December 04, 2008
October 26, 2008
The small, Switzerland-sized, Himalayan nation of Bhutan has only recently emerged from the Middle Ages and from its Middle-Ages-level reproductive health problems.
Fifty years ago in Bhutan, there were no schools, no currency, no mail, no roads and no health care beyond what traditional healers provided. There were no clinics, hospitals, doctors or nurses. There were no modern contraceptives. There were no statistics on either health or demography. The size of the population was unknown, as was life expectancy, and infant and maternal mortality. There was a tradition of traditional medicine, although the traditional medicine practitioners I spoke to professed not to know which herbs were and are currently used for pregnancy prevention and pregnancy termination.
From a standing start in 1960, Bhutan has developed, so that now there is universal primary education (classes are taught in English, except those in Bhutanese history and language), as well as a free health care system of hospitals and rural health clinics that reaches almost the entire population. It would reach all of it, but the rudimentary road system does not come close to covering the nation, and the vast majority of the populace has to walk or rely on overcrowded and sporadic busses to reach nearby towns.
Statistical gathering remains less than scientific. For instance, the UN reports that Bhutan has a population of 2.3 million, whereas the Bhutanese report a population of approximately 700,000. See the UN State of the World Population Report for 2007. http://www.unfpa.org/swp/2007/english/notes/indicators.html
Therefore, any statistics that are reported should be taken with a grain of salt. According to the UN, life expectancy is about 63 for males and 66 for females; infant mortality is 48 per 1000 live births (it was 102 in 1984) and the maternal mortality ratio is 420 (it was 770 in 1984), both about 20% lower than neighboring India; contraceptive coverage is around 20%; the TFR is 3.9 (it was 4.7 in 2000); about a quarter of births are attended by a skilled birth attendant. Childhood vaccinations are almost universal, and as a result of reduced infant mortality and increased life expectancy, the population has been growing rapidly (at 2.2% annually the UN reports; it was at 3.1% in the mid-1990’s), yet labor is imported for road and construction work from Nepal and India.
There is not the sex ratio imbalance at birth that is seen in India and China. In schools there is a dominance of females in the later grades, after many boys are sent to monasteries or drop out to work the family farm (about 10% of the male population are monks and 90% of the population work in agriculture or forestry). In one school I visited, in the 12 year old class, there were 16 girls and 7 boys. The society operates as a matriarchy. The eldest daughter inherits the family farm, and her husband comes to live with her, and with her parents until they retire after age 50 or so to a community monastery to pray and meditate.
Modern contraceptives are widely available, with the government health clinics offering free oral contraceptives, IUD’s, Depo-Provera and condoms, as well as male and female sterilization. Oral contraceptives are also sold in pharmacies at $2 per cycle and condoms are sold for $1 and $2 depending on the brand. Condoms are also distributed for free at various non-health locations in cities and towns. Still, as noted above, there are many couples not using contraception, due to a combination of a desire for large families and lack of access.
A visit to a rural health clinic gave some perspective on all these statistics. The following statistics (for 2007) were posted on the wall of the doctor’s office. This particular clinic covered an area with 243 households and 1257 inhabitants (about 5 persons per household), with slightly more females than males (641 to 616). There were 286 females of reproductive age between the ages of 15 and 49. There were 16 infants less than 1 year old and 91 children less than 5.
There were no reported infant deaths, child deaths or maternal deaths in 2007. The doctor has a network of “informants” around the village and as soon as it is known that a woman is pregnant, this fact is reported to him, and he makes a visit to the home, where he talks about prenatal care and sees to it that the woman has at least 4 prenatal appointments. When delivery time approaches, he arranges for the woman, if she can, to go to the regional hospital a week before her delivery date, accompanied by a relative who has her same blood type in case a transfusion is needed (anemia being a major complication in pregnancy). Naturally this is not possible in every case, and in 2007, of 18 pregnancies about half were attended at home and half delivered at the hospital.
Of the 286 females of reproductive age, there were 6 IUD users, 89 Depo users and 9 pill users. There were no sterilizations performed. Condoms are kept in a box by the door that woman and men can access without entering the clinic. The balance of the women of reproductive age presumably were using condoms, were not sexually active or were, or were trying to get, pregnant.
There are HIV/AIDS awareness signs in the clinic and along the roads of the town. Sex Ed begins in secondary school, though there is health and hygiene instruction in primary school, where teachers are required to inspect the children weekly to be sure that their uniforms and fingernails are clean, and that they have a handkerchief pinned to their uniform if their nose is running.
There is testing in the clinics for sexually transmitted diseases, and the rates are unofficially reported to be high. Bhutan is not a puritanical society, although public displays of affection are frowned upon, and couples pair and un-pair with some regularity and often get married only when the female becomes pregnant.
The abortion rate is unknown. I was told that abortion was against Buddhist ethics and was illegal except to save the life of the mother. Naturally, there is a problem of unsafe abortion. In a 1999 survey, of 654 obstetric complications, 71, or 14%, were due to septic abortion. In the clinic I visited, the physician did not report any septic abortions. Bhutan is surrounded by nations that have decriminalized abortion: India and China, and Nepal, although Nepal does not technically border Bhutan. One can hope that given the difficulties of travel for most citizens, Bhutan does not think it can rely on abortion tourism (or self induced abortion) to be the only alternatives for its women for pregnancy termination.
Despite its reputation as a Shangri-La, Bhutan has a domestic violence problem. Recently, one of the Queens founded an organization called RENEW to provide shelter and counseling for abused woman. It is located in a modern facility in the capital. Additionally, RENEW is constructing a residential safe house facility for women and their children to provided temporary housing until the woman can get divorced and resettled in society. They do a wonderful job, but it was sobering that such an organization needs to exist in this otherwise peaceful nation. See http://www.renew.org.bt/
Since Bhutan has a military force of only 4,000 (the Indian Army picks up the slack), it can, and does, spend a large proportion of its budget, approximately 15%, on health care. With improving infant and maternal mortality, the results are plain and commendable. One can hope that progress continues.
September 16, 2008
The law, passed in 2007 by the Mexico City Legislative Assembly, decriminalized abortion in the first 12 weeks of pregnancy. The law also defined a pregnancy as beginning upon implantation and required public health centers in Mexico City to provide abortion information and free services, with an opt-out for doctors with a conscientious objection. With this law, Mexico City joined Puerto Rico, Cuba and Guyana in the Hemisphere as having decriminalized abortion in the first trimester.
The law was immediately challenged by the pro-criminalization forces in Mexican society, as violating the right to life as set forth in the Mexican Constitution. The decision, finding that it did not, was a constitutionally limited one, unlike the broader Roe v. Wade decision from the U.S. Supreme Court in 1973. The Roe decision found that in the U.S. Constitution there was a right to privacy that required that abortion be decriminalized before fetal viability. The Mexican Court held that the Mexican Constitution permitted, but did not require, the state legislatures of the nation to decriminalize, or criminalize, abortion. One judge said, “It is not up to the Supreme Court to legalize or criminalize abortion.” With this decision as precedent, other states in Mexico can decriminalize abortion should they choose to do so.
The Mexico City abortion law addresses a catastrophic public health problem: unsafe abortion. There are estimates that there are between 500,000 and 1 million unsafe abortions a year in Mexico, with approximately 100,000 annual abortion-related hospital admissions. From 1990 to 2005, 21,646 women in Mexico died of maternal related causes, with abortion accounting for 537. These figures are probably understated given the illegality of the procedure. Since the decriminalization, there has been one death from abortion in Mexico City.
Additional maternal deaths in the past were in no doubt caused by lack of access to family planning services, which would have delayed pregnancies until the woman was older, spaced out a woman’s pregnancies and reduced the absolute number of pregnancies, thereby reducing the risk of death in childbirth. It was heartening to see that 58% of women seeking abortions in Mexico City ask for an IUD after their abortion to prevent their next pregnancy. Abortion decriminalization must be part of a broad public health plan to bring reproductive health care services to young, poor, indigenous, rural and uninsured women, who otherwise do not have access. About 40% of pregnancies worldwide are unintended. It is these pregnancies that result in unsafe abortion and maternal mortality and morbidity. This can be prevented only by simultaneously attacking gender inequality, gender violence, lack of information and access to contraceptive services, lack of an appropriate contraceptive method for every woman at every stage of her reproductive life, and, finally, the stigma that women face in many cultures in trying to control their bodies and their lives. A big agenda, but Mexico has shown that we can tackle it.
September 14, 2008
As far as global reproductive health, the foreign policies of John McCain and Barack Obama are as different as night and day. More particularly, the candidates have opposite positions on the Mexico City Policy, also known as the Global Gag Rule (the “Rule”), which prohibits U.S. foreign aid for family planning programs going to any U.S. non-governmental organization that either performs abortions, counsels on abortions or advocates for legal abortion. Senator McCain supports the Rule and Senator Obama opposes it. The difference is that clear. Senator McCain has voted consistently to support the Global Gag Rule in votes in the Senate to overturn the Rule, while Senator Obama has consistently voted to overturn it. In the September and December 2007 votes to overturn the Rule, neither Senator was present to vote. However, in a prior vote in April 2006 to overturn the Rule, Obama voted in favor of overturn and McCain voted against. In five previous votes since 1991, McCain voted to uphold the Global Gag Rule. Senator Obama was not a member of the U.S. Senate for those votes. Senator Obama told me personally in January 2008 that he would sign an executive order overturning the Global Gag Rule.
In the fight to reauthorize PEPFAR in 2008, the President’s Emergency Plan for AIDS Relief, both Senators were co-sponsors. In 2003 Senator McCain voted to require one-third of AIDS funds be spent on abstinence-only programs. Obama was not a member of the Senate for this vote.
With respect to funding UNFPA, McCain voted at least five times against funding UNFPA, while Obama has voted in favor. Obama says specifically that he will work to fund UNFPA as President. McCain has been silent on this issue.
The differences between the candidates on U.S. domestic reproductive health care issues are as stark, with McCain voting and calling himself “pro-life” and Obama voting and calling himself “pro-choice”. The Planned Parenthood Action Fund, the political arm of the Planned Parenthood Federation of America, rates McCain at 0% and Obama at 100% and has endorsed Obama for President. It is likely that, based upon past votes and statements made as candidates, as President that Senator McCain would continue the reproductive health policies of President Bush, while Senator Obama would pursue reproductive health policies more akin to those of President Clinton. The difference is clear.
May 31, 2008
In June 2007 the Ministers of Health of all Latin American nations issued a Health Agenda for the Americas: 2008-2015, (the “Agenda”) a supposedly comprehensive plan for improving the health of the people of the Americas that was anything but comprehensive. It managed to leave out many proven recommendations for improving the sexual and reproductive health of the citizens of Latin America.
Infant and Maternal Mortality
If the moral soundness of a society is measured by how it treats its children, then Latin America, while better than Africa, does not measure up.
Infant mortality in Latin America is stubbornly high ― averaging 23 per 1000 live births (versus 7 in the U.S.) ― though an improvement from 81 per 1,000 live births in the years 1970-1975.
Maternal mortality is far too high, with Bolivia and Peru leading at rates of 420 and 410 per 100,000 births respectively, as opposed to 17 in the U.S. Uruguay has the low at 27.
The major causes of high infant and maternal mortality are well known: poverty, lack of skilled birth attendants and deficiencies in emergency medical care. There are underlying causes as well that lead to these medical emergencies, and they all fall under the rubric of sexual and reproductive health. Health experts, and mothers, know that contraception which enables intended pregnancy can improve outcomes by 1) delaying first birth until a woman has fully matured, 2) birth spacing, permitting a mother to regain her health and to fully nurture the child she has before giving birth to the next, and 3) reduction in absolute number of births, allowing the mother to give more care to the children she has.
The Agenda, to its credit, called access to contraceptives “indispensable,” and called for continuous care to mothers before, during and after pregnancy, for increased efforts to prevent transmission of STI’s and for stronger men’s roles in all these.
While a good start, this is insufficient.
Contraceptive and Fertility Rates
The issue in Latin America is not contraceptive use; it is getting the contraceptives to those at risk for unintended pregnancy. Contraceptive prevalence in Latin America is the highest in the developing world, on average, with 75% of women in South America and 66% in Central America having access to a method (the corresponding figure in Africa is 27% and in the U.S. 73%). These rates are far less in rural and poorer areas, and thus the rate of unintended pregnancy there is higher. Increase in contraceptive prevalence (the rate was 60% for Latin America and the Caribbean in 1998) though has not translated into birth rate or abortion rate declines.
The reason is a combination of lack of contraceptive access in vulnerable populations, along with higher intended childbearing desires. In some Latin countries overall birth rates, including teen birth rates, increased during the 1990’s, while in the rest of the world they declined. On average, 20% of teens give birth in Latin America. The fertility rate for ages 15-19 is currently 78 in South America. In 1996, the South American rate was 75, indicating a 4% rise since then.
A comparison with the U.S. is instructive. The fertility rate for Hispanic teens in the U.S. is about 82 for 2005, or slightly higher than the overall fertility rate for teens in Latin America (about 76). The U.S. figure disguises ethnic variations among immigrant populations, with the fertility rate for teens of Mexican origin in the U.S. being 93. However, interestingly, the teen fertility rate in Mexico is 63, about a third less than for Mexican teens in the U.S. Hispanic teens in the U.S. in general have a higher fertility rate than Hispanic teens in their country of origin.
The reasons could include lack of access in the U.S. to contraception or more teen sexual activity. Also Hispanic culture meeting with more prosperity in the U.S. (as well as in those Latin countries that have prospered) could have led to increased teen birth rates. There are no figures, though, that I have seen as to the intentionality of these teen pregnancies.
Though adolescents especially were recognized in the Agenda as needing special attention, there was, however, no specific call for renewed sexuality education efforts and increased availability of contraceptives for adolescents. This is not dissimilar to the silence in official circles in the U.S. Government around teen sexual activity, except for calls for abstinence education.
One sure way to decrease unintended pregnancy for teens and adults alike is emergency contraception. In many Latin countries there are battles over the legality of emergency contraception, which is characterized, mistakenly, as an abortifacient. In Chile and Ecuador, cases challenging distribution of emergency contraception recently went up to their respective Supreme Courts where, alas, EC opponents prevailed. The Agenda makes no mention of emergency contraception.
An abortion rate about 50% higher than the North American level predominates throughout Latin America, along with attendant maternal mortality and morbidity. This would indicate pregnancy rates are higher than the desired childbearing rates. Still, women in Latin America have about one more child than they say they want.
Abortion is proscribed virtually everywhere in Latin America, except Cuba, Guyana and Mexico City. Four of the five countries of the world which prohibit abortion in all cases, even to save the mother’s life, are in Latin America: Honduras, Chile, Nicaragua and El Salvador. There are about 4 million illegal abortions a year, 95% of which are unsafe. About 5,000 women die a year, resulting in 20% of all maternal deaths being from unsafe abortion.
There has been progress during the last year in decriminalization. Colombia’s Constitutional Court decriminalized abortion in three cases: rape, for the life or health of the woman and for fetal deformity. The Mexico City legislature also decriminalized abortion, by a vote of 46 votes in favor and 19 against, despite a threat of excommunication.
The Agenda made no mention of de-criminalizing abortion or providing post-abortion care.
STI’s and HIV/AIDS
While HIV/AIDS levels are below those of sub-Saharan Africa, HIV is still at serious levels. The prevalence rate is at or below 1% in every South American country, similar to most Asian countries, compared to rates of 25% in southern Africa. Condom use in Latin America is low ― just 4% of women in Brazil and Mexico report using condoms, compared with 13% in the U.S. according to PAHO (other sources show a higher rate of condom use of 18% in the U.S.).
Approximately one-third of Latin women have never had a Pap smear. In the U.S. about 84% of women had a Pap smear within the last three years (including 81% of Hispanics), indicating that Hispanic women are not disproportionately marginalized from the U.S. health care system.
The Agenda made no specific recommendations for increasing condom use and the availability of Pap smears.
Violence Against Women
Violence against women is apparently more prevalent in Latin America than in the United States, though comparable and accurate statistics are hard to come by. In the U.S. there has been a steady decline in what the U.S. Department of Justice calls “intimate partner non-fatal victimization” (a gender neutral term) which had declined from 6 per 1000 persons to about 2 per 1000 from 1993 to 2005. The rate of violence against both Hispanic and non-Hispanic females in the U.S. declined as well and averaged about 4.2 per 1000 annually during the period 2001-5.
In Latin America, the few surveys that have been done show, for example, that over 40% of women ages 15 to 49, who have ever been in a union in Peru (42%) and Colombia (44%), have been victims of partner violence. This is a cumulative figure, but it would appear that violence against women is higher in Latin America than among Hispanics in the U.S. DHS surveys in Latin America reveal that, for instance, in Nicaragua 11.9% of women experienced domestic violence in the year preceding the survey.
There was not a single mention of violence against women or domestic violence in Health Agenda for the Americas: 2008-2015.
The Americas’ Health Ministers’ Recommendations… and Omissions
So, the Latin American Health Ministers made a less than sterling start in addressing the sexual and reproductive health needs on their citizens, leaving out sexuality education, teen access, condoms, safe abortion, emergency contraception and measures to combat domestic violence.
Not unexpectedly, they did call for increased spending on health. The region spends 6.8% of its GDP on health care, or about $500 per person (the U.S. figures are 16% and $7,600, respectively).
How to pay for increased sexual and reproductive health care? First, decriminalizing abortion will save health care dollars. So will providing preventive health care, including family planning, emergency contraception and condoms. Passing and enforcing domestic violence laws too will reduce health care expenditures.
If funds are needed, countries might consider increasing tax revenues. Latin American taxes average 18% of GDP (in the U.S. it is about 25% and about 36% in Western Europe.
Finally, the U.S. and other donor nations could also increase their ODA to the agreed-upon level of 0.7% of GDP. The U.S. ODA in 2006 was at 0.17%. Only three Scandinavian nations, the Netherlands and Luxembourg exceeded 0.7%. Having healthy neighbors is in our national interest.
 All data that follows comes from the following sources, except as otherwise noted: Pan-American Health Organization’s (PAHO) Gender, Health and Development in the Americas- Basic Indicators 2007, and the United Nations Population Fund’s (UNFPA) State of the World Population 2007.
 See http://www.eclac.org/cgi-bin/getProd.asp?xml=/prensa/noticias/comunicados/6/32166/P32166.xml&xsl=/prensa/tpl-i/p6f.xsl&base=/prensa/tpl-i/top-bottom.xsl and http://www.unicef.org/progressforchildren/2004v1/latinCaribbean.php
 See http://www.infoforhealth.org/pr/m17/m17.ppt#289,34,Married Women (Ages 15-49) Have About One Child More Than They Want, 1990-2001
 See http://www.guttmacher.org/pubs/fb_contr_use.html
 These figures vary by source but see http://www.eclac.cl/cgi-bin/getProd.asp?xml=/prensa/noticias/comunicados/3/32253/P32253.xml&xsl=/prensa/tpl-i/p6f.xsl&base=/prensa/tpl-i/top-bottom.xsl .
March 16, 2008
The No-Brainer Syndrome : the HPV Vaccine and Male Circumcision Recommendations as the Latest Weapons in the Fight Against HPV, HIV and AIDSDr. Paul Offit, director of the Vaccine Education Center at The Children's Hospital of Philadelphia, called the new HPV vaccine, Gardasil, approved last year by the Center for Disease Control (CDC), ”a no-brainer.” Many advocates in the blogosphere use the same phrase, “no-brainer”, to describe the World Health Organization (WHO) 2006 recommendation for male circumcision as an HIV/AIDS prevention strategy, at least in sub-Saharan Africa. Most health professionals agreed, even if they didn’t use the exact phrase.
The public disagreed. A mere 10% of girls in the U.S. have been vaccinated so far with Gardasil and few men in Africa have had “the snip”. Within the past weeks the Virginia Legislature has taken steps to repeal its mandate for the HPV vaccine for schoolgirls, and the Health Minister of South Africa has refused to endorse male circumcision as part of its national AIDS program.
So, are these recommendations “no-brainers” or not?
They aren’t, for three reasons: 1) rents did not rush to get their daughters vaccinated.
Aside from safety, effectiveness and cost issues, some parents and public health officials had additional concerns:
Male CircumcisionIn 2007 the World Health Organization announced that it was recommending male circumcision “as an efficacious intervention for HIV prevention.”
Circumcision has a long and often contested history ― socially, culturally, medically and religiously ― which the WHO was well aware of, yet in 2007 two studies, one in Kenya and one in Uganda, were halted early by medical authorities, when the preliminary results showed a 53% and 51% reduction in risk respectively in acquiring HIV infection by circumcised males as opposed to uncircumcised males. The case for circumcision was so clear that it appeared to be a “no-brainer”, even though scientists have no proof of how circumcision might actually work as an HIV preventative. Possible explanations include the keratinisation, or extra layers of skin forming on the penis, that occurs after circumcision serving as a retardant to HIV transmission, or the susceptibility to HIV in the Langerhans cells in the inner foreskin. Langerhans cells are immune cells which act as a reservoir and replication site for the HIV-1 virus. They also appear in other parts of the male and female genitals, including the clitoris. There was no suggestion by WHO that these cells, or the surrounding skin on the organs that contain them, be excised. The WHO circumcision recipe for the goose is not one for the gander.
Some policy makers raised similar objections to circumcision as those raised against HPV vaccination:
HPV Vaccination and Male Circumcision: Case Studies in the Failure of Public HealthSo, here we have two new, expensive public health recommendations relating to sexually transmitted infections, one for females and one for males. Neither is a “no-brainer.” Each is less than 100% effective, and has the real possibility of greater harm: Gardasil if the vaccination unleashes other HPV strains and circumcision if males have sex before the wound heals and if they embark on more partners without wearing condoms. Each risks draining resources from other prevention strategies, and each could harm women especially.
Cervical cancer can be caught and cured with pap smears, and HIV by a comprehensive ABC program. HIV in Africa is mostly transmitted by female prostitutes. Thailand embarked on a program to require condom use in brothels. Africa has not. The HIV prevalence rate in Thailand is now far lower than in Sub-Saharan Africa. ABC can work. The circumcision recommendation is, I believe, more a comment on the world’s failure to implement ABC than on the benefits of the procedure, just as the HPV vaccine recommendation is a sad commentary of the U.S. and the world’s failure to have a comprehensive public health system that gets Pap smears to every woman.
The foregoing is abridged from a longer article of the same title that can be found at www.AlexanderSanger.com
A citation for the proposition for the potential unleashing of other HPV strains caused by HPV vaccination is as follows: George F. Sawaya, MD and Karen Smith McCune, MD, Ph. D, HPV Vaccination: More Questions More Answers,
This editorial states in part:
"In contrast to a plateau in the incidence of disease related to HPV types 16 and 18 among vaccinated women, the overall disease incidence regardless of HPV type continued to increase, raising the possibility that other oncogenic HPV types eventually filled the biological niche left behind after the elimination of HPV types 16 and 18."
Alexander C. Sanger, the grandson of Margaret Sanger, who founded the birth control movement over eighty years ago, is currently Chair of the International Planned Parenthood Council.
Mr. Sanger speaks around the country and the world and has served as a Goodwill Ambassador for the United Nations Population Fund.
The new book by Alexander Sanger published by PublicAffairs
Purchase from Amazon.com
Click here for full book information
With reproductive freedom in jeapordy, Alexander Sanger, grandson of renowned family planning advocate Margaret Sanger and a longtime leader in the reproductive rights movement, has taken an urgent, fresh look at the pro-choice position—and even the pro-life position—and finds them necessary, but insufficient. In Beyond Choice he offers the first major re-thinking of these positions in thirty years.
“Well researched and readable, Beyond Choice should be required reading for both pro-choice and pro-life supporters.”
—Governor Christine Todd Whitman
» Much more on Beyond Choice, including an excerpt, discussion guides, reviews
Hypatia, Indiana University Press
Tina Morlock, Oklahoma City Pioneer
» Advocate: Abortion does involve morality
Paul Swiech, The Pantagraph
» Planned Parenthood founder: Republican Party is pro-choice
Elaine Hopkins, The Journal Star
» Women's Studies seminar covers controversial topic
Jamie Smith, The Daily Vidette
» Luncheon promotes teen responsibility
Dahlia Weinstein, Rocky Mountain News
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» The Margaret Sanger Papers Project, NYU History Dept.
» When Sex Counts: Making Babies and Making Law, by Sherry Colb