor. There are supports for Thai migrants abroad, but little is offered to foreigners at home. By 1997, the country's recession led to nonrenewal of many work permits. The 1998 economic crisis led to a new labor policy that deported illegal and unskilled migrant workers in order to create jobs for Thais. Policy encouraged Thais to seek work overseas.
On-the-job training through follow-up visits to improve the quality of family planning services.
This follow-up study evaluates the effectiveness of an on-the-job training program for health professionals in Turkey. The family planning training program was launched in 1992 in medical schools. Interns received further training during clinical practice at family planning clinics. National Family Planning Guidelines were established in order to create uniformity in in-service and pre-service training. Follow-up visits were conducted at 16 Maternal and Child Health/Family Planning Centers, which collaborated with universities for pre-service training. Follow-up visits included observations of actual clinical practice and performance ratings using a standard checklist on interpersonal interaction and method-specific counseling. Findings indicate that 55% of the 130 in the sample were midwives, 35% were general practitioners, and 7% were interns. 3% were specialists. Most of the clinics were in maternity hospitals with an average patient load of 25-35 clients per day. Clinics offered a range of methods. Quality of family planning improved with on-the-job training. Counseling, IUD insertion, and genital tract infection services improved with training. The evaluation did not measure improvement in motivation of health professionals or client satisfaction.
An exploratory study of Korean fathering of adolescent children.
This 1996 exploratory study uses an ecological model (Bronfenbrenner, 1989; DeLuccie, 1995; Belsky, 1984; and Barnett and Baruch, 1987) to assess variation in fathering styles among adolescents in Seoul, Korea. It examines determinants of fathers' involvement (task share, frequency of father involvement, and warmth). Data are obtained from a sample of 129 Korean families who had children aged 11-14 years in one of three middle schools. 66 families had low socioeconomic status (SES). Fathers' mean age was 41.8 years. 73% had two children. 13.2% of fathers had graduated from middle school. 41.1% had graduated from high school. 40.3% had attended some college. 25.7% of low SES fathers had attended college. Analysis of variance indicated that there was no significant effect of the three measures by child gender. Warmth of fathering and task share of father involvement varied by SES. Low SES fathers showed less warmth and shared significantly more tasks. Paternal support given to the mother was the strongest predictor of warmth of fathering. 42% of variance in frequency of father involvement was explained by warmth of mothering and paternal support. Task share was explained by maternal education, father's education, frequency of mother involvement, and SES.
Pediatric care and immunization among Jordanian children.
This 1983 study examines immunization coverage and use of health services for 4533 children among a national sample of ever married