29/06/2021 Comments Off on To the readers of my blog
I have not written much on this blog this year as work and mental survival have swallowed up my time and energy. However, I want to say very briefly that I do not appreciate people signing on to read this blog who do not identify themselves but who use made-up names. Several months ago, I removed everyone from the list who fit this “category” — having only just discovered I could do so. I will do it again.
To those of you who have stayed with me and who do identify yourselves, I thank you for your support. Doing a blog as an individual, I have discovered, is not the same as doing it as someone in a position such as a journal editor. I need to re-think what the point is, and I am hoping/intending to start writing again after the summer if not before!
Very best wishes, Marge
23/01/2021 Comments Off on HANDS OFF THE NHS!: A letter to my MP
Dear Nickie Aiken,
Of all the serious things your Government is doing wrong and all the hurt you are causing, I never thought I would have to send you an email about you agreeing to sell off the NHS. Let alone in the middle of a pandemic, when the NHS is on its knees because you have failed to fund it properly for many years, you have supported Brexit, which has pushed heaven knows how many European health professionals who worked in the NHS out the back door, and you have failed for years to ensure that the numbers of specific professionals, such as midwives, are adequate.
Yesterday I got an email from an NGO that supports the NHS, that said this:
“Last night we watched as Tory MPs
· Voted against an amendment to protect the NHS from trade deals by 357 to 266
· Voted against giving themselves a say over trade deals in future by 353 to 277.
I also read that: “The House of Lords put forward amendments to protect our NHS. And this government refused to listen.”
How dare you? And how often in the coming years are you going to keep up this foul behaviour? Why are you in Parliament if all you want to do is hand over your powers and our public services, built over a century, to sharks? Resign, Nickie, along with your good friend Boris. We need an MP who will stand up for the people she represents and speak up for and defend our needs.
We need the NHS like never before. Not privatised, not controlled by ignorant businessmen, not chopped up into pieces and sold off like meat. Not dominated by people with less public health experience than the size of their little toenails. What were the results of that pathetic consultation you did about changing the whole set up of the NHS? Over Christmas? Unpublicised? Unpublished and unheeded, I’m sure.
The people of this country need the NHS. Desperately need it. 100,000 have already died thanks to your government’s incompetence and corruption and insistence on privatising the services for test & treat, production of PPE and much more (putting billions in the pockets of their friends into the bargain). We don’t need your politics when all you do is spend your time making sure that no one who needs help with anything receives it.
Oppose and overturn this vote, Nickie, vigorously. Has Boris really kept so few Tories in the Party with any integrity at all? What a terrible legacy you will leave. If I have to say “shame on you” every remaining day of your term in office, as much as it angers and upsets me to have to do so, I will. But know that this is the bottom of the barrel. There is nothing worse than this except a wholesale sell-off all at once.
HANDS OFF THE NHS, Nickie. You will never be elected as a government again if you sell any more of it off and destroy it as a public health service. It belongs to us, not to you. Marge
To my friends and colleagues: PLEASE WRITE TO YOUR OWN MP AND REGISTER A STRONG PROTEST AGAINST THAT VOTE. WE CAN’T GO INTO THE STREETS TO PROTEST IN OUR THOUSANDS BECAUSE OF THE RISK OF SPREADING COVID-19 EVEN FURTHER, WHICH WOULD PUT EVEN FURTHER STRAIN ON THE NHS. BUT WE CAN STILL WRITE TO OUR MPs. WE NEED TO DO SO IN OUR TENS OF THOUSANDS. AND NOT JUST ABOUT THIS. THEY ARE GETTING AWAY WITH BLOODY MURDER. PROTESTING FROM HOME NEEDS TO BE DEVELOPED INTO AN ART.
14/01/2021 Comments Off on Sharing an important human rights statement about Israel-Palestine
A regime of Jewish supremacy from the Jordan River to the Mediterranean Sea: This is apartheid
by B’Tselem, the Israeli Information Center for Human Rights in the Occupied Territories, 12 January 2021
The article begins:
“More than 14 million people, roughly half of them Jews and the other half Palestinians, live between the Jordan River and the Mediterranean Sea under a single rule. The common perception in public, political, legal and media discourse is that two separate regimes operate side by side in this area, separated by the Green Line. One regime, inside the borders of the sovereign State of Israel, is a permanent democracy with a population of about nine million, all Israeli citizens. The other regime, in the territories Israel took over in 1967, whose final status is supposed to be determined in future negotiations, is a temporary military occupation imposed on some five million Palestinian subjects.
“Over time, the distinction between the two regimes has grown divorced from reality. This state of affairs has existed for more than 50 years – twice as long as the State of Israel existed without it. Hundreds of thousands of Jewish settlers now reside in permanent settlements east of the Green Line, living as though they were west of it. East Jerusalem has been officially annexed to Israel’s sovereign territory, and the West Bank has been annexed in practice. Most importantly, the distinction obfuscates the fact that the entire area between the Mediterranean Sea and the Jordan River is organized under a single principle: advancing and cementing the supremacy of one group – Jews – over another – Palestinians. All this leads to the conclusion that these are not two parallel regimes that simply happen to uphold the same principle. There is one regime governing the entire area and the people living in it, based on a single organizing principle.”
Read the full article here: https://www.btselem.org/publications/fulltext/202101_this_is_apartheid
And then read these:
11/01/2021 Comments Off on Covid-19 & Vaccines
“With a fast-moving pandemic, no one is safe, unless everyone is safe”
[This sub-title is taken from the WHO Covax report: “Working for global equitable access to COVID-19 vaccines.” Covax offers: Doses for at least 20% of countries’ populations; Diverse and actively managed portfolio of vaccines; Vaccines delivered as soon as they are available; End the acute phase of the pandemic; Rebuild economies.]
As of 7 January 2021, there were 85,929,428 confirmed cases of Covid-19 internationally, including 1,876,100 deaths reported to WHO. Data by region can be found here.
In 2020, the pandemic doubled the number of people who needed humanitarian aid worldwide, according to the UN, and is driving record-breaking humanitarian needs in 2021, according to the New Humanitarian.
Since April 2020, the Access to COVID-19 Tools (ACT) Accelerator partnership, launched by WHO and partners, has supported the fastest, most coordinated, and successful global effort in history to develop tools to fight a disease. With significant advances in research and development by academia, private sector and government initiatives, the ACT-Accelerator is on the cusp of securing a way to end the acute phase of the pandemic by deploying the tests, treatments and vaccines the world needs. But…
Donors have committed to fund the scale-up of the ACT-Accelerator but warn that major additional funding is critical to its success. As of 22 December 2020, contributions brought the total committed to over US$ 5.8 billion – but an additional US$ 3.7 billion was needed urgently, with a further US$ 23.7 billion required for 2021, if tools are to be deployed across the world as they become available.
The vaccines pillar of the ACT-Accelerator, convened by CEPI, GAVI and WHO, is supporting the building of manufacturing capabilities, and buying supply ahead of time, so that 2 billion doses can be fairly distributed to poorer countries by the end of 2021.
Announcements of effective and safe vaccines for Covid-19 were greeted with enthusiasm. But discussions continue about the ethical challenges of ensuring fair access to Covid-19 vaccines within and across countries, and which groups should be prioritised. (Lancet 397:10268, 10 December 2020) Thus: “Concerns about equity in access to the vaccines are growing. Estimates as of 2 December 2020 suggested direct purchase agreements had allowed high-income countries to secure nearly 4 billion vaccine doses, compared with 2·7 billion secured by upper and lower middle-income countries. Without such agreements, low-income countries would probably have to rely on COVAX, which would achieve only 20% vaccination coverage.
“While COVID-19 vaccines bring potential hope for a return to some kind of normality, vaccine-based protection is contingent on sufficient population coverage and requires effective governance, organisational, and logistical measures within a wider Covid-19 control strategy that includes continued surveillance and appropriate countermeasures. Successful vaccine roll-out will only be achieved by ensuring effective community engagement, building local vaccine acceptability and confidence, and overcoming cultural, socioeconomic, and political barriers that lead to mistrust and hinder uptake of vaccines.”
The World Health Organization announced in December 2020 that it had signed agreements to reserve some 1.3 billion doses for low- and middle-income countries under the COVAX programme, which was created with the goal of ensuring equal vaccine access.
The Pfizer/BioNTech vaccine, developed in Belgium, was the first vaccine to receive emergency validation from WHO on 31 December 2020 since the outbreak began a year ago. This opened the door for countries to expedite their own regulatory approval processes to import and administer the vaccine. It also enabled UNICEF and the Pan-American Health Organization to procure the vaccine for distribution to countries in need. However, this vaccine requires storage using an ultra-cold chain; it needs to be stored at -60°C to -90°C degrees. This requirement makes the vaccine more challenging to deploy in settings where ultra-cold chain equipment may not be available or reliably accessible. SOURCE: WHO, 31 December 2020
Two other vaccines have been approved as well: The Moderna vaccine, produced by Moderna in Spain, was authorised across the European Union on 6 January 2021; it also requires cold storage. And now there are several other vaccines making their way around the world as well.
The Astra-Zeneca vaccine, developed by Oxford University and Astra-Zeneca in the UK, has been approved in the UK, India and Mexico. Unlike the Pfizer and Moderna brands, it can be stored at higher temperatures and costs less to produce. India has an Astra Zeneca production facility in the country so it is said they can start producing vaccine and vaccinating people.
AstraZeneca’s vaccine costs providers about $4 per dose, while Pfizer’s costs $20 and Moderna’s costs $33, Al Jazeera reports. These prices will most likely fluctuate as time goes on and the vaccines evolve.
All three of these vaccines’ side effects are similar, including potential injection site pain and flu-like symptoms, including fever, fatigue, headaches, and muscle pain, which are to be expected when the immune system is first primed. Because all of these vaccines require two injections spaced several weeks apart, because none of them is 100% effective, and because it takes time for the protection to reach its height, wearing a mask and physical distancing after vaccination is still recommended. (Prevention, 4 January 2021)
Which countries have begun to roll out one or more vaccines?
The following is not an exhaustive picture but gives an idea of what is happening globally, including a sometimes chaotic situation and the fact that often unfair access issues that are emerging. It shows that having produced a vaccine versus successfully vaccinating a population are two very different things indeed. The one does not always lead smoothly to the other. This is proving to be true in the USA and UK, for example, where serious problems are emerging. The prospects for countries with weaker health systems are therefore concerning.
The UK was the first country to start administrating a Covid-19 vaccine, soon followed by over a dozen other countries. The following mainly well-off countries had approved and started administrating one or more vaccines by 29 December 2020:
Belgium, Canada, Chile, Costa Rica, Croatia, Cyprus, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary Israel, Italy, Kuwait, Malta, Mexico, Oman, Poland, Qatar, Romania, Russia, Saudi Arabia, Serbia, Slovakia, Spain, Switzerland, United Arab Emirates, UK, USA.
On 28 December, Sputniknews quoted the Russian Health Minister, Mikhail Murashko, as saying to the Russia-24 broadcaster that the Health Ministry had approved the Sputnik V vaccine for use in persons aged 18 and over. Thus, citizens over 60 years old could now be vaccinated against the new coronavirus infection. He added that the Sputnik V vaccine was considered to be safe and effective for older people. Vaccination began. Argentina also initiated the vaccination process using the Sputnik V vaccine, having received a first batch of 300,000 doses. (Pharmaceutical Technology, 28 December 2020) On 29 December 2020, Belarus also started administering the Sputnik V coronavirus vaccine to its population.(Moscow Times, 29 December 2020)
In Russia, compulsory vaccination of frontline health, education and social workers was already underway, but some members of the medical profession with priority access to Sputnik V are deeply sceptical of it. The Moscow Times interviewed 12 medics based in the capital, most of whom expressed reluctance – or outright refusal – to accept this vaccine as it had not yet been through sufficient trials for international clinical approval but was given a green light based on results from much smaller groups of volunteers than its Western counterparts. Some said their managers told them they could be sacked for refusing to be vaccinated. However, it was also reported that ongoing difficult relations between the medical profession and the Health Ministry, and anger at being forced to accept vaccination, may be playing a bigger role in this dispute than mistrust of the vaccine itself. In any case, data from clinical trials have not yet been published, but more than 50 countries have already asked to buy or produce Sputnik V, presumably because they will not get access to the more expensive ones any time soon. (Moscow Times, 29 December 2020)
Chinese pharma are also working on a number of vaccine versions. The Chinese authorities have given conditional approval for general public use of a vaccine called Sinovac, developed by the state-owned company Sinopharm, though published data about it are also limited. Other vaccines from other Chinese companies are said to be in the pipeline. Meanwhile, the Sinopharm vaccine is already being administered to in the United Arab Emirates and Bahrain, and Pakistan is said to have bought 1.2 million doses. Shipments of Sinovac have also arrived in Indonesia and deals with Turkey, Brazil and Chile are said to have been secured already one month ago. (BBC News, 3 December 2020)
Pfizer’s Covid-19 vaccine research trials were conducted with volunteers in Argentina, South Africa, Brazil, Germany and Turkey, as well as in the US. But Argentina, South Africa, Brazil, and Turkey have learned that they will have to be satisfied with Pfizer’s gratitude for their participation, because (like most countries in the world) they won’t be receiving enough of the vaccine to inoculate their populations sufficiently, at least not anytime soon. Producing enough vaccine to cover a large majority of the world’s population – 70% is said to be the optimum (minimum?) total – is not going to be a speedy affair. A UNICEF dashboard shows:
Meanwhile, the USA and Germany – along with Canada, the UK and the rest of the European Union – have contracted to buy enough doses of various Covid-19 vaccines to inoculate their populations several times over. But even that is proving not to be enough. The USA, for example, is struggling with the logistics of its vaccine rollout, which is taking much longer than was expected. (See also The Intercept, 31 December 2020)
Then there is what happens when deliberate discrimination for political reasons dominates vaccine rollout: There are reports that Palestinians living in the occupied territories are being excluded from Israel’s Covid-19 vaccine rollout and may have to wait months for vaccination, while injections go to Jewish settlers. (Guardian, 3 January 2021)
Negative consequences of not meeting unrealistic but powerful public expectations
What is most worrying is if people start thinking that the only thing they need now is to be vaccinated, and refuse to continue to endure lockdown and keep each other safe through masking and physical distancing, assuming even those preventive actions are both possible and happening adequately now (which they are not). The fact is, no matter how much demand there is for vaccination, most people will not be vaccinated immediately or soon, let alone necessarily during 2021.
In the UK, due to the massive failure to implement an effective test–trace–isolate programme in order to prevent the spread of the virus, a mutation of Covid-19 that was discovered some weeks ago has spread rapidly. This is happening in many other countries as well, not least because far too much unchecked international travel is also still taking place and being promoted. On one UK television station last night, an advertisement offered a 40% discount on 600,000 seats!
And reports are being published that vaccination rollout has been slower in many countries than was hoped for, not least because there are simply not enough staff to carry it out. Hence, public health people and governments will have to guard against something akin to panic at government level on how to deal with conflicting demands and limitations.
In addition to imposing a total lockdown in the UK after a far too lax Christmas period, a decision was taken by government public health officials in the first week of January to postpone giving the second injection of both the Pfizer and the AstraZeneca vaccines in order to provide first injections to many more people more quickly. The reasoning was that even one injection provides more protection than none. Then, within a few more days, they went even further and proposed to use the Pfizer vaccine for the first dose and the AstraZeneca vaccine for the second dose, that is, if they did not have enough supply of both to use the same brand twice for each person vaccinated. What was the response? As one expert from the USA said:
“Officials in Britain ‘seem to have abandoned science completely now and are just trying to guess their way out of a mess’.”
These policy decisions have caused major debates amongst the expert scientific community internationally, in which responses have ranged from: “Don’t try it”, to “There are no research data to support this”, and “You don’t know how long the first injection will remain effective if you delay the second injection” and “You need to trial these changes first”. All are absolutely correct. On the other hand, a few experts have acknowledged that the “trade-off” being proposed – under imperfect circumstances in which the health care system is already stretched to its limits of coping – is an understandable one, even if not evidentially supported.
Dr Anthony Fauci, the top expert on infectious diseases in the USA, said he would not recommend following Britain’s lead on this, while reports say Germany and Denmark are now also considering delaying the second Covid vaccine dose, presumably for reasons similar to Britain’s. At this writing, WHO has also stepped in and said postponing the second injection – Britain is proposing an interval of up to 12 weeks – is not supported by scientific evidence; they are also against it.
The US Centers for Disease Control and Prevention has made it clear that the approved Covid-19 vaccines “are not interchangeable,” and that “the safety and efficacy of a mixed-product series have not been evaluated. Both doses of the series should be completed with the same product”. This is a big gamble as none of it is data driven. At the worst, a huge number of first injections may prove useless if second injections are delayed too long, pushing everything back to square one.
Another major concern, just emerging and as yet unanswered, is whether any of the existing vaccines will be as effective against the mutated viruses (of which there are now several kinds reported from different countries) as against the original virus they were developed to block. This is the global situation as we send this newsletter out.
See the following articles, which address this growing list of unresolved issues and problems:
Panic, abandoning the COVAX agreements on equity of access to the vaccines that a large majority of countries supported less than a month ago, rushing to use vaccines whose trial data are still limited and/or have not yet been published and evaluated, ignoring good quality trial data to try and speed up a process that cannot be rushed – all of these are mistakes that in the longer term will not take the world where we need to be.
Prevention of infection remains a global priority
Our leaders need to convince people to hunker down, that this situation is with us for longer than we would all like, and that prevention of the continuing spread of infection from one person to another to another is still needed worldwide, based on what is known about the speed of spread of the mutated virus. Our leaders need to prepare for and put in motion major efforts to strengthen and expand national public healthcare services on a longer term basis.
Meanwhile, prevention includes mandatory masking of adults and children over the age of two in all public places, indoors and outdoors; better promotion of physical distancing – that is, to stay at least two meters (six feet) away from other people in public spaces; handwashing when arriving home and using disinfectants in shops; national lockdowns; effective test-trace-isolate programmes run by local health services in which isolation of everyone who tests positive is enforced and supported; closure of schools and supported home teaching of children; and economic support for all those who have lost their jobs or are unable to work – as well as effective protection for all key workers – are critical to defeating this pandemic.
Not just vaccines. And even with vaccines. Today, someone wrote that to vaccinate the world out of this pandemic, 70% of all our populations will need to be vaccinated. This is a gargantuan task and will take far more than one year, let alone a few months. This needs national and individual discipline and accepting the reality and complexity of disease prevention and control.
Lastly, we need to add public health education to the curricula of schools and the training of politicians, and for all our leaders. Our national media also need an education in how to promote public health far better than most of them are currently doing. We were already warned in 2016 that there were more pandemics to come. Most of our countries did not listen. And today, almost all our countries have proved we are far from ready. The few who were ready, and who have managed to contain and defeat this virus, such as Taiwan and New Zealand, have not been seen to be or used as models to follow by the rest of us. At our continuing peril.
Postscript: I published this report in the newsletter of the ICWRSA even though it’s not directly about abortion. I wrote it because I think everyone with any connection to public health issues needs to be sharing this kind of public health information in order to support control of this pandemic. Our lives depend on it. We also need to know much more about what is happening in the poorest countries, which this report clearly does not touch upon. Further information is more than welcome.
The pandemic is out of control because we’re not protecting ourselves and each other! We can do this better!!
01/01/2021 Comments Off on The pandemic is out of control because we’re not protecting ourselves and each other! We can do this better!!
Far too many people in the UK are not taking the two most important precautions to protect themselves and each other from Covid-19 when they are not at home:
* always wearing a mask &
* always staying away from other people (2 feet at least and 6 feet whenever possible)
When I go outside for a walk every day I am constantly faced with other people not wearing masks and not keeping any distance from others, more often men than women, especially young people, rambling along the pavement absorbed in what’s going on with each other — or totally absorbed in what’s going on in their earphones or on their mobile phones — laughing with their mouths wide open, running huffing and puffing and coming up right behind me before they pass me, walking right next to me even when there’s lots of room not to, including those on a bicycle. Never seeing me or anyone else. I must look like a drunkard, because I step off the pavement often and walk into the street to avoid them, or swerve to the right or the left to create space between us, with almost every person who passes. They don’t notice. When I was still taking walks along the north bank of the Thames, I would hold both my arms out to the sides when people approached who were ignoring my existence and were about to walk right next to me. That succeeded a lot better than saying anything, because it was inoffensive, unexpected and caught their attention. No one walked straight into my hands. I got at least a bit of space and with a lot more dignity than shouting. But other people’s lack of awareness can make going for a walk very tedious, even infuriating.
I have to ask: is it a sign that most people are not taking this pandemic seriously or don’t consider themselves (let alone others) at risk enough to change their behaviour?? This is why HIV & AIDS reached pandemic levels. And yet surely changing your sexual behaviour, i.e. always using a condom for penetrative sex, is a much more demanding form of behaviour change than wearing a damn mask. Which is nothing by comparison.
People aren’t stupid. But the pandemic is invisible for most people apart from a few brief shots of hospital staff covered in protective equipment on TV and the daily cases and deaths figures in the newspaper. How many of us have watched someone gasping and unable to breathe for hours, coughing their guts out, delirious, pouring sweat with fever, let alone dying from this virus? Not many. Unlike in the poorest countries, there are no bodies in the road, we see no images in mortuaries. Although we have the 5th highest number of deaths in the world, 73,000+ deaths, this is a tiny percent of the population. Never mind that Taiwan has had only 7 deaths since February, with a third of our population. Why haven’t we, why hasn’t our government, learned lessons from them — and from New Zealand?
Most people haven’t yet twigged that we are doing this to ourselves. Most of us probably know someone who has had it by now, but we only tend to see them after they’ve recovered. And we may hear someone talk about how awful it was, how weak they were, how they were on oxygen, or how they passed out and fell down and broke a bone. But we haven’t watched it happen, nor had to look after them while they’re ill or get them to hospital. And we’re not allowed to visit them in hospital or be with them when they die.
Equally importantly, a whole generation has grown up without a public health education. There is no Health Education Authority anymore in the UK, not since 2002 when it was shut down, for no apparent good reason. Maybe someone with no foresight thought that with the “end” of HIV (which is in fact still with us) or the advent of HIV treatment, it wouldn’t be needed. We’re paying for that decision daily. A vaccine isn’t going to get us out of this on its own either. And now we have an incompetent government with no public health knowledge, who have thrown away billions by putting a string of commercial companies with no public health competence in charge of the services we need. The government has grossly mismanaged this pandemic from Day One, and at this rate, they will go on doing so for the duration of their tenure in office.
Vaccine? We wouldn’t need one if we paid attention to what is in fact very simple science. There is already a very effective treatment for avoiding Covid-19 right now and there has been from the start. This is it, in case you didn’t hear what I said above:
STAY SIX FEET AWAY FROM OTHER PEOPLE, ALL THE TIME!!!
DON’T BREATHE, COUGH, LAUGH, SNEEZE, OR BLOW SMOKE NEAR ANYONE ELSE!!!
DON’T LET ANYONE BREATHE, COUGH, LAUGH, SNEEZE OR BLOW SMOKE ON YOU!!!
ALWAYS WEAR A MASK WHEN OUTSIDE YOUR HOME.
I REPEAT: ALWAYS WEAR A MASK WHEN OUTSIDE YOUR HOME!!!
The virus is spread by breathing on other people. No public message has been this clear. No public message has used visuals to show all the wrong ways people are masking (when they bother) – e.g. with their noses uncovered, with the whole mask on or under their chin, with it hanging from one ear, holding it in their hand, taking it off as soon as they exit a train – even while still on the platform, the escalator and in the corridor to the exit. Everywhere they walk that is close to other people, such as on the pavement of every street – in every shop – and on the bus. At work, in school, in a public toilet. Get it??
How often have there been videos on TV or on online news media showing how droplets of moisture in your breath make a fine spray all around you when you breathe, cough or sneeze, and travel long distances when you breathe hard, while running, laugh out loud, blow out the smoke of a cigarette. This spray carries the virus if the virus is in your lungs. Everyone’s breath makes this spray all the time. Including yours! These visuals should be shown daily.
WEARING A MASK SHOULD BE COMPULSORY THE WHOLE TIME THAT PEOPLE ARE NOT AT HOME – AND ENFORCED. This would reduce transmission immediately and enormously.
We’re the 5th richest country in the world. Why do good masks cost so much money, so that most people can’t afford to buy them? They should cost pennies or be free, and be distributed everywhere.
Why does a country full of intelligent people not realise any of this? Because no one has told them all these things so bluntly. Not in school. Not in the newspapers. Not on social media. Not on television or the radio.
In a war, sirens go off when there is danger. In a pandemic, when breathing on other people is the danger, these messages should be like sirens. They should be shown constantly. They should make noise and use bright colours to attract attention to themselves. Not just one-directional arrows on the stairs, half-worn away by now and ignored.
Young people think they aren’t at risk, they’ve been told again and again that even if they get the virus they’re likely to be all right. So they don’t understand how much they may pose a risk to others, spread the virus to friends who spread the virus, especially affecting people over 60. Many people with the virus have no symptoms. Many of them may be infecting people completely unknowingly, as they walk close to them, breathe on them, again and again and again, day in, day out. Children of all ages were sent back to school and university, but many schools were not made safe, and now children are spreading the virus.
People have been told to stay home, not to gather in crowds. But remember the beaches in summer? And just look at the crowds in all the public parks and along the river, all the time, with so many not wearing masks.
We are one of the richest and most educated countries in the world. Yet our government has allowed this to happen, and we all need to act and make fundamental changes in what we are or are not doing about it. Starting with our own behaviour in public and shared spaces.
At the same time, we need a competent Prime Minister and government to take charge. We went from bad to worse getting Boris Johnson. He can’t handle it.
Lastly, and most importantly, we all need to listen to the scientists and public health experts who do know what they are talking about. I strongly recommend following Independent SAGE, who are currently calling for an immediate national lockdown. They are a group of scientists who are working together to provide independent scientific advice to the UK government and public on how to minimise deaths and support Britain’s recovery from the COVID-19 crisis. They do research, gather evidence, talk to journalists and write articles, and they broadcast a public report on the web and answer questions every Friday at 1:30pm for an hour. Journalists are finally starting to quote them. You can quote them on social media. You can share this blog too.
Make safe behaviour your new year’s resolution, and stick to it!!! So that we can indeed have the chance of a happy, healthy, safer year in 2021.
There is not just one “Jewish community”: a response to misplaced efforts to shut down political debate and discussion in the Labour Party
20/12/2020 Comments Off on There is not just one “Jewish community”: a response to misplaced efforts to shut down political debate and discussion in the Labour Party
by Marge Berer
[This blog was revised on 23, 26 and 31 December 2020 and 3 January 2021 to clarify some points that were criticised by readers and add links to relevant new information.]
The amendment to the tabled resolution was: “The CLP regrets in particular the sense of so many Jewish party members, Jewish MPs, and British Jews that Labour had turned away from them due to anti-semitic acts and statements by a small number of party members who do not represent the vast majority of Labour members, supporters, and voters.”
It is beside the point what the original resolution was that led to this amendment being tabled, but it does matter that this amendment was not passed by the meeting as it contradicted the main resolution. What also matters is that it put on the table an issue that is dividing the Party, one that urgently needs to be confronted and resolved. I am very sorry that this “expression of regret” was felt to be necessary. But I am writing this to try and explain why I do not support what it says.
First, let me identify myself. I’m 74 years old, from the USA by birth; I came to live in London in the 1970s, and I have been an active member of the Labour Party since that time. I later became a British citizen, though I’m still seen as a foreigner and still feel like one myself.
I’m Jewish, raised to be religious, with grandparents who were immigrants to the USA at the turn of the last century from four different Eastern European countries. I am not religious, but I identify as Jewish when asked, including when asked for my race – when I tick “White Other” and add “Jewish” on forms.
I’m not religious, but I define much of my political thinking as Jewish, by which I mean I have been strongly influenced by the left-wing politics of many Jewish writers and thinkers, and specifically their emphasis on the overarching importance of justice. I identify the importance of justice as a Jewish concept, though obviously it is not only a Jewish concept. It is very important for me, probably more important than any other single influence on my political views alongside a feminist perspective.
The amendment quoted above identifies the highly unfortunate and widely articulated response of some members of the “Jewish community” in Britain to the Labour Party in the past few years. Nevertheless, it ignores the fact that there are many members of the Labour Party who are Jewish, myself among them, and many other British people, Jewish and non-Jewish, who do NOT think that the Labour Party has turned away from us. Who know that the vast majority of Labour Party members are not anti-semitic, and who believe that the Labour Party has been demonised by people who do not wish the Party well, and who have made accusations of rampant anti-semitism in the Party in order to discredit the Party. There is also no doubt that many good people, Jewish and not Jewish, believe those accusations. And it is a sad fact that when people like me try to explain why this is wrong, we are often not believed and have had doors slammed in our faces.
Anti-semitism exists in our society; it is historically part of many people’s learned prejudices. I grew up with a mother who was very religious, even when she was a child. She was in her teens and twenties when fascism became rife in Europe and Hitler came to power. I was born just after the War. It was pounded into my head from a very young age that I was different, that everyone believed that I was different, Jews and non-Jews alike, that anti-semitism was everywhere and would never go away, and that I could never trust anyone who was not Jewish. I rebelled against this world view as an adolescent, as it horrified me. I read a lot about these issues and have continued to reject this world view with every political bone in my body. I am lucky that my experience in the world has not been reflected in that picture. Nor has it been my experience in the Labour Party – on the contrary. And I am far from an isolated case.
The so-called “Jewish community” (when was the last time you heard talk of the “Christian community”?) is not a monolithic group with only one world view or only one political perspective or only one opinion about everything that is happening in the world. The Jewish Board of Deputies does not represent us all or speak for us all, nor did anyone elect or empower them to do so, officially or unofficially. They are as politically motivated as the rest of us, just as the Pope and every other religious and secular leader, for good or otherwise.
Anti-semitism, like racism, like hate speech, is a form of discrimination whose intention is to cause identifiable harm. That is the reason it is against the law. In the Equality Act 2010, it says that, “by law, [people] must not discriminate against, harass or victimise [people] on the basis of a number of protected characteristics, including race and religion”. This is quoted in the EHRC Report on page 4. The Equality Act 2010 includes “religion and belief” as protected characteristics, among many others such as age, sex, disability, marriage, and civil partnership. It says: “A person (A) discriminates against another (B) if, because of a protected characteristic, A treats B less favourably than A treats or would treat others.” Whether or not specific behaviours are anti-semitic under the Equality Act is not just a matter of anyone’s personal opinion, it requires examination under the terms of that law.
These issues, as well as well-intentioned but totally inadequate definitions of anti-semitism, have for several years now divided people, causing distress, anger, misunderstanding and despair, both inside and outside the Labour Party.
Keir Starmer and David Evans have attempted to short-circuit (or bury) this problem by dictat, by ordering us not to discuss, query or criticise – let alone reject – the EHRC Report, the IHRA definition of antisemitism, or the so-called ten commandments of the Jewish Board of Deputies – and by suspending a growing list of people and threatening them/us with being kicked out of the Party for disobeying. Yet these conversations are crucial. No one can resolve these disagreements, let alone achieve unity, by taking away the right to question, debate and disagree, let alone by censorship, threats or punishment. This stance is unethical, short-sighted and doomed to failure. But above all, it is missing the point.
The real issue is this: the “Jewish community” has been engaged in a civil war throughout my lifetime, and even before that. Too many people who are not Jewish do not seem to realise this, let alone the seriousness and extent of it. The cause is the existence of profoundly differing political views on the political behaviour and policies of the state of Israel, and whether or not Jewish identity requires unquestioning loyalty to Israel. My whole life as a Jewish person has been affected by this, and no one can nay-say the importance of this in regard to any accusation of anti-semitism today.
As a child, I put pennies in a tin box to plant trees in Israel. A green and fertile Israel was contrasted with the dry and empty desert of all the “Arab” lands. I grew up being told that if I was rejected by my own country because of anti-semitism, Israel was there for me, I was automatically a citizen. Kibbutz life – communal life – was made to sound like heaven, or as close as one could get. All Israeli Jews were heroes and freedom fighters; all Palestinians, all Arabs, were terrorists. And so on and on… The facts are other.
The most important facts underlying today’s contentious debates, as I see it, are these: Israel is a State, with a capital S. Statehood confers certain universal obligations, including those laid down in international human rights law, including the International Covenant on Civil and Political Rights (ICCPR), which every country that has ratified it must adhere to (see the United Nations website on this subject). That includes Israel, who ratified the ICCPR about 30 years ago. The ICCPR Part I, Article 1.1, says: “All peoples have the right of self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development.”
Israel wants to be seen as a “Jewish state”. But Israel is not a religion, it is a State, and it is not ONLY and never was ONLY a place where ONLY Jewish people were born and live, romanticised in the phrase: “the home of the Jewish people”. Not now, not 100 years ago, and not 4,000 years ago either. Yet Israeli law now says it is – in the 2018 Basic Law: Israel as the Nation-State of the Jewish People, which says: “The exercise of the right to national self-determination in the State of Israel is unique to the Jewish People” (Basic Principles 1c). This is a gross violation of the ICCPR. Millions of Palestinians were born in that land and have had children there, both before after after Israel gained statehood. (On 2 January 2021, Haaretz published an article about Avraham Burg, who has served as Israel’s Knesset speaker, and interim president and head of the Jewish Agency, and who is asking Israel to annul his registration as a Jew because of the discrimination present in this “Basic Law”. The Haaretz article is subscriber only, but it can be accessed in full here.)
When Jeremy Corbyn led the Labour Party, the Party supported the fact of the right to citizenship of Palestinians who were born in Israel-Palestine and/or born to Palestinian parents, millions of whom have been living as “refugees” in camps and as exiles in Europe, North America and many other countries since 1948 or 1967. No one who knows this history can deny that Israel is violating international human rights conventions with almost complete impunity, under the protection of one US president after another.
That is where the real problem lies today, and it is the basis of the civil war I am talking about inside the “Jewish community” – because some of us, that is, some of us who are Jewish, refuse to condone this state of affairs, while others want everyone else to believe we are “bad Jews” for doing so.
The fact is that Jewish people like me have long been called “self-hating Jews”, which is equated with being anti-semitic. How is it that Jewish people can be accused of and condemned for anti-semitism? My mother called me a self-hating Jew from the time I was an adolescent. Both because I do not practise the religion and because I support the right of Palestinians to their own land, citizenship and self-determination. I have been accused of self-hatred year in and year out for believing in justice. Yet justice, to have any meaning at all, must be available to everyone equally. A very Jewish concept.
By implication, however, if you are Jewish, you must hold the political position that human rights matter only for Jewish Israelis, not for everyone in Israel-Palestine. For anyone who believes in human rights and justice, this is untenable.
Let me be perfectly clear, the State of Israel must support the human rights of everyone, including everyone with a just claim to citizenship. I do not support Israel’s claim to be a Jewish State because any State in which only one religious group has a right to citizenship is discriminatory; it is against international human rights law. There are only a few other countries in the world today that claim or seek to be a State based on only one religion – the Vatican, for example. And India, where Narendra Modi is annihilating and displacing and impoverishing millions of Indian and Kashmiri Muslims while the world sits by watching in near-total silence. Read Arundhati Roy’s history of that decades-long tyranny. This is not about being Jewish or Catholic or Hindu or Muslim; it’s about the responsibility of being a State, and about the crime of legalising discrimination that leads to state-sponsored violence and state-sponsored denial of human rights, among which the right to citizenship and to your own land are vital civil and political rights.
Read Edward Said (a Palestinian historian). Read Raja Shehadeh, whose books about walking in the hills of Palestine trace the history of the increasing illegal occupation of Palestinian land – acre by acre, tree by tree, to the point where almost all the land had been stolen by the time Palestinian citizenship was formally revoked. Read the history from both sides of the wall that was built. Then let’s talk again.
If Keir Starmer and David Evans think they can whitewash global politics on their own personal say-so, based on what the Jewish Board of Deputies, the Jewish Labour Movement, the right-wing Jewish media, and certain Jewish MPs tell them – all of whom appear to have in common that they support Israel no matter what Israel does or does not do – they need to think again.
My uncle, who has been dead for many years now, a patriot who fought in the US Army in World War II and who was there to help to liberate the concentration camp of Bergen-Belsen, always said: “My country: right or wrong.” I can understand why, looking back, because he came home from Germany alive. But that stance is the source of all the silence in the face of all the injustice in the world, including standing up for the value of some human lives while totally rejecting others.
Expelling people from the Labour Party, kicking them out of the Shadow Cabinet, removing the Whip from them, telling us that we cannot discuss or criticise documents that deserve to be queried and challenged, if not downright rejected… these also represent gross injustice. They are not the way forward for the Labour Party, but anti-democratic and suicidal.
31st Special Session of the UN General Assembly in response to the Covid-19 pandemic (3-4 December 2020, 14 December 2020)
16/12/2020 Comments Off on 31st Special Session of the UN General Assembly in response to the Covid-19 pandemic (3-4 December 2020, 14 December 2020)
Report and comments, by Marge Berer, 16 December 2020
All sessions are available on: http://webtv.un.org/
This Special Session of the United Nations General Assembly (UNGA) was originally scheduled as a two-day event on 3-4 December 2020. On both days, it began at 9:30am New York time and ended late at night. The intention was to give every member of the United Nations the opportunity to make a statement to the General Assembly about what is happening in their countries due to the Covid-19 pandemic. There were also three panels on the second day with speakers and interactive question-and-answer between governments and panellists. In the event, in addition to opening and closing statements, only about 70 of the 160 governments who had asked to speak were able to make a statement during the two days, while none of the six NGOs who had also pre-recorded statements was able to do so. The three panels took place on the second day as scheduled. To fit everyone else in, a further session was scheduled for 14 December 2020, starting at 3pm New York time. Links to all these sessions are provided below. This has been an incredible event to listen too, and very worth watching as much of it as possible, above all the three panels though the whole event gave them far more context and meaning.
Each government statement was a maximum of five minutes. Almost all statements were pre-recorded and shown on video, introduced by the UN Country representative who was in the UNGA hall in New York. Many of the statements were by countries’ top leaders; others were by ministers of state, mainly health or development ministers.
Country Statements – Wearing their most formal, official clothes, not a hair out of place. standing behind a podium or a table or a desk, well-rehearsed, almost without emotion, surrounded by their national flags and/or national symbols, over two long days and nights some 70+ leaders made pre-recorded statements about how their countries were faring after having been hit for the best part of a year by Covid-19. What they articulated, with few exceptions, was a picture of a disaster, shared by all, and a heartfelt call for mutual support and help. They also revealed the extent of unpreparedness, lack of know-how and helplessness in the face of a virus that is transmitted by people breathing on each other.
As perhaps never before, world leaders called for solidarity, actually using the word “solidarity” again and again. Solidarity, preparedness, mitigation, resilience, connectivity, cooperation were called for. As regards finance, debt postponement, debt relief and debt cancellation were all called for – as well as the need for transparency, addressing corruption, and for the cessation of all wars in order for all countries to recover in terms of their economies, food production, education and health care. There were descriptions of health systems unable to cope, which had already been on their knees before the pandemic began, and now were worse. There were concerns that there was not going to be enough food, there was even talk of the threat of starvation among the poorest, a problem that had been relegated to history, and calls for urgent financial support for economies that have suffered terrible blows. Including from countries where climate disasters, in-migration and out-migration have been taking place as well.
In relation to vaccines, everyone who spoke talked about the importance of treating the vaccines as a global public good. A “global public good” means: no patents, no profits, no hoarding. Another definition given was: free of charge to the public, fairly distributed and based on need. There was a call for 20% of the populations of ALL countries to be vaccinated initially, as a first round to cover the most vulnerable people, rather than vaccinating everyone in a few (rich) countries, as would be “normal” if the usual “who can pay wins”/“every man for himself” behaviour was allowed. There were calls for ending discrimination, for equity, for universal health coverage, for promoting sustainable development and leaving no one behind – bringing together all the UN’s interlinking programmatic aims.
There was also evidence presented of unprecedented cooperation taking place between researchers and scientists across the world, the open sharing of information, and an agreement between a large majority of countries – called the COVAX initiative – that has been in the planning for much of this year and will soon begin to be implemented. Equally crucially, speakers identified the close links between the climate crisis, global public health exigencies, addressing grave setbacks in economic development due to the pandemic, and promoting and expanding the green economy as the only way to address what has led to this pandemic and will cause future pandemics, predicted to be coming (just as Covid-19 was predicted already in 2016).
Programme: Opening Statement
Opening of the 31st Special Session of the General Assembly in response to the Coronavirus disease (COVID-19) Pandemic (3-4 December 2020)
Plenaries (3-4 December 2020)
(Part 3) General Debate of the 31st Special Session of the General Assembly in response to the Coronavirus disease (COVID-19) Pandemic (3-4 December 2020)
Moderator: – Melissa Fleming, Under Secretary General for Global Communication
Panellists: – Dr Tedros Adhanom Ghebreyesus, Director General, World Health Organization
– Mr Mark Lowcock, Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator
– Ms Michelle Bachelet Jeria, United Nations High Commissioner for Human Rights
– Mr Achim Steiner, Administrator of the United Nations Development Programme
– Mr Filippo Grandi, United Nations High Commissioner for Refugees
– Ms Inger Ashing, CEO, Save the Children International
– Dr Asha Mohammed, Kenya Red Cross Society
This discussion took stock of the UN system’s response to the Covid-19 pandemic. It examined comprehensive and coordinated responses of UN entities and partners, focusing on the most vulnerable people and those disproportionally impacted in different operational contexts, including those in low-resource settings, conflict situations, and displaced communities. The role of, and impact on, women and girls was a focus, particularly women as front-line responders. The discussion outlined what has worked well, identify operational and policy gaps as well as lessons learned. It highlighted actions required for the continued immediate humanitarian and health response, protection of human rights, and the launch of urgent economic recovery and social protection measures.
Mark Lowcock, Michele Bachelet, and Achim Steiner were especially excellent on this panel.
A selection of points made by panellists during the session:
270 million people are marching toward starvation – funds have been provided to address this in 2020 but not yet for 2021. It will be catastrophic if funds are not available for 2021. A dozen countries are already at risk. The richer nations are not responding in a way that is commensurate with the need. One of three possible scenarios is 1 billion people living in extreme poverty by 2030. Another is the opposite. Other disasters have not stopped. The climate crisis still threatens the whole planet.
235 million people on the planet may not survive the current humanitarian crises. Poverty is increasing, hunger will grow, major famine threatens, hundreds of millions of children are out of school, and violence against women and girls due to the shocking behaviour of men has been increasing.
$4 billion has been raised from UN members to try and inform everyone on the planet about the virus and how to protect themselves. Social protection payments have been available for 2 billion people and more… yet the challenge is even greater.
It is important not to develop the Covid-19 vaccine at the expense of routine vaccination.
Programmes to protect women & girls are getting the least funding.
Significant shakeout among the NGO sector, many are not sure they will continue to be funded or survive, half of African NGOs are not sure they will survive.
Refugees are particularly vulnerable as well as the millions of people who host them, often in very poor countries of the world where most refugees are being hosted. They need to be considered with a special focus.
The UN Secretary-General has appealed for a global ceasefire in all wars.
Covid-19 is also a child’s rights crisis. There has been a 15% increase in children living in households with financial crisis. Many are not returning to school, many of whom are migrants on the move, and many others are girls. There are 1 billion children aged 2-17 who face violence of all kinds every year.
Women and girls know what they need. We need to listen and respond.
Stopping the virus is not just developing vaccines. We have to stop the virus from jumping from one person to another; that is the existing treatment that everyone can practise.
We need to vaccinate some people in all countries, not all people in some countries.
We need to intensify cooperation and strengthen the architecture of health systems, promote peace and justice. We cannot walk away from the inequities and vulnerabilities that this virus has exposed. Human behaviour has to change, discover mutual respect, solidarity. We need trusted leaders who will encourage people to participate and become part of the solution. Common humanity is what will bring about change. The IMF says $2.5 trillion dollars will be needed to support developing countries, but the money is not yet forthcoming at that level.
Small island states’ economic situation is among the worst in the last 9-10 months. Being a small country in a large world means [sometimes!] being ignored. A more robust international system is needed.
More than 11 million girls are at risk of not going back to school after the pandemic. See the UNESCO video.
Categorising countries as low- or middle-income countries is not adequate for deciding whether to provide funding in these new circumstances, when for example there are hurricanes and help is needed. [Feminists have also said this for a long time regarding countries where women’s issues are treated very poorly but the country is middle income and there is no longer funding available.]
Many NGOs put forward questions to this panel but they could not be heard or answered as time ran out.
Moderator: Lyse Doucet, BBC Presenter and Chief International Correspondent
Panellists – Part I: The Science
– Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization
– BioNTech: Prof Uğur Şahin and Dr. Özlem Türeci
– Prof Sarah Gilbert, Oxford University/AstraZeneca [Pre-recorded video by Adar Poonawalla, Chief Executive Officer, Serum Institute of India]
Panellists – Part II: Vaccines for All
– Dr Seth Berkley, Chief Executive Officer of GAVI
– Ms Henrietta H. Fore, Executive Director of the United Nations Children’s Fund
– Dr Richard Hatchett, Chief Executive Officer, Coalition for Epidemic Preparedness Innovations (CEPI)
– Sir Andrew Witty, WHO Special Envoy for ACT-Accelerator – on video
Significant progress has been made in developing new tools and strategies in the fight against COVID-19, including vaccines, as the result of unprecedented international collaboration, much-needed investments, and world-class scientific efforts in research and development. The world is at a critical acceleration point in the vaccine development and deployment timeline, poised to turn the corner into the vaccine era of the COVID-19 pandemic. The objective of this dedicated discussion on a Covid-19 vaccine was to breakdown the process of vaccine development and address the ‘infodemic’ around it in publicly digestible terms. How many vaccines are currently being tested and at which stages in the process is each one? How will vaccines be produced and distributed? How is the multilateral system working with governments and private sector partners to ensure the equitable distribution of, and access to, a Covid-19 vaccine as a global public good? How are the financial resources required to ensure equitable access to Covid-19 tools, including a vaccine, being mobilized? What other testing and treatments need to be readily accessible, pending the universal access to vaccines?
This was a fantastic panel. If you watch nothing else, watch all three panels. In all three cases, questions from countries from the floor of the sessions and responses to them by panellists were also very informative.
It was reported that an agreement had been reached that all countries should have access to a Covid-19 vaccine and all countries should initially be able to vaccinate 20% of their populations. One government and UN body after another who spoke during those two long days called for the vaccines to be treated as a “global public good”.
A first step, said the People’s Vaccine Alliance, would be to support South Africa and India’s proposal to the World Trade Organization Council to waive intellectual property rights for Covid-19 vaccines, tests and treatments until everyone is protected.
COVAX is the ground-breaking global collaboration to accelerate the development, production and equitable access to Covid-19 tests, treatments and vaccines. It is one of three pillars of the Covid-19 response launched in April 2020 by the World Health Organization, European Commission and France. It was endorsed by 167 countries, in two ways. Seventy-five countries submitted expressions of interest to protect their own populations and those of other nations through joining the COVAX Facility, a mechanism designed to guarantee rapid, fair and equitable access to Covid-19 vaccines worldwide. Those 75 countries agreed to partner with 92 low- and middle-income countries who would be supported to access tests, treatments and vaccines through voluntary donations to Gavi–the Vaccine Alliance, thus involving two-thirds of the world.
This initiative was described in those early days as a ‘tremendous vote of confidence’ in the effort to ensure truly global access to Covid-19 vaccines, once they were developed.
Since this event, the People’s Vaccine Alliance have called for “a transformation in how vaccines are produced and distributed, and for pharmaceutical corporations to allow the Covid-19 vaccines to be produced as widely as possible by sharing their knowledge free from patents. Instead, some companies are protecting their monopolies and putting up barriers to restrict production and drive up prices, leaving us all in danger. No one company can produce enough for the whole world. So long as vaccine solutions are kept under lock and key, there won’t be enough to go around.” They have called for
- Ensure the vaccine is purchased at true cost prices and provided free of charge to people.
- Ensure the vaccine is sold at affordable prices.
- Prevention of monopolies on vaccine and treatment production, by making public funding for research and development conditional on research institutions and pharmaceutical companies freely sharing all information, data, biological material, know-how and intellectual property.
- Implementation of fair allocation of the vaccine, which prioritizes health workers and other at-risk groups in all countries.
- Ensure full participation of governments in developing countries as well as civil society from north and south in decision-making fora about the vaccines (and other Covid-19 technologies) and ensure transparency and accountability of all decisions.
– Femi Oke – International journalist
– Dr Tedros Adhanom Ghebreyesus, Director General, World Health Organization / Dr. Zsuzsanna Jakab, Deputy Director General, World Health Organization
– Dr Natalia Kanem, Executive Director, United Nations Population Fund
– Ms Mari Pangestu, Managing Director, Development Policy and Partnerships, World Bank
– Ms Phumzile Mlambo-Ngcuka, Executive Director, UN Women
– Mr Guy Ryder, Director-General, International Labour Organization
– Mr Robert Piper, Assistant Secretary-General, UN Development Coordination
– Mr Pavan Sukhdev, President, WWF International / UNEP Goodwill Ambassador
Member States/Observers registered to ask a question:
Barbados (on behalf of CARICOM), Canada (on behalf of a group of Member States), China, European Union (on behalf of a group of Member States), Russia, Sierra Leone, Tanzania
This discussion examined the socio-economic impacts of the Covid-19 pandemic and considered the path toward a resilient recovery, including the requisite preparedness for future threats. There was a focus in trade and finance, including inclusive stimulus and recovery packages, addressing debt crises ensuing from the pandemic, mobilizing investment that support sustainable solutions and the implementation of the 2030 Agenda for Sustainable Development. The discussion highlighted opportunities for accelerating the implementation of the Sustainable Development Goals through recovery plans and policies that favour inclusion, sustainability and resilience – such as expanding universal protection; promoting green jobs; making sustainable food systems; and increasing digital connectivity.
In this added plenary, seven further videos were shown: five from Member States, one from the Holy See and one from Palestine. In addition, 16 statements from Member States were delivered by Permanent Representatives from the UNGA floor. After two hours of these statements, video statements from three civil society organisations were also shown, including Marianne Haslegrave for the Commonwealth Medical Trust, who raised issues of violence against women, sexual and reproductive health and rights, and unsafe abortion.
Overall, some 129 speeches were made. The fragility of developing country health systems was again noted by one speaker after another. Awareness that no country, rich or poor, can resolve this situation alone was high throughout the three days and nights of this special session. Many countries supported the call for the vaccines to be treated as global public goods, and many supported the Secretary-General’s call for a cessation of war.
A harsher reality is threatening, however
In addition to Armenia, Azerbaijan and Turkey bringing the Special Session on 14 December to an ignominious end by angry statements against each other, a harsher reality intervened not once but twice from outside the UN General Assembly.
On 8 December, in London, UK, a major spending cut in development aid, announced by the government of the United Kingdom, was reviewed by the UK Parliament’s International Development Committee, which was recorded on Parliament TV Live. This spending cut was one of the first major development aid policy changes made by the UK government in the wake of its decision to dissolve the Department for International Development. This policy change involved reducing the UK’s longstanding legal commitment of 0.7% of GNI for development aid to 0.5%. The Committee were told this represented something like a £4 billion per year cut in the UK’s development aid, which would devastate the poorest recipient countries, such as Yemen and Afghanistan, the most. The UK, it was said, will end the year with a deficit of £400 billion pounds, but not only because of Covid-19; therefore, a £4 billion cut in development aid would do nothing to alleviate that. So the Committee was asked: Is this cut using the pandemic as a cloak for re-prioritising money intended for international aid, e.g. to use it for defence spending, which is due to be increased.
The second even more serious setback was sabotage of the COVAX agreements. Several vaccines are reaching the end of initial trials and some have been submitted for approval and come or are about to come “on the market”… What has happened?
On the morning of 9 December 2020, the BBC published this report: “Rich countries hoarding Covid-19 vaccines”. Based on a report prepared by Amnesty International, Frontline AIDS, Oxfam, Global Justice Now, and others – it says poor countries are set to miss out, that there is not enough vaccine to go round being produced, and that pharmaceutical companies should share their technology to make sure more is produced.
The report also said that rich countries have bought enough doses to vaccinate their entire populations three times over if all those vaccines are approved for use. Canada, for example, has ordered enough vaccines to protect each Canadian five times. And even though rich nations represent just 14% of the world’s population, they have bought up 53% of the most promising vaccines so far, according to data from eight leading vaccine candidates in Phase 3 trials that have done substantial deals with countries worldwide.
Unless something changes dramatically, billions of people around the world may not receive a safe and effective vaccine for Covid-19 for a long time. Five of the 67 countries who may be left behind – Kenya, Myanmar, Nigeria, Pakistan and Ukraine – have reported nearly 1.5 million cases of Covid-19 between them.
So much for this global public good. This adds a closing twist of the knife to the UNGA Special Session proceedings, by governments that would of course not announce this from the floor of the United Nations. But it only means we will have to fight for it, as we do for everything good.
To close on a slighter more upbeat note, WHO D-G Dr Tedros has announced on Twitter:
“Today, @WHO launched the Universal Health Coverage Compendium, a set of tools to help country-level policy makers develop packages of the health services needed to achieve #HealthForAll: http://bit.ly/34aLZro.
For further reports arising from the Special Session, see www.ngosbeyond2014.org
06/12/2020 Comments Off on Three new papers on FGM worth reading
- Re-thinking the Zero Tolerance Approach to FGM/C: the debate around female genital cosmetic surgery, by Janice Boddy, Current Sexual Health Reports, 21 November 2020
The main point of this paper is that there is a growing phenomenon of young women having “cosmetic labiaplasty” in Europe, the Americas, and Antipodes, carried out by medically trained gynaecologists and plastic surgeons, which is based on the aesthetic belief that if the labia minora protrude beyond the labia majora this is deemed ugly, masculine, and ‘abnormal’, and they should be “trimmed”. The kind of surgery involved is the same as what the World Health Organization calls female genital mutilation type II. The fact that for the mainly white, western women having this form of surgery it is called cosmetic surgery and is legal, while for African women who have it, it is called genital mutilation and is criminalised, is the focus of this paper. The author, who is a Canadian anthropologist, also identifies the fact that in all the cultures where these very similar phenomena are happening, it is strong beliefs about what is aesthetically acceptable that influence the practice.
2. New advisor missed opportunity to celebrate FGM decline in UK, by Brid Hehir, Shifting Sands, 13 October 2020.
The main point of this paper is this: A small but important piece of original research in the British Medical Journal, which should have received more publicity, was published just a week before the International Day of the Girl Child this year. The research confirms that few young children (103 cases) are presenting with FGM in Britain (or Ireland) and none were found in Northern Ireland. Moreover, most of the cases still being reported are historic – 70% were carried out prior to the children arriving in Britain — indicative of changes in practice in communities that used to believe in FGM, which has been recognised in those communities in the UK for quite a few years now, though not acknowledged by everyone who is a UK activist opposing FGM.
3. How to ensure policies and interventions rely on strong supporting facts to improve women’s health: the case of female genital cutting, using Rosling’s Factfulness approach, by Birgitta Essen, Luce Mosselmans. Acta Obstet Gynecol Scand. 2020 Dec 11.
This paper applies Rosling et al’s framework from the book Factfulness, which aims to inspire people to use strong supporting facts in their analyses of issues and to fight dramatic instincts. The abstract says: In this paper, the Factfulness framework is applied to female genital cutting (FGC), in order to identify possible biases and promote evidence-based thinking in studies on FGC, clinical guidelines on management of FGC, and interventions aimed at abolishing FGC. The Factfulness framework helps to acknowledge that FGC is not a uniform practice and helps address that variability. This framework also highlights the importance of multidisciplinarity to understand causalities of the FGC issue, which the authors argue is essential. This paper highlights the fact that FGC is a dynamic practice, with changes in the practice that are ongoing, and that those changes are different in different contexts. The “zero tolerance” discourses on FGC fails to acknowledge this…
These papers all raise issues that a range of authors from several world regions have been writing about for the past 15-20 years. I was able to share that work and give a lot of attention to it as the editor of Reproductive Health Matters. These papers can be found on the first 2 pages of articles listed at this link (keyword FGM) and this link (keyword cosmetic surgery), though some items in these lists are on other issues. The papers cover not just genitals but also breasts and the meanings of altering the body to achieve beauty. Definitions of what is considered beautiful in girls and women in every culture create a lot of pressure to conform. See especially one article called Make me beautiful, by Omid Salehi, interviewed by Negar Esfandiary. Some practices carry health risks and the risk of complications. To me, part of the challenge of feminism for girls and women is that we should not feel we have to risk our health or even our lives to achieve what others want us to believe constitutes beauty, let alone what is defined as essential for being female. It seems we must keep coming back to these same issues with each generation as the forces that create this pressure often come from those who hope to gain something themselves.
Marge Berer, 6 December, revised 13 December 2020
22/11/2020 Comments Off on Telemedicine and self-managed abortion: a discussion paper
This paper was rejected by five journals in the space of a week. It was published in the newsletter of the International Campaign for Women’s Right to Safe Abortion on 26 August 2020.
Telemedicine for abortion care is the use of communications technology to arrange an abortion in a clinical setting or self-managed by the woman at home with medical abortion pills and for follow-up after the abortion. For International Safe Abortion Day, 28 September 2020, in the context of the Covid-19 pandemic, the International Campaign for Women’s Right to Safe Abortion (ICWRSA) is promoting the use of telemedicine to arrange and follow-up an abortion and to support women’s right to have an abortion at home in the first trimester of pregnancy with medical abortion pills if she so chooses.
This discussion paper provides a history of how the use of telemedicine and self-managed abortion with abortion pills at home have developed. Initially, in Brazil in the 1980s, women shared information about the use of misoprostol informally. Then, feminist-run safe abortion information hotlines were set up, starting in 2005, to provide women with the information they need (and in some cases provide the pills) to have an abortion at home. There are currently one or more such hotlines in at least 26 countries in all world regions. More recently, health professionals began to use what is now called telemedicine (or telehealth) for this same purpose. This paper is about telemedicine and the conditions that make self-managed abortion safe, and gives examples of abortion services that put telemedicine and self-managed abortion together. It also covers the role pharmacies can and are playing in support of these changes.
Telemedicine and self-managed abortion may not be feasible, preferred, appropriate or safe in all instances. They may be restricted by law and regulations, limited communications technology, lack of skills in conducting telemedical consultations, and/or lack of crucial conditions for women to abort at home, such as privacy. For the last almost 40 years, however, medical abortion pills have made it possible for women to take abortion into their own hands, and they are doing so increasingly and in greater and greater numbers, with a little help from their friends, safe abortion information hotlines, and a growing number of health professionals.
Given the changes that telemedicine is bringing into health care due to Covid-19, abortion services should be reconceptualised with a 21st century lens. This means access to telemedical consultations pre- and post-abortion where the in-person alternative carries a risk of infection. It means a choice between home-based, self-managed abortion and clinic-based abortions, the latter provided mostly by mid-level providers in primary-level and community-based services. It means recognition by the State of safe abortion as essential health care, the decriminalisation of abortion, the removal of unnecessary regulatory barriers, the training of mid-level providers, and women’s control over the abortion decision and where it takes place. Some of these changes are health systems issues. All of them depend on law, policy and practice that guarantees the right to a safe abortion at a woman’s request, no more, no less.
In 1997, WHO published a health telematics policy in support of health-for-all. By 2014 telemedicine was considered a “household term”. Since then, the use of telemedicine has entered healthcare in a wide range of specialisms, and very rapidly in 2020 due to the Covid-19 pandemic. In July 2020, the synonymous terms ‘telemedicine’ and ‘telehealth’ pulled up over 34K citations in PubMed and a number of specialist journals as well.
A 1999 article offered the following broad definition of telemedicine: “the use of electronic information and communications technologies to provide and support health care when distance separates the participants. Technologies used for telemedicine include “videoconferencing, telephones, computers, the internet, fax, radio, and television.” Each of these has distinct advantages and disadvantages. Apps are also being used, e.g. when internet access is limited. The 1999 article goes on to say:
“The internet-fueled empowerment of consumers and their expectations for speed, access, and convenience are creating more unmet expectations of the traditional health care system… Online drugstores are attracting most attention. Potential benefits of telemedicine include improved access to care, greater efficiency in diagnosis and treatment, higher productivity, and market positioning for the coming century. Telemedicine will tax the economic, regulatory, legal, ethical, and clinical care expertise of the entire health care system. Studies of the effectiveness, cost, and societal implications of telemedicine are needed, along with practice models and standards, training programs, and solutions to regulatory, licensing, and legal questions.”
In addition to ‘telemedicine’ and ‘telehealth’, the terms electronic health (e-health) and mobile health (m-health) also appear. Whatever it is called, telecommunication requires specific skills, depending partly on whether the interaction is one-off or repeated; for routine, acute or chronic care; and for arranging, monitoring or following up such care. In each case, the interaction should be assessed to determine whether the intended outcomes have been achieved.
After 2010, reviews and articles began describing and assessing the use of telemedicine in specific specialisms, countries and regions. Important barriers to telemedicine use also began to be identified. These included the lack of the right technology to make telemedicine feasible, the need for training of staff and support staff, how to ensure patient privacy, how to achieve standardisation, and issues of reimbursement. It was also recognised that well-defined patient groups for whom telemedicine is (or is not) appropriate had to be identified. All these issues are now considered critical to ensuring the successful use of telemedicine in health service delivery.
In 2020, a Lancet review reported that, due to the need for distancing with Covid-19, an almost overnight shift was taking place from in-person to virtual consultations between healthcare providers and patients in whole areas of healthcare. Having surveyed Canada, China, Germany, India, Italy, South Africa, UK and USA, the review noted that in Canada, “steps to sweep aside regulatory and hegemonic professional barriers were being taken” with the support of senior medical staff. As one expert pointed out: “The regulatory barriers that have held virtual health care back for all these decades were never justifiable. [Covid-19] is an opportunity to blow all these barriers away. The question now is: ‘How far are we willing to go?’”
All of this is relevant to safe abortion care. For example, a 2014 study in South Africa showed how mobile phones could be integrated successfully into abortion pill provision and replace in-person visits in three ways:
- coaching women through medical abortion using SMS/text messages;
- using a questionnaire to assess completion of abortion; and
- provision of information about post-abortion contraception.
Telemedicine has been found to be especially valuable for patients living in remote areas with few health professionals, as it makes long distance travel unnecessary for patients. This has been shown to be important for abortion care in Australia for example.
It is in this context that this paper looks at the use of telemedicine for arranging and following up an abortion, with the abortion either in a clinical setting or with the use of medical abortion pills for self-managed abortion at home. It also involves information and support from a trained safe abortion information hotline, a trained pharmacist and/or a healthcare provider.
Telemedicine and self-managed abortion with pills began with safe abortion information hotlines
Since the 1980s, when it first became known in Brazil that misoprostol can induce an abortion, women have been accessing misoprostol via pharmacies, drug sellers, street markets and online pharmacies, and self-managing their abortions, legally or otherwise. The information rapidly spread on the grapevine across Latin America and then to other regions.
Pharmacies have long been the main source of abortion pills for home use in India. Of an estimated 15.6 million abortions in India in 2015, over 70% were with abortion pills, while only 14% were surgical and 5% other methods. Of all the abortions with pills, 91% took place outside healthcare facilities, with only 2% in public facilities and 7% in private facilities. Although that study found that in most cases the pills were acquired without a prescription, chemists have reported in a newer study that between 71% and 100% of pills were obtained with a prescription. Yet guidelines issued by India’s Ministry of Health and Family Welfare on 25 March 2020, which made it legal to practise some telemedicine in India, did not include its use for abortion. Why not? The Medical Council of India is reported to have told the NGO Hidden Pockets that the Government of India allows only over-the-counter medicines to be e-prescribed, with only a few exceptions.
Globally, wherever women cannot access abortion pills via the formal health system, they are getting them from pharmacies, web-based pharmacies, online services by independent abortion providers – and information on how to use them from hotlines run by safe abortion advocates. In 2005, Women on Web, whose founder is a doctor, used telemedicine to help women around the world obtain medical abortion pills to use at home. They were followed by Women Help Women several years later, who not only counsel by telemedicine and provide pills, but have also encouraged the initiation of national safe abortion hotlines in many parts of the world to do the same and have supported networking between them.
Today, there are at least 31 safe abortion information hotlines in at least 26 countries, all listed on the ICWRSA’s website. They provide women with information and support on safe abortion and often other sexual and reproductive health information as well – by phone, email, website, app and social media. In most cases, their staff and volunteers are trained using WHO guidance, and variously include medical professionals, feminist activists, trained counsellors and researchers, among others.
The Ms Rosy Reproductive Health Information Hotline in Nigeria, a project of Generation Initiative for Women and Youth Network (GIWYN), is an example of a hotline addressing women’s needs during Covid-19. Their staff are working from home to increase access to information on effective contraception, abortion options and essential medicines. They consider this one of the most cost-effective, practical community interventions available, which will help to reduce unintended pregnancy and preventable deaths from unsafe abortion, particularly with the public healthcare system heavily overburdened by Covid-19.
Comparable helplines were started decades ago by national family planning associations for women seeking contraception and expanded to cover other sexual and reproductive health services; others were initiated for people with HIV. They have informed and educated so many people on these issues often in the absence of this help from national health systems, just as safe abortion helplines are doing with abortion. Their help is an important part of the reason why illegal abortions are far less unsafe than in the past. Indeed, the clandestine use of medical abortion pills at home has reduced the need to access dangerous backstreet providers using invasive methods, whose elimination so many government have failed to take responsibility for, or achieve.
Why telemedicine for abortion care is not being used widely by health systems
An estimated 150,000 abortion take place every day around the world, and one in four pregnancies ends in an induced abortion. On 1 June 2020, WHO declared (not for the first time) that safe abortion is essential health care.
Given the rapid growth in the use of telemedicine due to Covid-19, why is telemedicine for abortion care not being used more widely? Travel is restricted, people are in lockdown, healthcare services have postponed many essential services to deal with the virus, and reducing in-person contact wherever possible is recommended.
The short answer is that although abortion methods are safer than most other clinical procedures, abortion is still criminalised and/or legally restricted in the great majority of countries. While unsafe abortion deaths have been falling, almost 7 million women per year receive post-abortion care in hospitals for complications of unsafe abortion. In spite of decades of campaigns and support from a growing list of international bodies and meetings, it is still not possible for a woman to obtain an abortion at her own request up to 24 weeks of pregnancy (thus encompassing almost all abortions) except in a handful of countries. The contradictions are glaring.
Telemedicine is a valid use of widely available technology for abortion care. But it is this political reality that limits its use for abortion care.
First trimester abortion at home is a safe, acceptable alternative to a clinic-based abortion
In 2016, a wide-ranging review of qualitative research on women’s experiences of self-managed abortion found that overall self-management was acceptable to both women and providers, in both legal and legally restricted contexts, and with pills accessed through formal and informal systems.
There was enough evidence for WHO to say in 2018 that self-managed abortion at home in the first trimester of pregnancy is safe. Yet in most countries, home use of abortion pills is illegal. Faced with this contradictory situation, women who need an abortion are obtaining abortion pills and having abortions at home with or without permission, knowing the health system is there if they experience complications.
Telemedicine to arrange and follow-up an abortion can take place with the woman at home and the healthcare provider either at home or in a clinic. If managing abortion at home is not possible because of a woman’s circumstances or is not preferred by her, or if she is more than 12 weeks pregnant, the provider can arrange for her to have an in-person abortion. If she is less than 16 weeks pregnant, the abortion can be by aspiration (manual or vacuum) and take place in an outpatient setting, preferably at primary level by a mid-level provider. The procedure itself takes only minutes, simple protective clothing/masks can be worn, the sterile conditions of an operating theatre are not necessary, and it can all happen in a very short space of time. Nor is a gynaecologist required except for complicated cases or D&E. The overall reduction in in-person consultation and service delivery time and costs would be enormous.
The switch cannot be achieved overnight, but it is straightforward if it is not tied up in red tape or punitive regulations. Both the technology and the skills to use telecommunication with patients are needed. Abortion providers need to develop locally appropriate guidance that covers home use of abortion pills as well as in-person care. The in-person care should occur as close to home for both patient and provider as possible, with as few visits and the shortest possible in-person time as possible. Unnecessary barriers should be eliminated. Covid-19 alone calls for this, but it also makes good sense.
A 2013 analysis of data from the rural US state of Iowa showed that the introduction of telemedicine services for medical abortion was associated with a reduction in second‐trimester abortions and increased access to services for women living far from a clinic.
Canada began to allow telemedicine for early abortions in 2014. A systematic review of studies internationally up to November 2017, published in 2019, where telemedicine was used for comprehensive medical abortion services, found, according to a linked commentary:
“…reassuring evidence from a range of settings that telemedicine provision of medical abortion is safe, effective, and well‐liked by patients and providers. Clinical outcomes were found to be similar to those for models of care that involved an in‐person visit.”
In Europe, Ireland was the first country to allow telemedicine for abortion at the start of their Covid-19 pandemic in March 2020. Britain followed later in March and France in April, but few others have done so, in spite of national advocacy efforts. Catalonia in Spain reduced the number of required clinic visits from two to one, but Spain has not permitted telemedicine. In Moldova, in contrast, the Reproductive Health Training Center had been preparing a national telemedicine abortion service since 2019, obtaining pills and developing materials, particularly videos for patients. Serendipitously, the programme was ready to launch when Covid-19 happened (Personal communication, Dr Rodica Comendant, RHTC Director, 29 April 2020).
In Great Britain, the British Pregnancy Advisory Service (Bpas) is the largest independent abortion provider, covering 72% of all abortions in England and Wales in 2018. They had to close 23% of their clinics in March 2020 when Covid-19 hit, due to self-isolation by staff and lack of sufficient personal protective equipment. The government decided to allow telemedicine for abortion from 30 March 2020 and for the duration of the pandemic in response to pressure from abortion rights advocates, parliamentarians and a range of medical professional bodies. Women can now obtain approval for an abortion telemedically, receive abortion pills in the post, self-manage their abortion at home, and have post-abortion follow-up telemedically.
With the support of outside advice, it took only one week for Bpas to get their telemedicine services up and running across the country. By the end of April 2020, they had treated 35% more women than usual, around 10% above pre-Covid-19 levels up to mid-July 2020. By that point, they had provided over 15,000 early medical abortions using telemedicine. Staff worked from home, causing a decline in Covid-19 infection, less need for self-isolation by staff or personal protective equipment. In July, the government said they would hold a consultation on whether to allow telemedicine to continue post-pandemic.
Political resistance to telemedicine for abortion
The use of telemedicine is not simply a technical matter or the separate physical location of provider and patient. Politically motivated barriers must be overcome, and opposition to abortion rejected. It is not uncommon, unfortunately, for doctors (like governments) who control abortion services to want to retain control over them. A shift to telemedicine and home-based abortions may threaten their hegemony, their political support and/or their income, so they resist change. In the longer term, however, outdated practices and laws must be set aside. If not, more and more people will work around them or without them – because they can.
For example, Kenya published guidance on Covid-19 in April 2020 that called for maintaining continuity of reproductive, maternal, newborn and family planning care and services as essential services. The guidance suggested the use of telemedicine and other means of distancing for the safety of providers and patients. Yet it did not include legal abortions or post-abortion care in this, let alone telemedicine. In May 2020, the Reproductive Health Network Kenya, a network of healthcare providers offering quality reproductive health services across most of the country, including safe abortion, launched a new hotline in Kenya for counselling and referral of women and girls in Kenya to trained, youth-friendly, safe abortion providers, which operates 24 hours a day.
Self-managed abortion must be safe at a population level
Safety in an illegal, clandestine situation may be relative, however. In the years 2015-19, of the estimated 73.3 million abortions each year, it was unknown how many of the 7 million who sought post-abortion care had used medical abortion pills as opposed to dangerous and invasive procedures.
A study published in 2020 on abortion in six states of India – Assam, Bihar, Gujarat, Madhya, Pradesh, Tamil Nadu and Uttar Pradesh – covering 45% of the population, found that in 2015 a high proportion of all the women receiving post-abortion care were admitted with incomplete abortion after use of medical abortion pills – ranging from 33% in Tamil Nadu to 65% in Assam. These numbers are obviously very concerning, but they will differ between countries, depending on the extent of access to information and support women have.
A qualitative study from Chile among 30 relatively privileged young women who had a self-managed medical abortion at home between 2006 and 2016, while attending university, provided a window on the personal experience of clandestine use of abortion pills at home. The study recorded their pathways to abortion, how they used networks in the university to find the pills and learn how to use them, and their experiences during and after the abortion. These young women made use of formal healthcare services: they accessed ultrasound scans pre-abortion to rule out ectopic pregnancy and post-abortion, claiming they had miscarried, to check the abortion was complete. They also had support from contacts, partners and friends. Even so, the clandestine situation created uncertainty and fear, which dominated the whole process – from finding and purchasing the pills, to uncertainty about correct doses, whether the abortion was going as it should, and whether it was complete or not. There was a high perception that failure and complications might be occurring, which led many of them to seek post-abortion care, perhaps unnecessarily, but making them into statistics. The process was demanding, requiring information, time, privacy to have the abortion, support and resources – and the ability to deal with risk. This is not how “essential health care” should have to be obtained.
A Madagascar study conducted in 2015-16, also qualitative, looked at the experiences of 19 young women (ages 16-21 at time of abortion) who had complications after use of misoprostol for abortion, with or without additional methods; what information they received before use; what dosages and regimens they used; what complications they experienced; and what treatment they received post-use. It found that these young women sought advice from partners, friends, family members, and traditional practitioners, as well as health care providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens they used on the advice of others were extremely variable and did not match WHO guidelines. They were ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/haemorrhage, strong pain and/or infection. The authors called for urgent training for health care providers and pharmacists in correct misoprostol use and treatment of complications, as well as for women.
Let us be clear. Self-managed abortion in such circumstances is not what WHO means by “self-care” nor what the abortion rights movement means by “self-management” when in fact the health system is failing to do its job.
Again, however, the situation differs in other countries. A study in Nigeria in 2018, which used telemedicine in the research process, looked at the self-reported effectiveness of self-managed misoprostol abortion in a legally restrictive setting in which 394 women obtained misoprostol pills and information about their use from drug sellers. Although the drug sellers provided inadequate information about the pills, 94% of the sample reported a complete abortion without surgical intervention about 1 month after taking the medication. 86 women reported physical symptoms suggestive of complications, but only six of them said they needed health facility care, of whom four subsequently obtained care. The authors say that drug sellers are an important source of abortion pills in this setting, and despite the limitations of self-report, many women appear to have effectively self-administered misoprostol. These authors also call for additional research, but meanwhile, what is becoming clear as more and more such studies are published is that self-managed abortion is happening across the world and far fewer women are at risk of their lives as they were in the past.
Criminal laws passed in the 19th and early 20th century by colonial powers such as Great Britain and France automatically became part of the criminal law in many former colonies. In many cases, those laws are still in place today. They made it illegal to use any substance or instrument on oneself or others to cause an abortion. In their time, these laws were meant to protect women from dangerous, invasive methods. Today, they are used against women instead. Prosecutions for using abortion pills have been initiated in the USA, Britain, Ireland and Australia, for example, and some women imprisoned.
Safe abortion information hotlines deserve a huge amount of credit for helping to ensure that self-managed abortions are safe in the absence of legal abortion. Hotlines run by volunteers cannot take the place of national health systems, but they could be supported by governments to expand their outreach to provide national cover. Meanwhile, the need for hotlines highlights the ethical imperative on health systems to ensure that information, support and bona fide pills are available to everyone seeking an abortion who, legally or not, will self-manage at home.
Countries with the most restrictive abortion laws have not made policy statements about abortion as essential healthcare nor taken up telemedicine for abortion during the Covid-19 pandemic. Nor has much evidence-based information emerged from them to date on how the pandemic is affecting access to abortion, or perhaps even more importantly, access to post-abortion care. The reality is likely to be highly problematic, however.
Putting telemedicine and self-managed abortion together
Earlier this year, a sex education teacher and a doula created a set of eight podcasts called “Self-Managed, An Abortion Story in Eight Parts”, which introduces self-managed abortion, the story of a woman who has had a self-managed abortion, and in each subsequent podcast, a health professional, a lawyer and others who talk about the various aspects of the telemedicine services that support women managing their abortions at home in the USA. This is an excellent teaching tool and could be adapted for local use.
In Australia, the Tabbot Foundation, founded by Dr Paul Hyland in 2016, was the first telemedicine service by health professionals to provide medical abortion for home use via telephone consultation across all but one state, where it was not allowed. They started in Tasmania and expanded to cover seven Australian states within a few short years. The process was as follows: an initial telephone consultation with an expert doctor led to a decision whether a medical termination at home was suitable. If so, the clinic provided all necessary medications through the post, so the woman did not have to go to a pharmacy. A registered nurse supported the woman by phone through the process, and a 24-hour doctor was on-call. Follow-up by phone confirmed the pregnancy had terminated safely. The Foundation had to close down in March 2019, not due to problems with provision or lack of demand. On the contrary, it closed because “the cost of running the service, in a country where grants, government subsidies and benefactors [did] not exist for such things, was too much”.
Gynuity Health Projects initiated a telemedicine project in the USA called TelAbortion in 2018 that led to the opening of telemedicine abortion services in 13 US states who permit it legally. An evaluation of these services in five of the states was published in 2019. It covered 32 months in which 248 packets of pills were posted, demonstrating the safety, efficacy and acceptability of the services, which used video-conferencing and the mail to provide everything the woman needed. All 159 patients who completed questionnaires were satisfied with the service. However, of the 217 who received pills and provided meaningful follow-up data (88%), one was hospitalised for post-operative seizure and another for excessive bleeding; 27 had other unscheduled clinical encounters, though 12 of the 27 required no treatment. These are very few complications indeed, but they confirm that backup services should always be part of the plan.
The role of pharmacies in telemedicine and self-managed abortion
In many countries, people can walk into pharmacies and buy medications on prescription, or over or under the counter. Misoprostol, which is also used to treat gastric ulcers, has been available in pharmacies without a prescription in much of the world for decades.
Pharmacies and drug sellers have had a central role to play in most countries of the global south in providing abortion pills, both legally and extra-legally. Studies in countries as different as Nepal and Canada have shown that with simple training, pharmacists can manage the provision of abortion pills, provide information on their safe use, and counsel on complications when required. In a Nepal study, most of the 992 women seeking abortion pills were around six weeks pregnant, so the abortions were very early. The outcomes showed a high level of safety and effectiveness. The women were counselled on and purchased combined mifepristone-misoprostol abortion pills during a six-month period from pharmacies in two districts. In the one district, the pharmacists had been trained in 2010 to provide them; in the other district, the training took place near the time of the study in 2015. Complete abortions were achieved in 97-99% of cases in both districts, one primarily urban, the other more rural. The 2010 training was still in use in the one district in 2015. The women reported no serious complications, and satisfaction levels were high.
These authors also reported that trained pharmacists and pharmacy workers in Nepal have successfully delivered information and medications related to sexually transmitted infections, contraception and emergency contraception. Their success includes the ability to facilitate rapid access to medications, supplies, information and advice, while maintaining client confidentiality. Pharmacists are close to home and trusted for information about many health issues. Although Nepal is one of the world’s least resourced countries, their progressive law on abortion permit abortions up to 12 weeks on request and up to 18 weeks on a number of other grounds. This is an example for other countries to consider.
In Canada, direct-to-consumer telemedicine abortion services were initiated using methotrexate and misoprostol prior to approval of mifepristone. Canada adopted mifepristone with misoprostol only in 2017 but has moved fast ever since to update their policies. From April 2019, they have allowed direct access to abortion pills from a pharmacy without barriers, a blood test or a scan. In April 2020, in response to the pandemic, they published a protocol for provision of medical abortion via telemedicine. That protocol recommends providing an additional dose of 800 mcg of misoprostol, buccally or vaginally to use if needed along with the standard regimen of mifepristone 200 mg orally and misoprostol 800 mcg buccally or vaginally. The extra misoprostol is to reduce the low but existing risk of incomplete abortion. The recommendation of using additional doses of misoprostol if needed to achieve a complete abortion was first recommended in 2017 by FIGO and now seems to be more widely recommended.
WHO’s 2015 guideline on health worker roles in safe abortion care confirms that pharmacists can safely provide medical abortion pills during the first trimester of pregnancy, including assessing eligibility for medical abortion, administering the medications and managing the process and common side-effects independently, assessing completion of the procedure and the need, if any, for clinic-based follow-up.
Thus, pharmacies and drug shops should officially become an important alternate source of medical abortion pills, including for young people. For young women in particular, the costs of using these sources may be less than the non-financial costs of travelling to and being seen accessing services in a public health facility.
Many pharmacies and drug sellers see people as consumers. In many countries, pharmacies are a source of self-medication of all kinds. Others have physicians on call, while still others have the knowledge in-house to provide medicines advice safely. One pharmacy company with branches in many Latin American countries introduced a “doctor-in-the-house” policy, allowing those who are poor to consult a doctor at less cost and with less hassle than going to a public health clinic. However, not all countries regulate pharmacy services, and low- and middle-income countries may struggle with variable service quality, unregistered premises, untrained personnel and sub-standard commodities. Although easily accessible, this may result in reduced quality of care. (Personal communication, Lidia Casas Becerra, 24 August 2020)
WHO’s 2019 self-care guideline includes self-managed abortion
In 2019, the WHO Human Reproduction Programme published a consolidated guideline on self-care interventions for sexual and reproductive health and rights, whose section on self-management of medical abortion in the first trimester is summarised from their 2015 guidance, and is worth sharing in full:
“Self-management and self-assessment approaches can be empowering and also represent a way of optimizing available health workforce resources and sharing of tasks:
- To the full extent of the law, safe abortion services should be readily available and affordable to all women.
- Self-management approaches reflect an active extension of health systems and health care. These recommendations are NOT an endorsement of clandestine self-use by women without access to information or a trained health-care provider/health-care facility as a backup. All women should have access to health services should they want or need it.
- Individuals have a role to play in managing their own health and this constitutes another important component of task sharing within health systems.
- Therefore, the following recommendations for specific components were made related to self-assessment and self-management approaches in contexts where pregnant individuals have access to appropriate information and to health services should they need or want them at any stage of the process:
i. Self-assessing eligibility [for medical abortion] is recommended in the context of rigorous research.
ii. Managing the mifepristone and misoprostol medication without direct supervision of a health-care provider is recommended in specific circumstances, i.e. where women have a source of accurate information and access to a healthcare provider should they need or want it at any stage of the process.
iii. Self-assessing completeness of the abortion process using pregnancy tests and checklists is recommended in specific circumstances. We recommend this option in circumstances where both mifepristone and misoprostol are being used and where women have a source of accurate information and access to a healthcare provider should they need or want it at any stage of the process.”
Two additional notes are added from the WHO 2018 guideline “Medical management of abortion”:
– “When using the combination mifepristone and misoprostol regimen, the medical abortion process can be self-managed for pregnancies up to 12 weeks of gestation, including the ability to take the medications at home, without direct supervision of a healthcare provider; it should be noted that there was limited evidence for pregnancies beyond 10 weeks.”
– “Pregnancy tests used to self-assess the success of the abortion process are low-sensitivity urine pregnancy tests, which are different from those tests commonly used to diagnose pregnancy.”
Limits of telemedicine and self-managed abortion
“Telemedicine is not a panacea. It is not always suitable for low-resource settings where internet or phone access is limited, for people who are [also] looking for a long-acting form of contraception to be fitted, who are seeking an abortion at later stages of pregnancy or who are facing complications from a previous abortion attempt. It is therefore essential that we also keep facility-based services open safely and maintain a choice of options for contraception and safe abortion. This is particularly important as we could see a greater demand for second trimester abortion services following lockdown.”
Other reasons why telemedicine + self-managed abortion may not be acceptable or feasible include when the conditions do not exist at home for women and girls to go through the abortion, including privacy, safety from interference and violence from partner and/or family, not being able to give a reason to stop working, lack of safe 24-hour access to a toilet, inability to deal with the bleeding and the pain, and problems to dispose of the products of conception.
Girls and women who live with their families may have no privacy even for a phone or video call, let alone to go through an abortion at home, alone or with a companion. Several young women described these problems in the Chilean study referred to earlier, and they have been noted elsewhere too. In settings such as camps for refugees and displaced persons, there may be no access to a private toilet in the living space, and it may be risky to go outside, especially at night, to a common toilet.
In fact, the feasibility of telemedicine for women living in conditions of poverty and with limited literacy, especially in remote, rural and low-resource settings with few healthcare providers, requires far more attention in order to develop appropriate support systems.
Telemedicine relies on internet access, and video requires strong connections. Apps can fill this gap, but health systems must support the education of pharmacists, lay community health workers and activists to ensure access to abortion pills for everyone, including those without internet (Susan Yanow, personal communication, 19 August 2020). Moreover, access to support when and if needed 24/7 is an important adjunct, and should be treated as an integral part of the process too.
Vacuum aspiration abortion as a continuing option
Some women would choose a first trimester aspiration abortion over abortion with pills if they could. The concept of choice of method in regard to contraception has been an issue since the 1970s and 80s because many women, particularly in the global south and from poor and ethnic minority communities, were often pushed to “accept” a contraceptive method chosen by the provider. This has re-emerged in recent decades (if it ever disappeared) with long-acting contraceptives being pushed to reduce the user failure rate and the need for abortion. Many in the medical profession (and donor community) still want to choose women’s methods for them, and abortion is no exception. A roundtable of views on this matter makes it clear, however, that providers too have differing views. Supporting a woman’s choice of method, without outside pressure, remains crucial.
Second trimester self-managed abortions
Almost everything discussed in this paper is about first trimester abortions, and most research and documented practice has been about abortions up to 12 weeks. But second trimester abortions count too. Only a few hotline groups openly support women to have second trimester medical abortions at home; the Socorristas en Red in Argentina is among them. They began providing this support to women having abortions up to 24 weeks in 2015, with good results. Their results are good not least because members of the group have developed good relations with certain hospitals where they know women can go for help without fear. They also recommend a medical check-up as part of the post-abortion process.
The Socorristas believe that the woman must decide and be in charge of what she wants to do, and they advise and support her to confront every aspect of the process before she makes decisions. They point out that a second-trimester abortion can be started at home, but the woman can always decide to go to a hospital to complete it. As one Socorrista explained:
“…We haven’t had [any] health complications…. When women have gone [to the hospital], it has been because of their decision to expel [the fetus] in hospital.”
Disposal of a second-trimester fetus at home is not an easy proposition. Moreover, sometimes women may think they have expelled everything when they have not. To mitigate these risks, some Socorristas recommend that everyone over 16 weeks goes to a hospital where there are sympathetic health professionals to complete the process. They say: “Studies to evaluate the safety, effectiveness or acceptability of second-trimester abortions using this model are sorely needed.” Meanwhile, continuing availability of second trimester abortion in clinical settings, at primary level if possible, including during the Covid-19 pandemic, remains crucial.
A study of hotline data from Indonesia, published in 2018, found that between 2012 and 2016, 96 women with pregnancies beyond the first trimester called the hotline for information on abortion pills; 91 received counselling support, of whom 83 women successfully terminated their pregnancies using medication and did not have to seek medical care. Five had warning signs of potential complications and sought medical care, one sought care after a failed abortion, and two were lost to follow-up. These findings are far more positive than some might expect. These authors also call for further study and documentation of the model.
A recent study of case records on abortions between 13 and 24 weeks, from accompaniment groups based in Chile, Ecuador and Argentina, found that of 318 abortions, only 241 resulted in complete abortion with abortion pills alone. Surgical methods were needed to complete most of the rest (16 were not completed) and several in Chile led to complications (records of complications were not kept in Ecuador or Argentina). The (perceived) high need for surgery is not a positive outcome. Dosage and regimens should be compared between studies like these to see if that made a difference.
While countries with restrictive abortion laws are unlikely to permitting self-managed abortion at any stage of pregnancy, it remains the case that the failure to provide safe abortions legally will continue to drive women to have them outside the health system.
Outdated abortion service delivery models and pointers for the future
Abortion law and policy in most countries still dictates where the abortion is done, how many and which health professionals must approve it, what cadres of health professional can provide it, at which level of clinic or hospital, inpatient or outpatient, how early and late in pregnancy it can be provided, whether permission is required from anyone in addition to the pregnant woman herself – as well as which methods may or may not be used and which grounds are permitted. Even though they are on the WHO Essential Medicines List, abortion pills are more regulated and restricted in some countries than most other drugs. And no matter how liberal the abortion law, there are still many places where the woman is not given a choice of abortion method. There are also far too many countries where D&C as an anaesthetised, in-patient procedure in a tertiary hospital is still imposed by diehard, out-of-date senior clinicians, who should all be forcibly retired as punishment.
Positive changes, all supported by WHO guidelines, include:
- Neither first nor second trimester medical abortions need to be done on an inpatient basis or in tertiary hospitals.
- Nurses, midwives, GPs, other mid-level providers should be trained to manage most abortions at primary level, and both they and pharmacists can provide abortion pills for self-managed abortions at home.
- (Manual) vacuum aspiration can be done by mid-level providers in outpatient, primary level clinics and family planning clinics.
- Scans and blood tests need not be routine and can be dropped in the first trimester.
Lastly, it is worth emphasising the findings of a review of studies from 1995 to 2019 on the self-use of abortion pills following online access:
- women were increasingly using the internet to access abortion medication;
- available services were of varying quality;
- women accessing non-interactive services reported feelings of distress related to the lack of medical guidance, and the demand from them for interactive guidance through the abortion process was high; and
- women using services led by healthcare staff reported high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.
The first national assessment of telemedicine for sexual & reproductive healthcare and self-managed abortion: Britain
On 30 June 2020, the Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists in Britain published the findings of a survey of 1,000 of their members on changes to SRH care related to telemedicine during Covid-19. They reported that remote sexual and reproductive health consultations had risen from 18% at pre-pandemic levels to 89%.
Regarding abortion, they learned that: “Since lockdown, remote telemedical abortions now account for 78% of early medical abortions and around two-thirds of total abortion procedures in England. The average waiting time for an abortion has decreased from 10 days in February to 4.46 days in June. The average gestation time at the time of the procedure has reduced from 8 weeks to 6.7 weeks.”
Their only cautionary note was that “The decreased availability of face-to-face consultations is having detrimental impacts on the SRH care of vulnerable groups. Without face-to-face consultations, picking up on safeguarding issues, domestic abuse and teenage pregnancy is more difficult. The availability of different modalities of consultation – face-to-face, remote and online – is vital to provide comprehensive SRH care for all women and girls now and beyond the pandemic…. Remote and online services are a complement, not a substitute, to face-to-face consultations and, irrespective of consultation modality, best practice and guidelines must be observed to ensure safety and quality of care.”
The studies summarised here show that the use of telemedicine – by trained healthcare providers, trained pharmacists and trained safe abortion information hotlines – to provide accurate information on using medical abortion pills for self-managed abortion at home up to 12 weeks of pregnancy, is safe and effective, and serious complications are rare. Adding additional misoprostol to the standard dosage found in most combi-pack brands would move the proportion of complete abortions close to 100%, greatly reducing the risk of incomplete abortion. Further research on the safety of second trimester abortions at home and the role of the health system in supporting them is called for.
While the safe abortion information hotlines who are trained to use WHO guidance are not part of official health systems, they provide accurate information and sympathetic support, they develop contact with health professionals and hospitals in case women need them, and in many cases they include people with a healthcare background themselves. These hotlines serve as models of what is possible in the countries where they are currently an important source of information and support for women needing abortions.
It is only when women have been left on their own to obtain pills whose quality is unknown, without information on correct dosage and regimen, and without ongoing support, that safety and effectiveness may be compromised. Even so, medical abortion pills are not killing women; since the first studies around 1989, they have proved to be far safer than the dangerous methods of the past, which are finally becoming history.
In the past 20 years, greatly improved, easy to use abortion methods and new models of abortion care have emerged, but women’s access to them remains grossly inequitable and far from universal. To change this situation globally, safe abortion must be recognised as essential health care, abortion must be fully decriminalised, and women must have the right to make the abortion decision and decide the conditions in which it takes place. Some of these changes demand substantial health systems reforms but above all, they require reforms in law, policy and practice which guarantee everyone with an unwanted pregnancy the right to a safe abortion. No more, no less.
Grateful thanks to Susan Yanow (USA), Lidia Casas Becerra (Chile) and Lynette Shumack (Australia) for valuable information and substantive comments on the paper. Any errors are my own.
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19/09/2020 Comments Off on IN MEMORIAM: Ruth Bader Ginsburg (1933-2020): Fire and steel on the US Supreme Court
Ruth Bader Ginsburg was the second woman ever to sit on the United States Supreme Court and is known as the legal architect of the modern women’s movement. She, more than any other person, pointed out that many laws encouraged gender discrimination instead of guaranteeing equal rights and opportunities to all, as was intended by the United States Constitution. Her interest in the law started in primary school, when she wrote articles for her school newspaper about the Magna Carta.
She attended Cornell University, where she graduated with high honours in government. She married Martin Ginsburg, a law student, who predeceased her in 2010. She went on to Harvard Law School, where she served on the Law Review. There she was told that she and her eight female classmates – out of a class of 500 – were taking the places of qualified males. She transferred to Columbia University, where she graduated at the top of her class and then was unable to find a job. In 1970, she co-founded the Women’s Rights Law Reporter, the first law journal in the US to focus exclusively on women’s rights.
After working for a district judge, she joined the faculty of Rutgers University, where, in order to keep her job, she wore overly large clothes to hide the fact that she was pregnant. In 1972, she co-founded the Women’s Rights Project at the American Civil Liberties Union (ACLU), and in 1973, she became the Project’s general counsel. The Women’s Rights Project and related ACLU projects participated in more than 300 gender discrimination cases by 1974. As the director of the ACLU’s Women’s Rights Project, she argued six gender discrimination cases before the Supreme Court between 1973 and 1976, winning five of them. Her strategic advocacy extended to terminology; she used “gender” instead of “sex” after her secretary suggested the word “sex” would serve as a distraction to judges.
She was named a judge on the United States Court of Appeals for the District of Columbia in 1980 by President Jimmy Carter, where she served until 1993. In 1993, President Bill Clinton nominated her to the Supreme Court. She was confirmed by the Senate in a vote of 96 to 3, becoming the 107th Supreme Court Justice and its second woman jurist after Sandra Day O’Connor.
She served on the Supreme Court for over 27 years. She wrote 35 significant opinions, two important concurring opinions, and three selected dissenting opinions. She was a strong voice for the separation of church and state, a major legal issue today. In 1999, she won the American Bar Association’s Thurgood Marshall Award for her contributions to gender equality and civil rights. In 2013, on the 40th anniversary of Roe v Wade, she criticised the decision in Roe as terminating a nascent democratic movement to liberalise abortion laws which might have built a more durable consensus in support of abortion rights. In 2016, she published her first book, entitled My Own Words, which is a collection of her speeches and writings. One day before her death, she was honoured on Constitution Day and was awarded the 2020 Liberty Medal by the National Constitution Center.
She was barely five feet tall and weighed only 100 pounds, but she trained every day with a trainer, who wrote a book about her. She died at home of pancreatic cancer at the age of 87 on 18 September 2020. Mourners gathered at the Supreme Court after the announcement of her death.
The New York Times obituary said: “As Justice Ginsburg passed her 80th birthday and 20th anniversary on the Supreme Court bench during President Barack Obama’s second term, she shrugged off a chorus of calls for her to retire in order to give a Democratic president the chance to name her replacement. She planned to stay “as long as I can do the job full steam,” she would say, sometimes adding, “There will be a president after this one, and I’m hopeful that that president will be a fine president.”
One day after her death, there is already a “rapidly unfolding political fight over replacing her”, including whether or not to await the election of a new president before doing so.
A book about her by Eleanor H Ayer, published in 1994, described her as “fire and steel on the Supreme Court” – a fitting way to remember her.
INFORMATION AND PHOTOS FROM: Wikipedia as at 18 September 2020 ; PHOTO by SDkb outside Supreme Court 18 September 2020 ; Encyclopedia of Notable Biographies ; A Might Justice, 18 September 2020 ; AZ Central, 18 September 2020
This text and accompanying photos will be on the social media, website and in the newsletter of ICWRSA in the next few days.