Telemedicine and self-managed abortion: a discussion paper

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.

Introduction

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.

Background

In 1997, WHO published a health telematics policy in support of health-for-all.[1] 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.”[2] 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.[3]

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.[4] 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[5] 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[6] 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.[7] 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.[8] 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,[9] 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.[10]

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[11] 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.[12] 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.[13]

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.[14] 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.[15] On 1 June 2020, WHO declared (not for the first time) that safe abortion is essential health care.[16]

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.[17] 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.[18]

There was enough evidence for WHO to say in 2018 that self-managed abortion at home in the first trimester of pregnancy is safe.[19] 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.[20]

Canada began to allow telemedicine for early abortions in 2014.[21] A systematic review of studies internationally up to November 2017,[22] published in 2019, where telemedicine was used for comprehensive medical abortion services, found, according to a linked commentary:[23]

“…reassuring evidence from a range of settings that telemedicine provision of medical abortion is safe, effective, and wellliked by patients and providers. Clinical outcomes were found to be similar to those for models of care that involved an inperson 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,[24] 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.[25] 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.[26] 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.[27]

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.[28] 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.[29] 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,[30] 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”[31] 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.[32] 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.[33] 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.[34] 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”.[35]

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.[36] 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,[37] 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.[38] 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.[39] 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.[40]

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.[41]

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,[42] whose section on self-management of medical abortion in the first trimester is summarised from their 2015 guidance,[43] 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”:[44]

– “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.”[45]

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.[46]

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.[47] 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.[48] 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.[49]

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).[50] 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.[51]

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%.[52]

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.”

Conclusions

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.

Acknowledgements

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.

Visual: http://groupe-tawhida.com/

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[13] Women Help Women, https://womenhelp.org/en/page/346/women-help-women-is-about-access-information-and-activism

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[15] WHO. Preventing unsafe abortion. 26 June 2019. https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortion

[16] WHO. Maintaining essential health services: operational guidance for the COVID-19 context interim guidance. 1 June 2020. https://www.who.int/publications/i/item/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak

[17] Caitlin Gerdts, Divya Vohra, Jennifer Ahern. Measuring unsafe abortion related mortality: a systematic review of the existing methods. Plos One 2013;8(1):e53346. doi: 10.1371/journal.pone.0053346

[18] Megan Wainwright, Christopher J Colvin, Alison Swartz, Natalie Leon. Self-management of medical abortion: a qualitative evidence synthesis. Reproductive Health Matters 2016;24(47):155-67. doi: 10.1016/j.rhm.2016.06.008

[19] WHO. Medical management of abortion. Geneva: WHO, 2018. https://www.who.int/reproductivehealth/publications/medical-management-abortion/en/

[20] Daniel Grossman, Kate Grindlay, Todd Buchacker, Joseph E Potter, Carl P Schmertmann. Changes in service delivery patterns after introduction of telemedicine provision of medical abortion in Iowa. American Journal of Public Health 2013;103:73-78. https://ajph.aphapublications.org/doi/10.2105/AJPH.2012.301097

[21] Ellen R Wiebe. Use of telemedicine for providing medical abortion. International Journal of Obstetrics & Gynecology February 2014;124(2):177-78. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1016/j.ijgo.2013.07.038

[22] M Endler, A Lavelanet, A Cleeve, B Ganatra, R Gomperts, K Danielsson. Telemedicine for medical abortion: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology 14 March 2019. doi: 10.1111/1471-0528.15684

[23] D Grossman. Telemedicine for medical abortion – time to move towards broad implementation. BJOG: An International Journal of Obstetrics & Gynaecology April 2019. doi: 10.1111/1471-0528.15802

[24] Conseil-Etat.fr, 22 May 2020. https://www.conseil-etat.fr/actualites/actualites/ivg-medicamenteuse-a-domicile-durant-l-etat-d-urgence-sanitaire-ordonnance-du-22-mai?fbclid=IwAR1NRgrSvX8PR44heWU0YJTucLJDJ3It7wl_ph-KbbgEq9oxCVK_ld7wUYo

[25] Information from Rachael Clarke and Clare Murphy, British Pregnancy Advisory Service, quoted in: Marge Berer. To what extent have abortion services not been available since the Covid-19 pandemic began, and why? International Campaign for Women’s Right to Safe Abortion Newsletter. 16 July 2020. https://www.safeabortionwomensright.org/discussion-to-what-extent-have-abortion-services-not-been-available-since-the-covid-19-pandemic-began-and-why/

[26] Ministry of Health. Kenya Practical Guide for Continuity of Reproductive, Maternal, Newborn and Family Planning Care and Services in the Background of Covid-19 Pandemic, April 2020. http://www.health.go.ke/wp-content/uploads/2020/04/KENYA-COVID19-RMNH.pdf.pdf.pdf

[27] Saskia Hüsken with Nelly Munyasia. Covid-19: The resilience of safe abortion providers in Kenya. Rutgers Blog. 28 May 2020. https://www.rutgers.international/news/blog-archive/covid-19-resilience-safe-abortion-providers-kenya?destination=SafeChoiceNews%3F

[28] Susheela Singh, Rubina Hussain, Chander Shekhar, Rajib Acharya, Melissa Stillman, Ann M Moore. Incidence of treatment for post-abortion complications in India. BMJ Global Health, 19 July 2020;5:e002372. https://gh.bmj.com/content/bmjgh/5/7/e002372.full.pdf

[29] Irma Palma Manriquez, Claudia Moreno Standen, Andrea Alvarez Carimoney, Alondra Richards. Experience of clandestine use of medical abortion among university students in Chile: a qualitative study. Contraception 22 September 2017; doi: 10.1016/j.contraception.2017.09.008

[30] Dolorès Pourette, Chiarella Mattern, Rila Ratovoson, Patricia Raharimalala. Complications with use of misoprostol for abortion in Madagascar: between ease of access and lack of information.  Contraception 11 December 2017;97(2):116-21. 10.1016/j.contraception.2017.12.005

[31] WHO/HRP. Consolidated Guideline on Self-Care Interventions for Health: Sexual and Reproductive Health and Rights, Geneva: WHO, 2019. p. 67. https://www.who.int/reproductivehealth/publications/self-care-interventions/en/

[32] Melissa Stillman, Onikepe Owolabi, Adesegun O Fatusi et al. Women’s self-reported experiences using misoprostol obtained from drug sellers: a prospective cohort study in Lagos State, Nigeria. BMJ Open 2019;10(5). https://bmjopen.bmj.com/content/bmjopen/10/5/e034670.full.pdf

[33] Marge Berer. To what extent have abortion services not been available since the Covid-19 pandemic began, and why? International Campaign for Women’s Right to Safe Abortion Newsletter. 16 July 2020. https://www.safeabortionwomensright.org/discussion-to-what-extent-have-abortion-services-not-been-available-since-the-covid-19-pandemic-began-and-why /

[34] Apple Podcasts, by Anna Reid, Antonia Piccone, 2020. https://www.smapodcast.org/

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[36] TelAbortion. https://telabortion.org/. SEE ALSO: B Winikoff, PW Castilli, EG Raymond, E Chong, M Mary, et al. TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States. Contraception 24 May 2019;100:173-77. doi: 10.1016/j.contraception.2019.05.013

[37] Anand Tamang, Mahesh Puri, Sazina Masud, Minal Singh, Punam Sharma. Medical abortion can be provided safely and effectively by pharmacy workers trained within a harm reduction framework: Nepal. Contraception 18 September 2017;97(2):137-43. doi: 10.1016/j.contraception.2017.09.004

[38] Canada removes all access barriers to abortion with mifepristone + misoprostol. International Campaign for Women’s Right to Safe Abortion Newsletter. 19 April 2019. https://www.safeabortionwomensright.org/canada-removes-access-barriers-to-abortion-with-mifepristone-misoprostol/

[39] Guilbert E, Costescu D, Wagner M-S, Renner R, Norman WV, et al. Canadian Protocol for the Provision of Medical Abortion via Telemedicine. April 2020. https://sogc.org/common/Uploaded%20files/CANADIAN%20PROTOCOL%20FOR%20THE%20PROVISION%20OF%20MA%20VIA%20TELEMEDICINE-%20FINAL2.pdf

[40] WHO. Health worker roles in providing safe abortion care and post-abortion contraception, Geneva: WHO, July 2015. p.7. https://apps.who.int/iris/bitstream/handle/10665/181041/9789241549264_eng.pdf?sequence=1

[41] Lianne Gonsalves, Adriane Martin Hilber, Kaspar Wyss et al. Potentials and pitfalls of including pharmacies as youth-friendly contraception providers in low- and middle-income countries. BMJ SRH Journal August 2020. http://emails.bmj.com/c/1oay9nT81afW9pRgNV3byljAoe

[42] Op cit. WHO/HRP. Ref. 31.

[43] Op cit. WHO. Ref 40.

[44] Op cit. WHO. Ref 19.

[45] Marie Stopes International. Resilience, Adaptation and Action: MSI’s response to Covid-19. August 2020. https://www.mariestopes.org/media/3849/resilience-adaptation-and-action.pdf  

[46] Wendy V Norman, Sarah Munro. Let’s keep our eye on the ball. BMJ Sexual & Reproductive Health 2020;46(3). https://srh.bmj.com/content/46/3/159.long

[47] Kevin Sunde Oppegaard, Margaret Sparrow, Paul Hyland, et al. What if medical abortion becomes the main or only method of first-trimester abortion? A roundtable of views. Contraception 2018;97(2):82-85. https://www.contraceptionjournal.org/article/S0010-7824(17)30371-2/fulltext

[48] Ruth Zurbriggen, Brianna Keefe-Oates, Caitlin Gerdts. Accompaniment of second-trimester abortions: the model of the feminist Socorrista network of Argentina. Contraception February 2018;97(2):108-15. doi: 10.1016/j.contraception.2017.07.170

[49] Caitlin Gerdts, Ruvani T Jayaweera, Sarah E Baum, Inna Hudaya. Second-trimester medication abortion outside the clinic setting: an analysis of electronic client records from a safe abortion hotline in Indonesia. BMJ Sexual & Reproductive Health. 2018;44:286-91. https://srh.bmj.com/content/familyplanning/44/4/286.full.pdf

[50] Heidi Moseson, Kimberley A Bullard, Carolina Cisternas, et al. Effectiveness of self-managed medication abortion between 13 and 24 weeks gestation: A retrospective review of case records from accompaniment groups in Argentina, Chile, and Ecuador Contraception August 2020;102(2):91-98. https://www.sciencedirect.com/science/article/abs/pii/S001078242030130X?dgcid=raven_sd_via_email

[51] Margit Endler, Amanda Cleeve, Kristin Gemzell-Danielsson. Online access to abortion medications: a review of utilization and clinical outcomes. Best Practice & Research. Clinical Obstetrics & Gynaecology February 2020;63:74-86. doi: 10.1016/j.bpobgyn.2019.06.009. Epub 2019 Jul 2.

[52] Faculty of Sexual & Reproductive Healthcare (FSRH) of the Royal College of Obstetricians & Gynaecologists. FSRH Covid-19 Members Survey. https://www.fsrh.org/policy-and-media/members-survey/. SEE ALSO: FSRH Response: Capturing Clinical Changes in the NHS by NHS England and Improvement. 30 June 2020. https://www.fsrh.org/news/fsrh-responds-to-nhs-capturing-clinical-changes-survey/

IN MEMORIAM: Ruth Bader Ginsburg (1933-2020): Fire and steel on the US Supreme Court

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.

Why defending Julian Assange remains absolutely the right thing to do

06/09/2020 Comments Off on Why defending Julian Assange remains absolutely the right thing to do

7 September 2020 — This commentary was submitted in early July to the London Review of Books in response to its many comments about Julian Assange over the years. They rejected it. I am sharing it now as the UK court is about to hear the case for and against Julian Assange’s extradition, that is, whether or not to send him to a death sentence in Donald Trump’s USA this week after the UK having been complicit in his being imprisoned in solitary confinement for almost ten years already — for being a journalist.

Please see the Reporters Without Borders PRESS RELEASE published 4 September 2020 in their newsletter. See also JONATHAN COOK BLOG defending Assange published 2 September 2020.

On 18 June 2020 the London Review of Books (LRB) published a commentary by Patrick Cockburn in defence of Julian Assange (Julian Assange in Limbo, 18 June 2020, p.29-30). I was going to reply commending his stance. But before I had time, the LRB published a letter on 2 July from Patrick O’Connor, reminding us that Wikileaks and Assange himself in some emails had cooperated with Russian security surrogates and the Trump campaign to damage Hilary Clinton. It crossed my mind to check whether the LRB had published other articles about him in the last decade, during which time many people have turned against him. I knew of only one article on 6 March 2014, by Andrew O’Hagan, which I’ll come back to. A quick search showed they had published a number of articles about him and others that merely mention him, about a dozen or so all told.

What follows is a summary of how the LRB’s authors have portrayed Assange and the political issues surrounding his journalism since 2010. It started with Andrew O’Hagan (Short Cuts, With the Hackerati, LRB, 19 August 2010), focusing on how Assange looked and dressed: “If hackers possess a look, then Julian Assange would probably be best placed to carry it onto the runways at New York fashion week. Except that the founder of WikiLeaks – brown cargo pants, computer rucksack, and this season’s must-have, prematurely silver hair – would certainly be arrested as he attempted to cross into the land of the free…” Then, going on to the politically important issues involved, he describes Assange as follows:

“[H]e represents the democratic instinct at its most blunt.”

“Contemptible? Heroic? Assange may simply be fulfilling the journalist’s role in the new ways allowed by the internet.”

But he couldn’t stay focused on the real issues, he had to sidetrack onto Assange’s personality too in his inimitable, judgmental way: “Assange himself, meanwhile, behaves like someone balanced quite delicately between ego-less humanitarian, autistic showman and outrageous monomaniac.”

Jeremy Harding briefly showed a sort of respect for Wikileaks’ accomplishments in describing how the French were not yet sure of Assange or the issue of rights in: (Short Cuts, Les WikiLeaks, LRB, 16 December 2010):

“French opinion is uncertain about white knights like Julian Assange, and still slow to pick up the language of rights, as spoken by WikiLeaks. In the world of governance, rights culture is one of the great climate-changers, melting away old assumptions about the exercise of power, just as the web is doing.”

A month later, Glen Newey discussed the significance of the leaks in a wider political context (Diary Life with WikiLeaks, LRB, 6 January 2011), and argued that: “‘free’ speech incurs opportunity costs” and argued that whether or not secret or confidential information should be leaked should be decided “with reference to the public interest”. He leaves open the question of whether the information leaked by Wikileaks met this criterion. But in regard to Assange refusing to go to Sweden for questioning, Newey reminds us of: the case of Muhammad al-Zery and Ahmed Agiza – Egyptian asylum seekers abducted from Stockholm by the US in 2001 with Swedish complicity, then taken back to Egypt and tortured”.

He closes by saying, with some irony: a copious leak can do the state some service…. [However], it’s a service for which the state may prove signally ungrateful.”

Two weeks later, Slavoj Žižek takes Newey’s argument a major step further (Good Manners in the Age of WikiLeaks, LRB, 20 January 2011): “There has been, from the outset, something about [Wikileaks’] activities that goes way beyond liberal conceptions of the free flow of information. We shouldn’t look for this excess at the level of content. The only surprising thing about the WikiLeaks revelations is that they contain no surprises. Didn’t we learn exactly what we expected to learn? The real disturbance was at the level of appearances: we can no longer pretend we don’t know what everyone knows we know. This is the paradox of public space: even if everyone knows an unpleasant fact, saying it in public changes everything… What WikiLeaks threatens is the formal functioning of power…. that might reach beyond the limits of representative democracy…. However, it is a mistake to assume that revealing the entirety of what has been secret will liberate us.”

But Žižek concludes: “[T]oday we face the shameless cynicism of a global order whose agents only imagine that they believe in their ideas of democracy, human rights and so on. Through actions like the WikiLeaks disclosures, the shame – our shame for tolerating such power over us – is made more shameful by being publicised.”

Against the demand for Assange’s extradition, Jeremy Harding points out, 18 months later, that In Assange’s favour is the suggestion that any charge against him would also have to apply to Bill Keller, the former executive editor of the New York Times” – whose newspaper published some of the leaked information. Further, he says that Wikileaks and then Bradley Manning altered the global discussion by exhaustive confirmation that the war in Iraq had been a terrible mistake”. Who among us would disagree with that conclusion today? Yet at the time, the information was explosive. (I Could’ve Sold to Russia or China, LRB, 19 July 2012)

At some point during these years, Andrew O’Hagan was contracted to ghostwrite Assange’s autobiography. In 2014, he outed himself as such in the LRB, (Ghosting, LRB, 6 March 2014). I wrote a letter on 29 March to the editor about it at the time, but it was not published. As an editor myself, I believed it was unethical to publish that article as the contractual agreement was he would remain anonymous. In those often below-the-belt 25,900 words, I think O’Hagan did Assange a great deal of damage, belittling him and making him look very bad personally. What he went through as a ghostwriter was clearly very difficult, and I think he wanted to get his own back. Far worse, however, he blamed Julian Assange for his own need to have his experience seen and heard – on the grounds that he himself is a writer. (Letter to LRB, by Marge Berer, 29 March 2014, unpublished; posted in Berer Blog, 9 August 2015)

On the other hand, perhaps learning the details of Assange’s experiences firsthand stopped O’Hagan from seeing him as someone at a hacker’s fashion show. He wrote (Text-Inspectors, LRB 24 September 2014) that: “Surveillance in the UK is an implicitly sanctioned habit that has smashed the moral framework of journalism. Protection of sources is not an adornment, not some optional garment worn only when it suits, but a basic necessity in the running of a free press in a fair democracy. Snowden proved that, but not to the satisfaction of Britain’s home affairs establishment, or the police, who like to behave as if all freedoms are optional at the point of delivery.” He points out that Alan Rusbridger, former Guardian editor, had recently said that “source confidentiality is in peril”, that Glen Greenwald was also at risk of prosecution, not just Julian Assange, and that Edward Snowden taught us that “our freedom is being diluted by a manufactured fear of the evil that surveillance ‘protects’ us from”.

O’Hagan also acknowledges: “The first thing that amazed me about Julian Assange was how fearful he was – and how right, as it turned out – about the internet being used as a tool to remove our personal freedom. That surprised me, because I’d naively assumed that all hackers and computer nerds were in love with the net. In fact, the smarter ones were suspicious of it and understood all along that it could easily be abused by governments and corporations.”

Then the reporting goes downhill. In September 2015, in a review of a novel that had nothing to do with Assange, Adam Mars-Jones quotes a whole paragraph from the novel describing one of its characters, a barely disguised Julian Assange: “[T]here was a warrant out for his arrest for something sexual, nasty sexual. The consensus was confusing. He had raped someone, or he had not and the charges were trumped up. He was a free speech hero or international threat or both, and either being prosecuted for that or a pervert. Point is, he shopped around and got asylum.” Thus, the accusation of rape against Assange was inserted into the public space in a book review through guilt by association. (Sheer Cloakery, 23 September 2015)

In February 2016, Daniel Soar wrote a “cute” piece about Assange and Ai Wei Wei, “two bad boys” he called them, one locked up in the Ecuadorian embassy for three years by that time and the other locked up for three months in China. The first half of the article is about Ai Wei Wei and queries the friendship between the two men only because they are “famous”. The second half of the article gets serious, however. Soar argues: It isn’t Assange’s fault that he needs to keep himself close to the surface of the news: he has been inside the same building for – the counter on WikiLeaks currently reads – 1886 days and nights, and, like Scheherazade, if he doesn’t keep telling stories, he’ll disappear. But the phenomenon that was WikiLeaks depended on facelessness and anonymity. Not only for pragmatic reasons – leakers and whistleblowers have to be allowed the security of invisibility if they are to risk releasing dangerous secrets – but for reasons, too, of effective dissent.”

And by the end very serious: “Assange takes care to manage – or tries to manage – the stories about him. He needs to, because there are a lot of them about, not all of them fair: the sexual predator, the prima donna, the egotist, the reckless betrayer. And, after all, when he ran out of secrets, his image was all he had left. Since he first exploded into view, those in the secret-disclosing business who are sticking it to the Man have understood that once you’ve burned up those secrets, you’re faced with a choice. Either you go supernova, like Snowden, or – like Assange – you turn into a black hole.” (Short Cuts, Julian Assange, LRB, 18 February 2016)

Assange wasn’t managing well by then, and as people began deserting him, his personality was again dissected and the accusation of sexual predator made front page news. I think this did for him. In today’s world, there are certain accusations that, once fired at someone, make them a permanent pariah whether they turn out to be true or not. “Sexual predator/rapist” is one of them. I wonder if anyone in Sweden ever researched or questioned the behaviour of the Swedish authorities and whether these accusations were indeed cooked up, as Patrick Cockburn has suggested is possible.

James Meek, in an article about changes in the newspaper world and at the Guardian for 20 years (The Club and the Mob, LRB, 6 December 2018) quotes Alan Rusbridger: “Reflecting on the Guardian’s mutually beneficial but uneasy relationship with Julian Assange during the WikiLeaks affair, Rusbridger writes: ‘I once remarked to a senior intelligence figure that the British and American governments, instead of condemning our role, should go down on their knees in thanks that we were there as a careful filter. Without newspapers, they would be dealing with a much scarier and intractable problem…. How contemptuous Assange would be of such a thought. How he would despise even my contact with such a person, or the fact that I leave him anonymous in this narrative.’” Thus, Rusbridger reveals his own contempt for Assange.

In 2019, in an article about the Trump presidential campaign in 2016 and the involvement of the Russians (How to Get Screwed, LRB, 6 June 2019), David Runciman reports that Assange said: “We believe it would be much better for GOP to win so that the Democrats, media and other liberals would form a bloc to rein in their [the GOP’s] worst qualities”. Well, he got that wrong, didn’t he, and Trump is now after his life. In any case, the extent to which he “supported” Trump may well also be a cooked-up story.

Which leaves for last (to date) Mary Beard on the subject of Germaine Greer’s new book On Rape (The Greer Method, 24 October 2019). Julian Assange gets one sentence yet again, in a book review that is otherwise not about him. Nor does Beard say what Greer actually says about Assange, if anything, but once again Assange and rape are mentioned and linked.

In conclusion, during almost a decade of LRB articles, Assange’s contribution to journalism and exposé of vicious global politics is both taken seriously and supported politically, even while he himself is looked down upon personally. In some of the articles, the mentions are so minor, however, i.e. only a sentence or two and not the subject of the article concerned at all, that I wonder why the mentions were considered worthwhile.

Postscript – the real issue: On 3 July 2020, Reporters without Borders published an open letter calling on the UK government to “release Mr Assange from prison immediately, and block his extradition to the US” where he is facing 175 years in prison – i.e. a death sentence .

The letter says: “The US government has indicted Mr Assange on 18 counts for obtaining, possessing, conspiring to publish and for publishing classified information. The indictment contains 17 counts under the Espionage Act of 1917 and one charge of conspiring (with a source) to violate the Computer Fraud and Abuse Act, which uses Espionage Act language. This is the first ever use of such charges for the publication of truthful information in the public interest, and it represents a gravely dangerous attempt to criminalise journalist-source communications and the publication by journalists of classified information, regardless of the newsworthiness of the information and in complete disregard of the public’s right to know.

“On 24 June 2020, the US Department of Justice issued a second superseding indictment against Mr Assange, adding no new charges but expanding on the charge for conspiracy to commit computer intrusion. This new indictment employs a selective and misleading narrative in an attempt to portray Mr Assange’s actions as nefarious and conspiratorial rather than as contributions to public interest reporting.”

The letter was signed by 40 human rights, press freedom and privacy rights organisations on five continents, including Reporters Without Borders, International Federation of Journalists; PEN International and six national PEN branches; International Association of Democratic Lawyers; International Foundation for Protection of Freedom of Speech; Index on Censorship; Head of Europe and Central Asia of Article 19; International Press Centre; International Press Institute; World Association of Community Radio Broadcasters; Association of European Journalists; European Centre for Press and Media Freedom, a range of national groups in Australia, Norway, Palestine, Bahrain, Liberia, Sri Lanka, Nepal, Turkey, and others.

They think 100% support for the release of Julian Assange from many years of solitary confinement without trial is what is called for. I agree. Human rights are for everyone.

 

Dear Keir Starmer,

28/06/2020 Comments Off on Dear Keir Starmer,

RE: Covid-19, Kashmir, Antisemitism, Rebecca Long-Bailey

28 June 2020

I have spent a lot of my time in lockdown writing letters of protest. Yesterday, I sent an email to Boris Johnson, Matt Hancock and Jeremy Hunt about the Tory’s 300-strong vote in Parliament this week to deny NHS and care staff Covid-19 tests for their own safety and that of their patients. You can read it here.

I was very upset when you responded to the Kashmir situation by more or less saying it was up to India to deal with it. A group of us wrote you a letter about that. I then saw that a letter had been sent to you by 100 Muslim groups who said they would stop supporting Labour electorally if you did not change your stance. That same article reported your response, in which you changed what you said, as quickly as 24 hours later. Good for you, I thought, though some questioned how deeply it was meant.

Regarding Kashmir, I would like to recommend that you read Arundhati Roy’s book, My Seditious Heart (2019), a collection of her essays written over 20 years, in which among many other things she traces the history of Narendra Modi’s rise to power, starting in Gujarat, and details the persistent, horrific violence against Muslims in both India and Kashmir that he and his party and supporters are responsible for. I think it’s a book you will want to have read.

I voted for you as Party leader, enthusiastically. I was impressed with the range of people you appointed to your shadow cabinet and how you have been challenging Boris Johnson in the House of Commons.

Then, this week, you unceremoniously dumped Rebecca Long-Bailey. Maybe people behind the scenes knew it was coming. I was totally shocked. I’ve been reading what I can find about why it happened, and listening to all the various opinions flying around about it, many of which I think are beside the point. But the more I read, the more I think you’ve made a major mistake.

OK, she re-tweeted something about an interview with Maxine Peake. You thought (or someone convinced you) it was antisemitic? The interview? The tweet? Why? I can only presume you thought (or were told and believed) that it was false that US police were being trained by Israeli police. Then the situation was made worse when, instead of challenging this accusation head-on and presenting you with the facts surrounding it, Long-Bailey published a statement that her tweet wasn’t intended as a defence of the whole article. That wasn’t a defence at all, in my opinion, but then she apparently refused to withdraw the tweet. Very messy, from whatever angle you look at it. But it got messier.

I read on Skwawkbox, published 25 June, that there are big differences between the two of you regarding whether children should go back to school right away in July or not, with her supporting the NEU position of wanting to wait until everyone’s safety can be guaranteed, while you are thinking they should all go back right away. The Skwawkbox view is that this political disagreement was the real subject of conflict between you, and the real reason for you sacking her, but that you used antisemitism to justify yourself. So I have to ask you: is that true? I sincerely hope not. Today, however, just before I was planning to send this letter, I received details of a second article, making the same claim. This Covid-19 related issue is certainly an important political disagreement, but not just between you and her. In fact, it’s an issue for all of us in the Labour Party, and in far more ways than one. But why has it not emerged in the mainstream media as the real reason why you sacked her? And if it is indeed your real reason, how should you have addressed it? This question leads to further questions:

First, has the Shadow Cabinet got a collectively agreed position on the issue of children returning to school? Have they even been asked? If so, what is the position and when was it reached? I am an editor and author on women’s reproductive health issues and I have been reading widely about Covid-19. I happen to think the NEU is absolutely right. I believe the role of children in the transmission of this virus is greatly under-recognised. Preparation for their safety and the safety of everyone in the school community and in children’s own homes is critical. The government has failed to advise how to accomplish that preparation, as they have failed with everything else related to this virus. But isn’t it Long-Bailey’s role to stand up for the NEU position in the Shadow Cabinet if she is convinced it’s correct? Isn’t this her area of expertise? Or must she fall on her sword just because you disagree with her? That brings me to the question of what kind of Party Leader you are going to be, and most importantly how you will deal with dissent and disagreement within the Shadow Cabinet, as well as within the Party more widely. This is something you’ll confront every day. You can’t just go sacking ministers every time one of them disagrees with you. There’ll soon be no one left if you do. But this is not the only thing upsetting me and, it seems, many other people.

Coming back to the accusation of antisemitism, did you use that to set her up, knowing the mainstream (anti-Labour) media would jump on it, since they still get off on the bloodletting that occurs as soon as the words Labour and “antisemitism” appear together? You would know full well she would be crushed in five seconds with that. Or did you really believe the tweet (or the original article) were antisemitic?  If so, who convinced you?

One of my most politically astute friends thought her re-tweet was a stupid thing to do and that it proved she didn’t deserve to be in the Shadow Cabinet, that she should have known better. But that assumes the original article and the tweet were both antisemitic. Most people still understand very little about the parameters of what is and is not antisemitic. If Keir Starmer says it was antisemitic, it must be antisemitic, they would assume. But what if it wasn’t, and you used it anyway? Does it turn out that you are totally unethical? I hope you will explain and justify your reasoning and your actions.

Accusations of antisemitism raise many more issues. One is, what will the new process be in the Labour Party for dealing with allegations of antisemitism? I thought we’d all agreed by now that, in recent years, the process had been a disaster from start to finish. Any doubts on this were put to rest by the “leaked report”. I thought it had also been agreed that a new process is needed. But one thing is for sure – what you did isn’t it. Leader or not, you cannot be allowed to dismiss someone for antisemitism on your own, acting as judge, jury and hangman. It won’t do. If anyone in the Party actually supports your doing so, I fear I’m suddenly in the wrong party.

It is of course in your power as Leader to dismiss someone from the Cabinet over a serious political disagreement, but that’s NOT what you did. The uproar was inevitable. With wrongheaded political decisions being made left, right and centre on starting lockdown too late and stopping lockdown too soon, and all the risks attached to this, this is the last damn thing the country needed.

But returning to antisemitism and the Party. We’re waiting to hear from the EHRC. I think it’s crucial that whatever they say, we need a national discussion in the Party on how to respond, along with a process for dealing both with antisemitism and all other forms of racism, religious and ethnic discrimination – both in response to Black Lives Matter and following from the letter from the 100 Muslim organisations who support Labour. Not treating these separately from each other. And not focusing only on antisemitism.

I also believe the Party needs to tell the Jewish Board of Deputies to step back and stop acting as if they’re in charge. If you want to appoint them as the controllers of the Labour Party on the question of antisemitism, I think you need to ask Conference’s approval. That should also not be in your gift.

When you want Jewish opinions on something, there are hundreds if not thousands of members of the Party who are Jewish, including me, who are ready to give you advice – as long as you don’t expect us all to agree with each other. We are a part of the so-called “Jewish community” too, which is not a monolith and not beholden to the Board of Deputies either. Most importantly, we are Labour Party members. The Board of Deputies should never have been allowed to dictate terms to us, any more than we would allow the Pope to do so.

Lastly, there is the other issue that is part of the toxic mix from this event – the issue of Israelis training police from the USA. I have no idea what you know about this subject. I knew almost nothing till all this blew up. Having done my homework I can say there is no doubt such training is happening, like it or not. It was exposed some years ago by the US group Jewish Voice for Peace (JVP), who have been campaigning against what they call these “deadly exchanges” since 2014. These “exchanges” involve more countries than the USA and Israel, however. For evidence, I refer you to three articles, from the JVP website:

This last article says:

“Any militarized tactics or technologies acquired through police exchange programs go directly to executing the unchanged mission of the American police, established long before the founding of the state of Israel. Highlighting these police exchange programs without enough context or depth can end up harming our movements for justice. Suggesting that Israel is the start or source of American police violence or racism shifts the blame from the United States to Israel. This obscures the fundamental responsibility and nature of the U.S., and harms Black people and Black-led struggle. It also furthers an antisemitic ideology. White supremacists look for any opportunity to glorify and advance American anti-Black racism, and any chance to frame Jews as secretly controlling and manipulating the world. Taking police exchanges out of context provides fodder for those racist and antisemitic tropes.”

It goes on to say: “Police exchange programs are a mutual exchange of rights violations between like-minded governments. U.S. police have long built partnerships and swapped ‘worst practices’ with militaries and police forces that abuse human rights all over the world. Police exchange programs solidify partnerships between the U.S. and other governments, including Israel, and facilitate a two-way exchange in methods and equipment for state violence and control, including mass surveillance, racial profiling and suppression of protest and dissent.”

Lastly, in an article from 10 June 2020 in the Jerusalem Post, the Israel Police national spokesman Micky Rosenfeld acknowledges that there has been Israeli training in counter-terrorism for US police for some time. He says that the procedure used to kill George Floyd is not taught by them, however, and he argues that counter-terrorism techniques save lives. The difference between how JVP (and I) and the US and Israeli police see this training is a matter of very different politics, to be sure. But nothing, I would argue, nothing to do with antisemitism.

It is perhaps inevitable that the left of the Labour Party has interpreted your sacking of Long-Bailey as a sectarian act that proves you were always  intending to get rid of everyone on the left. But I can’t figure out why you would bother to appoint someone from the left of the party to a high-level position to begin with, if that was your intention. What I do know is that if this turns into a war between left and right internally, we will all lose. And it’s your responsibility to prevent that, not to fan the flames.

I think the anger on her behalf is justified, because she has been greatly humiliated by being called antisemitic over a stupid tweet that was not antisemitic. Now, everyone’s anger needs to be assuaged – so that no one loses face, yourself and Long-Bailey included. Is that possible?

I signed the petition to protest your decision. But I do want to see you bring everyone in the Party together, as you promised. We need unity very badly. For all the members who voted for her to be leader, unity includes Long-Bailey. That’s a lot of people for a new party leader to have pissed off all at once. There’s a lot to be said for not taking rash action. This did not have to happen.

With best wishes,

Marge Berer

Shame on Boris Johnson and his government

27/06/2020 Comments Off on Shame on Boris Johnson and his government

To: ‘boris.johnson.mp@parliament.uk’; ‘huntj@parliament.uk’; ‘matt.hancock.mp@parliament.uk’
Cc: ‘nickie.aiken.mp@parliament.uk’

Subject: Three hundred Tory MPs vote to deny NHS workers Covid-19 tests

Dear Boris Johnson, Jeremy Hunt, Matt Hancock,

Shame on the entire Tory party.

Shame on all of you who voted down needed Covid-19 tests to protect NHS staff and thereby also continuing to put patients at risk.

Special shame on Matt Hancock for failing in his remit to protect the NHS by this, and on Jeremy Hunt who supported more testing for NHS staff earlier in the day, and then voted against it.

Shame on the whole Tory government for failing to provide NHS and care workers with adequate PPE from the very start, let alone now.

Shame on all of you for failing to start testing and contact tracing, failing to promote the universal use of masks in public spaces, and failing to carry out adequate isolation/quarantine measures until so late in the day (if at all even now), and more shame on you for using the excuse that the apps didn’t work when manual contact tracing has always been feasible.

Shame on you for giving incompetent companies like Serco and DeLoitte vast amounts of money to do tasks that NHS labs should have been doing locally as regards testing and contact tracing and isolating people, and were stopped from doing.

Shame on you for ignoring the advice of scientists from East Asia and New Zealand who spoke in the Home Affairs Committee meeting broadcast recently on the Parliament Channel, who advised not opening the country to tourism this year because it was too high risk.

Shame on you for planning and carrying out more privatisation of the NHS behind our backs even now, when it has been pushed to the limit to try and make up for the damage your incompetence has caused.

And shame on you for giving such poor advice to the public that thousands of people have crowded together on our beaches in recent days and with everything else you have opened up prematurely, will contribute to a second wave of infections that data show has already begun.

Shame above all on Boris Johnson who almost died from Covid-19 and only survived because the NHS gave him first class care. You and your government and advisers have killed a very large number of people who never needed to die from this virus. This has not only been a total failure of leadership but also, in my opinion, criminal negligence, and I hope someone takes you to court for it.

Yours sincerely, Marge Berer

George Floyd: it was first degree murder and torture, and it happens every day

04/06/2020 Comments Off on George Floyd: it was first degree murder and torture, and it happens every day

The women’s movement has been condemning violence against women and calling for the impunity of the vast majority of men who are ”getting away with it” to be addressed. But we have not succeeded in finding a way to make that violence, let alone any other form of violence, stop happening to begin with.

There is men’s violence against each other, for example, another class of violence altogether. It probably creates even more victims than violence against women, not least because it is so often committed on a mass scale (especially in war and massacres based on race, religion and ethnic background). It is even turned into highly praised TV programmes about animals in the wild, by apparently peace-loving people such as David Attenborough, who always film animals fighting, stalking their prey and killing each other – as mercilessly as that policeman tortured and murdered George Floyd – with intent and without hesitation or probably even a passing thought for the life that he extinguished.

George Floyd was tortured – it was inhumane, cruel and degrading treatment. The word ‘degrading’ is especially apropos in this instance because above all it was an expression of race hatred.

As Spike Lee said, this has been going on for 400 years. That is, since the country that became the so-called United States of America came into existence through the conquest of the land and its peoples by foreign white men. Can a country whose forebears once practised slavery ever stop treating the descendants of slavery as inferior? What public policy can finally create a society that practises non-violence? Why does humankind not have the understanding and mutual respect to achieve that?

I emigrated from the US for many reasons, but one of them was because, having spent five years of my youth protesting against the US war that decimated Vietnam, I could not cope with the violence rampant in the US itself, including in the Philadelphia neighbourhood where I lived before I left. Let alone that country’s glorification of its own violence through patriotism and the unquestioned assumption that it has the right to dominate, invade and declare war on almost everyone else on earth if, when and how it pleases. While glorifying itself as the world’s greatest democracy, as the world’s saviour even, strutting around the globe like every dictator on earth, preening itself on the world stage. Donald Trump is the culmination of everything that is has ever gone wrong  in my country, whose daily outpourings of hatred and contempt are insufferable, and yet get endless airtime and thereby credibility.

The names of all the black and ethnic minority people who have been murdered by police in the USA and by the US military abroad would fill endless walls. The solidarity of the demonstrations against this latest and most foul death in so many countries was heartfelt, coming from other countries where racism is also rampant though perhaps sometimes less blatantly murderous. Until an event such as the Grenfell Tower fire takes place or a virus is allowed to murder so many healthcare workers, especially those of black and ethnic minority origin, whose lives – seen by their governments as expendable – are extinguished.

The inevitability of Death is bad enough. No one should have to die like that.

Many people are shocked because they watched this murder on TV. But this is a daily event in the USA, as it is in so many other countries, if not in all of them. Why? Because the world does not have enough leaders who can and do implement the profound changes needed to right these wrongs, to challenge and silence the contempt, and stop the violence before it happens to begin with. Let alone enough citizens who will stand up publicly and reject the utter hypocrisy of the inevitable Boris Johnsons who put themselves in front of cameras after events like these to express their… their what? Pfah! as my grandmother used to say.

George Floyd’s brother called for an end to the violence in his brother’s name. I don’t know how to stop it happening either. But I stand with him.

Criminal negligence by the Westminster government: close to 40,000 dead unnecessarily

25/05/2020 Comments Off on Criminal negligence by the Westminster government: close to 40,000 dead unnecessarily

Dear Nickie Aiken (Tory MP for the Cities of London & Westminster),

Hello. I’m afraid you will be receiving several emails from me during this bank holiday weekend. I am one of the few people locally who has not gone to the seaside for the weekend, as so many others appear to have done following the pathetically confused advice from the government, which I fear will lead to many new Covid-19 infections this week.

I find it ironic that everyone is baying for the resignation of Dominic Cummings when the Prime Minister himself broke the rules early on by visiting a hospital and shaking hands with patients with Covid-19 and laughingly said so to a media camera. I have the footage and it’s been shared many times. (See the video link in the report some pages below this one on this blog.)

But I am writing also to criticise the entire government policy on Covid-19. Although I do not have a degree in public health, I have been studying and publishing information on international women’s health issues since 1985. This has included information about the HIV pandemic, about which I published a 400-page book in relation to women’s health in four languages, and more recently regarding the Zika virus, which had a terrible effect on babies born to women with that virus. I am now publishing a twice weekly international newsletter on abortion rights and reproductive health and rights for readers in 129 countries, and have been informing myself about policy on preventing, mitigating and treating Covid-19 for that publication. What I have to say is very simple…

The number and rate of infections and deaths from Covid-19 in each country is a direct reflection of whether their government’s policy is correct or incorrect. In this country, every Tory MP who appears in the media and on television has apparently been instructed to say, like an automaton, that the government has been “following the scientific advice”. But the numbers do not lie. The numbers say that the government has failed, from day one, to implement evidence-based policy that would have prevented most of the current 37,000+ confirmed deaths and 257,000 confirmed cases of Covid-19 in the UK. These statistics, these dead human beings who gave their lives helping other people, are among the highest figures in the world for such a tiny country.

It is Boris Johnson and his whole government who should resign in shame for having killed so many people by ignoring World Health Organization advice, not just early on but up to this day.

Compare this to Taiwan, also an island, with a population of 23 million, compared to our 66 million. Taiwan, so near China, was one of the first places the virus could have hit. (In 2019, 2.71 million visitors from mainland China travelled to Taiwan and thousands of Taiwanese travel back and forth to China on a daily basis as well.) Yet Taiwan as of yesterday had had only 441 infections and 7 deaths from Covid-19. That is the measure of the failure of our government, your leader. What did Taiwan do that the UK has not:

1. Inspection of all travellers since January arriving from other countries for signs of infection and quarantine any who test positive.

2. Mobilisation of their Central Epidemic Command Center – a rapid-response agency formed in the wake of the 2003 SARS outbreak – to implement quarantines, give the government advice on proven policy, advise hospitals and publish daily informative messages for the public.

3. Testing large numbers of people from the start. Putting people with infection in a special quarantine hospital until 14 days after they test free of the virus.

4. Manual contact tracing to find everyone who had contact with the infected persons and testing and quarantining them if infected.

5. Producing millions of masks and ensuring they are sold cheaply to every citizen, and are always worn when people are outside their homes, especially on public transport. Fines for those who have been warned but do not mask.

6. Enforcing messages about how critical social distancing is, daily.

7. Ensuring that everyone seeing patients has proper PPE – in hospitals, care situations and many many others.

Unlike us, almost no one has died. Unlike us, they never needed lockdown. Unlike Johnson’s health minister and Public Health England cronies, they knew what the correct science was and they have implemented it to the letter.

The Johnson Tory government has done none of these things properly, or at all. The mucking about with apps has been appalling. The use of DeLoitte ad other incompetent private firms,  Johnson’s buddies no doubt, not using local NHS labs with expertise, refusing EU PPE equipment when it was offered, was/is outrageous. Johnson is lying to the people on a daily basis, just like he promised those millions for the NHS on the side of a bus last year. On top of the rest of it, they have been charging the least well paid and least protected NHS health workers and care workers for their own NHS care and only giving in when there was massive protest… the last straw for me.

The verdict: criminal negligence on a large scale. 40,000 people dead unnecessarily whose lives had no value to Boris Johnson because they probably wouldn’t have voted for him anyway. There’s not much to choose between Johnson, Trump, Bolsanaro and Modi. All very right-wing and self-serving. All dead ignorant about health, welfare and human rights. All incompetent in spite of all the money they can command and represent.

So I want Boris Johnson to resign, and that will take care of Cummings too. Two for the price of one.

‘The past six weeks have been unlike anything I’ve known’: a GP on how the pandemic has changed his work

19/05/2020 Comments Off on ‘The past six weeks have been unlike anything I’ve known’: a GP on how the pandemic has changed his work

This is a “long read” article in the Guardian, written by Gavin Francis, a GP in Scotland, published 12 May 2020. It’s very moving and informative.

A brutal but absolutely true comparison in three minutes: Jacinda Ardern of NZ vs. Boris Johnson UK on how to address Covid-19: watch the video

18/05/2020 Comments Off on A brutal but absolutely true comparison in three minutes: Jacinda Ardern of NZ vs. Boris Johnson UK on how to address Covid-19: watch the video

(https://twitter.com/mikegalsworthy/status/1260568774329225217?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed&ref_url=https%3A%2F%2Fwww.tvnz.co.nz%2Fone-news%2Fnew-zealand%2Fwish-we-had-leader-like-her-piers-morgan-raves-over-jacinda-arderns-covid-19-response)

Two must-read articles about the government’s incompetent and devious policies in dealing with Covid-19

03/05/2020 Comments Off on Two must-read articles about the government’s incompetent and devious policies in dealing with Covid-19

If you’re confused about what’s right and wrong in how different governments are responding to the Covid-19 pandemic, the answer to the following question is a good indicator of whether they’re doing an excellent job or making a complete mess of it: How many people have died?

In the UK, today, 3 May 2020, 6 minutes ago as I write this, the BBC reported that there are now more than 186,000 confirmed cases in the UK and 28,446 people with the virus who have died. It’s unclear whether that includes only those who have died in hospitals or also those who have died in care homes and in their own homes.

In contrast, Taiwan, with a third of the UK’s population, and among the first countries to be hit by the virus, but has done everything right to keep the population safe, they have had only 436 confirmed cases and 6 deaths. That’s how shockingly badly we are doing in the UK.

Here are two examples of recent truth-telling articles about this picture:

The Intercept, Boris Johnson’s Coronavirus Lies are Killing Britons, by Sonia Faleiro, 30 April 2020

The Lowdown Why bypass NHS labs for mass testing? Concerns over new super-labs, by the NHS Support Federation, 27 April 2020

The Intercept article explains what has been done wrong. The NHS Support Federation Lowdown article gives an example of the deviousness of the UK government’s response. The NHS saved Boris Johnson’s life and this is how he shows his gratitude — he still hasn’t provided 37% of them with personal protection equipment (PPE). And he has completely ignored and failed to implement the World Health Organization’s advice from Day One — testing of everyone with symptoms, contact tracing of everyone who tests positive, and quarantine in hospital of everyone who tests positive.

On 28 March 2020, the editor of the Lancet journals, Richard Horton, called for the entire Public Health England to resign when this is over. I support that, but why wait? A number of frontline health workers talked to the Guardian, published 18 April 2020, about refusing to work without PPE because of the high risk to their lives. I supported that in a letter published by the Guardian soon after. The government told them to shut up. The Intercept article calls for Boris Johnson and the whole government to resign because of the mass slaughter they have allowed to happen. I support that call too.

On Thursdays, don’t just clap for the NHS, also write to your MP — call for immediate provision of personal protective equipment for all NHS health workers, all social care workers, all auxiliary workers — but above all senior frontline staff and all frontline nurses. Call for mass testing and contact tracing with quarantine, not next week, not next year but today. Because we still have no idea how many people in the UK have Covid-19. Let’s not find out the hard way by watching deaths rise again when lockdown is eased.

And please share this blog. 3 May 2020