Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

24/09/2013 Comments Off on Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI – the Joint Action and Learning Initiative on National and Global Responsibilities for Health

I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH,  to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.

I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)

Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:

i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.

One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.

iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.

Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.


Botched motherhood

11/07/2012 Comments Off on Botched motherhood

A poem by Tiro Sebina – featured in Reproductive Health Matters May 2012
You may not want to hear
About a woman who died
In labour in a hut

You may not want to hear
About an expectant woman
Who perished aboard
A donkey cart
On a bumpy road to an apology
Of a health post
With neither doctors on site
Nor drugs in sight

You may not want to hear
About an expectant woman’s fatal fall
Off a rickety bike
Pedalled by a drunken man
Terrified of Emang Basadi
Concerned about his name
Appearing on the birth certificate

You may not want to hear
About a woman who expired
Without knowing
She was targeted by grand visions
And millennium schemes

You may not want to know
About a woman too hapless
To grace dinner-conferences
Held in her name
At exclusive venues

Who wants to know
About the bungled chaos
Of a dead mother

Trends in maternal mortality 1990-2010: latest data

18/06/2012 Comments Off on Trends in maternal mortality 1990-2010: latest data

by Marge Berer

Editor Reproductive Health Matters

Thanks to the Millennium Development Goals and much work on the part of the UN, WHO, many governments and NGOs globally and nationally, the press and media are now highly attuned to what is happening as regards maternal mortality. An announcement by WHO on behalf of the United Nations of the latest global estimates, published in May 2012, showed that the trend in maternal deaths appears to be falling overall, and resulted in many newspaper articles sharing this very good news. The global data were as follows:

  • The number of women dying due to complications of pregnancy, childbirth and unsafe abortion decreased from 543,000 in 1990 to 358,000 in 2008, and 287,000 in 2010.

This excellent news masks the fact that there has been a lot of change in some countries and virtually none in others. Here are some of the details of those differences, taken from the report:

  • Deaths are falling quickly in East Asia but the reduction is attributed largely to China.
  • Southern African countries have seen the beginnings of a reversal, but sub-Saharan Africa (56%) and southern Asia (29%) accounted for 85% of the global burden in 2010.
  • India (19%) and Nigeria (14%) alone accounted for a third of deaths globally.
  • 40 countries (20 % of the total number of countries) still have maternal mortality ratios greater than 300 deaths per 100,000 live births.
  • Countries with the highest maternal mortality ratios were: Chad, Somalia, Sierra Leone, Central African Republic, Burundi, Guinea-Bissau, Liberia, Sudan, Cameroon, and Nigeria; Lao PDR, Afghanistan, Haiti, Timor-Leste – these are among the world’s poorest countries, many of which are also sites of conflict, war and other crisis situations, such as earthquakes and flooding.

In other words, many countries still have very high maternal mortality ratios, including two very large countries, which account for a large proportion of deaths. Moreover, there is a growing gap between countries where improvements have taken place and many of the poorest countries, where most women are still simply not benefiting. Furthermore, as the May 2012 edition of RHM shows, there are differences within countries and between women (according to socioeconomic status, rural vs urban status, age and marital status) that are sometimes great and must not be ignored. The paper by Shah and Ahman, for example, shows that unsafe abortion deaths remain high in many countries and that young women are at the greatest risk of death and complications from unsafe abortion. A study in Nigeria shows that women in northern Nigeria are at far greater risk of maternal death than women in the south of the country. Given that the primary aim of the Millennium Development Goals is to reduce poverty and the consequences of poverty, celebration is perhaps not yet in order. However, countries where improvements have clearly taken place, such as Rwanda and Cambodia, as shown in other RHM papers, certainly deserve credit for enormous efforts.

Is eradication of congenital syphilis feasible?

05/03/2012 Comments Off on Is eradication of congenital syphilis feasible?

On 1 March, the Global Congenital Syphilis Partnership held a press conference to announce the launch of a global campaign to eradicate congenital syphilis, motivated by evidence from a seven-country pilot study that used a rapid blood test for screening. The aim of the studies was to test pregnant women for syphilis, treat any who were positive early in their pregnancies to avoid transmission of syphilis to their babies during pregnancy, and where possible also test and treat their husbands/partners.

If pregnant women are screened and treated as required in an antenatal visit early in pregnancy, congenital syphilis will be treated in the woman and prevented in the infant, but this is only as long as the woman is not re-infected during the rest of her pregnancy. To avoid that, her partner needs to be tested with her and both need to have an injection of penicillin if positive for syphilis. If the woman has more than one partner, then contact tracing and screening will also be needed.

Screening of pregnant women for syphilis is a long-time public health measure, and has been recommended as a routine antenatal test by WHO and other national, regional and global public health bodies for many decades now. However, periodic studies in the latter half of the 20th century showed that many women are not screened during antenatal care, others have not returned for their results, and still others are not screened because they have not attended for antenatal care at all, or only very late. Hence, efforts to eliminate congenital syphilis have failed. Although in most countries the rates appear to have been falling over the years, the burden of disease remains heavy.

Untreated syphilis in pregnancy leads to adverse pregnancy outcomes in more than half the women with active disease, including early fetal loss, stillbirth, prematurity, low birthweight, neonatal and infant death and congenital disease among newborn babies.[1] Similarly to HIV, syphilis in pregnancy is both sexually transmitted and transmitted through blood in shared needles by injecting drug users. Testing for both syphilis and HIV at the same time makes good sense in antenatal care settings, since the blood taken to screen for syphilis can also be tested for HIV, though treatment modalities are of course quite different.

In 2008, the latest year for which global data are available, approximately 1.9 million pregnant women were infected with active syphilis resulting in approximately 300,000 stillbirth sor early fetal losses, 140,000 neonatal deaths, and 380,000 infants that were preterm, of low birthweight, or had congenital disease associated with syphilis.[2]

Several new factors mean that it is becoming more feasible to lower these rates. First, the development of a rapid blood test for syphilis means health workers can get a result in only a few minutes without the need for laboratory facilities, as the kit includes a built-in testing mechanism.[3] If the test is positive for syphilis, an injection of penicillin can be given immediately. This is sufficient as treatment, and as long as there is adequate availability of penicillin, and unless re-infection is a risk, does not require follow-up.

The other important facilitating factor is that more and more women in the developing world are attending for antenatal care, and more often making more than one visit.  Ensuring that all of them are tested is a major task, however. According to a 2011 WHO report:

“In 2010, 63 low- and middle-income countries reported on the proportion of women attending antenatal care tested for syphilis at the first visit. In this subgroup, 17 low- and middle-income countries reported having achieved the global target of testing at least 90% of women attending antenatal care at the first visit for syphilis (Belize, Chile, Cuba, Fiji, Gabon, Grenada, Guyana, Kiribati, Malaysia, Mauritius, Namibia, Oman, Samoa, Seychelles, Sri Lanka, Uruguay and Venezuela (Bolivarian Republic of)). Overall global median testing coverage did not improve from 2008 to 2010 (Table 7.2). Nevertheless, median testing coverage improved in Latin America and the Caribbean (from 73% in 2008 to 80% in 2010) and in East, South and South-East Asia (from 52% to 78%). In 27 reporting countries from sub-Saharan Africa, a median of only 59% of pregnant women were tested for syphilis. Eight low- and middle-income countries reported not offering routine syphilis screening in antenatal care in 2010.”

Hence, there are big “ifs”. Shortages of essential medicines are well known. And re-infection is often a risk because husbands and other sex partners historically were often not tested and treated at the same time as the woman, or at all. To get most partners into antenatal clinics for testing will be one of the more difficult challenges for antenatal programmes, and may not be seen as a priority, given all the other demands on antenatal care these days which are not being met, such as the need for more trained midwives. Other cadres of health workers can be trained to do the test and give injections, but this too would take resources and people and time.

I am concerned that the new Global Congenital Syphilis Partnership is about congenital syphilis and therefore neonates only, and that the UNAIDS-led Global Plan toward the Elimination of New Infections among Children by 2015 and Keeping Their Mothers Alive, launched last year, which includes a global initiative to eliminate congenital syphilis, is about women and children only. But shouldn’t women and men be the focus of treatment in order to prevent syphilis in neonates? Luckily, unlike with PMTCT, efforts to reduce congenital syphilis must treat the pregnant woman to protect the fetus but will programmes also bring in the men?

My other concern is the use of the words “eradicate” and “eliminate” in the descriptions of the goals of this and other initiatives, such as the prevention of mother-to-child transmission of HIV, also in the UNAIDS Global Plan, and the so-called “Golden Moment” in relation to unmet need for family planning. The Americas and the Asia-Pacific region and several countries have developed integrated initiatives to eliminate mother-to-child transmission of both HIV and syphilis, given their common target groups and service delivery platforms.1

Can these new global health initiatives make such massive advances in reducing major disease burdens in a few short years that they will be able to eradicate or eliminate them? Do they think such claims are necessary to gain credibility?  Smallpox is the only disease that has ever been eradicated to date. Should we not continue to occupy the more cautious terrain of public health agencies and experts in terms of expectations? Perhaps this is an old-fashioned view.

The figures for declines in neonatal deaths are encouraging, even if they are happening less quickly than other infant and child mortality declines. In 2009, an estimated 3.3 million babies globally died in the first month of life, compared with 4.6 million in 1990. This is in spite of world population growth. More than half of all neonatal deaths occurred in five countries of the world (which also account for 44% of global live births): India 27.8% (19.6% of global live births), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%). Between 1990 and 2009, the global neonatal mortality rate declined by 28% from 33.2 deaths per 1,000 live births to 23.9. The proportion of child deaths that are in the neonatal period increased in all regions of the world, and globally is now 41%. Thus, neonatal mortality rates were halved in some regions of the world, though Africa’s rate only dropped 17.6% (43.6 to 35.9).[4] These reductions are impressive and give much hope of future successes.

At the press conference, Peter Piot, formerly head of UNAIDS and now head of the London School of Hygiene & Tropical Medicine (LSTHM), in his introduction, described treatment of congenital syphilis as a low-hanging fruit,[5] and Joe Cerrell, representative of the Bill & Melinda Gates Foundation for Europe, said, referring to the new test kits: “We have a simple solution to save a million children’s lives each year.”

Rosanna Peeling from LSHTM handed out a Rapid Syphilis Toolkit produced by the School and reported that 30 countries have already started scaling up rapid antenatal syphilis/HIV tests. She talked about wanting to avoid “more vertical programming” with this new programme. However, her definition of an “integrated programme” in this instance was the two-for-one combination of syphilis and HIV testing of pregnant women at one go. Given the limitations of antenatal care and the real meaning of integration, this is hardly it. The seven country studies have not yet been published, however, and details of what this does mean in practice were not provided.

In the pilot programme in Brazil, presented by Adele Benzaken, in the Amazon region they have shown that it is possible to do these tests in a very rural, hard-to-reach region. Yet they will have to test and treat two million pregnant women and their partners each year. Brazil has got a Brazilian pharmaceutical company to produce the test kits, thus controlling cost, and are funding 95% of the programme themselves (Simone Diniz, personal communication). Given their success with HIV, again optimism is warranted.

In China, the head of the National STD Control Programme said that it was precisely in the rural areas of the country that they have a major outreach problem that must be solved. China thought they had eradicated syphilis, but it returned in the 1980s. With the mass internal migration that has taken place in China in recent decades, eradication may be more difficult, especially since migrant women do not have access to health insurance and get far poorer maternity care.[6]

“Eradication” or “elimination” of congenital syphilis, rather than “control” has a very different meaning and implications. To achieve eradication of syphilis in women and children, according a paper by specialists from the Centers for Disease Control and Prevention (USA), published in RHM in 1995, you need:

  • a control measure that is completely effective in breaking up transmission
  • effective case detection and surveillance
  • recognition of the disease as of socioeconomic importance in the countries concerned
  • reasons to attempt eradication as opposed to control
  • adequate financial, administrative, person power and health service resources, and
  • the necessary socio-ecological conditions.[7]

Most low-resource countries couldn’t possibly meet these conditions. Still, syphilis in pregnant women could be reduced far more if antenatal care programmes were doing what all the guidelines and protocols have been telling them for years that they’re supposed to be doing – a range of antenatal screening tests that include not only syphilis and HIV, but also screening and treatment for anaemia, malaria and TB, and all the other checks that contribute to healthy pregnancies and babies.

What was not raised at all in the press conference were other STIs, in addition to syphilis and HIV. More than 448 million new cases of four bacterial STIs – gonorrhoea, chlamydia, and trichomoniasis as well as syphilis – are estimated to have occurred in 2005 alone.[8] These also contribute to major morbidity and even mortality. The point was made in this press conference that when HIV testing was made the screening priority in pregnancy by the global AIDS community, a lot of routine syphilis testing stopped. We should take good note, since this is a prime example of why so many of us working in health believe that vertical programming is a big mistake.

[3] The test used in the pilot studies, carried out by the London School of Hygiene & Tropical Medicine, cost US $1 per kit. However, in Brazil, where one of the studies took place, a national pharmaceutical company is producing their own test kits for use in scaling up the programme, whose price is likely to be far lower (Simone Diniz, personal communication 24 February 2012).

[4] Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. PLoS Medicine 2011. Oestergaard and colleagues develop annual estimates for neonatal mortality rates and neonatal deaths for 193 countries for 1990 to 2009, and forecasts into the future.

[5] For a discussion of this sort of assessment of complex health issues in: Richard F, Hercot D, Ouédraogo C, et al. Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model. Reproductive Health Matters 2011;19(38):42–55.

[6] RHM has a paper in press for May 2012 that illustrates this in relation to declines in maternal mortality in Shanghai.

[7] Kennedy MG, Spink Neumann M, Fichtner RR, et al. Can we eradicate syphilis in pregnant women and newborns? Should we try? Reproductive Health Matters 1995;3(6):94–103.

[8] World Health Organization.Prevalence and incidence of selected sexually transmitted infections: Chlamydia, Neisseria gonorrhoeae, syphilis and Trichomonas vaginalis. Geneva: WHO, 2011.

In defence of abortion on a woman’s request, including on grounds of fetal sex

24/02/2012 Comments Off on In defence of abortion on a woman’s request, including on grounds of fetal sex

Published on the British Medical Journal Guest Blog, 24th February 2012

Ach, what a furore. The Daily Telegraph is in its element and having a ball printing nasty allegations about doctors doing abortions illegally on grounds of sex selection. Let’s look at the issues a bit more dispassionately. First, is it actually illegal? Yes and no. The 1967 Abortion Act does not permit abortion on grounds of sex selection per se, it is true, and the law is framed so that anything that cannot be defended as coming under one or more of the named legal grounds is technically illegal. However, the question remains whether abortion on grounds of sex selection can be defended under the existing legal ground for abortions. I believe the answer is yes.

Sex selective abortion, like late second trimester abortion, lends itself to easy condemnation and stigma, and many otherwise pro-choice people are opposed to it. In India and China, where the laws on abortion are otherwise very liberal, sex selective abortion is subject to several laws banning it, all of which are totally ignored  ̶ both because women are under great pressure to have boys, especially women whose first child was a girl and who have only one or two chances, and because those doing the ultrasound scans are making a lot of money from them.

This isn’t a question of designer babies, though it is always the case that where something is possible technically, and is available for a range of reasons, e.g. determining whether there is a risk of sex-specific genetic anomalies, it will also be used in other ways. In this sense, finding out fetal sex during an ultrasound scan is inevitable and justified. This information belongs to the parents and should not be withheld. The baby is theirs after all. Preferring a baby of one sex over the other is nothing new, but has become more of an issue, according to the literature on sex selection in Asia, precisely because people are having so few children. But this is not just a cultural or ethnic issue. I watched my next-door neighbour treat her second child, a boy, badly throughout his childhood because she had wanted a second girl. She never forgave him for being born, at a time when there was no ultrasound for finding out fetal sex. Is this so uncommon?

I believe doctors faced with a request for abortion from women whose cultures practise discrimination against women and girls can justify it under the existing abortion law on the following grounds: taking the woman’s social situation into account, and because the woman’s physical and mental health and well-being may be at risk, and also her existing children. The potential for abuse of a woman by her husband and family, and poor treatment of and even purposeful neglect of girl children (leading to poor development and even death), are common outcomes in Asian cultures that demand that women produce boys. Women can be rejected and their lives made miserable. No one that I am aware of has ever investigated the existence or extent of such abuse and neglect in the UK among families from these cultures, but perhaps it’s time someone did. Moreover, it is also the case that a woman may not want another baby anyway, for other valid reasons, and fetal sex may be the only acceptable excuse she can give in her family situation for seeking an abortion.

Lastly, if anyone thinks that incrimination, condemnation and prosecution of pro-choice doctors is going to make this situation go away, they need to think again. Women will simply say they have a different reason and doctors will duly record it.

I believe health professionals and everyone who is pro-choice on abortion should support pro-choice doctors and women seeking abortions, whatever their reasons, even when sex selection may be involved.

The Daily Telegraph’s stories and the cowards who remain unidentified who went under false pretences to abortion providers and doctors who authorise abortions with the intention of incriminating them, should be condemned. Their aim is not to stop sex selection, which will not go away until discrimination against women and girls becomes history. Their aim is to stigmatise abortion and women who have abortions, to frighten women and abortion providers that they are breaking the law, and to seek to restrict the law on abortion. Their behaviour is unethical and under-handed, and constitutes harassment, which should be rejected and even subject to prosecution for wasting the Health Department’s and police time.

The UK needs to make abortion available legally on the request of the woman, and to decriminalise abortion altogether. This is an idea whose time would have come long ago if misogyny and harassment of women were illegal ̶ and prosecuted ̶ instead.

Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization

20/02/2012 Comments Off on Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization

Many feminists, including me, actively opposed the hormonal injectable contraceptive Depo Provera (DMPA) three decades ago  ̶  it was at a time when certain women weren’t being given a choice of method or any information about possible side effects, and before long-term post-marketing studies began to be done to monitor long-term safety. Here in the UK, we demanded that all women be given information about side effects and a choice of methods, and we called for long-term safety studies. The research was duly done, and it found that the side effects were within the range of what experts consider to be safe and acceptable. Once these were known and women began to be given a choice of method, there was nothing more to oppose.

Injectable contraception has distinct advantages  ̶  it is highly effective, the woman and her partner need do nothing more in between injections to gain protection from unwanted pregnancy, and women can use it without partner consent or knowledge if they need to. However, like all hormonal methods, female sterilisation and IUDs, injectables do not provide protection against sexually transmitted infections, including HIV. For that, people need to use condoms or other forms of safe sex, or always have sex with only one partner (who is negative) who also always has sex only with them (also negative).

Many studies have been done on whether hormonal contraceptives increase HIV risk or not, and the findings have sometimes shown an increased risk and sometimes not. This variation is because there are a lot of confounding factors and risks involved that are extremely difficult to control for. On PubMed, for example, a study on this subject at the very top of the page using the keywords “Depo Provera and HIV risk” today reached the following conclusion: “In this study conducted among [5,567] South African women, hormonal contraception did not significantly increase the risk of HIV acquisition. However, the effect estimate does not rule out a moderate increase in HIV risk associated with DMPA use found in some other recent studies.”[i]

Several other recent studies, however, have found an increased risk of HIV acquisition among Depo Provera users. As a result the Department of Reproductive Health and Research/Human Reproduction Programme at the World Health Organization held an expert consultation several weeks ago to consider the latest evidence and decide whether it warranted a change in their current guidance, dating from 2009, on this subject. They decided not to change their current advice. Below is the press release they sent out a few days ago, explaining this. The fact remains, it’s the lack of safe sex/condom use and sex with more than one partner, or with a partner who has more than one partner, that really puts women and men at risk of HIV. That hasn’t changed since the HIV epidemic began.

WHO Press Release (a different version of this release is available on the WHO site):

WHO upholds guidance on hormonal contraceptive use and HIV

Geneva, 16 February 2012. Following new findings from recently published epidemiological studies, HRP convened a technical consultation (from 31 January to 1 February 2012) regarding hormonal contraception and HIV acquisition, progression and transmission. It was recognized that this issue was likely to be of particular concern in countries where women have a high lifetime risk of acquiring HIV, where hormonal contraceptives (especially progestogen-only injectable methods) constitute a large proportion of all modern methods used and where maternal mortality rates remain high. The meeting was held in Geneva between 31 January and 1 February 2012, and involved 75 individuals representing a wide range of stakeholders. Specifically, the group considered whether the guideline Medical eligibility criteria for contraceptive use, Fourth edition 2009 (MEC) should be changed in light of the accumulating evidence.

After detailed, prolonged deliberation, informed by systematic reviews of the available evidence and presentations on biological and animal data, GRADE profile summaries on the strength of the epidemiological evidence, and analysis of risks and benefits to country programmes, the group concluded that the World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, the group recommended that a new clarification (under category 1) be added to the MEC for women using progestogen-only injectable contraception at high risk of HIV as follows:

Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not demonstrate this association. A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male and female, and other preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection is essential. These recommendations will be continually reviewed in the light of new evidence.

The group further wished to draw the attention of policy-makers and programme managers to the potential seriousness of the issue and the complex balance of risks and benefits. The group noted the importance of hormonal contraceptives and of HIV prevention for public health and emphasized the need for individuals living with or at risk of HIV to also always use condoms, male and female, as hormonal contraceptives are not protective against HIV transmission or acquisition.[ii]

[i] Morrison CS et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS 2012;26(4):497-504.

[ii] Technical statement: Hormonal contraception and HIV and background documentation.

An open letter to Shirley Williams

17/02/2012 Comments Off on An open letter to Shirley Williams

Dear Baroness Williams,

I have greatly appreciated your continuing efforts during the debate on the NHS Bill in the House of Lords until recently and that you took the time to send out the group emails that have kept those of us on the outside informed.

I am writing now, however, to say how disheartened I was to learn earlier this week that you have called for the Bill to be amended and passed, as if the entire Bill were not about competition, intended to open the door wide to privatisation and atomisation of the NHS, which is the Government’s strategy not only with the Health Service but with home and social care, with education and indeed almost everything else.

Your Party, as part of the Coalition, is certainly in an untenable position, as you are the ones who will make the passage of the Bill possible. I would not want to be in your shoes with the public when the true nature of the betrayal of the Health Service emerges if the Bill goes forward. Simon Hughes misguidedly believes that removing Andrew Lansley after you pass the Bill will save the situation, but it will not, though indeed Andrew Lansley should go precisely because he tried to sign away responsibility for his own position. But he must go along with the Bill, not after it or instead of it.

No one, from David Cameron on down, can ignore the increasingly articulated views of most health professionals as well as the public, which have grown in strength over the past few months as more and more people come to understand what is at stake. If democracy still means anything, then both Houses of Parliament must bow to the strength of public opinion and withdraw this Bill before it can do any further damage.

If all the Conservatives could find to say in defence of the Bill, e.g. on Question Time, is that the BMA didn’t support the NHS in 1948 either (a misreading of history), and that because it is already being implemented it is too late to turn back, then they (and you) have well and truly lost the argument.

Indeed, I would ask you whether the extent of implementation of the Bill – even before it has been debated fully, let alone voted upon – is unconstitutional. If it isn’t, then it should be.

I urge you from your position of leadership to convince both parties in the Coalition that this Bill is unsalvageable and should be withdrawn – as the only honourable thing left to do.


With kind regards,

Marge Berer

Editor, Reproductive Health Matters

The breast implant fiasco: a scandal of private medicine

18/01/2012 Comments Off on The breast implant fiasco: a scandal of private medicine

First published 17 Jan 2012 on the BMJ Group Blog

So, the silicone’s hit the fan.

The use of industrial-grade silicone intended for mattresses, the possible fraud in hiding information from inspectors at production stage, and the failure in quality control in the regulatory phase, are particularly outrageous. However, the rapidly expanding private sector provision of breast implants for cosmetic reasons, by an “industry” that has been permitted to remain self-regulating in spite of evidence of its shortcomings and the risks involved, was a public health problem waiting to happen.

According to a 2010 review by Melanie Latham, [1] after the Labour government came to power in 1997, Labour MP Ann Clywd raised debates in the House of Commons about the possible risks of silicone from breast implants leaking into the patient’s body. Some efforts to regulate the private cosmetic surgery sector took place: in the Standards Care Act 2000, the Health and Social Care (Community Health and Standards) Act 2003, the National Health Service Act 2006, and the Health and Social Care Act 2008. These acts provided for a system of registration and inspection of private facilities and providers, but left the supervision of these regulations within a system of self-regulation, largely in the hands of private surgeons and clinics themselves. [1] Powers of entry and inspection of premises were handed over to the Care Quality Commission in 2008, a body that has experienced more criticism than one could reasonably expect it to survive. [2]

In the meantime, criticisms arose which have dogged the industry for over a decade: [1] that clinics were not adhering to minimum standards set in 2000, not monitoring quality of care and not recording adverse events. Accusations were levelled that they lacked written guidance on clinic procedures, published misleading advertisements about the potential success of treatments and had informal and undocumented complaints procedures and inadequate registration of surgeons.

Ann Clywd’s calls for an independent umbrella body to govern the cosmetic surgery profession, the most recent in 2008, [3] went unheeded. In 2009, the president of the British Association of Aesthetic Plastic Surgeons said: “In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a ‘2-for-1′ advert for general surgery? That way lies madness!” [4]

Little did he know that Health Secretary Andrew Lansley, by opening the door to privatisation of health care on a wide scale, would make it even more likely that such problems might occur. The Health and Social Care bill is scheduled for report stage—where MPs discuss possible amendments—on 6 February. Lansley’s own response to the current implant fiasco has changed practically by the day and has included a mix of moral outrage on behalf of patients and threats to pursue, through the courts, the cosmetic industry companies that are refusing free removal of the sub-standard implants. [5] Why? Because, as he told the House of Commons, he didn’t think the NHS should foot the bill except for women whose implants were provided on the NHS (almost all of them women who have had breast cancer).

Some of the companies, for their part, are refusing to remove or replace the implants, or refusing to do it free of charge, for fear of bankruptcy. They hold the government responsible for failing to stop the implants coming into the country in the first place. The Medicines and Healthcare Products Regulatory Agency say there is no evidence of cancer risk and that women need not have the devices removed. [6] The bottom line is that in a fiasco, no one wants to take responsibility because of the cost, which reduces women’s health to a political football. Madness? No, these are the consequences of failure to control private medicine.

Is there a risk of cancer if you have mattress material in your tits for the next 5, 10, or 25 years? Who knows! Who wants to wait to find out the hard way? Women who fear the further risks of more surgery in order to have them removed, for a start. How are breasts repaired after they’ve had implants in place, particularly in women who have had breast cancer and may have tissue damage from surgery, radiotherapy, and chemotherapy? This is a serious dilemma, not the sort of “choice” Andrew Lansley goes on about.

Is there a greater risk of rupture with mattress material than with approved silicone gel? How can we know when private clinics are not obliged to keep such records and, even if they do, cite “commercial confidentiality” [7] to get out of reporting what data they may have? The so-called Independent Healthcare Advisory Service, which actually represents the major cosmetic surgery companies, claims to have audited all its members about the risk of rupture, and says data showed a rupture rate “within the industry standard of 1-2%.” Who set that “standard?” The industry, of course. Is it acceptable that implants have been found to rupture on average in one to two of every 100 women who have them? Let alone in the 7% reported in a small sample of 100 patients conducted by Transform, one of the biggest cosmetic surgery companies? [8] Acceptable—absolutely not!

Silicone gel removal

Silicone gel being removed from a ruptured implant RHM 2010;18(35):96

But that’s not all. Breast implants cause a lot of problems that we rarely hear about. Last month, for example, the New England Journal of Medicine reported the case of a woman, who had had a mastectomy and later heart surgery, whose breast implant was dislodged during a Pilates breathing exercise. It migrated through the space between her ribs to sit next to a lung and had to be surgically removed and replaced. [9]

The National Research Center for Women and Families, a USA-based, non-profit research and information centre that provides information about breast implants to about 1,000 women annually, reports that all breast implants carry a risk of the following: tightening or hardening of the scar tissue around the implant (which can be painful and disfiguring); rupture of the shell holding the silicone; leaking of silicone following rupture (requiring an MRI to detect accurately and surgery to remove it); autoimmune symptoms in women whose implants have leaked; risks related to removal (this “explanting” is a rare skill even in the USA, the breast implant capital of the world); negative effects on breastfeeding; reduced accuracy of mammograms (serious especially for women who have had cancer); breaking of implants due to pressure during mammography; and the need for subsequent surgery for many of these problems. [10] And let’s not forget the absence of any requirement to provide adequate information to women considering implants in the first place.

Lastly, what does it cost? Breast enlargement at a Transform clinic, according to their website last week, costs £1000 deposit and £224.58 per month payable over one year (a total of £3694.96), or £250 deposit and £88 per month over five years (a total of £5580). This is before we begin to talk about the financial implications for women of having to pay for additional procedures to check for and repair the consequences of a rupture, leaking silicone etc, on top of the implant surgery itself. What caused this fiasco? In the UK, breast implants for purely cosmetic reasons are a highly profitable part of our burgeoning private medicine industry. Welcome to Andrew Lansley’s “new” NHS, American-style.

And now solicitors can get their share too!

PIP support ad

Advertisement appearing on a website following the PIP scandal

1. Latham M. A poor prognosis for autonomy: self-regulated cosmetic surgery in the UK. Reproductive Health Matters 2010;18(35):47-55.
2. Hawkes N. The Care Quality Commission: unfit for purpose? BMJ 2011;343:d8034.
3. Hansard 6 March 2008, column 1957. Reported in Latham [1].
4. Mercer N. Clinical Risk 2009;15:215-217. Quoted in [1].
5. Boseley S. Breast implant scandal: comestic surgery companies face court action. The Guardian. 11 January 2012.
6. Reported in: Keeley B MP. Breast implants: why a review is welcome [Letter]. The Guardian 3 January 2012.
7. Campbell D. Plastic surgeons facing “significant” rise in legal action. The Guardian. 9 January 2011.
8. Boseley S, Meikle J, Willsher K. Implant firms say rupture rate is within the norm. The Guardian 4 January 2012.
9. Fong TC, Hoffmann B. Disappearance of a breast prosthesis during pilates. N Engl J Med 2011;365:2305.
10. Zuckerman DM. Reasonably safe? Breast implants and informed consent [Commentary]. Reproductive Health Matters 2010;18(35):94-102.
11. At: Accessed 13-1-12.

Jingle pills indeed

16/12/2011 Comments Off on Jingle pills indeed

This post first appeared on the BMJ Group Blog, 12th December 2011

Many years ago now, when news of female sterilisation first came out, Catholic priests in Puerto Rico and other Catholic countries preached from their pulpits against women being sterilised. As a result many more women learned that sterilisation existed, and many went out from church asking where to get it. In effect, the church gave family planning free advertising space by opposing it. Recently, the Daily Mailand others who rant against emergency contraception and abortion have played a similar role.

The British pregnancy advisory service (Bpas) received widespread coverage for their Christmas morning-after pill campaign, in which they offer to send women who request it free emergency contraception if they phone in and discuss it with a nurse.

This campaign represents several major advances in support of women who may be having sex without using a regular contraceptive method, but do not want to get pregnant. First, Bpas are making the service available by phone in advance of the “emergency” nature of the need. Thus, just as we keep pain medication in the medicine cabinet in case we get a headache, women are being encouraged to have morning-after pills on hand, in case they need them. Second, they are making the pills free when many chemists charge £25 for one dose, which many young and unemployed women would find prohibitive, and the phoneline will be open when GPs and chemists are closed. Third, they are able to broach regular contraceptive use with the women who phone and encourage them to start regular method use.

The morning-after pill has been available over the counter from chemists without a prescription for over-16s since 2001. So all the palaver about Bpas suddenly making it as easy as dialling for a pizza is silly. In any case, if you’ve had unprotected sex, the morning-after pill will help you far more than pizza. There are people who simply don’t want any form of birth control to be easily accessible and who still claim that emergency contraception (and abortion) promote promiscuity, just as their anti-abortion forbears claimed about the contraceptive pill and female sterilisation in their day. In the end, it’s sex they’re against. Perhaps Nadine Dorries should try putting that on prescription!

A Cochrane review in 2010 found that women who received an advance supply of the morning-after pill had the same chance of becoming pregnant as those who did not have early access to the method. However, these pills do prevent pregnancy when they are used. It seems that many of the women who have unprotected sex and get pregnant without wanting to are not the ones actually obtaining and using the morning-after pill. Perhaps Bpas’ campaign, with the help of all the media who have given it space, will help to change that.

According to the Bpas press office, 1,000 women phoned in the first 48 hours. If many more women find out about this method and start to keep a dose or two at home in case they need it, there is a far better chance they can avoid an unwanted pregnancy.

Andrew Lansley, the Health Secretary who doesn’t want responsibility for the NHS, told the Daily Telegraph that he would prefer there to be face-to-face counselling. Is that actually necessary when only a few questions need answering? And, someone has to seek face-to-face counselling first. For those who don’t, or won’t, this can only be a good thing.

Indeed, helplines for health-related issues are becoming more common and their value is clear. The FPA, for example, has run a helpline for years and has an excellent record of informing and referring for services for family planning and sexual health. The new aspect of Bpas’ campaign, sending the pills through the post, is like ordering something on the internet. Why not?

As for the under-16s, let’s get real. The under-16s who have sex may only do so very irregularly. But if they’re going to have sex, they need access to contraception. The morning-after pill may not be their best option in the long run, but it should be there if they need it.

We need contraception to be in the news more often – it’s good news. I applaud Bpas and all the media who have publicised their campaign. Jingle pills indeed!  Happy holidays!

On 11th January 2012 an update of the situation appeared on Abortion Review.

Fighting the English Health and Social Care Bill

03/10/2011 Comments Off on Fighting the English Health and Social Care Bill

I have just written a letter to 16 members of the House of Lords, asking them to intervene and make sure the Health & Social Care Bill is thoroughly examined and if possible rejected to prevent it passing into law as it is.

The letter was designed to support the efforts of those among the Lords already working actively to subject the Health & Social Care bill to the in-depth scrutiny it did not receive in the House of Commons via a special committee, and to urge them at the minimum to find ways to substantively amend it so as to reduce the damage from its worst clauses. Even more, what I really wanted was to convince the House of Lords to reject it altogether. The bill is fatally flawed. If it is passed, even with amendments, it will turn the “NHS” in England into a mere logo.

I believe one of the reasons why the Bill did not fall in the Commons was that the opposition did not attempt to defeat it per se, but rather put forward many amendments without consensus or unity among all those who were seeking to oppose/amend the bill. Cross-party opposition was totally absent on a subject that cries out to be treated in a cross-party manner because it affects us all (though not equally). Moreover, the time for debate was so limited that it made a farce of any serious examination of the bill itself, let alone the many amendments that had been tabled.

Many people who oppose the bill called on both Labour and the LibDems in the Commons to hold a consultation with expert key parties – in the NHS, in health professional associations, civil society health advocacy groups and patients’ groups. We wanted them to draft an alternative bill for which to campaign, as well as table a united set of amendments to this bill. This did not happen, to our great disappointment.

Many people are therefore looking to the Lords to play the role it is justly famous for – stepping into the breach in a crisis and putting things right.

Here are some compelling arguments against the Bill:

My blog, 17 reasons to oppose the bill, which outlines all the forms of privatisation envisaged in the bill, none of which have been ameliorated or cancelled out by amendments in the Commons, why they are a mistake and what to support instead.

 “It’s already happened” by James Meek writing in the London Review of Books is the best description I have seen to date of the negative consequences for hospitals of privatisation of the NHS. It uses the example of what has happened over recent years to the Wrightington Hospital near Wigan and its orthopaedic centre of excellence for hip and other joint replacements.

“An unsuitable case for treatment” by Hackney GP Jonathon Tomlinson describes the serious problems that privatisation and “choice” (highly restricted in reality) have already placed in the way of his treating one of his most vulnerable and ill patients and why he believes he can no longer do what is best for his patient in the face of NHS changes.

A diary by Andrew O’Hagan, also from the London Review of Books, is about Nye Bevan and the history of the NHS, how much the proposed reforms go against the ethos of Bevan to ensure universal access to health care, and a report of his conversations with a GP at the Kentish Town Health Centre in London, who explains what a disaster it will be if GPs have to hold the purse strings locally.

These contain incredibly strong arguments and examples for any debate, and the basis for alternatives to the clauses in this Bill, and to the Bill as a whole.

There are two campaigns being run to try and influence the House of Lords: one by 38 Degrees and the other by the TUC.

Join the fight against the privatisation of the NHS!

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