Just a few days before the tsunami disaster of Dec 26, 2004, the United Nations Food and Agriculture Organisation (FAO) published a document on the state of food insecurity in the world. In this document, FAO’s Director-General, Jacques Diouf, stated that 5 million children die every year because of lack of food. This means more than 400 000 deaths every month. In other words, since the tsunami tragedy, the world has silently witnessed a number of deaths which is nearly three times that seen on Dec 26, and which continues to increase at a rate of more than 13 000 each day. Now the risk is that the absolutely necessary and indispensable financial assistance for the victims of the tsunami tragedy will come at the expense of other funds set aside for assistance to countries affected by famine. (excerpt)
What medications counteract the pill?
Which drugs might impact the efficacy of the birth control pill? Comments are offered by Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville, and Susan Wysocki, RNC, NP, president and chief executive officer of the National Association of Nurse Practitioners in Women’s Health. Question: Would you please tell me what medications counteract with the birth control pill? A patient told me that she got pregnant after Nyquil cold medicine interacted with the pill. Is that possible? Kaunitz: When looking at concomitant use of medications in women using oral contraceptives (OCs), know that anticonvulsants represent the class of medications taken by U.S. reproductive age women that are most likely to impair OC efficacy. Since seizures increase during pregnancy and many anticonvulsants are teratogens, ensuring highly reliable contraception represents a health care priority in women taking anticonvulsants. (excerpt)
Give teens more info to bridge information gap.
Your next patient is a 17-year-old female who is interested in contraception. While she says she knows about the contraceptive patch and the vaginal ring, when you ask her about their effectiveness in preventing sexually transmitted diseases (STDs), she gives you a puzzled look. Results from a recent Menlo Park, CA-based Kaiser Family Foundation/Seventeen magazine survey show that while teens ages 15-17 have a fairly high degree of awareness about various contraceptive methods, there are significant gaps in their actual knowledge. About one in five of teens surveyed who had heard of new hormonal methods such as the patch and the ring thought these new methods were either “not too” or “not at all” effective at pregnancy prevention, even though both the patch and the ring have levels of effectiveness comparable to combined oral contraceptives. When it comes to knowledge of STD protection, adolescents surveyed were even less informed: While more than 75% said they had heard of birth control pills, more than one in four didn’t know that oral contraceptives offer no protection against sexually transmitted diseases. (excerpt)
Women's role in decision making in abortion: profiles from rural Maharashtra.
This paper presents a part of the qualitative exploratory study conducted in rural Maharashtra from April 1994 to April 1996 to understand the issue of abortion from women's perspective. The paper explores the decision making process in abortion and the factors that affect this process in the overall context of women's lives. Four important landmarks in a woman's life have been used as indicators to assess women's role in decision making. Profiles of women and men, collected through case studies, interviews and observation have been presented here to represent the various situations in which abortion was conducted, namely as a method of family planning, following foetal sex determination or when there was a risk to the woman's life. Some women who have undergone natural abortions have also been included to give an understanding of the family's attitude towards the woman during an abortion. The paper highlights the fact the process of decision making involves not only the couple in question, but the larger family, also. Multiple factors intervene during the decision making phase, making the process dynamic and situation-specific. The ethical and practical dilemmas that men and women go through during the process are also ignored. The findings make out a strong case for encouraging a dialogue between the couple through counselling services before and after the abortion, providing health education related to safe, effective, reversible and user-controlled contraceptives, reaching safe abortion services to women as closed to the village as possible and increasing women's decision-making capacity in all areas of life, including those related to reproduction and sexuality. (author's)
There is a need to document women's perceptions regarding the quality of their health care, including abortion services, since most studies to date have approached this issue from the viewpoint of service providers, policymakers, or the state. Basic maternal and child health (MCH) care, from both public and private sources, has been grossly neglected in India. MCH services, which are practically the only special program for women, receive a mere 2 percent of the national health budget. In fact, with less than 1 percent of the gross domestic product currently allocated for health services, there is a large gap between health needs in India and the public infrastructure intended to serve them. The number of health workers and the infrastructure available for even the existing limited services are inadequate and of poor quality. Added to this deficiency is a bias favoring urban areas in health care delivery. Whereas most government-run primary health centers (PHCS) lack functional equipment and trained personnel to carry out medical terminations of pregnancy (MTPs), the private sector, which is often characterized by inadequate equipment and insufficient facilities for such procedures, engages in profit-making through unstandardized treatment and charging practices . In fact, the use of unnecessary and even hazardous procedures and drugs has been found to be far more common in private clinics than in government clinics. (excerpt)
Abortion: Who is responsible for our rights?
Throughout history, women have practiced forms of birth control and abortion. These practices have generated intense moral, ethical, political and legal debates since abortion is not merely a techno-medical issue, but, "the fulcrum of a much broader ideological struggle in which the very meanings of the family, the state, motherhood and young women's sexuality are contested". Women have overtly or covertly resorted to abortion, but their access to services has been countered by the imposition of social and legal restrictions, many of which have origin in morality and religion. The norms governing the ethics of abortion have been constantly remoulded to suit the times and the social contexts, in which they are set. Despite the dissimilarities in their construct, intent and orientation, these norm's have invariably been directed to the fulfillment of social needs, that do not recognize women's right to determine their sexuality, fertility and reproduction. This paper reviews the abortion scenario, with particular reference to India. A brief historical account of the role of the medical profession in criminalising and decriminalizing abortion services, is followed by a discussion on the politics of abortion in India. An analytic review of the abortion situation in India, provides the reader with information about legal and illegal abortions and the paper concludes by placing the issue of abortion in the context of social (rather than individual) needs and rights. (excerpt)
Guidelines for sex education to adolescents.
These guidelines are not a curriculum. The guidelines provide a framework to create a programme/curriculum. The guidelines provide a comprehensive approach to human sexuality education. It is organised in a list of topics. A need based sexuality education programme can be generated by listing the topics along with chosen relevant messages. The supportive information regarding topics will be found in Part II of this book. The messages therein once introduced need to be reinforced repeatedly at different levels of age group. The characteristic of local situation should determine the exact contents of the local programme. Community attitudes, developmental differences in children, local socio- economic influence, parents' expectations, students' needs and expectations and religious and other perspectives should be paramount in designing the local sexuality education programme. The suggestions given in the agewise guidelines should also be flexible. It is important to allow as much autonomy as possible at local level to develop contents and methods which are suitable to local circumstances and preferences. (excerpt)
More women are looking at intrauterine devices.
Are more women at your family planning facility requesting information on intrauterine contraception? Chances are you are seeing an increase in interest: Almost 30% of respondents to the 2004 Contraceptive Technology Update Contraception Survey say they have performed six to 25 intrauterine device (IUD) insertions in the last year, up slightly from 2003’s figures. The popularity of the levonorgestrel intrauterine system (Mirena IUS, Berlex Laboratories, Montville, NJ) led to an increase in the number of IUD insertions, confirms Joe Childress, MD, an obstetrician/ gynecologist in private practice in San Antonio. Women in the United States have two choices when it comes to intrauterine contraception: the Mirena and the Copper T 380A IUD (ParaGard, FEI Women’s Health, North Tonawanda, NY). More IUD insertions are being performed at the Pinal County Health Department, a public health facility in Florence, AZ, reports Carolyn Brown, RNP, nurse practitioner. The facility uses ParaGard IUDs. (excerpt)
Reach out to teens: one agency's story.
Want to see more adolescents at your facility? Planned Parenthood of South Palm Beach and Broward County (PPSPBBC) in Boca Raton, FL, has captured teens’ attention by packaging a comprehensive health screening with a year’s supply of free birth control pills. Since the agency kicked off the Teen Health Broward program in July 2004 at its Fort Lauderdale, Pembroke Pines, and Tamarac health clinics, a steady stream of teens have been coming in for care, says Carla Shulman, RNC, OGNP, ARNP, LHCRM, vice president of medical services and risk manager for the agency. A $50 fee charged for the health screening covers a check of the heart, lungs, thyroid, and breasts, accompanied by an abdominal assessment, pelvic exam, and Pap smear. Teens also can opt to choose another form of birth control, but have to pay for the alternate selection. Those teens who cannot take the Pill do have to pay for an alternate method. While the offer of a free year’s worth of birth control pills may attract some teens, the service is not designed to advocate teen sex, she emphasizes. (excerpt)
Norplant -- a long acting contraceptive implant: a critical review.
Stree Shakti Sanghatana (Hyderabad) Saheli (Delhi), Chingari (Ahmedabad) and several women, were co-petitioners in a case in the Supreme Court in 1986 which demanded a court ruling on introduction of contraceptive NET-EN. The petition demanded that the contraceptive should be introduced in Indian family planning program only after it was adequately tested in the country for short and long-term risks. It also demanded that there is an assurance that the women were given adequate and accurate information so that abuse in a target oriented program would be prevented. Conditions for adequate medical screening and follow-up were, demanded to be assured at peripheral health centers before potentially dangerous contraceptives' were introduced in the Indian family planning program. An additional affidavit was filed in December 1990, bringing other hazardous contraceptives, such as sub-dermal implants, vagina rings, anti-fertility vaccines, nasal sprays etc, into the ambit of the earlier case. On 6-7 December 1990, Indian Council of Medical Research (ICMR) had a close door meeting with 'Health Advocates' to discuss introduction of NORPLANT and other spacing methods, into the national family planning program. NORPLANT was presented as an ideal contraceptive, 100% safe, 100% effective and 100% return of fertility on discontinuation of its use. This was being presented even when the mandatory Phase III trials and post introduction trials were not undertaken. (excerpt)
New report highlights abstinence programs.
Where does your state stand when it comes to funding for abstinence-only programs? A new report released by the New York City-based Sexuality Information and Education Council of the U.S. (SIECUS) details the amount, type, and use of federal abstinence-only-until-marriage funds in all 50 states and the District of Columbia. Federal funding for abstinence-only programs is set for $258 million in 2005, twice the amount allocated in 2004.2 Funding for such programs has jumped from the $59 million initially spent in 1998, when block grant monies were first implemented. “At a time when many states and localities are cutting both teen pregnancy and HIV/AIDS prevention programs, we felt it was critical to document the growth of unproven, and potentially harmful, abstinence-only-until-marriage programs across the country,” says William Smith, SIECUS director of public policy. “Hopefully, this project will encourage clinicians and other reproductive health providers to become involved, or even more involved, with comprehensive sexuality education in their community.” (excerpt)
As you check the chart of your next patient, you note she is scheduled for her quarterly injection of depot medroxyprogesterone acetate (DMPA, Depo-Provera; Pfizer, New York City). While she is on time for this shot, she was late for two such appointments in the previous year. What if there was a contraceptive injection that your patients could be instructed to use in selfinjection? Initial research on a new lower-dose form of DMPA indicates that women can obtain safe, effective contraception in this convenient form. The low-dose subcutaneous contraceptive injection, DMPA-SC, is not yet approved by the Food and Drug Administration (FDA) or in any other country. The drug is in Phase 3 testing in the clinical research pipeline, reports Rebecca Hamm, spokeswoman for Pfizer, the manufacturer of the drug. The company offers no information as to its potential cost. The new drug differs from DMPA’s current intramuscular (IM) formulation in that it contains two new buffering ingredients and one anti-flocculation agent, states Anita Nelson, MD, professor in the obstetrics and gynecology department at the University of California in Los Angeles and an investigator in the clinical trials. It is designed to be administered subcutaneously, not intramuscularly, as with the conventional 150 mg quarterly injection of DMPA. (excerpt)
Latest research sheds new light on DMPA's impact on bone health.
Your next patient is a 17-year-old who admits she has a hard time remembering to take the Pill, but says she wants to avoid unintended pregnancy. When you begin to counsel on the injectable contraceptive Depo Provera [depot medroxyprogesterone acetate (DMPA), Pfizer, New York City], what do you tell her about the drug? Results from a new study indicate that women who use DMPA experience bone loss. Women in the study who used the injectable for two years recorded an approximate 6% decline in bone mineral density, compared with a loss of 2.6% among women on oral contraceptives. While earlier research suggests that such loss is reversible after the method is stopped, providers may want to include recommendations on calcium replacement and exercise to promote bone health. DMPA works as a contraceptive by inhibiting pituitary gonadotropin secretion, which suppresses ovulation and ovarian estrogen production. Concern about the impact of reduced serum estrogen on bone has prompted a number of studies of bone mineral density (BMD). (excerpt)
Providing pills: readers speak out.
When it comes to oral contraceptives (OCs), when should pills be prescribed, and when should they be withheld? Respondents to the 2004 Contraceptive Technology Update Contraception Survey take a cautious approach when it comes to providing pills for older women who smoke. Almost three-quarters (72%) say they will not give pills to smokers ages 35-39, and 86% say they refuse pills to those age 40 and older. While oral contraceptives represent a safe, effective choice of birth control for many women, smoking raises the risk of cardiovascular complications, particular among women age 35 and older. Results from a 2003 study, which compared women who used higher-dose OCs vs. those who relied on nonhormonal contraception, indicated a moderate increase in the risk of death from ischemic heart disease in smokers who used the Pill compared with nonsmoking pill users. In comparison with nonsmokers, researchers found an increase in death from all causes of about 25% for light smokers and more than a doubling of death risk from all causes for those who smoked more than 15 cigarettes a day. (excerpt)
Family planning providers hold the line in salary and staffing levels in 2004.
Good news for family planning providers: Salary levels are reflecting a modest increase in 2004, according to the results of the annual Contraceptive Technology Update salary survey. (See “What is Your Salary Level?”, and "In the Past Year, How Has Your Salary Changed?") The survey was mailed in July 2004 to 1,247 subscribers and had a response of 229, for a response rate of 18.36%. Average salary for nurse practitioners (NPs) rose to $55,265 in 2004, up from $51,472 in 2003, according to the 2004 results. Median salaries for this group also moved up to $55,465, climbing from 2003’s $52,368 level. The gain in pay offsets a decline in salaries reported in 2003; NPs had recorded slight increases in their paychecks in 2001 and 2002. Nurse practitioners represent almost half (41.92%) of the 2004 responses. “It is encouraging that salaries are going up,” says Susan Wysocki, RNC, NP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health. When it comes to pay, location and place of employment can make a difference in compensation, she reports. About half (45.41%) of CTU responses came from those working in health departments, while another 24% said they were employed in a clinic setting. When analyzed by geographic location, 35% of CTU responses came from the Southeast, with about 23% from the Midwest and 21% from the Southwest. Jobs in Southeastern public health settings typically record lower levels of pay, Wysocki notes. (excerpt)
Pill remains powerful force in contraception.
Take a look at the last 10 patient charts in your outbox. If oral contraceptives (OCs) were prescribed, which ones were selected? When it comes to prescriptions for younger women, about 24% of respondents to the 2004 Contraceptive Technology Update Contraception Survey say their No. 1 pill of choice is Ortho Tri-Cyclen Lo (Ortho- McNeil Pharmaceutical, Raritan, NJ). Ortho Tri-Cyclen Lo provides a daily dose of 25 mcg estrogen for 21 days and three doses of the progestin norgestimate (180 mcg daily/days 1-7; 215 mcg daily/days 8-14; 250 mcg daily/days 15-21). The last seven days contain no active ingredients. The pill won Food and Drug Administration (FDA) approval in 2002. The higher-dose Ortho Tri-Cyclen, a 35-mcg ethinyl estradiol phasic pill also marketed by Ortho-McNeil, was named by 18.5% of survey respondents as their top nonformulary pill choice for a 21-year-old woman. While its numbers have dropped from its 22.6% ranking in the 2003 survey, the pill continues as the No. 1 formulary choice for young women. (excerpt)
DMPA: check snapshot of current clinical use.
The next patient in your exam room is a 16-year-old young woman who says she needs effective contraception. She has tried oral contraceptives (OCs), but she says she has trouble remembering to take a daily pill. What options can you offer her? The contraceptive injection depot medroxyprogesterone acetate (DMPA, marketed as Depo Provera, Pfizer, New York City) continues as a top choice for birth control, particularly among adolescents. About 90% of respondents to Contraceptive Technology Update’s 2004 Contraceptive Survey say they would prescribe the injectable for young teens, holding steady from 2003’s level. The use of DMPA is second only to OCs at Winnebago County Health Department, a public health facility in Rockford, IL, says Gayle Krevel, RN, MS, CLC, supervisor of women’s health. “Many teens like Depo,” states JoElle Thomas, WHCNP, nurse practitioner at Custer Family Planning, a not-for-profit family planning agency in Bismarck, ND. ”It is convenient.” (excerpt)
Direct distribution of birth control may be an effective strategy for school-based clinics wishing to remove barriers to contraceptive access, according to research findings from Minnesota public health officials. The Minneapolis Department of Health and Family Support operates comprehensive schoolbased clinics in five traditional high schools. Prior to 1998, its clinics issued vouchers redeemable for free birth control at community clinics. The voucher system proved less than effective, however; just 41% of students received all of the contraceptives they requested during the last year of voucher issuance. By switching to direct distribution, that number increased to 99% by 2000. School-based health centers are on the rise; their numbers have increased by 9% over the past two years, according to statistics from the Washington, DC-based Center for Health and Health Care in Schools. According to a 2002 survey conducted by the organization, there are 1,498 such centers across the country; 36% are located in high schools. Forty-three states plus the District of Columbia operate school-based health centers; seven states (Arkansas, Hawaii, Idaho, Montana, North Dakota, South Dakota, and Wyoming) do not have such facilities. (excerpt)
New contraceptives widen choices, but the Pill still is a top selection.
While the contraceptive transdermal patch (Ortho Evra, Ortho-McNeil Pharmaceutical, Raritan, NJ) and the contraceptive vaginal ring (NuvaRing, Organon, West Orange, NJ) are gaining increased use among women, many providers report that oral contraceptives (OCs) remain a popular form of birth control. Responses to the 2004 Contraceptive Technology Update Contraception Survey reflect the Pill’s continued popularity; 39% of survey respondents say more than half of their patients use OCs (compared with 35% in 2003), and about 24% say 26%-50% of patients are pill users, which falls in line with responses from the 2003 survey. “The number of clients leaving the clinic on pills has stayed stable over the months; however, the number of clients staying on pills seems to fluctuate with each new method that comes on the market,” notes Judy Nicksich, women’s health care nurse practitioner at Western Wyoming Family Planning, a not-for-profit family planning agency in Rock Springs, WY. She estimates more than 50% of her female patients leave her office using pills each month. (excerpt)
New study eyes link to DMPA use, STD risk.
Findings from a just-published study indicate that women who use the contraceptive injection depot medroxyprogesterone acetate (DMPA, marketed as Depo-Provera, Pfizer, New York City) appear to have a threefold increased risk of acquiring chlamydia and gonorrhea when compared to women not using a hormonal contraceptive. Researchers involved in the prospective cohort study analyzed results from 819 women from two Baltimore-area clinics who were allowed to choose a combined oral contraceptive (OC), DMPA, or a nonhormonal contraceptive. Most of the women (77%) were single and nulliparous; about half (52%) were white, while 43% were African American. After enrolling in the study, women were tested for chlamydial and gonococcal infection after three, six, and 12 months. The issue is whether DMPA increases a woman’s risk of sexually transmitted disease (STD), or are the women who choose DMPA are more likely to be at risk for STDs, says Susan Wysocki, RNC, NP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health. The study was not a randomized trial; women chose on their method on their own, Wysocki points out. (excerpt)
Improving nutrition in Romania.
8-year-old Clarisa Anastase knows all about taking food or sweets from strangers. Pausing during playtime at her Bucharest school, she explains her mother teaches her to be polite, but always say no, regardless of how tasty whatever is offered may look. As a result, she has very strong views on the vitamin tablets she is expected to take from next year: “I shall take them home and ask my mother, and if she says I am allowed to then I will— otherwise I shall say no.” Clarisa is not alone in her scepticism of the new government-backed scheme to improve the health of Romanian children. Teachers and medical professionals have raised similar objections to the planned forced addition of a government-prescribed dose of vitamins to school dinners next year. Officials in Romania, who have so far ignored criticisms, are meanwhile pressing ahead with plans to give children up to the age of 11 free vitamins. (excerpt)
Don't time first teen visit to first pap test.
The next patient in your exam room is 20 years old. When you note that this is her first gynecologic visit, she tells you that she didn’t think she needed such a checkup until her first Pap test. Adolescents and their parents may have become confused on when to schedule a teen’s first gynecologic exam when updated cervical cancer screening guidelines were issued in November 2002 by the Atlanta-based American Cancer Society (ACS). The 2002 guidelines called for Pap tests beginning either at age 21 or three years after a woman first has sexual intercourse; previous recommendations advised an initial Pap screen shortly after first intercourse or by age 18, whichever occurred first. The Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) followed up with similar guidance in July 2003. Now ACOG is clarifying its guidance with the issuance of a new committee opinion on the subject. Because of the changes in cervical cancer screening guidelines, there is concern that teens will delay important preventive care and sexually transmitted disease (STD) testing until they come in for their first Pap screening, says Paige Hertweck, MD, immediate past chair of ACOG’s Committee on Adolescent Health Care and associate professor in the department of obstetrics, gynecology, and women’s health at the University of Louisville (KY) School of Medicine. (excerpt)
Bulletin: FDA issues approvable status for single-rod contraceptive implant.
American women are one step closer to having a contraceptive implant option with the recent Food and Drug Administration (FDA) issuance of approvable status for Implanon, the single-rod contraceptive implant from Organon (West Orange, NJ). According to the FDA, an approvable letter signals that the agency is prepared to approve the product dependent on the company meeting specified conditions. Organon is in the process of meeting those requests, states Frances DeSena, company spokeswoman. “Our next step is to provide FDA with the information they have requested so that we are can obtain approval,” says DeSena. “Based on that approval, Organon plans to launch sometime in the first half of 2005.” Implanon is inserted under the skin of the upper arm, and provides contraception for up to three years. Consisting of a nonbiodegradable rod measuring 40 mm in length and 2 mm in diameter, the device releases the progestin etonogestrel at an average release rate of 40 mcg per day. Since the device does not contain estrogen, women who do not tolerate or are contraindicated to estrogen use may safely use it. (excerpt)
STDs: research aims at hidden epidemic.
You suspect that your 17-year-old patient may have a chlamydia infection. Thanks to a nucleic acid amplification screen on a urine specimen, you are able to detect the sexually transmitted disease (STD) and report the results the next day. Nucleic acid amplification tests (NAATs) that allow screening and diagnosis of such STDs as chlamydia and gonorrhea rank as top advances in the fight against these and other infections, say reproductive health experts. “The introduction of nucleic acid amplification tests, specifically for chlamydia and gonorrhea, has provided incredible improvement in our ability to accurately diagnose these infections in a whole variety of populations, whether symptomatic or not,” observes Julius Schachter, PhD, professor in the department of laboratory medicine at the University of California San Francisco (UCSF) and director of the UCSF Chlamydia Research Laboratory at San Francisco General Hospital Medical Center. (excerpt)
Assessing the vital needs of disasterstricken populations is essential to determine major health problems and priorities for aid interventions. Lamno town (4000 inhabitants) is located 40 km south of Banda Aceh on the western coast of Sumatra, Indonesia. After the tsunami struck on Dec 26, 2004, about 8000 people from surrounding villages found shelter in 11 sites (tents, schools, and mosques) located throughout the town. Médecins Sans Frontières (MSF) accessed Lamno on Jan 6, 2005, to provide medical care and safe drinking water to the displaced. On Jan 15 and 16, 2005, an epidemiologist did an assessment in a school where 2014 displaced people from nine villages received medical assistance from MSF. This assessment included a survey and general observations. The sample size was chosen to represent 20% of this population. In each of the 15 classrooms of the school, six heads of family were randomly selected by systematic sampling, and interviewed with a pretested questionnaire. Interviews were done in Indonesian or Achanese and translated into English. (excerpt)
African American women hit hard by HIV / AIDS.
African American women are far more likely to be infected with HIV than are white women and Hispanic women, a problem that has been growing, according to recent reports by the Centers for Disease Control and Prevention (CDC). Non-Hispanic black females have 19 times the rate of HIV infection as non-Hispanic white females and five times the rate as Hispanic women, according to surveillance data from 32 states between 2000 and 2003. In all, 28% of the HIV/AIDS cases diagnosed in the 32 states from 2000 to 2003 were of women; and of these cases, about 69% were African American women. CDC surveillance data counted 25,254 HIV/AIDS diagnoses among African American women, compared with 6,545 cases among white women and 3,792 cases among Hispanic women. “When you look at the HIV/AIDS rates, the rates were higher among minorities since the beginning, but the numbers didn’t [ratchet up] until the mid-’90s, and since then it’s been predominantly a racial minority epidemic,” says Robert Janssen, MD, director of the CDC’s Division of HIV/AIDS Prevention-Surveillance and Epidemiology. (excerpt)
Adverse event reports spark discussions on safety of Evra contraceptive patch.
Did the office telephone lines start buzzing when the media broadcasted reports of adverse events linked to use of the transdermal contraceptive Ortho Evra (Ortho-McNeil Pharmaceutical, Raritan, NJ)? There’s no doubt that clinicians have, since those reports, fielded many questions about the safety of the patch, which has been used by about 4 million women since its November 2001 approval by the Food and Drug Administration (FDA). Media reports were prompted by the April 2004 death of an 18-year-old New York City woman who had been using the transdermal contraceptive. An autopsy indicated the cause of death was due to a pulmonary embolism, and the medical examiner ruled it a side effect of the birth control device. The New York Post published a report stating that it had obtained FDA records “show[ing] that 17 patch users, ages 17 to 30, suffered fatal heart attacks, blood clots, and possible strokes since August 2002.”1 The FDA and Ortho-McNeil are examining the adverse event reports; however, both believe that the published numbers may contain duplications, states Kathleen Quinn, agency spokeswoman. (excerpt)
The tsunami coverage in The Lancet was timely. The Sri Lankan and Indian cases poignantly illustrate the miseries of the people and the role played by doctors and health services in alleviating suffering. However, a clinical response such as treating the injured and burying the dead is an extremely complex issue linked to the overall sociological and cultural context. A few socioepidemiological issues need to be considered, especially in the case of India. The first issue is the mindless and disrespectful disposal of dead bodies in India. Many dead bodies were thrown into pits without proper identification. This was done for fear of epidemics, despite evidence to the contrary, and will result in long-term miseries and legal tangles for the surviving families. In the age of digital technology and high-tech laboratory facilities, an effort should have been made to take digital photos and tissues for DNA analysis. (excerpt)
Tips on what to cover in an initial teen exam.
What do you cover when you conduct a teen’s first gynecologic exam? Understand that an adolescent’s initial visit may not necessarily include a pelvic examination or a Pap test, but that it should cover a wide spectrum of issues facing a young woman of reproductive age. The Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) has developed a confidential questionnaire based on the Chicago-based American Medical Association Guidelines for Adolescent Preventive Services (GAPS), a comprehensive set of recommendations for teen preventive health services. The ACOG questionnaire provides a quick overview of several subjects, including such issues as depression and substance abuse, says Paige Hertweck, MD, immediate past chair of ACOG’s Committee on Adolescent Health Care and associate professor in the department of obstetrics, gynecology, and women’s health at the University of Louisville (KY) School of Medicine. (excerpt)
Emergency contraception moves into mainstream.
What is the policy for providing emergency contraception (EC) at your facility? About 81% of respondents to the 2004 Contraceptive Technology Update Contraception Survey say their facilities prescribe EC on site and provide emergency contraceptive pills (ECPs) at any time, which continues a trend of strong support for the method. Stephani Cox, APN, CNP, DPS, director of patient services at Planned Parenthood Springfield (IL) Area, says the number of EC users have increased significantly over the past year. “We accept patients in need of EC at any time on any day as walk-in,” she says. “We talk about it with all of our patients when they are here for their annuals, negative pregnancy tests, and [at] just about any other opportunity.” The nurse practitioners carry a weekend pager for EC, and the number is advertised on the telephone message system, Cox says. “We also have included the pager number and EC information in with our monthly billing statements.” (excerpt)
Look to the future for bold changes in reproductive health.
Look ahead five to 10 years, and you may see a male contraceptive on the market, as well as a microbicide for women that offers contraception as well as female-controlled protection against HIV and other sexually transmitted diseases (STDs), say reproductive health experts. Researchers are examining different approaches to identifying molecules controlling spermatogenesis and oocyte maturation, sperm-egg fusion, and endometrial implantation of the early embryo. By applying genomics and proteomics technology or building upon genetic analysis of model organisms, scientists hope to unlock new discoveries that will lead to more contraceptive options. “The future will be very much influenced by new pharmaceutical agents,” forecasts Leon Speroff, MD, associate director of the Women’s Health Research Unit at Oregon Health & Science University in Portland. “The knowledge gained from molecular biology allows the development of drugs that will target specific tissues and functions, minimizing unwanted effects.” (excerpt)
Progress under way on the microbicide front.
Promising advances are being made on the microbicide front: U.S. funding appears imminent for microbicide research and development, a new corporate partnership has been struck with an international research group to step up testing of antiviral AIDS gels, and a number of potential candidates are moving through the research pipeline. Why is progress so important when it comes to microbicide development? With a microbicide in hand, women would have an effective female-controlled form of protection against infection. Even if a candidate were found to be 60% efficacious, it would aid in averting 2.5 million HIV infections across the globe over three years. The Senate Appropriations Committee has passed its FY 2005 foreign operations bill to include a $10 million increase for microbicide research and development, resulting in a total of $32 million aimed at global aid for microbicide research. Final action on the bill is expected by Contraceptive Technology Update press time, estimates Mark Mitchnick, MD, director of research and development for the Silver Spring, MD-based International Partnership for Microbicides (IPM), a nonprofit organization established to accelerate the development and accessibility of microbicides. If approved, IPM will receive $2 million of the increased funding. (excerpt)
Ask the experts: Answering your questions on DMPA use and weight.
Should a woman who is obese and continues to gain weight on Depo-Provera [depot medroxyprogesterone acetate (DMPA), Pfizer, New York City] be allowed to continue its use if she so desires? Are providers contributing to the health risk of obesity by allowing a woman to do so? These questions are addressed by two members of the Contraceptive Technology Update editorial advisory board: Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta, and Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville. (excerpt)
Your Jan 8 Editorial states that “mortality is an insensitive measure of health risk”, but it is a sensitive issue for some. In The Nation, Bangkok’s independent English newspaper, on Jan 5, the tsunami-related fatalities in Thailand were reported as 5246 Thai nationals and 90 Burmese nationals. However, in the same newspaper, there was an article entitled “Hundreds of Burmese dead”, which was based on information collected from the Human Rights Education Institution of Burma. According to the article, more than 500 Burmese migrant workers died and at least 2500 went missing in the tsunami. However, most went unrecorded and unreported in Thailand’s official death toll. The Burmese embassy also seemed to be indifferent to these workers, since most of them migrated into Thailand illegally. (excerpt)
Easy EC access doesn't increase risky behavior.
If it were easier for women to obtain emergency contraception (EC), would it result in an increase in unprotected intercourse, cause women to forego their current method of contraception, or increase the risk of sexually transmitted diseases (STDs)? Apparently not, according to the findings of a just-published study. Women enrolled at four California women’s health clinics were randomly assigned to one of three EC sources: the clinic, nearby pharmacies without a prescription, or an advance supply of pills. Researchers found about the same percentage of women in each group had unprotected sex over a six-month period, incidents of sexually transmitted disease were equal, and about the same percentage in each group became pregnant. About 37% of women in the group with advance EC used it at least once during the six months, compared with 21% in the clinic access group and 24% in the pharmacy access group. The results counter concerns voiced by opponents to expanded EC access, who have claimed that easier access will lead to increases in sexual promiscuity and STDs. Such concerns may have lead the Food and Drug Administration to issue an initial rejection to Pomona, NY-based Barr Pharmaceuticals’ application to move its levonorgestrel-only EC pill Plan B to over-the-counter (OTC) status. (excerpt)
Be prepared to counsel on use of DMPA and bone health issues.
It’s time to update your counseling on the injectable contraceptive depot medroxyprogesterone acetate (DMPA, Depo-Provera, Pfizer; New York City). The Food and Drug Administration (FDA) has added a “black box” warning to the drug’s labeling to highlight that prolonged use may result in the loss of bone mineral density (BMD). The new label states that bone loss in women who use Depo-Provera is greater with increased duration of use and may not be completely reversible. The injectable contraceptive should be used as a long-term birth control method (longer than two years) only if other birth control methods are inadequate, the label advises. Women who continue to use Depo-Provera past the two-year mark should have their BMD evaluated, according to the new labeling. Since Depo-Provera was approved for U.S. use in 1992, its prescribing information has included a warning that use of the product may be considered among the risk factors for development of osteoporosis. Two studies, one enrolling women ages 25-35 and the other aimed at adolescents, were begun in the mid-1990s to clarify the drug’s impact on BMD. Results from the studies, which have not yet been published, provide the background for the drug’s revised labeling. (excerpt)
The quality of family planning services in Uttar Pradesh from the perspective of service providers.
There is a growing realization in India that unless the quality of services in the public sector is improved, acceptance and continuation of contraception to the desired levels may not be achieved. It is important to understand the social, physical, and administrative environment in which the grassroots components of a health program function and provide services. Bruce created a framework that conceptualizes this environment as program effort consisting of policy and political support to the family planning program, resource allocation; and family planning program management and structure. Given the shortage of essential resources and the problems with facilities in many areas of India, providing a high quality of services is a challenging task. In a complex and bureaucratic system like the Indian Family Welfare Programme, workers at the grassroots level have limited Opportunities to discuss and resolve their problems. They often neglect their duties by not visiting field areas, not attending clinics, providing only a limited range of services, or meeting only some of the goals set by higher officials. Foremost among these goals has been the achievement of method-specific targets, particularly for sterilization. To improve the program's services, program managers must take into account not only the perspectives of users, but also the perspectives of providers. In this chapter we present health workers' perspectives on the quality of program services, specifically the readiness of health facilities to provide high-quality services and the obstacles that workers face in performing their jobs. We discuss providers' views on the need to offer a range of services, to inform clients about available contraceptives, and to follow up acceptors. We also examine, from the providers' perspective, the consequences of over-emphasizing family planning targets, particularly sterilization targets, for the quality of services. (excerpt)
New research eyes OC in acne treatment.
The next patient in your exam room is an adolescent female, who says she’s interested in birth control pills. Her chief focus? While she’s interested in contraception, she asks several questions about an “acne pill.” According to A Pocket Guide to Managing Contraception, all combined oral contraceptives (OCs) lower free testosterone due to their antiandrogenic compounds. However, only two pills — Ortho Tri-Cyclen (Ortho-McNeil Pharmaceutical, Raritan, NJ) and Estrostep (Warner Chilcott, Rockaway, NJ) — carry an approved indication from the Food and Drug Administration (FDA) for treatment of mild-to-moderate acne. Ortho Tri-Cyclen uses a combination of ethinyl estradiol and norgestimate, while Estrostep uses a mix of ethinyl estradiol and norethindrone acetate. Ortho Tri-Cyclen received its indication based on research published in 1997; Estrostep gained its approval on research published in 2001. Look for other OCs to seek similar acne indications; recently published research indicates that Yasmin (Berlex Laboratories, Montville, NJ), a combination of ethinyl estradiol and drospirenone, also is effective in treating the condition. Other OCs are now being evaluated for possible treatment of acne; two trials involving Alesse (Wyeth-Ayerst Laboratories, Philadelphia) showed total acne improvement of 23%-40% compared with 9%-23% with placebo. Alesse relies on a combination of ethinyl estradiol and levonorgestrel. (excerpt)
Male contraceptives are gaining momentum.
The first male contraceptives to make it to the market likely will be hormonal-based birth control, similar to what has worked well for female contraceptives for the past four decades. However, there are serious difficulties with hormonal contraceptives for men, so the possibilities that are beginning to excite researchers working in the contraceptive field are the nonhormonal methods. “We have to consider all of the possibilities,” says Deborah O’Brien, PhD, an associate professor at the University of North Carolina School of Medicine in the department of cell and developmental biology in Chapel Hill. There is a need for a variety of contraceptive options for men and women, she says. “Nonhormonal and post-testicular methods are what we’re shooting for,” she says. “We’d like to inhibit sperm specifically and not have side effects elsewhere.” O’Brien has been working on a contraceptive target involving novel sperm glycolytic enzymes. (excerpt)
Migraine and OCs: what options are open?
How many women do you see in your practice who say they have chronic or recurrent headaches? If the numbers are high, don’t be surprised: Headaches are a frequent occurrence in women of reproductive age. But what is your approach in determining whether these women may use combined oral contraceptives (OCs)? A just-published meta-analysis of several studies highlights the risk of stroke in women who use oral contraceptives and who have migraine headaches. What role does migraine headache play in determining OC use? Clinicians must use their diagnostic skills in determining what type of headache women are describing when offering guidance on birth control, says John Guillebaud, MD, emeritus professor of family planning and reproductive health at University College in London. While guidelines from the Geneva-based World Health Organization (WHO) state that nonmigrainous headache, whether mild or severe, is not a contraindication to OC use, the agency’s Medical Eligibility Criteria lists migraine headaches with aura at any age as a clear contraindication to combined oral contraceptive use. (excerpt)
A woman would prefer to prevent an unwanted pregnancy rather than having an abortion or carrying the pregnancy to term. No amount of legal or religious restrictions, social stigma or lack of access to professional care can stop her if she decides to seek termination of an unplanned pregnancy. Society and the health care providers should help in preventing abortions. A late abortion is particularly distressing for both the woman and the professionals involved in her care. In spite of this, it is surprising that an estimated 40-60 million women seek termination of pregnancy every year. Unfortunately, a large percentage of the induced abortions, particularly in developing countries, are performed by unqualified persons under unsafe conditions. As a result, the woman faces a risk of death perhaps 100-500 times greater than the woman who has access to a skilled operator working in aseptic conditions. In fact, unsafe abortion is one of the greatest neglected problems of health care in developing countries and a serious concern to women during their reproductive lives. At least 70.000 of the approximately 580,000 maternal deaths that occur annually are a consequence of complications of unsafe abortion procedures. The available methods of fertility regulation are quite safe and effective, and their use can help couples to decide when and how often to allow pregnancy to occur. In addition to the regular methods of contraception, there are contraceptives available, commonly referred to as emergency contraception, which can be used postcoitally and provide a back-up in individuals at risk of unplanned pregnancy. Indications for emergency contraception include unprotected intercourse, failure of barrier method, missed oral contraceptive pills, and sexual assault. Emergency contraception has therefore rightly been referred to as "the Casualty Department of Family Planning" as it offers a last chance, secondary method of contraception to prevent an unplanned pregnancy. (excerpt)
Update: FDA strengthens mifepristone labeling.
The Food and Drug Administration (FDA) has strengthened the warning information on the labeling for the abortion drug mifepristone. The labeling change is in response to reports of infection, bleeding, and death among women who have taken the drug, according to the FDA. Changes to the existing “black box” warning on the product, marketed in the United States as Mifeprex (Danco Laboratories, New York City), reflect heightened information on the risk of serious bacterial infections, sepsis, bleeding, and death that may occur following any termination of pregnancy, including use of Mifeprex. The changes follow reports of such incidents to Danco and to the FDA. Danco Laboratories has revised the drug’s labeling, medication guide, and patient agreement, and it has alerted providers regarding the new information. (excerpt)
Clinical trials begin for spray-on contraceptive.
A spray-on birth control method for women recently has entered a Phase I clinical trial in which six women in Sydney, Australia, are using the new product as part of a study to determine whether the transdermal contraceptive can be used in spray formulation effectively. Named Nestorone Metered Dose Transdermal System, the fourth-generation progestin is being studied through a joint development agreement between the Population Council of New York City and Acrux, a pharmaceutical company of Melbourne, Australia. FemPharm, a wholly owned subsidiary of Acrux, is the study’s sponsor. Nestorone has strong progestational activity and antiovulatory potency, but it has no androgenic or estrogenic activity in vivo, which makes it suitable for contraception use. Since it is very potent, it can be delivered via long-term delivery systems, such as vaginal rings, implants, and transdermal system. “This is only a beginning of clinical trials to see if Nestorone could be used in spray formulation to deliver the Nestorone progestin in sufficient amounts to be effective,” says Regine Sitruk- Ware, MD, executive director of product research and development for the Center for Biomedical Research at the Population Council in New York City. (excerpt)
Demographic and cultural aspects of prenatal technology.
The two issues in the field of fertility that have received widest publicity in the recent times in India are the rapidly growing number of clinics that are performing amniocentesis, which is followed by female foeticide and the birth of a test-tube baby in Bombay. The practice of female foeticide has generally sent shock waves even when it is getting a wider acceptance as indicated by the rapidly increasing number of medical practitioners who are participating in the services of amniocentesis though they do not have the sophisticated gadgetry for the chromosomal analysis. These doctors are located in far flung areas of the country covering several States and rural and urban populations. The expensive gadgetry that is required for chromosomal analysis is available in very limited number of laboratories located in metropolitan areas. The services of these laboratories are available to these doctors practicing in far-flung areas. They send the amniotic fluid obtained from their pregnant clients, to these laboratories for advising the women on the sex of their conceptions. Abortion services are available freely, all over the country under the Medical Termination of Pregnancy (MTP) Act of 1971. So the women can easily avail of these services. Separating the stages of the services from amniocentesis to foeticide also has helped the doctors's protecting themselves from action of law because none of these in themselves are against law. (excerpt)
Hormonal-based male contraceptive moves ahead.
Clinical trials for a male contraceptive that is a combination of progesterone and testosterone are expected to begin this year. “We have a protocol for one agent that we’re going to start in clinical trials this year for the National Institutes of Health [NIH],” says Michael Rosenberg, MD, MPH, clinical professor of obstetrics/gynecology and epidemiology at the University of North Carolina-Chapel Hill and president of Health Decisions also in Chapel Hill. The U.S. trials are planned to be Phases I and II studies to look at the pharmacokinetics and effectiveness of a combination of testosterone and nestorone, which is a long-acting progestin that also has been tested in women, he reports. The contraceptive likely will be administered in two pills to about 50 male volunteers, he says. While surveys show men are very interested in having a male contraceptive and might prefer an oral contraceptive, the problem is that hormonal-based contraceptives can cause unpleasant side effects, experts say. (excerpt)
CDC warning: family planners should be on the lookout for lymphogranuloma venereum.
An outbreak of a type of Chlamydia trachomatis, lymphogranuloma venereum (LGV) has occurred in the Netherlands and other European countries, which has led infectious disease officials with the Centers for Disease Control and Prevention (CDC) to ask U.S. clinicians to look out for LGV cases. Clinicians may find it difficult to diagnose LGV since its symptoms are not recognized as typical symptoms of an STD and are similar to those that are caused by other conditions and infections, notes Catherine McLean, MD, medical epidemiologist with the CDC Division of STD Prevention. “So it’s important to alert health care providers to watch for these symptoms in their patients, especially among MSM [men who have sex with men], and evaluate and treat patients as appropriate,” she says. The systemic STD LGV is extremely rare in the United States and Europe, although its prevalence is greater in Africa, Southeast Asia, Central and South America, and Caribbean countries. However, from April 2003 to September 2004, there were 92 confirmed cases of LGV reported among MSM in the Netherlands. (excerpt)
Teens improve contraceptive use, but more women at risk for pregnancy.
Just-released information from the National Survey of Family Growth offers family planning clinicians a mix of good and bad news: While sexually active teens are more likely to be using contraception, many teens are uninformed about birth control choices. The research also indicates that the number of women ages 15-44 at risk of pregnancy but using no method of contraception rose from 7.5% in 1995 to 10.7% in 2002. While this 3.2% rise may appear small in numbers, it translates into potentially large problems with unintended pregnancy, says James Trussell, PhD, professor of economics and public affairs and director of the Office of Population Research at Princeton (NJ) University. In 1994, the last year for which data are available, the small minority (7.5%) of women using no contraception contributed almost half (47%) of the 3 million unintended pregnancies in the United States, he reports. “What we have witnessed is a 43% rise in that small minority, which would lead, everything else held constant, to an 18% rise in unintended pregnancies,” he explains. (excerpt)
Fertility transition in India: problems and prospects.
The rapid rate of population growth in India is adversely affecting every sector of its economic and social development and the country seems to be in the grip of the vicious circle of economic backwardness-high rate of population growth-more economic backwardness. The unprecedented rate of population growth in India has been caused due to the drastic decline in mortality without being accompanied with the commensurate decline in fertility after 1950. The ultimate solution to the growing population therefore, lies in the control of fertility. The results of the 1991 census alarmed every one, as the intercensal growth rate of the population was as high as 2.14 percent per year, though slightly lower than that during 1971-81. The decline in the death rate as well as the birth rate during the 1970s and 1980s has been rather slow. However, the important feature brought out by the 1991 census is that the decadal growth rates in 15 major states (those with a population of 10 millions and above) has varied widely between 13.4 percent in Kerala to 25.0 percent in Rajasthan. Also, the in demographically backward states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh accounting for 40 percent of India's population the growth rate over the previous decade has increased, imparting higher momentum to their population growth. According to SRS 1993, the birth rate in Uttar Pradesh is 36 per thousand population against the death rate of 11. These figures clearly imply that in the near future U.P. might experience an even higher rate of growth of its population because of the further decline in the death rates, if the birth rate does not decline faster. (excerpt)
In the land of goddess worship.
It is taking discrimination against women to the womb. It is denying women the right to equality and the right to life on the grounds of gender. It is like telling them that they are not wanted. The issue of female foeticide simply does not shock or disturb anyone any longer. Maya got up early that morning. After a bath and the daily ‘Puja’, she called the neighbour’s daughter, made her sit over an asana, washed her feet and put a kumkum tilak over her forehead. She offered the child sweets, fruit, new clothes and prostrated before her. As Maya finished her ‘Kumari Puja’, her husband returned from the temple of the Mother Goddess with Prasadam which they consumed with Shraddha. In the evening, Maya’s husband took her to a gynaecologist for a test. Two days later, she aborted her child –it happened to be a female… Lakhs of such events, with minor modifications occur in the villages, towns and even the large cities. These Mayas, Marys and Miriams cut across all boundaries of caste, class, communities and cultures. The problem of sex-selective abortions, however, is not merely of numbers or the scale of propagation. It is a problem of conscience. That the ever-growing ‘Femicide’ in the land of goddess worship does not shock or disturb anyone is the problem. It is difficult not to feel frustrated when decade-long efforts of campaign and advocacy produce a law only on paper. This article is an attempt to share this anguish, with a hope to rekindle the fire which initiated the nation-wide campaign against sex-determination tests in 1986. Before a medical device (drug) is introduced in the market, it is subjected to extensive tests on animals and humans for years to assess its efficacy and safety. But no risk/benefit analysis is carried out before introducing a medical technology in society, although its effects could be damaging and even irreversible. An international conference held in Geneva in 1974 warned of the possible serious social, moral and demographic effects of technologies like amniocentesis on countries like India. (excerpt)
Population growth and development relationships: a critique.
Population growth and development relationships have been focus of debate in various contexts but more often than not receiving an arbitrary deal. The mushroomed views expressed in this regard, no doubt, acknowledge the complexities and magnitude of the population growth related issues, these appear to be inconsistent and difficult to be linked in a systematic manner. The present paper attempts to put precisely the diverse arguments advanced by noted scholars of this field, as far as possible, in a coherent way underlining the problem, dual facets (dilemma) of population-development relationships, imperatives and ironies of situations, relevant issues and pertinent questions, etc. Prior to summing up, sonic explanations and certain suggestive measures have been succinctly discussed. Although illustrative in nature with examples drawn from developing countries, particularly India, this paper's significance lies in its being related to the population factor which has bearing on practically all the inputs of development planning. At the out set, it can be observed that the menacing rise of population on the one hand and miserable failure of population control measures on the other has rather led many to believe that rapid population growth is the single most important factor impeding variety of development efforts and causing deterioration in environmental quality. Surprising is its use as a good excuse to explain inadequate provision of basic social facilities, low rate of child survival, slow rate of economic growth and, above all, poor performance of any policy or programme. Though no serious attempt has been made to investigate into real causes, some scholars have questioned the tenability of the aforesaid views as such and have tried to seek explanation in factors other than population. Their main plank remains improvement in socio-economic conditions reflecting in substantial increase in rural income, reduction in child death rates, enhancement in life expectancy and general fall in average family size in spite of so-called alarming population growth. To them, not less important is the rising expectation and demand for equitable international economic order necessitating a model around population-development syndrome. However, it should not be inferred from the foregoing that population growth is a desired proposition. Rather, the need of the hour is a balanced view and an honest assessment of the situation. (excerpt)
Advice and restrictions during pregnancy.
What a woman eats and what she does directly affects the well-being of her child-to-be. This idea underlies traditional care during pregnancy. It may be true that in pregnancy a woman has more access to food and other things. But, communities have ways to oversee foetal growth and development. They subject women to restrictions and recommendations regarding diet and activities. Much of the time such advice help to improve the health of the woman, too. But this is not always so, particularly when the health of a woman is already compromised by poverty, over-work and gender-discrimination. When pregnancies are frequent, food too little, and work heavy, women don't get enough time for their health to recoup. Nutritional stress leads to loss of iron, protein and fat stores entailing numerous problems and complications. Not enough food throughout childhood and youth leaves women stunted, putting them at risk of obstructed child-birth. For fear of this, food is further restricted during pregnancy. People hope that a smaller baby will make birth easier, or possible. Food restrictions may not be adequate, however, to slim the foetus enough to drop the risk of obstructed labor. But, they will certainly worsen the nutritional status of die woman. (excerpt)
Making labor and child-birth easier.
Child birth is a natural but complicated event, laden with labor and pain yet exuding the joy of bringing a bit of humanity into being. In most of the rural areas in India, bringing humanity to the light of day is collectively and deftly managed by the dai along with other experienced women and the laboring woman herself. Women still have confidence and skills centered around child-birth. Their warm encouragement and natural support of labor enables the birthing woman to move through this event with courage, power and ease. Traditionally, in giving birth a woman is believed to gain a second life. The relatives' and the dai's concern is deep for the well-being of both woman and child. The dai's practices and rituals are meant to help and make labor and child-birth smoother and faster. Labor is handled spontaneously. When a woman starts feeling the pains of early contractions, she carries on with her work. Gradually, as the contractions become, strong, some neighbor woman may gather around her and when she can 'hold back' no longer, someone goes off to call the dai. Frequently, the dai enters the house when the child's head is 'crowning' and birth is near. She settles down next to the woman, coaxing and cajoling her, soothing her while the contractions abate. She may call upon the goddess of birth to separate the two lives early. She may ask the family members to open all the locks on the trunks and the woman in labor to let her hair loose to enable early child birth. (excerpt)
Kachha ghada phootne mey jyaada takleef hoti hai ... (With the shattering of an un-baked earthen pot the suffering is more... women in Rajasthan) Women use images of earthen pots breaking, flowers or fruits falling, to symbolize the loss of pregnancy. kachha ghada phoota (UP Rajasthan), phool jhade (Madhya Praciesh), kaacho padi gayo (Rajasthan), garbha-alasyam (Kerala) are some of the terms used to describe miscarriages. In english, human embryo death and its exit from the womb if unintended is called miscarriage, or if caused purposefully it is called abortion. Spontaneous abortion and induced abortion are terms that doctors use. Miscarriages are not uncommon among women in India. In the west, research has estimated that between fifteen to thirty conceptions out of a hundred are miscarried. Most are 'silent', near the time of the expected menstrual period. Early miscarriages are now largely understood as natural selection by a woman's body to weed out genetically blighted embryos. But early miscarriages can also result from poverty-linked and gender-tainted factors like under-nutrition, infections, work stress, accidents, domestic violence and so on. (excerpt)
Keeping women healthy after child-birth.
After the birth, a woman's dhatus are drained, her body is loose and cool. Because of her labor, and the flow of waters and blood from her womb, her body is as if empty, in, a vacuum (translated from a shloka in Ashangu Hridaya) Traditional care consists of numerous practices which mean to bring her back to 'rosy health and vigor' and to enable her to feed her child with sufficient nutritious milk. As the woman's health is all the more vulnerable after child-birth, practices are adopted to sustain her health. The forty five days or one and half month after a child's birth is a period of high significance within most communities. People observe 'sutak' a pollution which afflicts family members when someone is born or dies. The family even refrains from worshiping the gods in the house-temple. The entire process of child-birth is considered a polluted affair. The family members refrain from touching the woman, the dai and helping woman during child-birth, which easily follows in to the after childbirth care. It is a common belief that a woman has peculiar fragrance after child-birth which lures the daakin or churel (evil spirits) to hold her. Rituals such as nazar utaarna, keeping iron knife or instrument under the pillow of the woman are done to ward off the spirits. The woman is kept in isolation. No body is allowed to touch the cot. She is advised against going out, in the dark and not to speak loudly, laugh loudly, talk too much or remain sitting (she should lie down). (excerpt)
A lady in yellow suit entered the house to see the newly wed bride and the bride was tactfully instructed by the grand lady of the house to leave the place, so as to avoid the shadow of the lady. The visitor was sent back without giving a chance to interact with bride. Poor lady also left silently. What was wrong with her? She was married for 10 years and she had lost six pregnancies during this period and had no live issue. If the shadow of such a lady had fallen on the bride, it would have been bad omen for the bride's future fertility. It is believed, that, the unlucky lady is in a grip of some bad soul. Her family has tried many "ojha's" to break the grip of bad soul over her, but to no effect. She conceives, but it aborts or the foetus dies, or she has a prematurely delivers and child dies during birth. She is unable to understand and is helpless, torn physically, emotionally and psychologically due to social contempt towards her. This is not the only example. Such cases are scattered all over the country, in urban as well as in rural areas, more so in remote areas, among illiterate and poor populations. Is there no way out? Has science helped us to understand the misery of such women? Yes, we have added a lot to our knowledge to reduce this misery and this knowledge must be disseminated for the benefit of suffered women and their families. Let us discuss, in brief, what are the causes for 'bad obstetrical histories', that are known to us and how they can be prevented. (excerpt)
Population control: state sponsored violence against women.
The planet is getting polarized in demographic and economic terms. Developing countries experience problems with their population growth along with pervasive poverty. Demographic projection of population raise questions on the ability of the earth's carrying capacity to maintain people at adequate standard of living. Inspite of the overall improvement there are wide variations in the quality of life of people. High rates of growth of population therefore certainly need to be contained. Thomas Malthus in 1798, exactly two centuries ago, had warned about maintaining the balance between population and flood-supply unless population size was controlled. The population in these two centuries has grown six fold from one billion to six billion. Food available in the market is enough to feed all, and on this count Malthus is proved wrong. If people still go hungry it is because of absence of distributive justice in the prevailing social system. Similar situation prevails with respect to other resources. The problem of having adequate resources is not necessarily a problem of the future. Many non-renewable and renewable resources are already being used in an sustainable manner and consumption is more than the earth can regenerate. Available information indicates that the economic inequity among people is very rapidly growing. A fraction of the world's people consume disproportionate amount of natural resources. (excerpt)
Target free approach (TFA) and reproductive and child health (RCH) as population policy.
The women's groups were able to actively agitate against population control policies at conference on environment held in Rio-de-Janeiro in 1992, at conference on human rights at Vienna 1993, and then they were able to get the POA (Programme of Action) of the conference on population and development (ICPD) held in Cairo in 1994 to clearly state that the population control will not be promoted through incentives or disincentives nor will any targets be given by the governments for achievements in distribution of contraceptives. The discussions at the conference also pointed that women have problems regarding their reproductive health and these were not attended to. The 'culture of silence' surrounding issues related to sex and reproduction further prevented women from discussing their problems. It was stated at the ICPD that the states will take up programmes for empowerment of women, provide information and services on methods of regulating fertility and promote reproductive health. With the policies of globalisation and structural adjustment, accepted by the government, pressures from international agencies are influencing the functioning of several programmes in India. Since promotion of population control in the Third World countries has gained considerable importance for several international agencies, reproduction has received attention from these groups. Lower status of women in the society has been exploited to promote vested interests. Though the government of India was a party to the decisions at the ICPD at Cairo, a review of the functioning of the family planning programme shows that the decisions such as 'no-targets' are on paper but women are being oppressed to accept family planning. Health of women continues to be neglected. (author's)
Breast feeding patterns in an urban resettlement colony of Delhi.
Studies on duration and patterns of breast feeding based on recall may lead to a bias about the exact feeding status. The present study was designed to overcome this bias using the 'current status analysis method'. Mothers of 650 infants from 0 to 12 months of age attending a Health Center were interviewed about the current feeding patterns of the infants and other socioeconomic variables. Month-wise prevalence of feeding patterns was determined. It was observed that breast feeding was maintained at a high level (more than 90%) throughout infancy while exclusive breast feeding showed a rapid decline. At 1 month, 74% and at 4 months, 46% of infants were exclusively breast-fed. The median duration of exclusive breast feeding was 3.83 months. Mothers with lesser education and lower family income were more likely to exclusively breast feed (p < 0.05). The time interval between birth and first breast feed was 24-48 hours in most (48.9%) of the infants. Majority (76.9%) of the infants received pre-lacteal feeds. Hospital-born infants received their first feed earlier and were less likely to receive pre-lacteal feeds as compared to those born at home (p < 0.001). Thus, the practice of exclusive breast feeding has to be promoted amongst pregnant and lactating mothers by health personnel. Also knowledge regarding infant feeding has to be imparted in schools and colleges. (author's)
From dias to doctors: the medicalisation of childbirth in colonial India.
If she have sent her servants in our pain, If she have fought with Death and dulled his sword, If she have given back our sick again, And to our breasts the weakling lips restored, Is it a little thing that she hath wrought? Then Birth and Death and Motherhood be nought. -- Rudyard Kipling…Kipling was paying tribute to the Vicereine who established the Fund associated with her name. This was an organisation which employed medical women (or 'lady doctors') to run a chain of hospitals and dispensaries all over India and Burma. Established in 1885, the avowed aims of the Dufferin Fund were to provide medical tuition to Indian women, medical relief to Indian women, and trained female nurses and midwives for women and children in hospitals and private homes. Because the Fund was the first large endeavour in the area of women's health in colonial India, and because it enjoyed the patronage of the successive Vicereines and was associated with a great degree of official interest, it assumes more importance to historians than it perhaps deserves. It is said that no less august a personality than Queen Victoria herself was the moving force behind the establishment of the Fund. The medical missionary, Elizabeth Bielby, is said to have carried back to the Queen-Empress a message from the Maharani of Panna, imploring her to 'do something' for her 'daughters in India' who suffered so terribly in childbirth. When Lord Dufferin was sent out as Viceroy in 1883, the Queen asked his wife to interest herself in maternal health. (excerpt)
Breast feeding, the working and the law.
Great concern is currently being expressed, about the trend towards decline in breast-feeding and its implications for the health and development of children. The efforts consequently being made to promote breast feeding through social policy and proposed new legislation, such as the infant Milk Substitutes, Feeding Bottles and Infant Feeding Bill (1992) tend to, focus attention almost exclusively on the welfare of the child. However, keeping in mind women's dual roles as productive workers and citizens on the one hand and mothers on the other, it is necessary to raise certain issues related to working mothers and the law it order to take a more comprehensive and balanced view of the needs of both women and children. This becomes even more important since some of the existing and proposed laws seem to be contradicting instead of complementing each other in seeking to attain common goals. It is also inadequate to consider laws alone. A holistic perspective must take account not only of laws (and rules under them) but also of Government policies as, expressed in schemes as well as prevailing work-place norms and conventions. This paper ishence divided into three sections: 1. The rationale for an approach to the issues related to working mothers, breast-feeding and the law. 2. Review of prevailing laws and policies, and their implementation. 3. Proposals for comprehensive legislation and policies. (excerpt)
The critique grows out of the basic assumption that women perform three roles - the productive, reproductive and the consumer. It has been customary to speak about the "double burden," of women, setting the work role against the domestic role. However, when the child bearing and rearing role is merged with the consumer, role under the rubric of "housewife" or domestic role, certain critical differences in the nature and duration of the two tasks are blurred. On the one hand, the periods of child-bearing and child rearing are limited, yet fixed by factors beyond a woman's control, while housekeeping is a permanent and ongoing feature. On the other hand specific housekeeping tasks may be postponed, avoided or delegated, while the child requires continuing attention and cannot be treated in the same way. So separating the two into three roles' offers greater clarity of definition. From this standpoint, it is possible to define as a continuum the period during, which the woman, in her role as worker, requires certain support services from family, society, employer and state in order to fulfill her reproductive role without hazard or lost to herself, her children or her capacity to contribute to society as a worker. Though very precise definitions may be difficult at this stage, for practical purposes it can be stated that the mother and child dyad requires maternity and child care support from the third trimester of pregnancy up to the time the child is of school age, that is five/six years old. (excerpt)
Mother's milk is the best milk for children.
Breast-feeding is part of human culture since time immemorial. Even today 4326 animals breast-feed their babies. Mother's milk is Baby's birthright. Breast milk is natural and nutritious. It is priceless, clean and wholesome food for the baby. Compared to other foods, children digest mother's milk easily. But, it is distressing to note that the practice of breast-feeding among human beings has been declining in the world over the past sixty years. However, in the western countries an increase in breast-feeding began in 1970's after decades of gradual decline. The mean duration of breast-feeding, there is about 5-6 months only. While in the developing countries, including India, the practice of breastfeeding has been declining. A shift from breast-feeding to bottle has been noticed in these countries, especially in cities and urban areas with detrimental consequences for the health and survival of infants. Children, who are fed on other than mother's milk, are more prone to diarrhea. At times, it may lead to the death of the child. Differences in breast-feeding patterns have been noticed between rural and urban areas in most of the developing countries. In India more than 95 percent of the women in rural areas breast-feed their infants while in. urban areas only about 70 percent of the infants are breast-fed. Educational differences in breast-feeding practices have been noticed in most of the developing counties of the world including India. More years of the schooling generally result in consistently less breast-feeding among women. (excerpt)
Population concern before independence.
Explicit concern over India's rapid rise of population originated in the third decade of this century. Until 1920, India's population had been growing very slowly owing to the heavy toll from famines, epidemics, and wars. According to census reports, the population of the country within its present geographical boundaries actually declined between 1911 and 1921, from 252.1 to 251.3 million because of the high mortality inflicted by the influenza pandemic of 1918-19. It is estimated that about 5 per cent of the country's population-some 13 million persons-died in that epidemic. The population has increased steadily since 1921, largely because of epidemic, famine control and sanitation measures undertaken by the provincial governments. For the first time, since the initiation of a systematic population census in 1881, India's population increased slightly by more than 10 per cent (or by 27.7 million) in a decade, with the 1931 census enumerating a population of 279.0 million (Hutton:1932). In this context, concern over such an unprecedented rapid rise in population arose from four quarters: intellectuals, social reformers (especially those interested in improving the status of women), the Congress Party (the leading political party that spearheaded the movement for political independence), and the government. (excerpt)
Sexuality, unchastity and fertility: economy of production and reproduction in colonial Haryana.
A fear of female sexuality and therefore, the need to control it have been felt in many societies and civilizations. This control has assumed different forms in different societies. In colonial Haryana, the custom of widow remarriage emerged as one of the most effective and socially valid forms of this control. The custom did not merely control the limited inheritance rights of the widow, an aspect which we have investigated extensively elsewhere, it also controlled her sexuality, fertility and labour. In this chapter, the question of inheritance is explored in relation to these other aspects. This refocusing affords a wider dimension to the analysis by shifting the spotlight from the landowning class/caste to hitherto unexplored but significantly crucial aspects of the peasant economy which were being manipulated and controlled through the use of customs and 'traditions'. Not only were these traditions being constantly shaped, challenged and reshaped by patriarchy to fit the particular needs of a community, but in the given limited colonial space they were also open to negotiation by the widows themselves. Consequently, widow remarriage emerges as a complex custom, which shows contradictory facets in operation. On the other hand, it severely restricted a widow's right as to whom she could marry by enforcing upon her a levirate alliance and, on the other, it showed a rare flexible liberal sexual attitude which was willing to accommodate even her unchastity in it fold. The present chapter attempts to explore the social dimensions of widow remarriage in colonial Haryana. It analyzes the reasons behind this ostensibly 'liberal attitude' towards women in the context of remarriage and sexuality. Such an analysis highlights the specific geo-economic and social needs of this region, which carved out a special productive and reproductive role for its women. This role sanctified certain cultural norms like widow remarriage which was--unlike in other areas of India-hailed as a progressive high status norm for women. Yet in the female consciousness and life experience it was perceived as a repressive custom. The repressive elements ranged from forcible cohabitation and remarriage, an unmatched and undesirable alliance, sexual exploitation, polygamy and the status of a co-wife, to the loss of inheritance. Male attitudes emerge in sharp contrast to female attitudes showing an entirely different view of concepts such as morality, illegitimacy, and autonomy, both sexual and economic. (excerpt)
Social and cultural influences on fertility behaviour.
Governmental efforts towards fertility reduction often face a dilemma: babies who are planners' worry are also a parent's hope and joy. The beliefs of the people on this subject and what planners believe ought to be done may on occasion diverge substantially. Planners generally assume that people suffer from ignorance and need only to be educated about population and family planning activities in order to change their behaviour. The underlying assumption is that the people gratefully accept the proffered package of advice and services. As, studies have shown, people are not motivated to reduce the size of their families by the lessons provided by statistics of rampant population increase with its negative impacts on the process of development overall. Nor are they motivated by the case and availability of virtually foolproof methods of fertility control. People have their own ideas about the family size, the importance of the male child, and so forth. As these beliefs are rooted in religion, culture and tradition, there is also a deep attachment to them. Acknowledging their critical role in the choices that the people make in this regard, a perceptive study noted: "Social and cultural factors dominate all others in affecting fertility". (excerpt)
Modern fertility control: people's experiences.
Modem means of fertility control have made inroads into Mogra in recent times. Since these means were introduced mainly under the national Family Planning Programme (FPP), this chapter focuses on people's response to it. How did FPP find its way into the village? What do people think about it? Do they evaluate its philosophy and techniques and then accept/reject the total package, or do they judiciously select certain components? Does FPP reinforce prevailing fertility practices or interfere with them? How is it seen in relation to indigenous practices of fertility control discussed in Chapter 6? How do these varying frameworks co-exist in the village? What is the process of acceptance of FPP in the context of prevailing norms, values and cosmology of fertility and its control? Although India is the first country in the world to have officially introduced FPP in 1952 along with the five-year plans, the people of Mogra became familiar with it during the national emergency of 1975-7. A state of national emergency was declared in June 1975 family planning then entered the forefront of Indian politics. The family planning compaign during this period was more intense than at any other time in India, using sometimes coercive methods for its acceptance. During the 22-month period 11 million people (many of them unmarried, many average, and many with less than two children) were sterilized compared with 1.3 million in the preceding year. (excerpt)
Social and cultural context of fertility.
Fertility behaviour includes not only biological but also social reproduction, involving a complex network of institutions. As Fortes highlights: 'The process of social reproduction, in broad terms, includes all those institutional mechanisms and customary activities and norms which serve to maintain, replenish and transmit the social capital from generation to generation'. Biological reproduction needs to be seen in the context of social reproduction. Fertility behaviour, including childbirth, is the outcome of a complex web of institutional mechanisms regulated by social norms and cosmology. People's perception of fertility, and their values and attitudes are intricately interwined with social institutions. For analytical purposes, fertility behaviour is divided into domestic, economic and political spheres. (excerpt)
In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41–72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality—two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal—ie, for all settings—outreach and family-community care at 90% coverage averts 18–37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high-coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival. (author's)
Health must come before politics in WHO-Africa's reforms [editorial]
An impressive fanfare of melodic African gospel music heralded the long-awaited launch last week of the final report of the Commission for Africa. The 17-strong Commission, chaired by UK Prime Minister Tony Blair, set out to take “a fresh look” at Africa’s past and present, and make realistic recommendations for the continent’s survival. The Commission’s report is a laudable achievement: the hefty volume is a pragmatic and decisive review of Africa’s needs. It is, as promised, unfalteringly honest— and health initiatives are not spared criticism. According to the report, the failings of current health efforts are clear: there are too many initiatives and too little coordination. The Commission’s solution focuses on harmonisation of health policy at a national level and integration of donor-led initiatives into governmental plans. As if in preparation for these recommendations, Luís Sambo, head of the WHO’s African Regional Office, last week concluded a tour of the UK and USA by announcing sweeping reforms of WHO/AFRO. He plans to decentralise activities and give more authority to country representatives “to cope with potential increases in resources”. (excerpt)
All jokes aside, it is an extremely serious topic, as you are all well aware. HIV/AIDS is currently probably the biggest wreck facing humanity. And, the differences in prevalence between developing and developed countries tells an interesting story. Somehow, developed countries have managed to control their epidemics; they’ve managed to keep prevalence levels low. Whereas these prevalences in underdeveloped countries, or (unintelligible) countries continue to rise unchecked. So, what exactly is going on here, and what can we learn from this situation? Well, the answer must lay somewhere in the fact that somehow, developed countries were able to address this; somehow they have the capacity to address their epidemics. And, for some reason, developing countries lack that capacity to address their epidemics. (excerpt)
Country profile: HIV / AIDS. Madagascar.
At the end of 2000, the island nation of Madagascar reported only 280 HIV/AIDS cases from a population of 16 million. Due to underreporting, weak surveillance, and unavailability of HIV testing services, experts considered this figure to be quite low. The 2001 UNAIDS estimation was 22,000 people were living with HIV/AIDS in Madagascar, which yielded an adult prevalence of 0.3 percent. Results from a survey in 2000 suggest that HIV prevalence among patients seeking care for sexually transmitted infections has increased substantially, and Madagascar may be experiencing an accelerated spread of HIV/AIDS. Complicating the situation are rates of sexually transmitted infections, such as syphilis and gonorrhea, which are among the highest in the world. In 1997, more than 14 percent of pregnant women in specific regions of Madagascar tested positive for syphilis, and syphilis prevalence among sex workers ranged as high as 35 percent. (excerpt)
Country profile: HIV / AIDS. Namibia.
Namibia is one of the most sparsely populated countries in Africa. With a total population of 1.8 million, the country has an estimated 250,000 HIV infected individuals. Namibia has a severe, generalized HIV epidemic. HIV transmission is primarily through heterosexual contact or during birth, and at-risk populations include migrant workers, truckers, the military, young women and girls along transportation routes, commercial sex workers, sexually active youth, and orphans and vulnerable children. The HIV seroprevalence among pregnant women has grown rapidly, from 4.2 percent in 1992, to 22 percent in 2002. There is no significant difference between rural and urban antenatal seroprevalence and the overall prevalence of HIV is estimated at 17.9 percent (12.5 percent males, 18.9 percent females). Namibia’s tuberculosis case rate of 628 cases per 100,000 is the highest in the world, with HIV coinfection estimated at greater that 60 percent. Tuberculosis continues to be the leading cause of death for people with HIV/AIDS, even with the availability of antiretroviral therapy. Additionally, in spite of per capita gross domestic product of $1,173, Namibia has one of the world’s highest rates of income disparity. (excerpt)
Guidelines for medico-legal care for victims of sexual violence.
Sexual violence is ubiquitous; it occurs in every culture, in all levels of society and in every country of the world. Data from country and local studies indicate that, in some parts of the world at least, one woman in every five has suffered an attempted or completed rape by an intimate partner during her lifetime. Furthermore, up to one-third of women describe their first sexual experience as being forced. Although the vast majority of victims are women, men and children of both sexes also experience sexual violence. Sexual violence can thus be regarded as a global problem, not only in the geographical sense but also in terms of age and sex. Sexual violence takes place within a variety of settings, including the home, the workplace, schools and the community. In many cases, it begins in childhood or adolescence. High rates of forced sexual initiation have been reported in population-based studies conducted in such diverse locations as Cameroon, the Caribbean, Peru, New Zealand, South Africa and Tanzania. According to these studies, between 9% and 37% of adolescent females, and between 7% and 30% of adolescent males, have reported sexual coercion at the hands of family members, teachers, boyfriends or strangers. Sexual violence has a significant negative impact on the health of the population. The potential reproductive and sexual health consequences are numerous – unwanted pregnancy, sexually transmitted infections (STIs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) and increased risk for adoption of adoption of risky sexual behaviours (e.g. early and increased sexual involvement, and exposure to older and multiple partners). The mental health consequences of sexual violence can be just as serious and long lasting. Victims of child sexual abuse, for example, are more likely to experience depression, substance abuse, post-traumatic stress disorder (PTSD) and suicide in later life than their non-abused counterparts. Worldwide child sexual abuse is a major cause of PTSD, accounting for an estimated 33% of cases in females and 21% of cases in males. (excerpt)
Mini-compendium of HIV / AIDS interventions.
Advance Africa is a five-year family planning and reproductive health (FP/RH) project funded by the United States Agency for International Development (USAID). Advance Africa responds to the continuing need to strengthen and expand FP/RH services in Africa within the context of HIV/AIDS. It is a flexible, comprehensive project, managed by a consortium of six organizations: Academy for Educational Development (AED), Centre for African Family Studies (CAFS), Deloitte Touche Tohamatsu (DTT), Family Health International (FHI), Forum for African Women Educationalists (FAWE), and Management Sciences for Health (MSH). The project’s strategy is to reposition FP/RH as a health intervention through a range of state-of-the-art FP/RH expertise, innovative tools, and a solid understanding of the African setting. The Repositioning Family Planning strategy reorients and reenergizes the family planning agenda on national, regional, and international levels. Repositioning advocates for FP/RH as a cost-effective lifesaving health intervention, promotes FP/RH best practices, and supports the integration of family planning into other HIV/AIDS, health, and non-health programs. (excerpt)
Multi-country study of trusted partners among youth: Eritrea, Tanzania, Zambia, and Zimbabwe.
The objectives were to: Explore youth’s definitions of “trust”; Establish criteria youth use to determine the trustworthiness of partners; Identify types of individuals youth believe they can and cannot “trust”; Examine trust’s influence on sexual decision-making and STI/HIV risk perception; and Identify how sexual partners violate trust and the effects on sexual decision-making. Data were collected in October 2001 as part of a regional Behavior Change Communication (BCC) strategy in East and Southern Africa. Country programs chose to participate in research based on project priorities and levels of interest in participating in a regional BCC strategy. Four county programs agreed to collect and share data, Eritrea, Tanzania, Zambia, and Zimbabwe. A total of 33 focus groups were conducted. Research teams in each country used the same discussion guide and pretested the guide prior to data collection. Discussion groups lasted between an hour and an hour and a half, were audiotaped, and transcribed into English. Each research team conducted two discussion groups in the major urban area composed of the following strata: males 15-19 years, females 15-19 years, males 20-24 years, and females 20-24 years. The Zambia program conducted one additional focus group with males aged 15-19. (excerpt)
The HIV / AIDS / STD situation and the national response in Nepal.
Over the last years the HIV/AIDS epidemic in Nepal has gained ground, and Nepal has progressed from a “low prevalence” country to one with a so-called “concentrated” epidemic in certain sub-groups of the population. For Nepal the window of opportunity is closing fast to effectively address the epidemic. Without mounting a vigorous, broad-based response now, AIDS may become the leading cause of death in the age group 15-49 years over the next ten years. His Majesty’s Government has recognized HIV/AIDS as a priority issue and has recently established a National AIDS Council chaired by the Rt. Honorable Prime Minister. The Council met for the first time on 3 October, 2002 and endorsed Nepal’s National HIV/AIDS Strategy 2002-2006, which will guide the future multisectoral response in Nepal. The aim of the “The HIV/AIDS/STD Situation and the National Response in Nepal” booklet is to give an overview of the situation and the response to HIV/AIDS in Nepal, and to touch on priorities and challenges. This publication is jointly published by the National Centre for AIDS and STD Control (NCASC), and the United Nations Theme Group on HIV/AIDS in Nepal. It is not meant to be all-inclusive and to provide a complete listing of all programmes and projects, which are currently implemented in Nepal to address HIV/AIDS (this will be the task of a future response data-base). (excerpt)
Malaria misconceptions [letter]
Malaria misconceptions We have serious concerns about the content of three letters published on Nov 13. In the first, Arthur Caplan refers to the recently published report of the US Institute of Medicine and writes: “there is concern that the artemisinin derivatives are associated with greatly increased rates of birth defects in pregnant women”, quoting one of our publications. This is an error: in the cited study there was only one birth defect among singleton babies and the mother had been treated with quinine. The “international agreement” on the use of artemisinin in pregnancy demanded by Caplan was reached by WHO in 2003. It would be disastrous if artemisinin-based combination therapy (ACT) was compromised by fears of liability based on groundless allegations. (excerpt)
HIV-infected women in ART programmes [letter]
We are confident that James Shelton and Anne Peterson appreciate the broad reproductive health needs of women in developing countries. However, by focusing their Comment solely on the promotion of contraceptive use for women on antiretroviral therapy (ART), their discussion overlooks the importance of supporting reproductive choice among individuals infected with HIV and greatly oversimplifies women’s reproductive health-care needs in the context of ART programmes. The Comment outlines several compelling reasons for promoting effective contraception among women infected with HIV. Although these concerns are appreciated, this strictly preventive approach to reproduction focuses only on reasons why infected women should not have children, overlooking the important role that fertility has in women’s lives, individual and social, especially in many parts of sub-Saharan Africa. There is growing evidence that despite stigmatisation by health-care providers, childbearing is an important feature of life for many women infected with HIV. (excerpt)
Global overview of injecting drug use and HIV infection.
Late in 2004, Carmen Aceijas and colleagues, on behalf of the United Nations Reference Group on HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries, presented global estimates of the prevalence of injecting drug use and the prevalence of HIV in such users. These authors did a Herculean task in searching for and compiling these important estimates. Not surprisingly, data are sparse or missing for many transitional and developing countries, particularly those in Africa and the Caribbean. Also, there are no incident data reported. Nevertheless, this report presents the most recent available estimates of prevalence, which can be used to help to define the global problem and assist policymakers. Injecting drug use and HIV in transitional and developing countries has been a cause of concern since earlier in the HIV epidemic. The escalation and international diffusion of injecting drug use and the resultant effect on the HIV epidemic was reported early. In 1992, it was estimated that there were at least 5.5 million injecting drug users in 80 countries. Aceijas and colleagues estimate 13.2 million injecting drug users in at least 130 countries. A part of this increase might be due to better reporting rather than an increase in injecting drug use; however, it is credible that injecting drug use is diffusing into additional countries and poses the threat of increased incidence of HIV. (excerpt)
The Millennium Project: the positive health implications of improved environmental sustainability.
Ensuring environmental sustainability is essential to achieving all the Millennium Development Goals. Longterm solutions to problems of drinking-water shortages, hunger, poverty, gender inequality, emerging and reemerging infectious diseases, maternal and childhood health, extreme local weather and global climate changes, and conflicts over natural resources need systematic strategies to achieve environmental sustainability. For this reason, the UN Millennium Project Task Force on Environmental Sustainability has concluded that protection of the environment is an essential prerequisite and component of human health and well-being. Economic development and good health are not at odds with environmental sustainability: they depend on it. One important dimension of environmental sustainability is the need to maintain ecosystem services critical to the human population. These services include providing food, shelter, and construction materials; regulating the quantity and quality of fresh water; limiting soil erosion and regenerating nutrients; controlling pests and alien invasive species; providing pollination; buffering human, wild plant, and animal populations from interspecific transfer and spread of diseases; and stabilising local weather conditions and sequestering greenhouse gases to contain climate change. A second and equally important dimension of environmental sustainability is the need to control water pollution and air pollution, including the emission of greenhouse gases that drive climate change. These so-called brown issues can have a severe effect on human health and ecosystem function. (excerpt)
Boris Vasiliev stomps down the snowcovered track that is the main street of his village and pauses outside a dilapidated single-storey building. “That used to be the doctor’s surgery”, he says, then points back the way he came. “Down there was the shop. A bit further: the social club.” Either side of the track are two long lines of empty wooden cottages. This is Buyavino, in the Tver region, 130 miles north of Moscow, one of tens of thousands of Russian villages that are slowly dying out as the country faces an alarming decline in population. “Once there was a family in every one of these 50 houses”, says Vasiliev, 58, a forestry worker. “Now there are just 13 of us left.” Vasiliev, who lives with his wife Nina, is the youngest person in the village and the only one with a job. Two of the villagers do nothing but drink, he says, and the son of another recently died from a heroin overdose. (excerpt)
The influence of violent media on children and adolescents: a public-health approach.
There is continuing debate on the extent of the effects of media violence on children and young people, and how to investigate these effects. The aim of this review is to consider the research evidence from a public-health perspective. A search of published work revealed five meta-analytic reviews and one quasi-systematic review, all of which were from North America. There is consistent evidence that violent imagery in television, film and video, and computer games has substantial short-term effects on arousal, thoughts, and emotions, increasing the likelihood of aggressive or fearful behaviour in younger children, especially in boys. The evidence becomes inconsistent when considering older children and teenagers, and long-term outcomes for all ages. The multifactorial nature of aggression is emphasised, together with the methodological difficulties of showing causation. Nevertheless, a small but significant association is shown in the research, with an effect size that has a substantial effect on public health. By contrast, only weak evidence from correlation studies links media violence directly to crime. (author's)
Transforming health systems to improve the lives of women and children.
Ambitious quantitative goals for reducing mortality and increasing access to health interventions are nothing new to the areas of child, maternal, and reproductive health. They are the standard fare of global declarations and national 5-year plans. They come. They go. What makes the Millennium Development Goals (MDGs) different? With health firmly embedded in this wider poverty-reduction initiative, which has garnered unprecedented consensus and support from governments and multilateral organisations, the global health community has a rare opportunity to break through to new ways of thinking about the obstacles now blocking improvements in the health of women and children and to translate that thinking into bold new steps to meet goals 4 and 5 (table). For the UN Millennium Project Task Force on Child Health and Maternal Health, the potential breakthrough lies in putting health systems at the centre of MDG strategies and in addressing these systems, not only as delivery mechanisms for technical interventions but also as core social institutions—as part of the very fabric of social and civic life. In high-mortality countries today, especially for the poorest populations, health systems are frequently the source of catastrophic costs, humiliating treatment, and deepening social exclusion. But a different way is possible. Health systems can be a vehicle for fulfilling rights, for active citizenship, and for true democratic development—poverty reduction in its fullest sense. (excerpt)
Critical health objectives for adolescents and young adults.
The 21 Critical Health Objectives represent the most serious health and safety issues facing adolescents and young adults (aged 10 to 24 years): mortality, unintentional injury, violence, substance use and mental health, reproductive health, and the prevention of chronic diseases during adulthood. (excerpt)
A growing body of research exists about practices and strategies that have been proven to promote adolescent health. However, there is often a disconnect between research and practice as some of this information can be difficult to locate. A variety of research articles, websites, organizations and publications disseminate information about what works in adolescent health. However, adolescent health practitioners often work on a variety of issues at once, including unintentional injury, reproductive health, substance use, violence, mental health, nutrition and physical activity, and youth development. It can be a major task to locate information about Best Practices in every outcome area. This issue brief provides an overview of Best Practices and a comprehensive listing of resources for Best Practices in each of the areas listed above. (excerpt)
America's adolescents: Are they healthy? Revised and updated edition.
Adolescence represents a unique period in the life cycle, bringing with it special challenges and opportunities. No longer children and not yet adults, adolescents make significant choices about their health, and develop attitudes and health practices that continue into adulthood. Adolescents face choices in areas including driving habits, substance use, sexuality, physical exercise, and diet. Risky behavior in these areas contributes to the leading causes of adult morbidity and mortality. Thus, fostering healthy adolescent development and behavioral choices has the potential to improve the health of adults as well as adolescents. This monograph presents an overview of the health status of American adolescents. (excerpt)
Investing in clinical preventive health services for adolescents.
This monograph begins by presenting a rationale for providing clinical preventive services to adolescents; defining clinical preventive services; and reviewing evidence about the efficacy of these services. Turning to implementation issues, we explore the extent to which these services are being delivered, barriers to service delivery, and promising strategies to reduce these barriers. The monograph then addresses financial issues, reviewing current research on the costs of adolescent health problems and clinical preventive services. Finally, we consider current trends that can potentially improve the delivery of clinical preventive services. The monograph concludes that, despite the need for further research on cost and efficacy, existing evidence makes a compelling case for investing resources to increase the delivery of clinical preventive services to America’s adolescents. (excerpt)
Health care reform: opportunities for improving adolescent health.
There is little doubt that adolescents are a significant underserved segment of our population. The major health risks facing the estimated 34 million adolescents in the United States today are traceable to psychosocial, behavioral, and economic factors. The following statistics illustrate the challenge of meeting adolescent health needs now and in the foreseeable future : Unintentional injury is the leading cause of adolescent deaths, and accounts for more deaths than all other causes combined; Homicide is the second leading cause of death for adolescents ages 15 through 19; Suicide is the third leading cause of death for adolescents ages 15 through 19; Every year, 1 million 15- to 19-year-old adolescent females become pregnant; Every year, 3 million adolescents ages 19 and younger contract a sexually transmitted disease; Among 9–12th grade students surveyed in the 1991 Youth Risk Behavior Surveillance System, 27.5 percent we re current smokers, and 51 percent consumed alcohol during the 30 days preceding the survey; 1 out of 7 adolescents is without health insurance. (excerpt)
The policy analysis embodied in Improving Adolescent Health: An Analysis and Synthesis of Health Policy Recommendations was compiled by the National Adolescent Health Information Center (NAHIC) to help create a common agenda, and clarify the steps critical to improving the health of America’s adolescents. This document is intended to provide a framework for considering the policy recommendations outlined in 36 nationally-focused reports and books produced during the past decade. Promising future directions are also suggested for developing policy action, establishing priorities, and mobilizing the private and public sectors. The goal of our analysis is four-fold: 1. To identify consensus policy recommendations; 2. To highlight strategies reflecting consensus policy priorities; 3. To delineate health policy areas that have been overlooked or have recently emerged; 4. To define critical barriers that may hamper implementation of consensus policy. A major premise of this report is that there is an “economy of effort” by bringing together the collective wisdom represented by the over 1,000 policy recommendations synthesized here. These recommendations, representing significant professional concurrence, can be utilized to plan for substantially improving the health status of adolescents. It is time to use these recommendations to develop and evaluate the next generation of programmatic and policy efforts. (excerpt)
Fact sheet on reproductive health: adolescents and young adults.
Highlights: Adolescent pregnancy rates have decreased to record lows; White adolescent females have a lower rate of pregnancy than their Black and Hispanic peers; Adolescents' initiation of sexual activity has declined during the past decade; About 4 in 10 Black male students have had sex with 4 or more people during their lifetime; The prevalence of chlamydia is over six times higher for female adolescents than their male peers; Females account for more than half of the HIV cases among adolescents. (excerpt)
Investing in adolescent health: a social imperative for California's future.
The health and well-being of California teens has a major impact on the overall social and economic health of our state. Today’s teens are tomorrow’s workforce, parents, and leaders, and their future is shaped by the opportunities we create for them today. Most parents make significant personal investments in their children’s future. Yet as a society, we are not making the investments necessary to ensure the health and well-being of all of our youth. During adolescence (10 to 19 years of age) young people confront new issues that affect their physical and mental health. Similarly, young adults (20 to 24) continue to experience many of the same challenges to their health and well-being. The health issues of teens and young adults are easy to overlook because they are not, for the most part, acute illnesses or chronic diseases. Instead, they are largely behavioral and social issues. Addressing these issues requires change at multiple levels—from service delivery, to funding priorities, to community resources and environments, and, more fundamentally, to the behavior and attitudes of California’s adults. (excerpt)
Data can be used in many ways to shape an initiative to improve the health of adolescents and young adults. For example, data can be used for assessment, program design, evaluation, and policy analysis. Data can be a powerful tool because it helps to make issues concrete, make arguments more persuasive, challenge assumptions, guide decision-making, illustrate a need for policies and programs, demonstrate the effectiveness of interventions, and illuminate important new directions for research, policy and program development. This document will examine different ways data can be used to promote young people’s health, review indicators of adolescent and young adult health, and describe different sources of data and data collection. The primary aim of this document is to describe how communities can create a youth health profile based on the Healthy People 2010 21 Critical Health Objectives for adolescents and young adults and conduct a needs-and-assets assessment in order to shape a local health initiative for youth. (excerpt)
Family planning and HIV service integration. Potential synergies are recognized.
Service integration holds the potential for helping women and others — such as men, youth, and couples — prevent unintended pregnancy and HIV infection. Experience with integrating a variety of health services, such as maternal and child health and family planning or family planning and management of sexually transmitted infections (STIs), has been mixed. But the most successful experiences suggest that integration enables providers to offer more convenient, comprehensive services. Integration is also expected to expand access to services and make them more cost-effective. (excerpt)
HIV services for family planning clients.
When the HIV epidemic emerged in the 1980s, family planning organizations responded with some of the first HIV prevention projects in the developing world. Yet, a review of the contribution of sexual and reproductive health services to HIV prevention, conducted in 2003 for the World Health Organization (WHO), found that integrating HIV prevention into family planning services had not yet been implemented effectively, except in a few cases. Still, it would be premature to conclude that integrating HIV prevention into family planning services does not work, says Dr. Ian Askew, the Population Council’s representative in its office in Nairobi, Kenya, who helped conduct the review. Much has been learned, moreover, from implementing various strategies designed to achieve that goal. Such strategies include diagnosis and treatment of sexually transmitted infections (STIs) that increase the risk of acquiring HIV, sexual risk-reduction counseling, condom promotion, and voluntary counseling and testing (VCT) for HIV. (excerpt)
As efforts begin to shift toward integrating family planning into HIV/AIDS services, voluntary counseling and testing (VCT) centers are emerging as primary targets for integration. Research from Africa and the Caribbean shows that such integration is feasible and acceptable, and large-scale integration efforts are being launched and expanded there. VCT services have become one of the most common means of preventing, detecting, and improving access to care and support for HIV/AIDS. And VCT services are likely to greatly expand with support from the five-year U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which focuses on fighting the HIV/AIDS epidemic in 15 resource-poor countries, mostly in Africa and the Caribbean. (excerpt)
Case studies. Uganda: integrating family planning into VCT.
If you visit the impoverished neighborhood of Kisenyi in Kampala, Uganda, near the largest public transportation hub in the country and the biggest outdoor market in the city, you may be able to catch a glimpse of the new headquarters of the AIDS Information Centre (AIC). From the outside of the building, however, you will not be able to appreciate just how much the organization has evolved in recent years. Opened in 1990 as a single site offering only HIV voluntary counseling and testing (VCT), the AIC now offers VCT integrated with multiple reproductive health services to thousands of clients each year at six main sites in Uganda. Receiving about 250 clients daily at these sites, the AIC is now one of the largest nongovernmental providers of VCT services in the country. (excerpt)
Case studies. Cambodia: Clients find everything they need in one place.
The year was 1996. HIV incidence was clearly rising in Cambodia, but in Phnom Penh only one group — the Pasteur Institute — provided voluntary counseling and testing (VCT) for HIV. Incidence of HIV was mainly rising among people at high risk of infection. Yet, ominously, between 30 percent and 40 percent of clients (mainly married women) served at that time by the two-year-old Reproductive Health Association of Cambodia (RHAC) had reproductive tract infections (RTIs) or sexually transmitted infections (STIs). Such infections are, in themselves, risk factors for HIV infection. Furthermore, the same sexual behaviors that put people at risk for RTIs and STIs also put them at risk for HIV. RHAC, an International Planned Parenthood Federation affiliate primarily supported by the U.S. Agency for International Development (USAID), was quick to act. That year, it sent staff to Thailand to learn to do HIV/AIDS counseling. It also began drawing blood samples for clients wanting to know their HIV status and sending samples to the Pasteur Institute for testing. (excerpt)
Case studies. Zimbabwe: 'I have the knowledge and skills to help'.
In Zimbabwe, Hebron Gotora’s workday officially ends at 4:30 p.m., but it is often later than 6:00 p.m. when he navigates his bicycle down the bumpy dirt road to his home in the community of Chihota. His dedication and pride as a community-based distributor (CBD) of contraceptives for the Zimbabwe National Family Planning Council (ZNFPC) is evident. Seemingly everywhere, people seek him out for advice. Gotora has been a CBD worker for nearly a decade, taking family health services beyond clinic walls to the doorsteps of people in the community. But his job was recently expanded to include the more holistic approach of providing information about HIV/AIDS, sexually transmitted infections (STIs), HIV voluntary counseling and testing (VCT), referrals to VCT services, access to prevention of mother-to-child transmission services, and much more. “With my new role, I feel renewed,” Gotora, 39, and a father of three, said in a recent interview with the Advance Africa project, supported by the U.S. Agency for International Development (USAID). “Now I can assist many people.” (excerpt)
Case studies. Jamaica: system-wide integration of services.
Most integrated delivery of family planning and HIV services is limited to pilot projects in one or a few health facilities. Little is known about how to integrate these services throughout a health care system. But a study in Jamaica seeks to identify changes needed to make family planning and HIV service integration a reality system-wide. Conducted by the Jamaican Ministry of Health (MOH) and the Washington, DC based POLICY Project of the Futures Group among 100 health care providers, program managers, policy-makers, and potential clients, the study will determine the feasibility and potential cost of integrating family planning and HIV services in the rural parish (district) of Portland and the urban area of St. Ann’s Bay. “We are asking, ‘What policies, regulations, and guidelines need to change to actually institutionalize integration?’” explains Dr. Karen Hardee, research director for the POLICY Project. (excerpt)
Averting HIV-infected births. Integrating family planning services can help achieve goal.
In the midst of an unrelenting AIDS epidemic, attention is increasingly being paid to the prevention of HIV infection among the world’s most vulnerable individuals: its newborns. In 2003, an alarming number of new HIV infections — about 700,000 — occurred among children, the vast majority of whom were infected by their mothers. Four main approaches to reducing such infections have been promoted by the World Health Organization (WHO) and its United Nations partners. To date, funding for developing countries has primarily supported an approach of providing voluntary counseling and testing (VCT) for HIV during pregnancy and then a short course of antiretroviral (ARV) drug therapy to HIV-infected pregnant women and their newborns. This is to prevent HIV transmission from mother to infant during delivery. Another approach is to provide care and support to women, infants, and families infected and affected by HIV/AIDS. But minimizing HIV-infected births will likely be best achieved through a combination of approaches that includes preventing unintended pregnancies among HIV-infected women and preventing HIV infection among reproductive- age women. (excerpt)
Preventing pregnancy among HIV-infected women.
Providing family planning counseling and services to HIV-infected women — to prevent initial or subsequent unintended pregnancy — is critical to the prevention of mother-to-child transmission (PMTCT) of HIV. Indeed, without such family planning services, achieving international goals to reduce the proportion of HIV-infected infants by 20 percent by 2005 and by 50 percent by 2010 may not be possible. HIV-infected women must be carefully counseled about the risk of transmitting HIV to their infants during pregnancy and delivery. Those women who wish to either limit or space childbearing should have access to highly effective contraception. And, because all women have the right to decide the number and timing of their children, anyone counseling an HIV infected woman should support her family planning decisions. (excerpt)
Preventing HIV infection among pregnant women.
Antenatal care (ANC) services present excellent opportunities to help pregnant women who are uninfected or of unknown HIV status avoid infection that they could transmit to their fetuses. The risk that a woman will transmit HIV to her fetus during pregnancy is 5 percent to 10 percent. This risk may be even greater if a woman becomes infected while pregnant, since her HIV virus level may be especially high immediately after infection. ANC services also present opportunities to help women protect themselves from infection postpartum and possible subsequent transmission to their infants during breastfeeding. Infection rates in the postpartum period are high in many countries. In Southern Africa, 5 percent to 10 percent of HIV-uninfected women become infected in the year after they give birth. Interventions to prevent HIV infection in pregnant women, as in nonpregnant women, focus on counseling about reducing potentially risky behaviors by the woman or her partner. Also, any pregnant woman who is unaware of her partner’s HIV status or feels that she may be at risk of infection should encourage her partner to use condoms. A woman may have little control over her partner’s behavior. But involving men in counseling, when possible, can be a key to raising awareness of the need to practice safe sex to prevent infection during pregnancy. In fact, to reflect men’s role in transmitting HIV to children, the term “parent-to-child transmission” sometimes is preferred to the biologically precise term of “mother-to-child transmission.” (excerpt)
Involving men. Impact of integrated services depends on male cooperation.
Family planning programs that have integrated HIV prevention into their services have discovered that the full benefits of their efforts will not be realized if they overlook a group of people they may have been unaccustomed to serving: men. Reproductive health experts have long recognized that involving men in family planning yields such benefits as client satisfaction and the adoption, continuation, and effectiveness of contraceptive use. But it has also become clear that the cooperation of male partners is necessary for women to act on HIV prevention messages delivered through integrated services. Recognition of the central role that men play in most decisions about reducing HIV risks — from initiating sex to remaining faithful to one partner to using a condom — has accelerated efforts to involve them in protecting reproductive health. (excerpt)
Integrating services to appeal to men.
Reaching men requires a holistic approach. Men’s concerns about sexual and reproductive health issues that family planning programs rarely address — such as infertility and sexual dysfunction — “give the provider an opportunity to discuss issues related to reproductive health and sexually transmitted infections, ”says Manisha Mehta, who manages EngenderHealth’s Men as Partners program. For the Mexico-based nongovernmental organization Salud y Género, appealing to men’s pride in fatherhood has proved effective for opening dialogue with men who might feel threatened by topics such as violence, alcohol use, or sexuality. In the Gambia, men agreed to participate in Stepping Stones workshops when the HIV prevention intervention was adapted to emphasize preventing infertility. And in New York City, where the Young Men’s Health Clinic attracts male clients by providing physical examinations required for participation in school, sports, or jobs, one out of four young men attending the clinic for a routine exam was also treated for a sexually transmitted infection. (excerpt)
Assessing men's attitudes about gender roles.
Use of a new tool to evaluate interventions that seek to change health-threatening attitudes about gender roles is helping to clarify whether more egalitarian gender attitudes are associated with behaviors that ultimately reduce reproductive health risks. The evaluation tool, called the Gender-Equitable Males (GEM) Scale, was developed by the Washington, DC-based Horizons program of the Population Council and by the Brazilian nongovernmental organization Instituto PROMUNDO. The scale consists of 24 statements about attitudes regarding gender roles in domestic work and child care, sexuality and sexual relationships, reproductive health and disease prevention, and intimate partner violence, as well as attitudes toward homosexuality and close relationships with other men. A test of the scale in a community-based survey among 749 men in three Rio de Janeiro neighborhoods revealed statistically significant associations between GEM Scale scores and behaviors such as partner violence and contraceptive use. Men ages 15 to 24 years who least supported egalitarian gender attitudes were most likely to report violence against a partner and least likely to report contraceptive use. Among men ages 25 to 59 years, support for more equitable gender norms was associated with condom use. (excerpt)
“Without any study and knowledge of institutional inequities based on gender and risk factors, we will not be able to produce adequate strategies to face HIV and other STDs… In a nutshell the strategy to control, stop, and reduce the HIV epidemic needs to incorporate a clear gender perspective” (Sept.1999); “We must summon the courage to talk frankly and constructively about sexuality. We must recognise the pressures on our children to have sex that is neither safe nor loving. We must provide them with information, communication skills and, yes, condoms. To change fundamentally how girls and boys relate to each other and how men treat girls and women in painstaking work. But surely our children’s lives are worth the effort.” (July 2001). Pascoal Mocumbi, Prime Minister of Mozambique. This manual offers some simple learning activities that can help HIV/AIDS educators or trainers develop young people’s critical gender awareness, which is so crucial for effectively promoting safer sexual behaviour. The manual is based out of the work that the Living for Tomorrow project explored in Estonia. The project focused on the central and crucial role of gender issues in HIV/AIDS education and prevention. It explored the dilemmas and challenges in implementing gender/focused HIV prevention education in contexts where people have barely begun to explore critically the realities and consequences of the gender system they inhabit. (excerpt)
Pharmacist in charge of the ART Programme: Represents the pharmacy on the CPGH ART Eligibility Committee. As Secretary, takes the minutes of the meetings; Maintains a list of eligible patients; Maintains a signature file of doctors who are authorized to prescribe for ART patients; Works with the CPGH ART team and the CPGH training coordinator to organise continuing education on ART; Prepares and presents Adverse Drug Reaction (ADR) summary reports to the CPGH ART Eligibility Committee and makes recommendations on action to be taken; Assists in implementing prescribing and drug utilization reviews (DURs). Prepares ARV DURs for review by the CPGH ART Eligibility Committee; Carries out periodic spot checks of ARV storage and record keeping on wards at CPGH. (excerpt)
Accountability and health systems: overview, framework, and strategies.
Improved accountability is often called for as an element in improving health system performance. At first glance, the notion of better accountability seems straightforward, but it contains a high degree of complexity. For accountability to serve effectively as an organizing principle for health systems reform, conceptual and analytical clarity is required. This paper elaborates a definition of accountability in terms of answerability and sanctions, and distinguishes three types of accountability: financial, performance, and political/democratic. The role of health sector actors in accountability is reviewed. An accountability-mapping tool is proposed that identifies linkages among health sector actors and assesses capacity to demand and supply information. The paper describes three accountability-enhancing strategies: reducing abuse, assuring compliance with procedures and standards, and improving performance/learning. Using an accountability lens can: a) help to generate a system-wide perspective on health sector reform, and b) identify connections among individual improvement interventions. These results can support synergistic outcomes, enhance system performance, and contribute to sustainability. (author's)
HIV / AIDS, food security and rural livelihoods: understanding and responding.
In this paper, we describe the kinds of understanding and responding that are needed for agriculture, food and nutrition-relevant organizations to effectively confront HIV/AIDS. First, we outline some underlying principles that need to be grasped in order to understand the variable and changing nature of AIDS epidemics. Key concepts here include the variance among different epidemics and the notions of susceptibility, vulnerability, resistance and resilience. We illustrate these concepts through describing the particular interactions between food and nutrition insecurity and HIV/AIDS, and their implications for response strategies. Second, we examine the implications of this understanding for the ways in which different people in affected households, communities and in affected sectors -- may best respond. We focus on the particular importance of food and nutrition for the four conventional aspects of response -- prevention, care, treatment and mitigation and why it is a mistake to compartmentalize these approaches. The imperative and different rationales for multi-sectoral mainstreaming are then discussed. And third, we move on to describe a flexible and evolving aid, the HIV/AIDS lens, and the processes through which agricultural and other professionals can learn to employ it in order to respond more effectively. We highlight the fundamental principles that comprise the lens and then illustrate how it can be used in practical situations to review agricultural, food and nutrition policies and programs at different levels. The paper draws on the experience of countries participating in RENEWAL (Regional Network on HIV/AIDS, Rural Livelihoods and Food Security) where the lens and the processes in which it is being put to use are being refined. As we make clear, the lens is not a static construct, rather, its distortions are hopefully reduced through practice and shared experience in using it. Action research by sector organizations is key to this process of refinement and learning. A recent workshop explored methodological challenges and opportunities in research and evaluation. Two forthcoming RENEWAL publications will synthesize these methodological issues and describe the development of networks to advance practical understanding. (excerpt)
Handbook on reproductive health indicators.
The Emerging Social Issues Division is pleased to bring out the publication entitled Handbook on Reproductive Health Indicators. This is an outcome of one of several recommendations provided by the participants attending the Workshop on Reproductive Health Indicators and RH Indicators Database Development, held at Seoul from 13 to 17 November 2000. The Workshop was organized by the United Nations Economic and Social Commission for Asia and the Pacific in collaboration with the Korea Institute for Health and Social Affairs, with financial support provided by the Government of the Republic of Korea. The main objective of this Handbook is to provide a list of reproductive health indicators that are essential to assess, monitor and evaluate reproductive health programmes. An attempt has been made to provide for selected indicators simple definitions, data requirements, data sources, and usefulness and limitations. It is hoped that this Handbook will be useful for planners, policy makers and researchers who are involved in the implementation of reproductive health programmes at the national and subnational levels. (excerpt)
The long-run economic costs of AIDS: theory and an application to South Africa.
Most existing estimates of the macroeconomic costs of AIDS, as measured by the reduction in the growth rate of GDP, are modest. For Africa – the continent where the epidemic has hit the hardest – they range between 0.3 and 1.5 per cent annually. The reason is that these estimates are based on an underlying assumption that the main effect of increased mortality is to relieve pressure on existing land and physical capital so that output per head is little affected. We argue that this emphasis is misplaced and that, with a more plausible view of how the economy functions over the long run, the economic costs of AIDS are almost certain to be much higher. Not only does AIDS destroy existing human capital, but by killing mostly young adults, it also weakens the mechanism through which knowledge and abilities are transmitted from one generation to the next; for the children of AIDS victims will be left without one or both parents to love, raise and educate them. To analyze this problem, we use an overlapping generations (OLG) model, in which parents have preferences over current consumption and the (expected) human capital attained by their children. Two family structures are analyzed: ‘nuclear’ and ‘pooling’, whereby under the latter all children are cared for within an extended family. The decision about how much to invest in education is influenced by premature adult mortality in two ways: first, the family’s lifetime income depends on the adults’ health status, and second, the expected pay-off depends on the level of premature mortality among the children when they attain adulthood. Furthermore, if one or both parents die while their offspring are still children, the transmission of knowledge across generations is weakened. The outbreak of AIDS leads to an increase in premature adult mortality, and if the prevalence of the disease becomes sufficiently high, there may be a progressive collapse of human capital and productivity. The policy problem, therefore, is to avoid such a collapse. The instruments available for this purpose are (i) spending on measures to contain the disease and treat the infected, (ii) aiding orphans, in the form of either income-support or subsidies contingent on school attendance, and (iii) taxes to finance these expenditures. When calibrated to South Africa, the model yields the following results. In the absence of AIDS, the counterfactual benchmark, there is modest growth, with universal and complete education attained within three generations. If nothing is done to combat the epidemic, however, a complete economic collapse will occur within three generations. With optimal spending on combating the disease, and if there is pooling, growth is maintained, albeit at a somewhat slower rate than in the benchmark case in the absence of AIDS. If pooling breaks down, and is replaced by nuclear families, growth will be slower still. Indeed, if school-attendance subsidies are not possible, growth will be distinctly sluggish. In all three cases, the additional fiscal burden of intervention will be large, which reinforces the gravity of the findings. Sensitivity analysis suggests that these findings are robust to changes in a variety of key assumptions and parameter values concerning mortality, the efficiency of measures taken to combat it, and the formation of expectations. A delay in responding to the outbreak of the epidemic, however, can lead to a collapse. (author's)
Key issues in clinic functioning: a case study of two clinics.
An in-depth case study was done looking at two primary care clinics serving the same community. One clinic is a typical government-funded public sector clinic offering a comprehensive 24-hour service; the other is an NGO-funded day clinic offering a range of primary care services. The aim of the research was to understand and explore key issues in the functioning of the two clinics, in order to draw out lessons for district management teams. A variety of information was collected, using different methods. This included patient statistics, staff numbers, stock levels of drugs, perceptions of patients in the clinic and of people in the surrounding community, perceptions of staff using both questionnaires and individual interviews, perceptions of students, participant observations, etc. Comparison of each set of data collected in the two clinics was done, to highlight common issues and to understand similarities and differences. (excerpt)
There are a great many lessons reflecting the diversity of the districts. We highlight the most important lessons as well as those which are not only applicable to the local circumstances but which are generic to improvement of primary health care around the country. There are two overarching lessons which are applicable to every district in the country and which we consider fundamental to improving the quality of primary health care and the health of the people within the district. The first is that without a permanently appointed management team, which is given full responsibility and accountability for being in charge of the health services in the district, it is difficult to make sustainable changes for improvement. Having a management team without the authority to make and implement decisions is a recipe for no or little progress. This has been seen in numerous districts in different provinces. The second lesson is that the role of the national and provincial health departments should be one of guidance, protection from undue pressure, support and nurturing of their districts. We have seen countless incidents where national and provincial senior managers are disrespectful of district managers’ diaries and ad hoc meetings are called at short notice causing cascading disruption through the district. This usually affects the least resourced districts the most as the district managers from these districts have to spend the most time travelling to the provincial capital. (excerpt)
The strategic use and potential demand for an HIV vaccine in Southern Africa.
HIV prevalence in Southern Africa is the highest in the world and the impacts of HIV/AIDS in the region are devastating at all levels of society, including the wider economy. Government response to date has lagged behind the pace of the epidemic, but intervention programs are now beginning to focus on a broad range of interventions to combat its further spread and to mitigate its impacts. The purpose of this paper is to investigate the issues around the targeting of an eventual HIV vaccine. There is at present no vaccine against HIV. Although several candidates are in the trial stage, it is not likely that a vaccine effective against the sub-type of the virus prevalent in Southern Africa will be available for 10-15 years. When it is, it may be expensive, only partially effective, and confer immunity for a limited period only. Vaccination programs will need to make the best use of the vaccine that is available and effective targeting will be essential. The analysis identifies potential target groups for a vaccine, and estimates how many individuals would be in need of vaccination. It develops a method for estimating how many cases of HIV infection are likely to be avoided for each vaccinated individual. The cases avoided are of two kinds: primary? the individual case that might have occurred in people who are vaccinated , and secondary—the number of people that the vaccinated individual would otherwise have caused to become infected. Both of these depend on assumptions about the efficacy and duration of protection of the vaccine and the extent and nature of sexual risk behavior in the population groups. The analysis distinguishes between the HIV cases averted per vaccination, and the cases averted per 100 recruits into a vaccination program. The cases averted per 100 recruits is used to develop a priority ranking of the identified population groups for vaccination. The paper discusses the issue of ease of access to those groups, and how the differential costs would affect the vaccination strategy. The essential conclusion is that an expensive vaccine should be administered to commercial sex workers first, while an inexpensive vaccine would be better administered first to general population groups, in particular schoolchildren. The paper concludes with a discussion of current levels of public and private expenditure on HIV prevention and treatment, and the implications for an assessment of the willingness to pay for an eventual HIV vaccine. (author's)
Voluntary surgical sterilization is the most widely used contraceptive method in the world, with about 80 million couples currently using it to control their fertility. The number of people choosing sterilization has increased dramatically in recent years, from an estimated 3 to 4 million globally in 1950, to 20 million in 1970, and 65 million in 1975 (329,365,366). Interest in voluntary sterilization as a contraceptive measure has evolved rapidly since the 195Os, but especially so in the last five years. Surgical sterilization offers many advantages over other contraceptive methods: for couples desiring no more children, it is the most effective contraceptive method available; it is a one-time procedure that does not require sustained motivation, check-ups at regular intervals, or expenditures for contraceptive supplies; It can be performed on either men or women; the risk of complications or death is minimal, if the procedure is performed according to accepted medical standards; and it is extremely cost-effective if the procedure's cost is amortized over the couple's remaining reproductive years. (excerpt)
Selected bibliography with abstracts on voluntary sterilization 1970-1972.
This bibliography with abstracts represents a preliminary compilation of periodical articles, papers, book chapters, abstracts, and personal communications reporting on male and female sterilization - surgical procedures, legal issues, and new developments - during 1970, 1971, and 1972. Animal studies have not been included except where tests or experimental methods may have a direct relevance for human use. An expanded data base, fully indexed, will be available for computerized retrieval later in the year. This publication is being distributed in the hope that comments will be made on the content, format, and abstracts which can be taken into account in the final computerized file. Anyone whose work may have been inadvertently omitted is invited to send copies for inclusion. On a trial basis, copies of the articles cited can be provided in limited numbers to qualified researchers, medical personnel, or officials in developing countries. No more than five copies will be sent with each request. Please identify each request by the six-digit number found at the end of the abstract. (excerpt)
DMPA at a glance. Lessons learned about injectables.
Maximizing access and quality of services for injectable contraceptives requires well-planned introduction of the method, through training, balanced and extensive communication with the public, application of scientific medical guidelines for provision and use, and informative and sensitive counseling. For policy-makers: if not already done, register injectable contraceptives; ensure that injectables are offered in family planning programs; and avoid restrictions based on age and parity. There are no medical reasons to require users of injectables to have reached a certain age or to have had children or a certain number of children. (excerpt)
Injectable contraceptives are convenient, private, and very effective. This guide will help you, the family planning provider, tell your clients about the 3-month injectable called Depo-Provera (DMPA) or the 2-month injectable called Noristerat (NET EN). Counseling is a step-by- step discussion between you and the client. Counseling helps each client choose and use the family planning method that best suits that person’s needs. Good counseling involves friendly, open talk with the client to find out politely what she wants and what concerns her. (excerpt)
Norplant is a set of contraceptive implants-six capsules filled with levonorgestrel, one of the hormones most widely used in birth control pills. The capsules do not contain estrogen. A specially trained health care provider places the capsules just under the skin in a woman's upper arm and later also removes them. Insertion and removal are minor surgical procedures done under local anesthetic. No stitches are needed. Various Women Might Choose Norplant: women who do not want a child for several years but may want a child later; women who do not want any more children but do not want sterilization; women who can accept changes in menstrual bleeding patterns; women who want nothing to remember daily or before sexual relations; and women who are troubled by estrogen side effects of pills. (excerpt)
Chlamydia -- a testing issue [editorial]
This week began with the ancient celebration of St Valentine’s day. On a related, but less romantic theme, Melanie Johnson, UK public health minister, announced last week a two year pilot scheme to offer free Chlamydia trachomatis testing in pharmacies. Chlamydia is the most common bacterial sexually transmitted disease, infecting people irrespective of their sex, race, or nationality. Recent reports suggest that more than 10% of Japanese teenagers are infected with chlamydia, that the incidence of chlamydia infection in UK men rose by around 15% between 2001 and 2002, and that the prevalence of chlamydia in black American women is over 13%. Alarmingly, only 14% of sexually experienced 18–26 year olds in the USA perceived a risk of infection from chlamydia. In addition, the risk of infection is not restricted to teenagers and young adults. The UK Health Protection Agency has found that in 45 to 64 year old women, rates of chlamydial infection rose by 177% between 1995 and 2003. (excerpt)
HIV, malaria and beyond: reducing the disease burden of female adolescents.
In sub-Saharan Africa the highest overlap between malaria and HIV infections occurs in female adolescents. Yet control activities for these infections are directed to different target groups, using disparate channels. This reflects the lack of priority given to adolescents and the absence of an accepted framework for delivering health and health-related interventions to this high-risk group. In this paper it is argued that female adolescents require a continuum of care for malaria and HIV – prior to conception, during and after pregnancy and that this should be provided through adolescent services. The evidence for this conclusion is presented. A number of African countries are commencing to formulate and implement adolescent-friendly policies and services and disease control programs for malaria and HIV will need to locate their interventions within such programs to ensure widespread coverage of this important target group. Failure to prioritize adolescent health in this way will seriously limit the success of disease control programs for malaria and HIV prevention. (author's)
Epidemiological, clinical and biological features of malaria among children in Niamey, Niger.
Malaria takes a heavy toll in Niger, one of the world's poorest countries. Previous evaluations conducted in the context of the strategy for the Integrated Management of Childhood Illness, showed that 84% of severe malaria cases and 64 % of ordinary cases are not correctly managed. The aim of this survey was to describe epidemiological, clinical and biological features of malaria among <5 year-old children in the paediatric department of the National Hospital of Niamey, Niger's main referral hospital. The study was performed in 2003 during the rainy season from July 25th to October 25th. Microscopic diagnosis of malaria, complete blood cell counts and measurement of glycaemia were performed in compliance with the routine procedure of the laboratory. Epidemiological data was collected through interviews with mothers. 256 children aged 3–60 months were included in the study. Anthropometrics and epidemiological data were typical of a very underprivileged population: 58% of the children were suffering from malnutrition and all were from poor families. Diagnosis of malaria was confirmed by microscopy in 52% of the cases. Clinical symptoms upon admission were non-specific, but there was a significant combination between a positive thick blood smear and neurological symptoms, and between a positive thick blood smear and splenomegaly. Thrombopaenia was also statistically more frequent among confirmed cases of malaria. The prevalence of severe malaria was 86%, including cases of severe anaemia among < 2 year-old children and neurological forms after 2 years of age. Overall mortality was 20% among confirmed cases and 21% among severe cases. The study confirmed that malaria was a major burden for the National Hospital of Niamey. Children hospitalized for malaria had an underprivileged background. Two distinctive features were the prevalence of severe malaria and a high mortality rate. Medical and non-medical underlying factors which may explain such a situation are discussed. (author's)
Periodic epidemics of malaria are a major public health problem for many sub-Saharan African countries. Populations in epidemic prone areas have a poorly developed immunity to malaria and the disease remains life threatening to all age groups. The impact of epidemics could be minimized by prediction and improved prevention through timely vector control and deployment of appropriate drugs. Malaria Early Warning Systems are advocated as a means of improving the opportunity for preparedness and timely response. Rainfall is one of the major factors triggering epidemics in warm semi-arid and desert-fringe areas. Explosive epidemics often occur in these regions after excessive rains and, where these follow periods of drought and poor food security, can be especially severe. Consequently, rainfall monitoring forms one of the essential elements for the development of integrated Malaria Early Warning Systems for sub-Saharan Africa, as outlined by the World Health Organization. The Roll Back Malaria Technical Resource Network on Prevention and Control of Epidemics recommended that a simple indicator of changes in epidemic risk in regions of marginal transmission, consisting primarily of rainfall anomaly maps, could provide immediate benefit to early warning efforts. In response to these recommendations, the Famine Early Warning Systems Network produced maps that combine information about dekadal rainfall anomalies, and epidemic malaria risk, available via their Africa Data Dissemination Service. These maps were later made available in a format that is directly compatible with HealthMapper, the mapping and surveillance software developed by the WHO's Communicable Disease Surveillance and Response Department. A new monitoring interface has recently been developed at the International Research Institute for Climate Prediction (IRI) that enables the user to gain a more contextual perspective of the current rainfall estimates by comparing them to previous seasons and climatological averages. These resources are available at no cost to the user and are updated on a routine basis. (author's)
Severe falciparum malaria in Gabonese children: clinical and laboratory features.
Malaria continues to claim one to two million lives a year, mainly those of children in sub-Saharan Africa. Reduction in mortality depends, in part, on improving the quality of hospital care, the training of healthcare workers and improvements in public health. This study examined the prognostic indicators of severe falciparum malaria in Gabonese children. An observational study examining the clinical presentations and laboratory features of severe malaria was conducted at the Centre Hospitalier de Libreville, Gabon over two years. Febrile children aged from 0 to 10 years with Plasmodium falciparum infection and one or more features of severe malaria were enrolled. Most children presenting with severe falciparum malaria were less than 5 years (92.3% of 583 cases). Anaemia was the most frequent feature of severe malaria (67.8% of cases), followed by respiratory distress (31%), cerebral malaria (24%) hyperlactataemia (16%) and then hypoglycaemia (10%). Anaemia was more common in children under 18 months old, while cerebral malaria usually occurred in those over 18 months. The overall case fatality rate was 9%. The prognostic indicators with the highest case fatality rates were coma/seizures, hyperlactataemia and hypoglycaemia, and the highest case fatality rate was in children with all three of these features. Prompt and appropriate, classification and treatment of malaria helps identify the most severely ill children and aids early and appropriate management of the severely ill child. (author's)
Population genetic structure of Anopheles gambiae mosquitoes on Lake Victoria islands, west Kenya.
Understanding the genetic structure of island Anopheles gambiae populations is important for the current tactics in mosquito control and for the proposed strategy using genetically-modified mosquitoes (GMM). Genetically-isolated mosquito populations on islands are a potential site for testing GMM. The objective of this study was to determine the genetic structure of A. gambiae populations on the islands in Lake Victoria, western Kenya. The genetic diversity and the population genetic structures of 13 A. gambiae populations from five islands on Lake Victoria and six villages from the surrounding mainland area in the Suba District were examined using six microsatellite markers. The distance range of sampling sites varied between 2.5 and 35.1 km. A similar level of genetic diversity between island mosquito populations and adjacent mainland populations was found. The average number of alleles per locus was 7.3 for the island populations and 6.8 for the mainland populations. The average observed heterozygosity was 0.32 and 0.28 for the island and mainland populations, respectively. A low but statistically significant genetic structure was detected among the island populations (FST = 0.019) and between the island and mainland populations (FST = 0.003). A total of 12 private alleles were found, and nine of them were from the island populations. A level of genetic differentiation between the island and mainland populations was found. Large extent of gene flow between the island and mainland mosquito populations may result from wind- or human-assisted dispersal. Should the islands on Lake Victoria be used as a trial site for the release program of GMM, mosquito dispersal between the islands and between the island and the mainland should be vigorously monitored. (author's)
The objective was to examine the enabling and constraining factors that influence African social scientists involvement in malaria control. Convenience and snowball sampling was used to identify participants. Data collection was conducted in two phases: a mailed survey was followed by in-depth phone interviews with selected individuals chosen from the survey. Most participants did not necessarily seek malaria as a career path. Having a mentor who provided research and training opportunities, and developing strong technical skills in malaria control and grant or proposal writing facilitated career opportunities in malaria. A paucity of jobs and funding and inadequate technical skills in malaria limited the type and number of opportunities available to social scientists in malaria control. Understanding the factors that influence job satisfaction, recruitment and retention in malaria control is necessary for better integration of social scientists into malaria control. However, given the wide array of skills that social scientists have and the variety of deadly diseases competing for attention in Sub Saharan Africa, it might be more cost effective to employ social scientists to work broadly on issues common to communicable diseases in general rather than solely on malaria. (author's)
By 2030, more than 50% of the African population will live in urban areas. Controlling malaria reduces the disease burden and further improves economic development. As a complement to treated nets and prompt access to treatment, measures targeted against the larval stage of Anopheles sp. mosquitoes are a promising strategy for urban areas. However, a precise knowledge of the geographic location and potentially of ecological characteristics of breeding sites is of major importance for such interventions. In total 151 km2 of central Dar es Salaam, the biggest city of Tanzania, were systematically searched for open mosquito breeding sites. Ecologic parameters, mosquito larvae density and geographic location were recorded for each site. Logistic regression analysis was used to determine the key ecological factors explaining the different densities of mosquito larvae. A total of 405 potential open breeding sites were examined. Large drains, swamps and puddles were associated with no or low Anopheles sp. larvae density. The probability of Anopheles sp. larvae to be present was reduced when water was identified as "turbid". Small breeding sites were more commonly colonized by Anopheles sp. larvae. Further, Anopheles gambiae s.l. larvae were found in highly organically polluted habitats. Clear ecological characteristics of the breeding requirements of Anopheles sp. larvae could not be identified in this setting. Hence, every stagnant open water body, including very polluted ones, have to be considered as potential malaria vector breeding sites. (author's)
Following the tsunami, a detailed overview of the area specific transmission levels is essential in assessing the risk of malaria in Sri Lanka. Recent information on vector insecticide resistance, parasite drug resistance, and insights into the national policy for malaria diagnosis and treatment are important in assisting national and international agencies in their control efforts. Monthly records over the period January 1995 – October 2004 of confirmed malaria cases were used to perform an analysis of malaria distribution at district spatial resolution. Also, a focused review of published reports and routinely collected information was performed. The incidence of malaria was only 1 case per thousand population in the 10 months leading up to the disaster, in the districts with the highest transmission. Although relocated people may be more exposed to mosquito bites, and their capacity to handle diseases affected, the environmental changes caused by the tsunami are unlikely to enhance breeding of the principal vector, and, given the present low parasite reservoir, the likelihood of a malaria outbreak is low. However, close monitoring of the situation is necessary, especially as December – February is normally the peak transmission season. Despite some losses, the Sri Lanka public health system is capable of dealing with the possible threat of a malaria outbreak after the tsunami. The influx of foreign medical assistance, drugs, and insecticides may interfere with malaria surveillance, and the long term malaria control strategy of Sri Lanka, if not in accordance with government policy. (author's)
Mosquitoes sampling is an important component in malaria control. However, most of the methods used have several shortcomings and hence there is a need to develop and calibrate new methods. The Mbita trap for capturing host-seeking mosquitoes was recently developed and successfully tested in Kenya. However, the Mbita trap is less effective at catching outdoor-biting Anopheles funestus and Anopheles arabiensis in Madagascar and, thus, there is need to further evaluate this trap in diverse epidemiological settings. This study reports a field evaluation of the Mbita trap in a rice irrigation scheme in Kenya The mosquito sampling efficiency of the Mbita trap was compared to that of the CDC light trap and the human landing catch in western Kenya. Data was analysed by Bayesian regression of linear and non-linear models. The Mbita trap caught about 17%, 60%, and 20% of the number of An. arabiensis, An. funestus, and culicine species caught in the human landing collections respectively. There was consistency in sampling proportionality between the Mbita trap and the human landing catch for both An. arabiensis and the culicine species. For An. funestus, the Mbita trap portrayed some density-dependent sampling efficiency that suggested lowered sampling efficiency of human landing catch at low densities. The CDC light trap caught about 60%, 120%, and 552% of the number of An. arabiensis, An. funestus, and culicine species caught in the human landing collections respectively. There was consistency in the sampling proportionality between the CDC light trap and the human landing catch for both An. arabiensis and An. funestus, whereas for the culicines, there was no simple relationship between the two methods. The Mbita trap is less sensitive than either the human landing catch or the CDC light trap. However, for a given investment of time and money, it is likely to catch more mosquitoes over a longer (and hence more representative) period. This trap can therefore be recommended for use by community members for passive mosquito surveillance. Nonetheless, there is still a need to develop new sampling methods for some epidemiological settings. The human landing catch should be maintained as the standard reference method for use in calibrating new methods for sampling the human biting population of mosquitoes. (author's)
Focusing on improved water and sanitation for health. Millennium project.
A silent humanitarian crisis kills some 3900 children every day and thwarts progress towards all the Millennium Development Goals (MDGs), especially in Africa and Asia. The root of this unrelenting catastrophe lies in these plain, grim facts: four of every ten people in the world do not have access to even a simple pit latrine; and nearly two in ten have no source of safe drinking water. To help end this appalling state of affairs, the MDGs include a specific target (number 10) to cut in half, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. Far more people endure the largely preventable effects of poor sanitation and water supply than are affected by war, terrorism, and weapons of mass destruction combined. Yet those other issues capture the public and political imagination—and public resources—in a way that water and sanitation issues do not. Why? Perhaps in part because most people who read articles such as this find it hard to imagine defecating daily in plastic bags, buckets, open pits, agricultural fields, and public areas for want of a private hygienic alternative (as do some 2.6 billion people). Or perhaps they cannot relate to the everyday life of the 1.1 billion people without access to even a protected well or spring within reasonable walking distance of their homes. (excerpt)
Reflections after Mexico [letter]
One of the main aims of the Ministerial Summit and the Forum 8 Meeting on Health Research in Mexico City in November, 2004, was to consider how health research could contribute to achieve the Millennium Development Goals (MDGs). In your Nov 27 Editorial, you acknowledge the importance of the meeting, and its support for an increased focus on health systems research. It seems that many have taken for granted this essential role of research since the Commission on Health Research for Development met in Stockholm in 1990 and published its report entitled ”Health research: an essential link to equity in development”. The crucial role of popuhealth research was also underlined in the Forum 8 statement from Mexico: “The attainment of the MDG poverty target will depend on increased research directed to the health needs of those living in absolute poverty”. (excerpt)
Co-trimoxazole prophylaxis in African children with HIV-1. Authors' reply [letter]
We are pleased that Shabir Madhi and colleagues recognise the importance of the results of the CHAP trial in promoting evidence-based use of co-trimoxazole prophylaxis in HIV-1-infected children in Africa. However, we believe that their concerns about the ethics of randomising children with CD4% of less than 15, based on 1995 US guidelines, are misguided. Co-trimoxazole prophylaxis for children older than 1 year is recommended for prevention of PCP in 1995 US guidelines, on the basis of evidence extrapolated from US trials in HIV infected adults. Although it is established that PCP is common in African infants, data from several studies (including ours) suggest that this pathogen occurs relatively infrequently in older children in resource-limited settings and that bacterial pneumonias and tuberculosis predominate. The Zambian postmortem study quoted by Madhi and colleagues as having a PCP prevalence of 29% included mainly infants (median age 9 months); only 7% of the total pathology among children older than 1 year was due to PCP, and this is a higher proportion than that of other post-mortem studies from the region. (excerpt)
Newborn survival: putting children at the centre.
This week we begin the second phase of The Lancet’s campaign on child survival by launching a major new series of papers devoted to the health of newborns. For this initiative we owe much to the expertise of two individuals—Joy Lawn and Simon Cousens. Both developed the original idea, put together a Lancet Neonatal Survival Steering Team, and coordinated meetings to synthesise evidence, refine conclusions, and draft papers. At The Lancet, we view this partnership between scientists, health workers, and journal editors as the most important public-health campaign we have taken part in for a generation. There has been an unusual confluence of events during the past 2 years to make the issue of child survival a moral as well as a health barometer of our times. First, the arguments about child health have come to be underpinned by an unusually robust body of knowledge. The science of child survival has reached a critical mass. Second, policymakers have recognised that their commitment to meet the Millennium Development Goals will come to nothing unless survival is made a reality for millions of children. And third, there is a growing awareness that the goodwill of international agencies is simply not good enough. (excerpt)
Achieving the Millennium Development Goals [letter]
The world is focusing on poverty and Africa, thanks to the recent four-country visit of UK Chancellor Gordon Brown, the Davos summit, the focus on progress towards the Millennium Development Goals, last week’s Commission for Africa report, and the upcoming G8 Summit. It is therefore timely to point out that many millions in Africa are today living in poverty, and are unable to lead healthy, productive lives because they are incapacitated by parasitic and infectious diseases such as schistosomiasis, lymphatic filariasis, onchocerciasis, intestinal helminths, and trachoma in addition to the well publicised epidemics of HIV/AIDS, malaria, and tuberculosis. Current data suggest that these parasitic and infectious diseases could be the cause of about 25% of disability-adjusted life years (DALYs)—almost half of those of HIV/AIDS, tuberculosis, and malaria combined. Co-infections are common, owing to an extensive overlap in their distribution, but today we are in a position to eliminate morbidity and blindness due to these infections with just four drugs: praziquantel, albendazole, ivermectin, and azithromycin. (excerpt)
The health objectives set out in the United Nations Millennium Development Goals (MDGs) do not share the focus on poor people that typifies the MDGs overall. Rather, they call for improvements in national averages that can be achieved through gains in both advantaged and disadvantaged groups. As a result, any reduction in society-wide average rates of death or illness can provide a wide range of outcomes for poor people. Since expanded health services typically reach better-off groups before disadvantaged ones, poor people are unlikely to be the principal beneficiaries of efforts to accelerate progress towards the MDGs by providing additional resources to the health sector, as presently constituted. More plausible is faster progress among privileged groups and a rise in poor-rich health disparities. Such an outcome is not inevitable; but achieving faster progress for poor populations will need reorientation in addition to expansion of health activities. (excerpt)
Reflections after Mexico [letter]
Your Editorial on the Mexico Statement refers to the dominance of basic science over public health, and the relatively mild approach to dealing with this imbalance preferred by the health ministers at the Mexico Summit. If health ministers and other policy makers were provided with specific details of this imbalance in their respective countries through objective documentation and analysis of health research output, it would serve two major functions. First, the policy makers themselves would have less doubt about the imbalance and the harm it causes, and second, objective evidence would give them the teeth to push for action from resistant stakeholders. For example, analysis of health research output from India highlights several stark imbalances. First, of the health research output in 2002 available in the public domain, only 3–4% was in public health, with the remaining almost equally divided between basic and clinical sciences. (excerpt)
On Nov 14, 2004, the United Nations Development Fund for Women (UNIFEM) announced grant awards to 17 groups in developing countries for projects to address gender-based violence in conflict and postconflict situations. Totalling US $900,000, the grants will fund projects that include: a training programme for community leaders in the Democratic Republic of the Congo to deal with the communal effects of violence against women in that war-torn country; a project in southern Sudan to improve women’s access to services during post-conflict reconstruction and to train them to participate in the peace process; education for government officials in Georgia and Azerbaijan on how to use violence prevention and prosecution mechanisms at institutional and policy levels; and studies of the extent of gender-based violence in Honduras, Guatemala, El Salvador, Nicaragua, and Costa Rica, to raise awareness of the problem in those countries, lobby for legislative and policy reforms, and increase accountability of offenders. Money for the grants comes from the UN Trust Fund to Eliminate Violence Against Women, which was established by UNIFEM in 1997. Within 3 years of its inception, the Trust Fund had raised $4.3 million in government and private donations, which, in turn, has funded more than 105 projects in over 65 countries throughout the world. (excerpt)
Reflections after Mexico [letter]
Global Forum for Health Research (Forum 8) was held in Mexico City in conjunction with the Ministerial Summit on Health Research on Nov 16–20, 2004. Forum 8 brought together more than 700 participants, including representatives from governments of developed and developing countries, intergovernmental organisations, non-governmental organisations, the private sector, researchers and research councils, leaders and users of health research, and representatives from civil society. The Ministerial Summit and Forum 8 had a common theme: “the health research necessary to achieve the Millennium Development Goals (MDGs)”. Complementing the statement produced by the Ministerial Summit on Health Research, the Global Forum for Health Research presented a statement at the end of Forum 8. This statement was developed by the Global Forum Secretariat with the assistance of inputs from regional consultations and from participants in Forum 8. (excerpt)
Co-trimoxazole prophylaxis in African children with HIV-1 [letter]
Although we appreciate the potential of C Chinto and colleagues’ study to promote wider use of prophylaxis in African HIV-1-infected children, we are concerned about the ethics of a placebo group and disagree with the authors’ interpretation and explanation of their findings. We are disturbed that severely immunocompromised children (CD4% <15) were randomised to placebo in breach of widely accepted 1995 Centers for Disease Control (CDC) guidelines and subsequent UNAIDS recommendations on co-trimoxazole prophylaxis for HIV-1-infected children in developing countries. These recommendations advocate prophylaxis for any child born to an HIV-1-infected woman; any HIV-1-infected infant; and children older than 15 months who have had Pneumocystis jiroveci pneumonia (PCP), have symptomatic HIV disease, have an AIDS-defining illness, or have a CD4% of less than 15 (excerpt)
Achieving the Millennium Development Goals [letter]
I could not agree more with J D Sachs and J W McArthur about the need for urgent action in 2005 if the Millennium Development Goals are to be met. The scaling up of investments in targeted sectors and regions must be combined with the development of indigenous capacity to deliver them; in health, nothing short of a revolution is required. If equity in health is ever to be a possibility, the major pharmaceutical companies must overhaul their policies and prices of drugs for the poorest people and initiatives should focus on motivating and equipping staff to work effectively in rural areas. Immediate quick-win solutions are tempting, particularly when they are linked to numerical targets, but unless measures are taken to build infrastructure in places where it does not exist, the rural poor will see no benefit. In fact the gulf between the rich and poor in less developed countries will continue to widen as the international community strives to show that it can, at least partly, reach these fundamental targets at the expense of those who will continue to suffer. (excerpt)
Achieving the Millennium Development Goals [letter]
J D Sachs and J W McArthur stress the importance of a breakthrough in 2005 in achieving the Millennium Development Goals (MDGs). They estimate that official development assistance required during the next decade will be US$135 billion in 2006, rising to $195 billion in 2015 (0.44% and 0.54% of donor gross national product [GNP], respectively), but do not suggest any specific sources for this funding. World arms spending is expected to be around $900 billion in 2005— about 2.4% of global GNP, most of it by the developed countries. The arms trade is second only to the oil trade in size, and fuels the 30 or more conflicts, most of them in the developing world, which are a major factor in preventing the achievement of the MDGs. (excerpt)
A continuum of care to save newborn lives.
The global community recently declared a commitment to “create an environment—at the national and global levels alike—which is conducive to development and to the elimination of poverty”. This declaration led to an agreement on eight goals in key areas of global concern: the Millennium Development Goals. Central among those goals are two that aim to reduce maternal and child mortality, goals 4 and 5. Investment in maternal, newborn, and child health is not only a priority for saving lives, but is also critical to advancing other goals related to human welfare, equity, and poverty reduction. The United Nations has led the global community in articulating a rights-based approach to health, giving special attention to mothers and children. The Universal Declaration of Human Rights, ratified in 1948, states that “motherhood and childhood are entitled to special care and assistance”. The Convention on the Rights of the Child, ratified in 1989, guarantees children’s right to the highest attainable standard of health. Other conventions and international consensus documents focus on redressing the gender-based discrimination that might undermine good health, particularly that of girls and women. (excerpt)
Television as a source of health information for Thai elderly.
With the rapidly growing elderly population in the world, increasing attention has been focused on health promotion in later life. Health promotion usually suggests self-care activities that allow elderly people to take initiative and responsibility to maintain healthy life and functional ability in the aging years. In order to take such initiative and responsibility, however, health information is needed, that encourages individuals to become knowledgeable about diseases, to avoid health risk behaviors, and to practice preventive behaviors. Health information thus becomes a prerequisite for the process of healthy aging. In addition to advice from health professionals, people utilize various forms of mass media for obtaining health information. Historically, the mass media has disseminated a variety of health information including personal health issues, health habits, medical miracles, and technological breakthroughs. In recent years, television has appeared to be a frequently cited source of health information than conventionally cited sources such as newspapers, books, magazines, and medical personnel. Given the easiness of access, it is expected that television will continuously play a significant role in disseminating health information among elderly populations. (excerpt)
Conceiving and dying in Afghanistan.
Since the first International Safe Motherhood Conference in 1987, there has been increased focus on maternal health and maternal mortality. The design and implementation of effective programmes for maternal health require data of adequate quality, despite the challenges of generating such data. Typical approaches have produced data of low quality and limited usefulness. Therefore, Linda Bartlett and colleagues’ report in today’s Lancet is of particular merit for its use of rigorous methodology. The methodology of the reproductive-age mortality study (RAMOS), while costly and cumbersome, represents the gold standard for measuring maternal mortality. Bartlett and colleagues should be commended for their efforts, under difficult circumstances, to identify all deaths in women of reproductive age in the study area and further assess whether the deaths were due to maternal causes. With their two-stage methodology, Bartlett and colleagues recorded 154 maternal deaths in a population of more than 90,000, a national maternal mortality ratio of 1600–2200 maternal deaths per 100,000 livebirths in Afghanistan, and 6500 maternal deaths per 100,000 livebirths (in Badakshan province)—the highest maternal mortality ratio ever reported. Maternal mortality, compared with other causes of mortality, remains a relatively rare event, and for this reason is commonly expressed per 100 000 rather than per 1000. (excerpt)
Modernization and divorce in Thailand: 1940s to 1970s.
In this study, it is attempted to document the level and determinants of divorce in Thailand, particularly during the period of modernization. The author questions existing Thai divorce estimates and the methodology used in previous to derive these estimates. The conventional wisdom that modernization invariably leads to a rise in divorce is challenged. This study is based on marital histories available in the 1975 Survey of Fertility in Thailand. The life table and proportional hazards models to document level and determinants of divorce in Thailand from the 1940s to 1970s are used. While the life table model takes care of data censoring issues and examines correlates of divorce descriptively, the proportional hazards model provides an assessment of variations in divorce in a multivariate framework. From the 1940s to 1970s, modernization began to spread across Thailand. This can be observed in how socioeconomic characteristics of Thai women change over these periods of time. There were increased proportions of women attaining at least primary education, participating in modem labor force prior to marriage, and marrying at later ages. However, The strong evidence to support that "traditional" social statuses (e.g., having no schooling, marrying early) are associated with lower odds of divorce is not found. From the 1940s to 1960s, divorce was not uncommon in Thailand, nor did the rates of divorce increase as Thai society became more modernized. (excerpt)
Reproductive health is a major health problem among immigrant laborers worldwide. Reproductive morbidities, obstetric health problems and adverse pregnancy outcomes are apparently higher among immigrant women than the native population. On average, immigrant women workers compared to native women have lower socioeconomic status, less education, and receive less reproductive health care due to sociocultural and language barriers. Factors associated with the immigrant situation such as migration stress, the rupture of previous social networks, religious and cultural factors and racial discrimination, complicate access to health care and result in poorer health outcomes than for the general population of the host country. In 1998, the Asian Research Center for Migration Statistics reported the number of illegal migrants in Thailand as 733,640. Among them, approximately 20 percent live in border areas and 80 percent are inside the country. The majority (80 percent) come from Myanmar, 14 percent from Cambodia and 6 percent from Laos. In 2001, the government enforced legislation for controlling health problems of immigrant workers, including family planning services, to control reproductive health and child health problems. Along with this, a special health service improvement was introduced. The current study examines contraceptive use behavior and responses to such service among the Myanmar immigrant women workers in southern Thailand. (excerpt)
Some indirect techniques to estimate maternal mortality in Nepal.
A mother sometimes loses her own life during the process of giving birth to a child. In most developing countries like Nepal, childbearing is valued, highly expected and an inevitable part of a woman's life. Some key causes of maternal deaths in Nepal are hemorrhage, sepsis, toxemia, obstructive labor and septic abortion, etc. Due to less access to quality health care, maternal mortality continues to be a leading cause of death during the reproduction process. It is difficult to know the maternal mortality level and trend in a country or in a community from the limited data available. Indirect techniques may be appropriate tool to diagnose such a situation. In fact, an indirect method of estimation has its origin and produce estimates of certain parameters on the basis of information, which is only related to its value (parameter) indirectly. Traditionally, estimation of demographic parameters has been done on the basis of data collected by census or by vital registration system. Unfortunately, however, in many countries today, the data collection by these systems either do not exist or their quality is so poor that estimates based on such data yield inconsistent results. (excerpt)
Over the past two decades, Brazil has seen improvements in women’s nutritional status, education, smoking habits, and antenatal care. Neonatal mortality rates (deaths of liveborn infants up to 1 month of age), however, have changed little. In this issue of The Lancet, Fernando Barros and colleagues present fascinating data from three birth cohorts which suggest that falling mortality in term infants (37 weeks’ gestation or more) has been offset by a rise in preterm births and deaths, resulting in little change in neonatal mortality. Brazilian health authorities can claim fairly that more preterm infants survive because of better neonatal care: gestation-specific mortality rates have fallen by 50% since 1982. Nonetheless, many preterm deliveries result from pregnancy interruption, either by caesarean section or induction. Such early delivery is often a direct consequence of inappropriate medicalisation. The road to hell is paved with good intentions, and efforts to improve perinatal care have often had unintended consequences. Diethylstilbestrol was used in millions of pregnancies before its association with vaginal cancer in offspring was noted. (excerpt)
Predictors for quality of life of pulmonary tuberculosis patients in Yunnan Province of China.
Quality of life (QoL) of patients has social differentials. For example, QoL of male is better than that of female for coronary artery disease using Seattle Angina Questionnaire Survey. Among people suffer from acute coronary syndromes, QoL of the rich is better than that of the poor. Tuberculosis (TB) is a serious chronic infectious disease, identified by WHO as a global emergency. WHO estimated that worldwide eight million people have TB, of which two million die of TB every year (WHO, 1998). However, there have been very few reports on QoL of TB patients. There is a need to develop an instrument to measure QoL for this population. With better understanding and research, the QoL of patient can be improved and TB control program can be made more effective. In this study, we developed and validated TB quality of life scale (TBQoL) and explored its socio-demographic predictors. (excerpt)
The aims of this study are twofold. First, it attempts to explore how rural Thai women perceive factory employment in terms of contributions to the household economy. This study focuses particularly on female workers, because as described in the next section the majority of the rural factory workers are females. The second goal of this study is to consider the potentiality that rural factory employment may contribute to diverting and mitigating the rural-urban migration flow. The data used in this study were obtained from a survey and focus group discussions conducted by the authors from April to June 2001. The next section of this paper attempts to conceptualize factory employment and migration for rural Thai women by reviewing the existing literature. In the third and fourth sections, we will briefly describe the research setting and the sample. The main findings from the survey and focus group discussions are then presented in the fifth and sixth sections, followed by the concluding remarks. (excerpt)
Middle-income countries will need to drastically reduce neonatal deaths to achieve the Millennium Development Goal for child survival. The evolution of antenatal and perinatal care indicators in the Brazilian city of Pelotas from 1982 to 2004 provides a useful case study of potential challenges. We prospectively studied three birth cohorts representing all urban births in 1982, 1993, and from January to July, 2004. The same methods were used in all three studies. Despite improvements in maternal characteristics, prevalence of preterm births increased from 6.3% (294 of 4665) in 1982 to 16.2% (342 of 2112) in 2004, corresponding to a 47 g reduction in mean birthweight. Average number of antenatal visits in 2004 was 8.3 per woman, but quality of care was still inadequate—97% of women had an ultrasound scan, but only 1830 (77%) had a vaginal examination and 559 of 1748 non-immunised women did not receive tetanus toxoid. Rate of caesarean sections increased greatly, from 28% (1632 of 5914) in 1982 to 43% (1039 of 2403) in 2004, reaching 374 of 456 (82%) of all private deliveries in 2004. The increased rate of preterm births seemed to result largely from caesarean sections or inductions. Newborn care improved, and gestational-age-specific mortality rates had fallen by about 50% since 1982. As a result, neonatal mortality rates had been stable since 1990, despite the increase in preterm deliveries. Excessive medicalisation—including labour induction, caesarean sections, and inaccurate ultrasound scans—led by an unregulated private sector with spill-over effects to the public sector, might offset the gains resulting from improved maternal health and newborn survival. These challenges will have to be faced by middle-income countries striving to achieve the child survival Millennium Development Goal. (author's)
Migration to southern Thailand: an analysis of Lee's theroy.
Lee (1966) states that there are four factors which enter into the decision to migrate and the process of migration: factors in the place of origin, factors related to the place of destination, intervening obstacles between the place of origin and the place of destination and individual factors. In each of the first three, there are many pull factors attracting people to migrate. At the same time there are push factors forcing people to move out. Both push and pull factors will affect different people in different ways. Some factors, though, would effect only certain people. This might be engendering positives in some people but negatives in others. Thus, any factor could produce different effects on different people. (excerpt)
Population futures for the next three hundred years: Soft landing or surprises to come?
World Population in 2300 (United Nations 2003b), reporting on the proceedings of a December 2003 expert group meeting on long-range population projections and presenting the results of a new set of United Nations population projections, bears out Hajnal's argument. Among his three propositions, the validity of the second is the most obvious. There has been a veritable outpouring of demographic projections during the last 50 years, prepared by various international organizations and national agencies, as well as by independent analysts. Among these, the United Nations Population Division's now biennially revised projections are by far the most detailed, best known, and most widely used. This well-deserved prominence reflects the Division's unparalleled access to national data, its in-house analytic experience and resources, and its willingness to draw on outside expertise whenever that might usefully complement its own. The most recent of the biennial projections, the 2002 Revision (United Nations 2003a), is the immediate predecessor of World Population in 2300, and indeed the former provides the year 2000 to 2050 component for the new set of long-term projections covering the next 300 years. This new set is not just one among the many. It is distinguished from the routine by an exceptionally brave ambition: to draw a picture of plausible demographic futures up to the year 2300 and to do so in extraordinary detail: country-by-country according to the political map of the early twenty-first century. (excerpt)
Does late reproduction extend the life span? Findings from European royalty.
Ultimate explanations for the physiology of human aging can be found only by studying the biological evolution of this physiology. Because lifetime reproductive success, not longevity, is selected for by natural selection, the links between reproductive events and mortality risks over the lifetime are the key to any evolutionary explanation of the human life span. There are many reports of a positive statistical association between late reproduction and female life span. The mechanism behind this statistical association, however, is unclear. Traditional evolutionary theory predicts a tradeoff between investment in children and a woman's own survival. An alternative approach, also supported by empirical findings from animal and human populations, speculates that selection for increased reproductive success simultaneously may drive the selection of longevity. A longer reproductive life span would allow a more efficacious timing of births, thereby increasing survival of parents and offspring. Also, a longer post-reproductive life span may increase total parental investment per child. (excerpt)
Consequences of demographic transition on Thai elderly living arrangements.
Fertility, as an important component of demographic change, has significantly altered family composition with regard to size, type and characteristics of kin. The total fertility rate (TFR), i.e. the average number of births during a woman's reproductive age, declined from 6.4 in the early 1960s to 2.6 in the late 1980s and is below the replacement level, 1.9, at the present time. This is due to an effective National Family Planning Program started in 1970, and social and economic development, together with advances in public health services. Although care for the elderly by their children is prominent in Thai culture, with both seniority and filial piety playing an important part, studies indicate that probability of coresidence with children depends on the number of children in a family. The drastic decline in fertility of the past three decades is hypothesized to result in a shortage of familial caregivers during the current demographic transition in this country. Coresidence has historically provided financial, emotional, instrumental and information support as well as assistance in daily living for the elderly. The levels and chances of receiving support are greater if the elderly coreside with their families. In consequence, living arrangement is very important in terms of providing support for the elderly and can, in general, guarantee their well-being. In Thai society, where the family has an obligation to care for the elderly, the consequences of rapid declines in fertility and mortality on elderly living arrangements are an interesting issue in the field of population and development and should be researched carefully. (excerpt)
Systematic scaling up of neonatal care in countries.
Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes—eg, safe motherhood and integrated management of child survival initiatives—reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes. (author's)
James Mill on the growth and limitation of population.
The brief passages reproduced below from James Mill's 1821 work, Elements of Political Economy, present an early analysis of total and net fecundity, a discussion of the scope and limits of government influence on fertility, and a reflection on the goal of a stationary population. In his preface Mill describes the Elements as "a school-book in political economy "-it was in fact based on the lessons he gave to his then barely teenaged son-and he disavows any claim to originality. Moreover, the chapter on wages, from which the excerpts come, has been generally disdained because of its espousal of the discredited wage-fund theory of wage determination. But Mill's treatment of population is as fresh and stimulating as it is concise. (excerpt)
Changing population mobility in West Africa: Fulbe pastoralists in Central and South Mali.
Mobility is the most important response by the inhabitants of the Sahel to climatic adversity. This 'condition sahklienne', characterized by unstable climatic circumstances, irregular rainfall patterns and periods of drought, has an important influence on people's decision-making processes regarding their livelihood. Migration studies mainly focus on labour migration to urban areas. Although mobility is part of the repertoire of Sahelian people, the form it takes varies considerably between social groups and individuals, and over time. In this article we focus on a neglected and almost invisible category of rural-rural migrants in the Sahel, more specifically on Fulbe pastoral people and their developments over the last three decades in the Sahel and the Sudan zone of West Africa and the economic and social conditions in which they find themselves. It concludes that these rural-rural migrations are deeply engrained in cultural patterns in West Africa, exemplified by specific institutions for dealing with hosts and strangers. However, mobility is often not a planned process, and all kinds of survival strategies are used in a very flexible manner. The phenomenon has given rise to a specific character of cultural dynamics and ways of defining identity for the people involved. (author's)
African history and environmental history.
Environmental concerns have necessitated moving from well-thumbed administrative files to explore new archival sources. They have opened the way to consideration of fascinating non-human agents in history such as fire and water, animals, insects, and plant invaders. They have raised further questions for oral fieldwork which are strongly familiar to the great majority of Africans who, until recently, lived in rural settings. Both African people, and the settlers and colonists who came to the continent, debated environmental issues intensely; nature and landscape have also been evoked in many different modes of cultural expression. An environmental approach facilitates the mining of rich but still neglected seams of intellectual and cultural history-from African fables and eco-religions to colonial fascination with botany and wildlife. (excerpt)
Constitutional treatment of religion and the politics of human rights in Nigeria.
The debate about the proper relationship between religion and politics in Nigeria has been clouded historically by ideological partisanship and conceptual confusion. This article examines the topic against the backdrop of an emergent constitutional culture in the country and the paradox that this creates in a religiously pluralistic context. It argues that it would be foolhardy to repress pluralism in the attempt to resolve this paradox, and instead defends a kind of pluralist orientation that is compatible with the desire to build and nurture a stable constitutional culture. (author's)
Briefing: riding the tiger: contextualizing HIV prevention in South Africa.
The fight to reduce HIV transmission in South Africa is shaped and constrained by complex, interconnected layers of factors ranging from the political to the psychological. The H N epidemic reached South Africa a decade or so after central and East Africa providing a window of opportunity within which to implement appropriate prevention and management programmes. However, the apartheid government largely ignored HIV/ AIDS and the post-apartheid government has not risen to the challenge of the epidemic so that South Africa looks set to become the AIDS capital of the continent. Current estimates are that one in five adult South Africans are living with HIV or AIDS and 1,700 more are being infected every day. The highest rates of infection are among those aged 20 to 40 years, the most economically active and also the parents to a new generation of children. While the macro-economic impact of the epidemic will only be known with time, many of the social impacts are more easily predicted. By the year 2010 five million children will have lost at least one parent. Already there are households headed by children as young as nine years old acting as guardians to younger siblings, sometimes with no source of income. Having weathered the trauma of losing parents the high rates of mother-to-child transmission mean that they will now have to care for terminally ill siblings. (excerpt)
For Mrs Luat, the H5N1 avian flu virus could bring economic ruin. Three years ago, she and her husband borrowed US$12,500 to establish a small chicken farm in Hay Tay province, near the Vietnamese capital Hanoi. They raise 6,000 chickens at a time in their single shed, selling the entire stock every couple of months to a Thai company that distributes the meat within Vietnam. But last year, their shed lay empty for six months after H5N1 flu hit neighbouring farms. Mrs Luat estimates the couple's losses at $1,500. If it happens again, they maybe unable to service their debts. While smallholders such as the Luats face the most immediate threat, the continuing presence of the H5N1 virus in Vietnam and neighbouring countries could spell a global disaster, in both economic and humanitarian terms. H5N1 is deadly to both chickens and people, but thankfully isn't easily transmitted from person to person. But if it exchanges genes with a mammalian flu virus, H5N1 could become a mass killer that would rapidly sweep the globe. If that happens, tens of millions of people could perish. Since H5N1 starting spreading through Asian poultry flocks in 2003, the World Health Organization (WHO) has been sounding the pandemic alarm. Two main actions are required. First, surveillance for human and animal flu viruses in affected countries needs to be stepped up, to provide an early warning of the emergence of a possible pandemic strain. Second, nations around the world must develop plans to protect their populations should this occur. This will require stringent quarantine procedures, plus the rapid deployment of vaccines and antiviral drugs. (excerpt)
Consumption patterns of major food items in Turkey.
Demand estimates for food not only provide information bases to characterise food demand structure, but also provide a complete and consistent framework to evaluate the impacts of policy changes, since both price policies and the human capital policies related to health and nutrition are closely related to the determination of expenditure (or income) elasticities. This study attempts to produce a complete set of expenditure and price elasticities based on the estimates of food demand parameters in Turkey. The Linear Expenditure System (LES) is estimated using the last available cross-section budget survey data. The estimates throw light on certain characteristics of Turkish household behaviour that has some consequences for government policies. (author's)
Objective: To determine dental canes prevalence and severity among primary and intermediate schoolchildren in Riyadh and Qaseem Regions, and to determine any correlation between dental caries and fluoride levels in drinking water. Design: Cross-sectional. Methods: 1,104 children; 431 (6-7-year-old) primary schoolchildren (249 in Riyadh and 182 in Qaseem) and 673 (12-13-year- old) intermediate schoolchildren (392 in Riyadh and 281 in Qaseem) were examined for dental caries utilising the WHO criteria for diagnosis of dental caries. Results: In primary schoolchildren the prevalence of caries was 91.2% both in Riyadh and Qaseem. The mean dmft scores were similar in Riyadh (6.53, SD 4.30) and Qaseem (6.35, SD 3.83). Among the intermediate schoolchildren the prevalence of dental caries was slightly higher in Riyadh (92.3%) than Qaseem (87.9%). The mean DMFT score was higher in Riyadh (5.06, SD 3.65) as compared with Qaseem (4.53, SD 3.57) with marginal statistical significance (p=0.057). Among the primary schoolchildren there was statistically significant (p<0.05) difference in mean dmft scores at various fluoride levels with lowest dmft scores at the optimum water fluoride level (0.61-0.80ppm) and highest at two extremes i.e. 0.0 to 0.3ppm and >2.5ppm, while in intermediate schoolchildren no significant difference in overall mean DMFT scores of children at various water fluoride levels could be found. Conclusion: The caries experience among the primary and intermediate schoolchildren in Riyadh and Qaseem was very high, and that there was no linear correlation between water fluoride level and caries experience in these children. (author's)
Aging, childlessness, or overpopulation: the future's right to choose [editorial]
By far the most frequent argument I encounter against the wisdom of curing aging is that it would cause unacceptable global overpopulation. While most other potential drawbacks of indefinite lifespans are generally acknowledged to be speculative, this one is robustly asserted to be inevitable, short of a compulsory sterilisation policy of unprecedented proportions. I therefore feel that it is worth devoting this space to why that particular objection to curing aging is every bit as wrongheaded as all the others. If I sound remarkably sure of myself in this, it is not merely because that's how I usually sound. It's because my reasoning is painfully simple. There are plenty of much less simple ways to argue that the threat of overpopulation doesn't justify a pro-aging policy, but I regard some of those ways as positively flawed and most of the rest as at least somewhat fragile. I will begin, therefore, by clearing some of these altogether less satisfactory arguments out of the way. First let us dispose of some of the alternative scenarios that some more futuristic than myself have suggested over the years. The most straightforward of these is mass emigration into space. (excerpt)
Predicting adolescent risk behaviors based on an ecological framework and assets.
The objectives were to examine the relationship between an aggregate risk score (smoking, drinking, and number of sex partners) and measures of youth assets in a sample of 3439 youth aged 14–18 years. Linear regression models for African American and white males and females predicted an aggregate risk score. After adjustments, the youth asset most predictive of risk was self / peer values regarding risk behaviors. Perceived school support was also predictive. Taking an ecological approach to the measurement of adolescent health behaviors contributes to our understanding of these risk behaviors. (author's)
Risk behaviors of youth living with HIV: pre- and post-HAART.
The objective was to examine the transmission behavior among youth living with HIV (YLH), pre- and post- HAART. Two cohorts were recruited: (1) 349 YLH during 1994 to 1996 and (2) 175 YLH during 1999 to 2000, after the wide availability of HAART. Differences in sexual and substance-use risk acts and quality of life were examined. Post-HAART YLH were more likely to engage in unprotected sex and substance use, to be more emotionally distressed, and to have lower quality of life than were pre-HAART YLH. Targeted interventions for YLH that address reductions in transmission acts and aim to improve quality of life are still needed. (author's)
Past it? HIV and older people in England, Wales and northern Ireland.
The majority of those infected and affected by HIV are younger adults. The ability of highly active antiretroviral therapies (HAART) to extend survival means that those infected when younger may reach older age, and future increases in numbers of older individuals living with HIV in England, Wales and Northern Ireland (E,W&NI) are expected. Evidence that older individuals engage in risky sexual behaviours suggests potential for HIV transmission. Data from national HIV/AIDS surveillance systems were reviewed (1997-2001). An older individual is defined as aged 45 years or over. Between 1997 and 2001, 2290 older individuals were diagnosed with HIV; 361 in 1997, rising to 648 in 2001. Heterosexual acquisition accounted for 1073 (47%) infections; 662 were male. Where reported, 666 (65%) older heterosexuals were probably infected in Africa, 144 (14%) in the United Kingdom and 113 (11%) in Asia. There were 1020 (45%) new diagnoses acquired homosexually; white (92%), infected in the United Kingdom (78%). Numbers of older individuals accessing HIV-related services more than doubled between 1997 (2488) and 2001 (5175). In 2001, 2270 (53%) were London residents. Between 1997 and 2001, among HIV-infected older individuals attending genitourinary medicine (GUM) clinics, the proportions previously undiagnosed were 60% and 82% in heterosexual males and females respectively, and for men who have sex with men (MSM), 42%. Numbers of older individuals newly diagnosed with HIV have increased in recent years. The increase in numbers of older individuals accessing HIV-related services were in excess of younger adults. A significant proportion of older HIV-infected female heterosexuals and MSM were undiagnosed Awareness must be raised among clinicians and an 'aged response' to HIV is required. (author's)
Sheila Kitzinger's letter from Europe: Moslem values and childbirth.
It was one of the most imposing houses near Buckingham Palace. I had been summoned to teach a young pregnant woman from one of the Gulf States about childbirth. She was not allowed to attend classes, so it had to be one-to-one and I was expected to do it in a single meeting. She spoke no English. It all had to be enacted with my flexible baby doll, plastic pelvis, and foam rubber vagina and a dramatic performance by me. I breathed my way through contractions, sighed, relaxed, tackled a difficult late first stage with a torrent of powerful contractions, pushed, groaned, breathed, gasped, pushed, panted, and gently, gently smiling and shiny-eyed, gave birth to a gorgeous baby whom I lifted straight to my breast. But the only thing the older woman (her mother-in-law, or a senior wife, I never found out which) who was in charge of the proceedings was concerned about was that I should show her young pupil how to push, long and hard. That was what she had to be taught. The mother was a little slip of a girl and the older woman feared she wouldn’t have the stamina or willpower to do it. My drama training helped. I felt exhausted afterwards, but I gather the birth went well. (excerpt)
Syrian women's preferences for birth attendant and birth place.
Women’s preferences for type of maternity caregiver and birth place have gained importance and have been documented in studies reported from the developed world. The purpose of our study was to identify Syrian women’s preferences for birth attendant and place of delivery. Interviews with 500 women living in Damascus and its suburbs were conducted using a pretested structured questionnaire. Women were asked about their preferences for the birth attendant and place of delivery, and an open-ended question asked them to give an explanation for their preferences. We analyzed preferences and their determinants, and also agreement between actual and preferred place of delivery and birth attendant. Only a small minority of women (5–10%) had no preference. Most (65.8%) preferred to give birth at the hospital, and 60.4 percent preferred to be attended by doctors compared with midwives (21.2%). More than 85 percent of women preferred the obstetrician to be a female. The actual place of delivery and type of birth attendant did not match the preferred place of delivery and type of birth attendant. Women’s reasons for preferences were a perception of safety and competence, and communication style of caregiver. Most women preferred to be delivered by female doctors at a hospital in this population sample in Syria. The findings suggest that proper understanding of women’s preferences is needed, and steps should be taken to enable women to make good choices. Policies about maternity education and services should take into account women’s preferences. (author's)
In utero programming of atopic manifestations has been suggested. We investigated the association between oral contraceptive (OC) use before, and complications during pregnancy (CDP) and asthma, along with other atopic manifestations. The study is based on neonates from Kingston and St Andrew, a geographic subcohort from the Jamaican Perinatal Morbidity, Mortality Survey conducted in 1986–1987. Information on OC use and CDP was extracted from maternal interviews and medical records. In a follow up in 1997–1998, via interviews with mothers, trained nurses collected information on asthma/wheezing, coughing, eczema, and hay fever. Data, specific to this paper, from birth and 11–12 yr of age was available for a total of 1040 of the 1720 members of the geographic subcohort. Using logistic regression, controlling for confounders, we estimated adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CI). For asthma or wheezing, and coughing, aOR for OC use were 1.81 (95% CI: 1.25–2.61), and 2.72 (95% CI: 1.41–5.24), respectively. CDP was only shown to be a significant risk factor for hay fever. Additionally, a higher number of older siblings were protective for hay fever. The results suggest that asthma in childhood may be programmed in utero. (author's)
The study was designed to investigate the attitudes and practices of private medical practitioners towards abortion, postabortion care and postabortion family planning in Nigeria. Three hundred and twenty-three private practitioners who were proprietors of private clinics in three states of the country were interviewed with a structured questionnaire that elicited information on their knowledge and experiences of abortion and postabortion care in the cities. Twenty-four percent of the doctors reported that they routinely terminate unwanted pregnancies when requested to do so by women, while 82% reported that they frequently treat women who experience complications of unsafe abortion. Over 45% reported that they use manual vacuum aspiration (MVA) for the management of abortion in the first trimester, while 25% use dilatation and curettage (D&C). Nearly 28% reported the use of MVA followed by D&C in the first trimester. Fifty-seven percent reported their lack of expertise in managing second-trimester abortions, while those admitting that they manage second-trimester abortions reported nonstandard methods and procedures. In addition, there was evidence of inadequate counseling of women, lack of institutional protocols and poor use of postabortion family planning by the doctors. These results suggest the need for a program of retraining of private practitioners on the principles and practices of safe abortion, postabortion care and family planning in Nigeria and the integration of these topics into medical training curricula in the country. (author's)
Background: Postpartum hemorrhage (PPH) is the single most common cause of maternal death in the world, oxytocin is known to be effective for its prevention and treatment. The use of syringes can be problematic in areas affected by HIV. The aim of this study was to introduce Uniject(TM) (a new disposable device for administration of 10IU oxytocin) as part of active management of the third stage of labor (AMTL) and try to reduce PPH. Methods: A prospective, comparative study was performed between March 1998 and May 2000 in Luanda. Seven hundred and eighty-two parturient women with physiological management were compared to 814 with AMTL. Postpartum lost blood was collected using a plastic sheet during labor and a bucket placed under a cholera bed for 2h postpartum. Student's t-test and ?(2)test were used. Result: PPH was reduced from 40.4 to 8.2% and severe PPH (=1000ml) from 7.5 to 1% in the AMTL group (P<0.001). Conclusions: Uniject(TM) was well tolerated and offers an alternative for oxytocin administration. AMTL should be implemented also in resource-poor settings as a routine management to reduce PPH. (author's)
Impact of postpartum depression on the mother-infant couple.
Few studies have explored the influence of postpartum depression on later life among mothers in Taiwan. The present follow-up study aims to explore the effects of postpartum depression on the psychosocial health of mothers and on the overall development of their infants. Follow-up evaluations were carried out on 29 postnatally depressed and 31 nondepressed mothers and their infants at 1 year after childbirth. Dependent variables were measured by means of five structured questionnaires. Postnatally depressed mothers reported significantly higher perceived stress, but lower social support and self-esteem than nondepressed mothers at 1 year after childbirth. The participants’ postpartum depression had no significant effect on their infants’ eight developmental areas, nor did depression influence their plans about the number of children to have in the future. Postpartum depression may have a negative influence on the psychosocial health of women, but it does not appear to influence the overall development of their infants and their family planning. (author's)
Role of progestins in contraception.
Progestins have been used for contraception for more than 30 years. The main goal was to develop a contraceptive method devoid of the metabolic or clinical side-effects associated with the use of estrogens. The development of new contraceptive methods and formulations is time-consuming and requires devotion, belief, and also strong economical basis. As a result of this endeavor new methods have been developed: oral progestins, implants, injectables, intrauterine hormonal systems, and vaginal rings. Progestin-only contraceptives may be preferable in some situations, which have absolute or relative contraindications to estrogen, side-effects to estrogen containing hormonal contraception, lactation, and comfort and feasibility of formulations for long-term use. At present, emergency contraception is also performed with progestin. (author's)
Briefing: Recent changes in the South African government's HIV / AIDS policy and its implementation.
Since 2002 there has been a shift in the South African government’s policy response to HIV/AIDS, culminating in a commitment by the Cabinet in August 2003 to develop a plan to provide antiretroviral (ARV) drugs. While this shift in policy was greeted warmly, if cautiously, by most analysts and activists, we need to understand why it has occurred, in order to assess its sustainability and whether it will translate into meaningful change on the ground. As a civil society submission to the government noted: ‘The success and sustainability of an ARV roll-out programme depends on a number of interlocking social, medical and political factors.’ This briefing provides an outline of the government’s AIDS policies, recent policy shifts, the social and political factors at play and some explanations for these shifts. (excerpt)
STD / AIDS knowledge, attitude, practice, and characteristics of market vendors in Hefei, China.
Little is known about the information on sexually transmitted disease (STD)/AIDS in the population working in congregating trading markets in China. A cross-sectional study was conducted among three big congregating trading markets in Hefei City. Seven hundred fifty-two market vendors completed a questionnaire, 333 of two markets provided specimen for STD/HIV testing. The majority of market vendors in China are sexually active youths and adults, and have little education. The market vendors had poor knowledge of STD/AIDS. The rates of correct answers to questions about STD/AIDS varied between 21.1%–81.9%. More than 50% of the market vendors had a negative attitude toward HIV-infected individuals. Among the subjects, 27.6% had had premarital or extramarital sex; 15.9% reported using condoms in the past 12 months. Among those who provided specimens, 3.9% were identified with STD, approximately 9 times higher than that in the general population of Hefei (0.4%). Our study suggests China should implement STD/HIV prevention interventions for market vendors to prevent STD/HIV infection. (author's)
Under the gaze of the 'big nations': refugees, rumours and the international community in Tanzania.
In most academic literature refugees are portrayed either as those who lack what national citizens have or as a threat to the national order of things. This article explores the effects of being excluded in such a way, and argues that Burundian refugees in a camp in northwest Tanzania find themselves in an ambiguous position, being excluded from the national order of things — secluded in the Tanzanian bush — while simultaneously being subject to state-of-the-art humanitarian interventions — apparently bringing them closer to the international community. The article explores the ways in which refugees in the camp relate to the international community. Ambiguous perceptions of the international community are expressed in rumours and conspiracy theories. These conspiracy theories create a kind of ontological surety by presenting the Hutu refugees as the victims of a grand Tutsi plot supported by ‘the big nations’. Finally, the article argues that refugees — being excluded from the nationstate and being subject to the government of international NGOs — seek recognition from the international community rather than any nationstate. This does not, however, destabilize the hegemony of the nation-state, as refugees perceive their own position as temporary and the international community as the guarantor of a more just international order in the long run. (author's)
The AIDS epidemic in Africa: "openness" and human rights.
Early diagnosis of HIV infection combined with greater individual oneness about the disease are vital for effective prevention and care. But greater openness is only feasible if there is a recognition of the extent of the human rights violations that contribute to HIV infection, that face people with HIV/AIDS and that place them at risk if they disclose their status. Mark Heywood documents violations that are common in Africa and makes suggestions about the obstacles that must be overcome if they are to be challenged. He examines the role of domestic, regional and international legal systems, and the responsibility of government, the private sector and civil society in protecting the human rights of people with HIV/AIDS. In July 1994 at the first Inter-country Consultation on Ethics, Law and HIV in Africa two important steps were taken to protect the human rights of people with HIV/AIDS (PWAs) in Africa. The African Network on Ethics, Law and HIV was launched and the Dakar Declaration - a set of ten ethical and human rights principles on the treatment of PWAs - was adopted. The primary objective of the Network is to "promote human rights, empower persons, develop guidelines, make representations and support national and international law reform to meet the challenges posed by HIV/AIDS in Africa". (excerpt)
Despite the large numbers of displaced persons and the often lengthy periods of displacement, little is known about the impact of forced migration on long-term under-five mortality. This paper looks at the Brass Method (and adaptations of this method) and the Preceding Birth Technique in combination with a classification of women by their migration and reproductive histories, in order to study the impact of forced migration on under-five mortality. Data came from the Demography of Forced Migration Project, a study on mortality, fertility and violence in the refugee and host populations of Arua District, Uganda and Yei River District, Sudan. Results indicate that women who did not migrate in a situation of conflict and women who repatriated before the age of 15, had children with the highest under-five mortality rates compared with women who were currently refugees and women who repatriated after the age of 15. (author's)
Imported malaria has been an increasing problem in several Western countries in the last 2 decades. To calculate the risk factors of age, sex, and travel destination in Swedish travelers, we used data from the routine reporting system for malaria (mixture of patients with and without adequate prophylaxis), a database on travel patterns, and in-flight or visa data on Swedish travelers of 1997 to 2003. The crude risk for travelers varied from 1 per 100,000 travelers to Central America and the Caribbean to 357 per 100,000 in central Africa. Travelers to East Africa had the highest adjusted odds ratio (OR = 341, 95% confidence intervals [CI] 134–886) for being reported with malaria, closely followed by travelers to central Africa and West Africa. Male travelers as well as children <1–6 years of age had a higher risk of being reported with malaria (OR = 1.7, 95% CI 1.3–2.3 and OR = 4.8, 95% CI 1.5–14.8) than women and other age groups. (author's)
Violence and abortions: what's a doctor to do?
Before 1989, in hospitals across Canada, groups of 3 physicians would meet once a week to read and consider stories of failure and remorse. No legal abortion could be performed in this country without such a committee’s approval. For years I spent Friday mornings with a gynecologist and a psychiatrist in a small room at our downtown Toronto hospital, reviewing pleas for care from women whose histories were marked by sadness more than by irresponsibility. In 1988 the Supreme Court of Canada struck down the existing abortion law (section 287 of the Criminal Code) as unconstitutional. A woman who wishes to terminate a pregnancy is no longer required to obtain a committee’s opinion that continuing the pregnancy would endanger her health or life. A paradoxical effect of the decriminalization of abortion is that there is no requirement for anyone to bear witness, as William Fisher and colleagues do in a study published in this issue, to stories of lives disrupted by violence. Although their findings are neither new nor unique, they merit reiteration. Of 1127 women who completed a 65-item self-report questionnaire at a hospital abortion service in London, Ont., 68% were undergoing a first abortion, 23% a second, and 9% a third or subsequent abortion. Overall, 20% had experienced physical abuse by a male partner, and 27% had a history of sexual abuse. The vast majority (90%) had used contraception sometime in their lives, and, of note, at the time of the current conception 60% were using condoms and 40% were using an oral contraceptive. Compared with women seeking a first abortion, repeat abortion seekers were older, and were more likely to have given birth and to have had a sexually transmitted disease in the past. They had more limited personal and financial resources and were more likely to have been victimized at some time in their lives. (excerpt)
The effects of implementation WHO/UNICEF Breastfeeding Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates were examined during and after the breastfeeding promotion campaign in one county of Croatia. Comparison with a control group indicated increase of breastfeeding prevalence in a period of BFHI implementation 11994-1998) - 68% us. 87% at infant age 1 ma., 30% us. 54% at 3 mo., 11.5% vs. 28% at 6 mo., and 2% us. 3.5% at infant age 11-12 mo. (chi-square test, p < 0.05). More considerable increase has been noticed in period 1999-2000 which is characterized by breastfeeding support groups activity: 68% us. 87% at infant age I no., 30% us. 66% at 3 mo., 11.5% us. 49% at 6 mo., and 2% vs. 23% at infant age 11-12 ;TO. (chi-square test, p < 0.05). Our conclusion is that activities aiming to promote breastfeeding in maternity hospitals have had limited success. They have resulted in satisfactory increase of breastfeeding prevalence in early infant's period, but for far-reaching effect postnatal support is also required. (author's)
Reinventing global health: the role of science, technology, and innovation.
The Millennium Development Goals have become an international standard against which to assess trends in development and human well being. Their adoption in 2000 coincided with two important factors: the growing recognition of the role of science and technology in solving human problems, and the emergence of new infectious diseases. These developments have helped to define biomedical research as one of the most critical public policy issues facing the global community. The state of human health in much of the developing world continues to decline at a time when the world’s fund of biomedical knowledge continues to expand. This challenge offers new opportunities for promoting international cooperation in biomedical research of relevance to developing countries as outlined in the report of the Millennium Project Task Force on Science, Technology and Innovation. Addressing health challenges of the developing world will require new forms of international partnerships that take into account emerging opportunities in the globalisation of scientific knowledge. (excerpt)
Malaria and urbanization in sub-Saharan Africa.
There are already 40 cities in Africa with over 1 million inhabitants and the United Nations Environmental Programme estimates that by 2025 over 800 million people will live in urban areas. Recognizing that malaria control can improve the health of the vulnerable and remove a major obstacle to their economic development, the Malaria Knowledge Programme of the Liverpool School of Tropical Medicine and the Systemwide Initiative on Malaria and Agriculture convened a multi-sectoral technical consultation on urban malaria in Pretoria, South Africa from 2nd to 4th December, 2004. The aim of the meeting was to identify strategies for the assessment and control of urban malaria. This commentary reflects the discussions held during the meeting and aims to inform researchers and policy makers of the potential for containing and reversing the emerging problem of urban malaria. (author's)
Sexual health among male college students in the United States and the Netherlands.
The objectives were to assess differences in sexual health behaviors, outcomes, and potential sociocultural determinants among male college students in the United States and the Netherlands. Survey data were collected from random samples of students from both national cultures. American men were more likely to report inadequate contraception, HIV/STD infection, and unintended pregnancy than were Dutch men. Religiosity and sexuality education were able to explain national differences in these sexual health outcomes. Findings suggest that sexuality education seems to decrease, rather than increase, sexual risk in heterosexually active male college students. (author's)
Characteristics of women undergoing repeat induced abortion.
Background: Although repeat induced abortion in common, data concerning characteristics of women undergoing this procedure are lacking. We conducted this study to identify the characteristics, including history of physical abuse by a male partner and history of sexual abuse, of women who present for repeat induced abortion. Methods: We surveyed a consecutive series of women presenting for initial or repeat pregnancy termination to a regional provider of abortion services for a wide geographic area in southwestern Ontario between August 1998 and May 1999. Self-reported demographic characteristics, attitudes and practices regarding contraception, history of relationship violence, history of sexual abuse or coercion, and related variables were assessed as potential correlates of repeat induced abortion. We used ?(2) tests for linear trend to examine characteristics of women undergoing a first, second, or third or subsequent abortion. We analyzed significant correlates of repeat abortion using stepwise multivariate multinomial logistic regression to identify factors uniquely associated with repeat abortion. Results: Of the 1221 women approached, 1145 (93.8%) consented to participate. Data regarding first versus repeat abortion were available for 1127 women. A total of 68.2%, 23.1% and 8.7% of the women were seeking a first, second, or third or subsequent abortion respectively. Adjusted odds ratios for undergoing repeat versus a first abortion increased significantly with increased age (second abortion: 1.08, 95% confidence interval [CI] 1.04-1.09; third or subsequent abortion: 1.11, 95% CI 1.07-1.15), oral contraceptive use at the time of conception (second abortion: 2.17, 95% CI 1.52- 3.09; third or subsequent abortion: 2.60, 95% CI 1.51-4.46), history of physical abuse by a male partner (second abortion: 2.04, 95% CI 1.39-3.01; third or subsequent abortion: 2.78, 95% CI 1.62-4.79), history of sexual abuse or violence (second abortion: 1.58, 95% CI 1.11-2.25; third or subsequent abortion: 2.53, 95% CI 1.50-4.28), history of sexually transmitted disease (second abortion: 1.50, 95% CI 0.98-2.29; third or subsequent abortion: 2.26, 95% CI 1.28-4.02) and being born outside Canada (second abortion: 1.83, 95% CI 1.19- 2.79; third or subsequent abortion: 1.75, 95% CI 0.90-3.41). Interpretation: Among other factors, a history of physical or sexual abuse was associated with repeat induced abortion. Presentation for repeat abortion may be an important indication to screen for a current or past history of relationship violence and sexual abuse. (author's)
Maternal mortality in Afghanistan is uniformly identified as an issue of primary public-health importance. To guide the implementation of reproductive-health services, we examined the numbers, causes, and preventable factors for maternal deaths among women in four districts. We did a retrospective cohort study of women of reproductive age (15–49 years) who died between March 21, 1999, and March 21, 2002, in four selected districts in four provinces: Kabul city, Kabul province (urban); Alisheng district, Laghman province (semirural); Maywand, Kandahar province (rural); and Ragh, Badakshan province (rural, most remote). Deaths among women of reproductive age were identified through a survey of all households in randomly selected villages and investigated through verbal-autopsy interviews of family members. In a population of 90 816, 357 women of reproductive age died; 154 deaths were related to complications during pregnancy, childbirth, or the puerperal period. Most maternal deaths were caused by ante-partum haemorrhage, except in Ragh, where a greater proportion of women died of obstructed labour. All measures of maternal risk were high, especially in the more remote areas; the maternal mortality ratio (per 100,000 live-births) was 418 (235–602) in Kabul, 774 (433–1115) in Alisheng, 2182 (1451–2913) in Maywand, and 6507 (5026–7988) in Ragh. In the two rural sites, no woman who died was assisted by a skilled birth attendant. Maternal mortality in Afghanistan is high and becomes significantly greater with increasing remoteness. Deaths could be averted if complications were prevented through optimisation of general health status and if complications that occurred were treated to reduce their severity—efforts that require a multisectoral approach to increase availability and accessibility of health care. (author's)
The treatment for Plasmodium falciparum malaria in Sudan has been in process of change since 2003. Preceding the change, this study aimed to determine which artemisinin-based combination therapies is more effective to treat uncomplicated malaria in Malakal, Upper Nile, Sudan. Clinical trial to assess the efficacy of 2 antimalarial therapies to treat P. falciparum infections in children aged 6–59 months, in a period of 42 days after treatment. A total of 269 children were followed up to 42 days. Artesunate plus Sulfadoxine/ Pyrimethamine (AS+SP) and Artesunate plus Amodiaquine (AS+AQ) were both found to be efficacious in curing malaria infections by rapid elimination of parasites and clearance of fever, in preventing recrudescence and suppressing gametocytaemia. The combination of AS+SP appeared slightly more efficacious than AS+AQ, with 4.4% (4/116) versus 15% (17/113) of patients returning with malaria during the 6-week period after treatment (RR = 0.9, 95% CI 0.81–0.96). PCR analysis identified only one recrudescence which, together with one other early treatment failure, gave efficacy rates of 99.0% for AS+AQ (96/97) and 99.1% for AS+SP (112/113). However, PCR results were incomplete and assuming part of the indeterminate samples were recrudescent infections leads to an estimated efficacy ranging 97–98% for AS+SP and 88–95% for AS+AQ. These results lead to the recommendation of ACT, and specifically AS+SP, for the treatment of uncomplicated falciparum malaria in this area of Sudan. When implemented, ACT efficacy should be monitored in sentinel sites representing different areas of the country. (author's)
Small steps can make a big difference. Achieving millennium goals requires "practical investments."
The Millennium Development Goals (MDGs), which include halving world poverty and slashing child mortality by two-thirds, are as challenging as they are ambitious, Mr. Sachs said at UN headquarters in New York in late September, in briefings on the work of the Millennium Project, which he directs. But meeting those goals, said Mr. Sachs, can be as simple as distributing a $1.50 mosquito net or providing a family farmer with a sack of fertilizer. "These are not metaphysical problems. These are not grand cultural problems.... These are practical problems, and they don't cost very much money." Mr. Sachs asserted that while substantial progress has been made in some regions of the world, "Africa on the whole has not achieved progress and has experienced significant regress in many areas." The continent is the epicentre of global poverty, he continued. World leaders are slated to review progress towards the goals in September 2005. The reasons for Africa's halting progress are numerous, he said, including poor soils, the effects of climate change and shortages of basic transportation and communications. But these problems have been worsened by the donor community's insistence on market mechanisms, inadequate and poorly targeted aid and a tendency to blame Africa. The continent's problems "cannot be folded under the rubric that poor Africa just doesn't govern itself properly," Mr. Sachs observed. "Blaming the poor will not solve the problem. Nor is it an accurate, analytical picture" of the obstacles to Africa's development. (excerpt)
4 million neonatal deaths: When? Where? Why? Neonatal survival 1.
The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0.5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week—the highest risk of death is on the first day of life. Almost all (99%) neonatal deaths arise in low-income and middle-income countries, yet most epidemiological and other research focuses on the 1% of deaths in rich countries. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10–15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birthweight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century. (author's)
A wide range of childhood illnesses are accompanied by fever,, including malaria. Child mortality due to malaria has been attributed to poor health service delivery system and ignorance. An assessment of a mother's ability to recognize malaria in children under-five was carried out among the Bwatiye, a poorly-served minority ethnic group in north-eastern Nigeria. A three-stage research design involving interviews, participatory observation and laboratory tests was used to seek information from 186 Bwatiye mothers about their illness-related experiences with childhood fevers. Mothers classified malaria into male (fever that persists for longer than three days) and female (fever that goes away within three days) and had a system of determining when febrile illness would not be regarded as malaria. Most often, malaria would be ignored in the first 2 days before seeking active treatment. Self-medication was the preferred option. Treatment practices and sources of help were influenced by local beliefs, the parity of the mother and previous experience with child mortality. The need to educate mothers to suspect malaria in every case of febrile illness and take appropriate action in order to expose the underlying "evil" will be more acceptable than an insistence on replacing local knowledge with biological epidemiology of malaria. The challenge facing health workers is to identify and exploit local beliefs about aetiology in effecting management procedures among culturally different peoples, who may not accept the concept of biological epidemiology. (author's)
Beyond the wasteland: the voluntary sector and the challenge of HIV / AIDS.
In some parts of South Africa up to a quarter of the population is infected with HIV/AIDS and numbers are rising. One and a half thousand people are newly infected each day. Within ten years, more than 18 per cent of the country's people may have contracted the disease. A decade later, most of these people will have died. Aside from the human costs - loss, grief and the disruption of communities - the HIV/AIDS epidemic threatens to derail all the government's and civil society's carefully laid plans for development and reconstruction. HIV/AIDS could cut a swathe through the cadre of skilled workers vital to the regeneration of the economy; it can exacerbate poverty as less and less people are able to work; and it could place enormous burdens on health and social service departments already struggling to cope. Add to that the depletion of teachers, civil servants and writers, artists and musicians and we are confronting an economic and cultural apocalypse that is all too real. Traditionally education and awareness about the dangers of HIV/AIDS and care and treatment of those infected have been confined to AIDS service organisations (ASOs). By their specialism and their targeted interventions, the ASOs have let us off the hook. Peter Busse argues that unless the rest of the voluntary sector gets involved, our efforts at post-apartheid reconstruction and development may amount to nought: the endeavours of the sector to mitigate poverty and inequality will be subsumed in a wasteland of lost human potential. If we are to combat the spread of this disease, then the voluntary sector needs to integrate an awareness of HIV/AIDS and the dangers it poses to sustained development into their programmes. (excerpt)
Africans push to tame malaria. But funding shortages and drug resistance hamper control efforts.
The Ugandan government announced in October that it would distribute 4.5 mn free insecticide-treated bed nets to protect children and pregnant women from malaria, thereby boosting the East African country's efforts to conquer the mosquito-borne disease. According to Mr. John Bosco Rwakimari, head of the Ugandan Health Ministry's malaria-control programme, the treated net has several benefits: it works as a barrier between the body and the mosquito, it repels mosquitoes and it kills those that land on it. "Our target is the country's entire 5 million households," explains Mr. Rwakimari. "But the funds we have got are inadequate." Currently, there is enough money to supply 2 million households with bed nets. Through the initiative, made possible by a $6 mn grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Uganda will also mobilize community members to help implement the programme. Worldwide, there are at least 300 mn acute cases of malaria each year, resulting in more than a million deaths. Around 90 per cent of these deaths occur in Africa, mostly among young children. In Uganda, malaria is the leading cause of death among children under five years old. (excerpt)
Intravaginal and intrarectal microbicides to prevent HIV infection.
About 40 million people worldwide have HIV infection (UNAIDS 2004 report [www.unaids.org/bangkok2004/ report.html]). In 2003 alone, almost 5 million new infections occurred, more than 90% of which were sexually acquired. Nearly 50% of the worlds’ HIV-infected people are women, and over 30% of HIV positive women in some sub-Saharan African countries are teenagers. More than 1000 HIV-infected babies are born each day, often to teenaged mothers. Despite the effectiveness and availability of the condom, the HIV epidemic continues to spread. New prevention strategies are urgently needed. Topical microbicides are being developed as a possible new therapeutic approach to prevent HIV infection. They are formulated as gels, foams, films or vaginal rings designed to be inserted into the vagina or rectum and meet the urgent need for an effective female-controlled method of HIV prevention. More than 60 potential microbicides are being assessed in preclinical and clinical trials. (excerpt)
Objective: To determine and compare levels of levonorgestrel (Lng) in serum and peritoneal fluid (PF) of patients on the Lng intrauterine system Mirenar (Schering Health, Berlin, Germany) for endometriosis and to relate these symptoms. Design: Prospective clinical trial. Setting: Gynecology unit of a teaching hospital. Patient(s): Women with minimal to moderate endometriosis at diagnostic laparoscopy. Intervention(s): Mirenar was inserted at diagnostic laparoscopy and blood and PF collected for Lng levels. Levonorgestrel was again quantified in serum at 1, 3, and 6 months and PF at 6 months. Main Outcome Measure(s): Serum and PF Lng levels during 6 months, differences in levels before and 6 months after Mirenar insertion, and the relationship between these levels and symptoms of endometriosis. Result(s): There was significant improvement in symptoms after 6 months on Mirenar. The mean (SD) serum Lng levels were 459.2 (100.2), 368.2 (51.8), and 357.3 (53.0) pg/mL at 1, 3, and 6 months, respectively. The PF levels at 6 months were approximately two-thirds the serum levels in patients showing improvement in symptoms. Conclusion(s): Mirenar delivers significant amounts of Lng into the PF and serum. The relationship between Lng levels in these compartments is linear. (author's)
Creating conditions for greater private sector participation in achieving contraceptive security.
The growing gap between donor/government funding and the expected need for contraceptives is an issue of great concern for most developing countries. Addressing this resource shortfall, and meeting the goals of contraceptive security requires that countries mobilize the full and active participation of the private sector in the contraceptive market. Private sector involvement will not only increase the resource base available for contraceptives, it can also free up scarce donor and government resources to serve those who have the greatest need for public subsidies. This paper provides an overview of policy processes, strategies, and tools that can be used in developing countries to create an enabling environment for greater private sector participation, foster complementary public–private sector roles, and enhance the contribution of the private sector to contraceptive security. (author's)
Objective: To analyze the influence of the factor of the physician performing the ET with a standardized procedure on the ongoing pregnancy rates in an IVF-ET program. Design: Prospective observational study. Setting: Tertiary university hospital. Patient(s): Subfertile women with an IVF indication. Intervention(s): None. Main Outcome Measure(s): Ongoing pregnancy. Result(s): Six physicians performed 977 Ets. Ongoing pregnancy rates ranged from 19.1% to 29.0%, with an average rate of 23.1%. Logistic regression analysis revealed that physician is not a statistically significant variable. Differences between the pregnancy rates achieved by the physicians are within the limits of random variation. Conclusion(s): The probability of success in IVF is not dependent on the physician, provided the transfer procedure is standardized. (author's)
Objective: To compare the effects of oral contraceptive (OC) pill pretreatment in recombinant FSH/GnRH-antagonist versus recombinant FSH/GnRH- agonist stimulation in in vitro fertilization (IVF) patients, and to evaluate optimization of retrieval day. Design: Prospective, randomized, multicenter study. Setting: Private practice and university centers. Patient(s): Eighty patients undergoing IVF who met the appropriate inclusion criteria. Intervention(s): Four study centers recruited 80 patients. The OC regimen began on cycle days 2 to 4 and was discontinued on a Sunday after 14 to 28 days. The recombinant FSH regimen was begun on the following Friday. The GnRH-agonist group was treated with a long protocol; the GnRH-antagonist was initiated when the lead follicle reached 12 to 14 mm. When two follicles had reached 16 to 18 mm, hCG was administered. Main Outcome Measure(s): The primary outcome measures were the number of cumulus-oocyte complexes, day of the week for oocyte retrieval, and total dose and days of stimulation of recombinant FSH. Secondary efficacy variables included pregnancy and implantation rate; serum E(-2) levels on stimulation day 1; serum E(-2), P, and LH levels on the day of hCG administration; follicle size on day 6 and day of hCG administration; the total days of GnRH-analogue treatment; total days on OC; total days from end of OC to oocyte retrieval; and the cycle cancellation rate. Result(s): Patient outcomes were similar for the days of stimulation, total dose of gonadotropin used, two- pronuclei embryos, pregnancy (44.4% GnRH-antagonist vs. 45.0% GnRG-agonist, P=.86) and implantation rates (22.2% GnRH-antagonist vs. 26.4% GnRH-agonist, P=.71). Oral contraceptive cycle scheduling resulted in 78% and 90% of retrievals performed Monday through Friday for GnRH-antagonist and GnRH-agonist. A one day delay in OC discontinuation and recombinant FSH start would result in over 90% of oocyte retrievals occurring Monday through Friday in both groups. Conclusion(s): The OC pretreatment in recombinant FSH/GnRH-antagonist protocols provides a patient-friendly regimen and can be optimized for weekday retrievals. No difference was seen in number of 2PN embryos, cryopreserved embryos, embryos transferred, implantation and pregnancy rates between the two stimulation protocols. (author's)
Improving vaccination status of children under five through health education.
The objective was to improve awareness and knowledge of mothers regarding vaccine preventable diseases and the immunization status of children under five through health education messages by medical students, at Gulshane- Sikanderabad, a squatter settlement adjacent to Ziauddin Medical University, Karachi. The undergraduate medical students' visit families in the squatter settlement. This study compared the effect of intervention by medical students on vaccination status of children under five in the intervention households versus those without intervention. A baseline study was done in 1998 and a follow-up study was done after four years to assess the differences in knowledge and practices of mothers regarding immunization. A total of 110 houses from block I and 207 houses from block V were selected. An increase of 22% (52% vs 30%) in block-I (p=0.003) and 19% (32% vs 13%) increase in block V was seen in the utilization of PHC Center for vaccination (p=0.001). Mothers' knowledge regarding the age when first vaccine is administered to the child, increased in the follow-up from 60% to 76.5% (p<0.01) in block I and from 50% to 62% in block V. The immunization status increased significantly in block I from 46.5% to 75% after the intervention (p<0.005), no significant difference could be seen in block V (p=0.16). In the follow-up survey a significant difference was seen in the vaccination status between the two blocks (p=0.001). The health education messages significantly increased the vaccination status of children under 5 in the intervention area. (author's)
The private demand for an AIDS vaccine in Thailand.
A contingent valuation survey of Thai adults revealed that private demand for a hypothetical AIDS vaccine that is safe, has no side effects, and lasts 10 years, rises with income, the lifetime risk of HIV infection and vaccine efficacy, and declines with vaccine price and respondent’s age. Demand for both high (95%) and low (50%) efficacy AIDS vaccines is substantial. Nearly 80% of adults would agree to be vaccinated with a free vaccine. Government will have an important role to ensure that those at highest risk of HIV infection with low incomes have access to the vaccine and to reinforce other safe preventive behavior to prevent reductions in condom use. (author's)