Infant and Maternal Mortality
If the moral soundness of a society is measured by how it treats its children, then Latin America, while better than Africa, does not measure up. Infant mortality in Latin America is stubbornly high -- averaging 23 per 1000 live births (versus 7 in the U.S.) -- though an improvement from 81 per 1,000 live births in the years 1970-1975. Maternal mortality is far too high, with Bolivia and Peru leading at rates of 420 and 410 per 100,000 births respectively, as opposed to 17 in the U.S. Uruguay has the low at 27. The major causes of high infant and maternal mortality are well known: poverty, lack of skilled birth attendants and deficiencies in emergency medical care. There are underlying causes as well that lead to these medical emergencies, and they all fall under the rubric of sexual and reproductive health. Health experts, and mothers, know that contraception which enables intended pregnancy can improve outcomes by 1) delaying first birth until a woman has fully matured, 2) birth spacing, permitting a mother to regain her health and to fully nurture the child she has before giving birth to the next, and 3) reduction in absolute number of births, allowing the mother to give more care to the children she has. The Agenda, to its credit, called access to contraceptives "indispensable," and called for continuous care to mothers before, during and after pregnancy, for increased efforts to prevent transmission of STI's and for stronger men's roles in all these.
While a good start, this is insufficient.
Contraceptive and Fertility Rates
The issue in Latin America is not contraceptive use; it is getting the contraceptives to those at risk for unintended pregnancy. Contraceptive prevalence in Latin America is the highest in the developing world, on average, with 75 percent of women in South America and 66 percent in Central America having access to a method (the corresponding figure in Africa is 27 percent and in the U.S. 73 percent). These rates are far less in rural and poorer areas, and thus the rate of unintended pregnancy there is higher. Increase in contraceptive prevalence (the rate was 60 percent for Latin America and the Caribbean in 1998) though has not translated into birth rate or abortion rate declines. The reason is a combination of lack of contraceptive access in vulnerable populations, along with higher intended childbearing desires. In some Latin countries overall birth rates, including teen birth rates, increased during the 1990's, while in the rest of the world they declined. On average, 20 percent of teens give birth in Latin America. The fertility rate for ages 15-19 is currently 78 in South America. In 1996, the South American rate was 75, indicating a 4 percent rise since then. A comparison with the U.S. is instructive. The fertility rate for Hispanic teens in the U.S. is about 82 for 2005, or slightly higher than the overall fertility rate for teens in Latin America (about 76). The U.S. figure disguises ethnic variations among immigrant populations, with the fertility rate for teens of Mexican origin in the U.S. being 93. However, interestingly, the teen fertility rate in Mexico is 63, about a third less than for Mexican teens in the U.S. Hispanic teens in the U.S. in general have a higher fertility rate than Hispanic teens in their country of origin. The reasons could include lack of access in the U.S. to contraception or more teen sexual activity. Also Hispanic culture meeting with more prosperity in the U.S. (as well as in those Latin countries that have prospered) could have led to increased teen birth rates. There are no figures, though, that I have seen as to the intentionality of these teen pregnancies. Though adolescents especially were recognized in the Agenda as needing special attention, there was, however, no specific call for renewed sexuality education efforts and increased availability of contraceptives for adolescents. This is not dissimilar to the silence in official circles in the U.S. Government around teen sexual activity, except for calls for abstinence education.
One sure way to decrease unintended pregnancy for teens and adults alike is emergency contraception. In many Latin countries there are battles over the legality of emergency contraception, which is characterized, mistakenly, as an abortifacient. In Chile and Ecuador, cases challenging distribution of emergency contraception recently went up to their respective Supreme Courts where, alas, EC opponents prevailed. The Agenda makes no mention of emergency contraception.
Abortion
An abortion rate about 50 percent higher than the North American level predominates throughout Latin America, along with attendant maternal mortality and morbidity. This would indicate pregnancy rates are higher than the desired childbearing rates. Still, women in Latin America have about one more child than they say they want.
Abortion is proscribed virtually everywhere in Latin America, except Cuba, Guyana and Mexico City. Four of the five countries of the world which prohibit abortion in all cases, even to save the mother's life, are in Latin America: Honduras, Chile, Nicaragua and El Salvador. There are about 4 million illegal abortions a year, 95 percent of which are unsafe. About 5,000 women die a year, resulting in 20 percent of all maternal deaths being from unsafe abortion.
There has been progress during the last year in decriminalization. Colombia's Constitutional Court decriminalized abortion in three cases: rape, for the life or health of the woman and for fetal deformity. The Mexico City legislature also decriminalized abortion, by a vote of 46 votes in favor and 19 against, despite a threat of excommunication.
The Agenda made no mention of de-criminalizing abortion or providing post-abortion care.
STD's and HIV/AIDS
While HIV/AIDS levels are below those of sub-Saharan Africa, HIV is still at serious levels. The prevalence rate is at or below 1 percent in every South American country, similar to most Asian countries, compared to rates of 25 percent in southern Africa. Condom use in Latin America is low -- just 4 percent of women in Brazil and Mexico report using condoms, compared with 13 percent in the U.S. according to PAHO (other sources show a higher rate of condom use of 18 percent in the U.S.).
Approximately one-third of Latin women have never had a Pap smear. In the U.S. about 84 percent of women had a Pap smear within the last three years (including 81 percent of Hispanics), indicating that Hispanic women are not disproportionately marginalized from the U.S. health care system. The Agenda made no specific recommendations for increasing condom use and the availability of Pap smears.
Violence Against Women
Violence against women is apparently more prevalent in Latin America than in the United States, though comparable and accurate statistics are hard to come by. In the U.S. there has been a steady decline in what the U.S. Department of Justice calls "intimate partner non-fatal victimization" (a gender neutral term) which had declined from 6 per 1000 persons to about 2 per 1000 from 1993 to 2005. The rate of violence against both Hispanic and non-Hispanic females in the U.S. declined as well and averaged about 4.2 per 1000 annually during the period 2001-5.
In Latin America, the few surveys that have been done show, for example, that over 40 percent of women ages 15 to 49, who have ever been in a union in Peru (42 percent) and Colombia (44 percent), have been victims of partner violence. This is a cumulative figure, but it would appear that violence against women is higher in Latin America than among Hispanics in the U.S. DHS surveys in Latin America reveal that, for instance, in Nicaragua 11.9 percent of women experienced domestic violence in the year preceding the survey.
There was not a single mention of violence against women or domestic violence in Health Agenda for the Americas: 2008-2015.
The Americas' Health Ministers' Recommendations … and Omissions
So, the Latin American Health Ministers made a less than sterling start in addressing the sexual and reproductive health needs on their citizens, leaving out sexuality education, teen access, condoms, safe abortion, emergency contraception and measures to combat domestic violence.
Not unexpectedly, they did call for increased spending on health. The region spends 6.8 percent of its GDP on health care, or about $500 per person (the U.S. figures are 16 percent and $7,600, respectively).
How to pay for increased sexual and reproductive health care? First, decriminalizing abortion will save health care dollars. So will providing preventive health care, including family planning, emergency contraception and condoms. Passing and enforcing domestic violence laws too will reduce health care expenditures.
If funds are needed, countries might consider increasing tax revenues. Latin American taxes average 18 percent of GDP (in the U.S. it is about 25 percent and about 36 percent in Western Europe.
Finally, the U.S. and other donor nations could also increase their ODA to the agreed-upon level of 0.7 percent of GDP. The U.S. ODA in 2006 was at 0.17 percent. Only three Scandinavian nations, the Netherlands and Luxembourg exceeded 0.7 percent. Having healthy neighbors is in our national interest.
]]>This article was first posted at Alternet.
The public disagreed. A mere 10% of girls in the U.S. have been vaccinated so far with Gardasil and few men in Africa have had "the snip." Within the past weeks the Virginia Legislature has taken steps to repeal its mandate for the HPV vaccine for schoolgirls, and the Health Minister of South Africa has refused to endorse male circumcision as part of its national AIDS program.
So, are these recommendations "no-brainers" or not?
They aren't, for three reasons: 1) they might not be as effective as advertised; 2) they run the risk of diverting funds from more effective prevention strategies; and 3) there is a real risk of unintended harm to women.
Both epidemics, HPV and HIV, have certain similarities: both are viruses, both are transmitted sexually, and both flourish because of the molasses-like pace of change in the human sexual behavior needed to thwart them. The US government's ABC (Abstinence, Be faithful, Use Condoms) approach has been effective in some countries in Africa and elsewhere, especially where it resulted in more condom use, but alas, condom use is not universal for many reasons - cultural, sexual, economic and otherwise, including the prosaic fact that the worldwide condom supply is both erratic and insufficient. Alas, even when condoms are available and used, they are not universally effective against HPV/genital warts. And, significantly, the U.S. and the world have failed to ensure access to Pap smears for the world's women. Thus HPV and HIV march on.
In desperation the public health establishment embraced two seeming magic (and expensive) bullets in the fight against HPV and HIV: a new vaccine and a re-branding of circumcision.
The HPV Vaccine: Gardasil
Gardasil is recommended for young females, preferably ages 11-12, who are not yet sexually active and hence not already infected with HPV, though it has been approved by the FDA for all females ages 9-26. In clinical trials for the 16-26 year old age group, Gardasil was virtually 100% effective for five years against the four strains of HPV that it targets (there are over 100 strains of HPV). Yet parents did not rush to get their daughters vaccinated.
Aside from safety, effectiveness and cost issues, some parents and public health officials had additional concerns:
1) Efficacy - while the vaccine does protect against HPV-16 and HPV-18 (the strains that cause 70% of cervical cancer), by so doing the vaccine may be unleashing other HPV strains which can infect the woman - thus, the ultimate efficacy of the vaccine against all HPV infections and, ultimately, against cervical cancer may be less than the initial studies indicated;
2) Misallocation of Funds - money to pay for Gardasil as part of the Medicaid program or some other government program would have to come from somewhere, perhaps leading to a reduction in health prevention or treatment of HPV itself. There is an argument that whatever millions are spent on HPV vaccination might be better spent on a more comprehensive STI prevention program, including condom use and more extensive Pap screening.
3) Risk Compensating Behavior - conservative groups argued, only somewhat disingenuously, that HPV vaccination would inevitably lead to adolescents engaging in more, earlier and unprotected sex, thereby causing more transmission of HPV and other sexually transmitted infections. Vaccinated, and unvaccinated, adolescents might have a reduced fear of contracting HPV, and might thus engage in more and riskier sex. This is known in the public health world as "risk compensation," and occurs when there is a perceived change (i.e. reduction) in the risk of acquiring a disease or being involved in an accident, for instance with drivers with seat belts and air bags driving faster. The fact that there is still a multiplicity of sexually transmitted infections out there (including other HPV strains) that Gardasil does not prevent, and thus that there should be no false sense of immunity, has not dissuade these conservative groups from their campaign. This argument might be, in theory, a valid concern, but remains unproven.
Male Circumcision
In 2007 the World Health Organization announced that it was recommending male circumcision "as an efficacious intervention for HIV prevention."
Circumcision has a long and often contested history - socially, culturally, medically and religiously - which the WHO was well aware of, yet in 2007 two studies, one in Kenya and one in Uganda, were halted early by medical authorities, when the preliminary results showed a 53% and 51% reduction in risk respectively in acquiring HIV infection by circumcised males as opposed to uncircumcised males. The case for circumcision was so clear that it appeared to be a "no-brainer," even though scientists have no proof of how circumcision might actually work as an HIV preventative. Possible explanations include the keratinisation, or extra layers of skin forming on the penis, that occurs after circumcision serving as a retardant to HIV transmission, or the susceptibility to HIV in the Langerhans cells in the inner foreskin. Langerhans cells are immune cells which act as a reservoir and replication site for the HIV-1 virus. They also appear in other parts of the male and female genitals, including the clitoris. There was no suggestion by WHO that these cells, or the surrounding skin on the organs that contain them, be excised. The WHO circumcision recipe for the goose is not one for the gander.
Some policy makers raised similar objections to circumcision as those raised against HPV vaccination:
1) Efficacy - the WHO itself emphasized that circumcision was not 100% effective, and that, in fact, the HIV infection rate in circumcised males in the African clinical trials was still unacceptably high. There was no evidence that male circumcision protects female partners, or the partners of men who have sex with men. Both these sad facts have been born out by subsequent trials. Circumcised men who are HIV positive transmit the virus to their partners at the same rate as uncircumcised men. In fact, there was an observed increase in infection in the female partners of circumcised men who commenced sexual intercourse before their circumcision wounds had healed, despite extensive counseling of the couples to abstain until they got a go-ahead from a nurse.
2) Misallocation of Funds - some public health officials argued that a more effective use of funds was the current armament of HIV prevention strategies, such as ABC, especially the "C." It is hard to imagine an effective public health campaign that urged circumcision and continued condom use - why should a man go through circumcision if he still has to wear a condom?
3) Risk Compensating Behavior - there is a real prospect of an increase in risky sexual behavior by those circumcised, including reduced condom use and more sexual partners. In Africa the widespread male dissatisfaction with condom use and a desire for multiple partners and large families would likely be the chief motivators for males to seek circumcision in the first place, so that they would have a ready excuse not to wear condoms.
A final danger for women is that there might be a conflation of male circumcision with female genital mutilation, especially if the theory of the Langerhans cells (which appear in both the foreskin and the clitoris) is proven. The conflation in some parts of the world of male and female circumcision as a cultural marker or initiation rite is already problematic. It would be horrific if the call for more males to be circumcised in cultures where it is not practiced led to more female genital mutilation.
HPV Vaccination and Male Circumcision: Case Studies in the Failure of Public Health
So, here we have two new, expensive public health recommendations relating to sexually transmitted infections, one for females and one for males. Neither is a "no-brainer." Each is less than 100% effective, and has the real possibility of greater harm: Gardasil if the vaccination unleashes other HPV strains and circumcision if males have sex before the wound heals and if they embark on more partners without wearing condoms. Each risks draining resources from other prevention strategies, and each could harm women especially.
Cervical cancer can be caught and cured with pap smears, and HIV by a comprehensive ABC program. HIV in Africa is mostly transmitted by female prostitutes. Thailand embarked on a program to require condom use in brothels. Africa has not. The HIV prevalence rate in Thailand is now far lower than in Sub-Saharan Africa. ABC can work. The circumcision recommendation is, I believe, more a comment on the world's failure to implement ABC than on the benefits of the procedure, just as the HPV vaccine recommendation is a sad commentary of the U.S. and the world's failure to have a comprehensive public health system that gets Pap smears to every woman.
]]>The foregoing is abridged from a longer article of the same title that can be found at www.AlexanderSanger.com.