Moises Russo's blog

Ignorant Church: Analyzing Opinions of an Archbishop

2007-07-30T08:45:00-04:00

On June 10, I read an interview in the most important and conservative Chilean newspaper, "El Mercurio", with the Archbishop of Santiago, Cardinal Francisco Javier Errázuriz -- who is also the President of CELAM, the Episcopalian Council for Latin America and the Caribbean. He is arguable one of the most important men in the Catholic Church in Latin America.

Below I quote some of the questions and his answers (the translations are mine):

Interviewer: What will you do to keep this continent being mostly Catholic in a world where socialists and progressives are taking the lead, and where there is legalization of abortion, divorce, euthanasia and homosexual marriage?

Cardinal: It has always seemed to us an aberration calling the union of two people of the same sex "marriage." Sometimes "progressive" ideas are the most retrograde of the world. ¿What is more retrograde than what Mr. Zapatero is doing in Spain, forcing, by law, that the union between two people of the same sex is marriage? If you abandon natural law, I do not see what is the criterion not to go back to polygamy and polyandry, or not to call marriage the union of one woman with five men and two women. More retrograde policies I do not know!

Interviewer: How will you handle issues of birth rates in a world poorer everyday? Generally, poor people have more kids, since they don't have the means to avoid it.....

Cardinal: That is not the reason. A mother of a poor environment values being a mother, and does not make the decision of dividing her time: 20 percent for kids, the rest for her profession. Many young women in universities don't have maternity in their horizons. For some of the policies that are implemented to be successful -- such as policies on gender for women empowerment, it is important that they have few kids.

Interviewer: Do you think women empowerment is a bad thing?

Cardinal: No. It is very good. But causing the twilight of maternity for any reason is bad. I am very skeptical of policies that do not want to speak of marriage and maternity, but want to speak of sexuality and empowerment of women. They only value work outside of the home, they further contraception and do not favor the presence of the mother in the growth of her children.

Although the interview covered many different topics, these three questions do a good job in summing up what he thinks about sexual and reproductive rights. There are many issues that could be discussed, not least his adherence to the very discredited idea of a natural law, or his inability to understand the meaning of marriage as a union between two persons instead of man and woman, but I want to comment on two issues that I think are at the moment more pressing for Latin America, birth rates and maternity.

How is it possible that one of the most important men in the Catholic Church in Latin America believes that the increased birth rate in poor populations is due not to poverty and lack of opportunities, but to a real desire of those women to be mothers, which, according to him, is not found anymore in women who decide and have the opportunity to become professionals? Such a statement is nothing more than evidence of his total ignorance on issues of population and development. Disregarding the links between birth rates and development is nothing but a sign of his misunderstanding of these issues. That these kinds of men, who are not prepared to read, study and learn about what they babble on, and are leading millions of people in Latin America, is more than disappointing. You can't advocate on behalf of the poor (one of the supposed main objectives of the Catholic Church) from a position of ignorance and disregard of the knowledge being generated by those who are truly dedicated to overcoming poverty.

The second issue that I want to point out from this interview is what I think is a failure of the progressive civil society movements in Latin America. We have not been able to clearly convey to the population that we are not against maternity, which is how we are all too often portrayed by zealots like the one interviewed above. We have focused for years on access to contraception (which is still scarce), equal rights for women (an objective still out of reach) and the right to safe abortion (out of reach would be an understatement...).

We have neglected to talk about motherhood, and so we still have a long way to go in having the population understand that what we strive against is not maternity, but forced motherhoods, undignified lives due to a lack of control over one's own body, and the conception that women's role in life is reproductive. I do not intend us to be able to have men such as the one interviewed above change their opinion, since most of them are not willing to listen and learn, but we should be able to show the population that there is nothing more pro-motherhood than being progressive. We still have much work to do.

Birth Control and Social Investment in Latin America

2007-07-11T08:40:00-04:00

Latin America has been consistently reducing its fertility rates during the past decades. It is headed now to a window of opportunity for development that results from "demographic momentum." It is a chance that happens only once, and it requires effective policies to cash in on the benefits it can produce for a population.

Demographic momentum is a period of continued population growth that happens despite reduced fertility rates. It happens because there is an increase in the percentage of people in the population who reach reproductive age, the result of a reduced infant mortality rate that is also usually coupled with the fertility decline. Below you will see six population pyramids, numbered from the least developed country pyramid to the most developed population. If you have never seen a population pyramid before, you have only to know that it represents the number of people in every age group in a given population, the youngest of the population at the bottom of the pyramid and the oldest on the top of the pyramid. In effect, this means that the clearest pyramid shape will be seen when a pyramid has a broad base (large percentage of people in the youngest age groups) and a small summit (small number of people in the oldest age groups). You can see this in pyramid 1.

As a country develops and its population matures, its fertility and mortality rates decline. This causes a wavelike motion from the bottom to the top of the pyramid, where the bottom of the pyramid becomes smaller (less people of the youngest age groups), the middle of the pyramid broadens and the top starts to broaden as well. You can see the result in pyramids 3 and 4. Eventually, the decrease in infant mortality, fertility rates and mortality in general will cause the wavelike motion to continue to the top, making the pyramid seem more like a rectangle or even an inverted pyramid, what you can see here in pyramids 5 and 6.

Demographic momentum occurs in populations that look like pyramids 3 and 4. This means that the population may continue to grow despite its low fertility rates because of the large number of people who are now in reproductive age. The two pyramids in here correspond to what most Latin American countries look like right now.

However, this momentum is also coupled to what is known as "demographic bonus." This same population structure means that the working-age population is increased relative to the non-working population. The dependency rate of this population, that is, the number of very young or very old people that are dependent on middle aged people for survival is reduced, giving the population a possibility of strong economic growth and increased savings. The opportunities for accelerated development are obvious.

Nevertheless, the population bonus requires governments to institute appropriate policies to take advantage of it. Investment in education, reduction of gender inequalities, expansion of health services and provision of employment opportunities for the increased workforce are essential. A continued supply of sexual and reproductive health services and family planning alternatives is also indispensable, to avoid an increase in fertility rates that will again increase the dependency rate.

Too often in Latin America we hear conservative groups pointing out that some of our fertility rates are too low for a developing country (such as Chile, with a fertility rate of 2.1, which is the replacement rate for a population). This is a wrong assessment of the situation, since it is based on not recognizing the effects of demographic momentum on continued growth of a population; it also obviates the need for increased investment in social programs to boost development by taking advantage of the demographic bonus. Many Asian countries successfully used this window of opportunity in the late 80's and early 90's.

Latin America still has time left to take advantage of this opportunity. The wide inequalities between countries in Latin America, and especially between wealthy and poor populations in Latin America, have caused the demographic window to take longer to develop than in other regions of the world; it is just starting in some countries and will be fully in place between 2015 and 2030. We are just in time to advocate for investments in development that will benefit from this opportunity—and sustained and well funded sexual and reproductive health services are of utmost importance.

Note: the population pyramids were made using freely available software from the U.S. Census Bureau.

Opt-out HIV Testing: Moving Forward

2007-06-28T08:40:00-04:00

Last month, the World Health Organization issued new recommendations for HIV testing (PDF), moving from the current "opt-in" HIV testing model to the "opt-out" HIV testing model. The basic difference between the two is that the "opt-out" testing strategy is provider initiated, meaning that the health care provider, usually a physician, informs the patient that he or she will be tested for HIV, discusses the risks and possible outcomes, and advises the patient she or he has the right to reject testing with no negative consequences to him or her for taking this decision. Unlike the "opt-in" strategy, where the patient must explicitly ask for the test, the new strategy also eliminates the need for a written informed consent form from the patient and comprehensive pre-test counseling.

Since testing became available for HIV, it has been subject to what is denominated "HIV exceptionalism." The constraints put on health care providers, regarding testing their patients for HIV, are not present for any other infectious agent. These constraints have multiple causes—amongst them the initial uncertainty of what testing positive for the virus meant, the fact that there were no possibilities for treatment available, and most importantly, the risk of stigma and discrimination faced by people who tested positive for HIV. The human rights violations of HIV-positive individuals that have been a hallmark of the HIV pandemic revealed that society's understanding of the connections between health and human rights was virtually non-existent; the work of HIV activists is one of the important reasons for the understanding we have today of the right to informed consent and the respect for patient autonomy.

The new guidelines effectively overturn some of the constraints previously put on health care providers, mainly in light of the epidemiological evidence that suggests that the number of people who are HIV-positive but don't know it, especially in developing countries, could be close to 80 percent. I have heard many activists react against this new testing strategy, chiefly on considerations that they may lead to new abuses of power by health care providers and the possible violations of human rights that may follow.

However, I disagree; I think the new testing guidelines are a timely change from the old scheme, and that they are based not only on epidemiological concerns and medical developments (such as the existence now of antiretroviral drugs), but on a better understanding of what protecting human rights means and what the role of health care providers is.

The epidemiological reasons for the change in strategy are quite clear, and so I will not discuss them here. Suffice it to say that on public health grounds this change has been called for since the end of the 80's (PDF), perhaps earlier. Amongst the reasons given, are the possibility of a better epidemiological tracking of the infection, the positive effects derived from people knowing their HIV serostatus, the epidemiological identification of interrupters of transmission, and so forth. This call has been repeated by public health specialists ever since. The increase in testing uptake by the population, triggered by the change in strategy, is well documented.

The ethical issues behind this change in strategy are especially interesting to me, mainly with regards to individual autonomy, its balance with public health concerns and the role of health care providers. For example, it is now extremely difficult for any person in a developing country to have an HIV test without having to undergo a "voluntary" counseling process. This is because the legal provisions in many health systems mandate that a complete counseling and signed informed consent be performed by the health care provider before testing the patient. Is this really necessary? Does everyone who wants to know their HIV serostatus have to discuss with the health care provider whether they engage or not in risky behaviors, and how to make them less risky? The idea of voluntary counseling many times assumes that there is a relationship of trust between the health care provider and the patient, when in fact in most developing countries patients are randomly assigned a health care provider by the public health system, which furthermore will probably change from one visit to the other.

Health care providers are an essential part of the "opt-in" strategy, since counseling, because of the time it takes and resources it needs, is usually offered after health care providers do a risk assessment of their patients. It is not routinely offered. Even more importantly, we know that counseling and testing uptake is dependent not only on the information given to the patient, but also on who the counselor is and how much time the counseling session takes. The risk assessment often reveals that the people to be tested are the health care provider's stereotypes of what individual is at risk (usually vulnerable and disadvantaged populations), and so many people who perhaps have been at risk but are afraid to ask for testing will not know their status for long periods of time. Routine offering of the test to every patient will dissipate the discrimination that is present when those tested are only the ones who the health care provider deems are at risk.

The main problems associated with the scaling up of provider initiated testing are the remaining social burdens and risks of being identified as HIV-positive. However, these problems must be addressed through the creation of policies that ensure patient confidentiality and the enactment of laws that protect persons from stigma and discrimination. It will be up to us, civil society, to keep pressuring our governments for more and better policies that protect rights and enhance the possibility to enjoy them. Policies that base their protection of people in the possibility of staying ignorant about their serostatus do not represent progressive ideals. A defense of people's rights not only entails the protection of these from outside interference, but also calls to people to be responsible and protect every one else's rights. Routine HIV testing is a good development in the struggle to stop HIV, and is consistent with furthering patients' autonomy and recognizing the connections between health and human rights.

Compromising Human Rights

2007-06-14T08:15:00-04:00

It is happening all around us. The most recent is the notorious episode of the Democrats' decision to not only continue, but increase funding for abstinence-only programs in the United States. In other parts of the world, progressive parties are forming coalitions with "moderate" conservative parties in order to gain power in government. These coalitions are now interpreting international treaties' ideals of universal ARVs (antiretroviral drugs) coverage to a fixed number of beneficiaries or a frail "as many as possible." What is this all about?

Compromise. Compromise, compromise, compromise. The word is being used by our leaders in a way that shames their understanding of the limits of compromise. Human rights are defined as universal and indivisible precisely because they cannot be subject to any kind of compromise without it being a violation. They represent legitimate demands grounded in the dignity of all persons. Demands that are not negotiable. The word "compromise," used against respect for the rights to the highest attainable standard of health, education, life, forming a family, and all other human rights does not have the meaning "finding a common ground," but the meaning "making concessions that are not supposed to be made."

Let's rephrase what is happening right now with the true understanding of what the word compromise means in these situations. Politicians accepting education programs that are not based on evidence, but do in fact go against evidence are compromising the lives and health of young people. This sentence is what politicians should acknowledge in the news when they smile smugly showing their capacities of negotiation. They should receive a pat in the back from someone actually affected by their ability to locate the non-existing middle ground in human rights that tells them "thank you for compromising my life."

Progressive parties forming coalitions with conservatives have compromised their integrity. Every time they parade out of closed meetings holding hands like best friends, smiling at the result of their negotiations, they should say "We have reached a compromise. We just traded our values for a few years in power."

What happens in the end? Those of us who are progressive not because of political affiliation, but because of our common values and a morality that appreciates justice, autonomy and solidarity have nowhere to go. We realize sometimes too late that our leaders have been compromised.

At least I can say that it is not too late yet. Not too late for sexual and reproductive rights. We still have a strong civil society movement, and our roots are deeply grounded in human rights. We must not let the labels of "progressive" being worn by some of our leaders deter us from showing them the miserable work they are doing when they compromise human rights. We must show them that even if you were progressive once, it doesn't mean you are progressive now, and if you are not acting in a progressive way, either you are not acting at all or you are moving backwards.

Making Youth Participation Real

2007-05-24T08:55:00-04:00

Much is talked about how youth participation is an important asset on the response to the spread of HIV, or about how youth are a key population to target prevention efforts, considering that roughly half of the new HIV cases are in people under 25 years old. Even more, debates on issues such as whether schools should have comprehensive sexuality education programs or Middle Ages-styled chastity seminars are an everyday topic in the current political debate. We can even say that youth are starting to become an economically relevant group in developed countries, where an important burden of the health care costs of the aging populations will have to be shouldered by a smaller active workforce.

However, there are some issues that continue to stay unmentioned, except for youth activists that make efforts to bring them to the table. Not only governments, but also civil society organizations should reread some of the commitments undertaken at the International Conference on Population and Development in 1994 (ICPD), such as the following paragraph:

ICPD Para. 6.15 Youth should be actively involved in the planning, implementation and evaluation of development activities that have a direct impact on their daily lives. This is especially important with respect to information, education and communication activities and services concerning reproductive and sexual health, including the prevention of early pregnancies, sex education and the prevention of HIV/AIDS and other sexually transmitted diseases.

Since I consider myself to be a youth activist (although already 26), I may be biased in considering this paragraph important. However, I think it is fair to say that it is probably one of the most neglected commitments on the Cairo agenda, and at the same time one of the most important, since by definition it implies a look into the future and how to get ready for it.

Youth participation not only increases the knowledge and skills of the young people who get involved, but also increases self esteem and creates commitment towards our goals as societies. The result on development intervention programs and policies is that they are better focused on the target populations, include a broader understanding of the "real world" where they are supposed to be effective and provide a new source of information and data that may be analyzed during monitoring and evaluation. The list of benefits from youth participation is endless.

The International Planned Parenthood Federation (IPPF) has more than 140 Member Associations working in more than 180 countries, and has taken seriously the commitment that was undertaken—not only by governments, but also by civil society at ICPD. Youth participation has been institutionalized, and the Governing Council of IPPF has a minimum of 20% youth participants (who at the time of election are under 25 years old).

At a more local level, the Western Hemisphere Region of IPPF (IPPF/WHR) has been undergoing a careful process in the past years of restructuring its policies in order to open spaces for meaningful youth participation, and currently has a 20% youth participation rate in its regional Board of Directors. Considering that these changes mean little if they are not replicated at the country level, the more than 40 associations in the Western Hemisphere Region (which includes all countries in the Americas and the Caribbean) are all institutionalizing youth participation, with several of them already engaging youth under 25 years old in their respective Boards of Directors. By 2008, approximately 30% of the Regional Council of IPPF/WHR, its main governing body, will be youth participants.

The process has not been easy. A period of adjustment has been necessary in order to create the partnerships between adults and young people that are the essence of youth participation. However, nobody thought ICPD commitments were going to be easy, only that they were the right thing to strive for. Much work needs to be done to make youth participation effective and genuine, and avoid tokenism. Flexibility in schedules must be present in order to allow youth to attend meetings after school or university, provisions for expenses of transportation must be made to allow for participation of anyone regardless of economic status, and of course, time must be dedicated to training the young people who are just starting to get involved. However, the most crucial thing is the institutionalization of youth participation, making it a right to participate, not a charitable gift. The partnerships that have been developed at IPPF have proved enriching, both to the young people who benefit from the experience and knowledge of adults, as for the adults who may find new ideas and energy in the creativeness and enthusiasm of the youth they are partnering with.

The latter of course does not mean that grassroots work has been weakened—on the contrary! Throughout Latin America and the Caribbean, IPPF and its Member Associations provide more than 18 million services a year, and thousands of youth volunteers walk the streets of their communities providing valuable information and empowering their peers to take control of their lives and being able to live them in a responsible and fulfilling manner. But most important of all, policies like these ensure one thing: there will be someone to keep fighting for sexual and reproductive rights, and, just like at the beginning, IPPF will remain as brave and active as ever.

Brazil: People Before Profits

2007-05-24T08:35:00-04:00

Brazil is setting an example of good public health policy. Along with Chile, Brazil is one of the few developing countries that provide free antiretroviral (ARV) drugs to all the people diagnosed HIV-positive who meet medical criteria that warrants the beginning of therapy. Unlike Chile though (and many other developing and developed countries), Brazil also has one of the most successful, evidence based and rights based HIV/AIDS programs in the world. By this I mean basic strategies, like the distribution of condoms and the free provision of ARVs to those who need it.

Recently, on April 24, Brazil's Health Ministry issued a Public Ordinance declaring the ARV drug Efavirenz (Patented by Merck) of public interest, for the purpose of granting a compulsory license for public non-commercial use.

What does this mean? Well, it basically means that Brazil can either manufacture or import generic versions of Efavirenz without Merck's authorization. This of course will dramatically reduce the price Brazil is currently paying for the drug, which is used daily by 38% of the identified HIV-positive people in the country.

The ordinance occurred after Brazil rejected Merck's offer of selling the drug at U.S. $1.10 for a daily dose. Although this price may not seem much to some people (little more than U.S. $30 a month), we can bring it into perspective if we relate it to other countries in Latin America. For example, those 360 dollars a year are more than the WHO figures for total per capita expenditure in health of Haiti, Bolivia, Honduras, Nicaragua, Peru, Guatemala and Ecuador.

How has Brazil done this? Is it legal to dismiss a patent for a drug? When a patent for a drug is issued, it lasts for 20 years, and the pharmaceutical company that holds the patent can charge whatever it deems necessary to make profit. Prices only go down as competition starts, which is usually with the advent of generic medications to the market. Many people don't know (and many governments apparently don't remember) that international trade agreements give governments the necessary provisions to protect their citizens' health....even against "big pharma"! Issues related to international trade and patents are regulated by international law set by the World Trade Organization with the agreement of most of the world's countries. Patent regulations are in the document "Trade Related Aspects of Intellectual Property Rights", commonly know as TRIPS agreement (if you want the full document you can download it here as a PDF), which were further regulated in the 2001 Doha "Declaration on the TRIPS agreement and public health".

WTO, unlike other international bodies, has a political system that works by consensus. That is, any decision taken in WTO must be accepted by every one of its members, who then also agree to follow the decision taken. This gives financially disadvantaged countries considerable political clout compared to what they have in other international institutions (such as the IMF or World Bank).

The 2001 Declaration established provisions that safeguard the populations against patent restrictions that may endanger public health. Amongst them is the right of any country to declare an emergency situation and issue a compulsory license, which means that generic drugs may be produced or imported without consent of the patent holder. Some other provisions are the right to undergo parallel negotiations, which basically means that a country can do some "window shopping" around the world for the best price being offered in any country of any branded drug. In effect, this means the use of globalization to cut the costs of a country's expenses for a drug. For example, you may know that drugs in India are offered by pharmaceutical companies at substantially lower prices than in Bolivia or Nicaragua, be it because of the large quantity being bought or because of the strong competition by local pharmaceutical companies. Finally, it provided the least developed countries with a 10 year extension to comply with the TRIPS agreement, pushing the date to year 2016.

Brazil is making use of internationally accepted mechanisms to protect its population. Allowing the manufacturing of generic drugs decreases the price of an ARV treatment from roughly U.S. $10,000 a year in developed countries to U.S. $300 a year. You can imagine the positive change in access that this causes for people in poor countries.

Although pharmaceutical companies sometimes whine about how this may damage research and development (R&D) of new drugs, this is nothing but spoken garbage. Developed countries amount to more than 75% of the pharmaceutical market, and regions such as Africa to nothing more than 1%. In an industry with a profit margin of roughly 30%, it is ridiculous to think that this would damage them in any way. Besides, the R&D argument has absolutely nothing to do with developing countries that, besides HIV, are dealing with tropical or neglected diseases and only about 1% of the new drugs developed are aimed towards helping people facing these diseases. This information and a call for corporate social responsibility from pharmaceutical companies can be found in a report from Oxfam on the matter (PDF). There are many other arguments put forward that are also implausible, and you can see them refuted by Oxfam here.

There are some medicines that are essential if we truly believe in a right to the highest attainable standard of health. The WHO defines essential medicines as those "that satisfy the priority health care needs of the population", and you will notice that in this case, Efavirenz is in the updated WHO list of essential medicines. Brazil is an example not only of a country that establishes a good national strategy to stop HIV, but also of the correct use of international provisions to protect its citizens.

It is up to all of us to hold governments accountable for using every available means to insure access to essential medicines. Remarkable initiatives like the "Campaign for Access to Essential Medicines" of Doctors Without Borders can only be successful once we take notice, think globally and act locally.

Male Circumcision and HIV Prevention

2007-05-01T09:00:00-04:00

As HIV continues to spread, the search for new and effective methods of prevention continues. Male circumcision is one of the proposed strategies, and shows potential in countries where circumcision rates are low and HIV prevalence is high. In a post April 5, Masimba Biriwasha mentioned some of the dangers he sees in establishing policies of male circumcision for HIV prevention. I want to go deeper into the issue.

In the past few years, many studies have indicated a reduced rate of transmission of HIV in men who have been circumcised compared to uncircumcised men of similar characteristics; some studies were even stopped due to ethical reasons because of the lower transmission rate identified in the groups of circumcised men. The results of these trials show an important reduction in HIV transmission (approximately 50%), not only within observational studies, but also in a randomized trial conducted in South Africa.

Although there continues to be doubts regarding how circumcision prevents HIV from being transmitted, some experimental evidence suggests understandable biological mechanisms for the lower transmission rates. This makes the results of these observations and trials all the more promising.

Statistical modeling for wide programs of circumcision in southern Africa estimate that 2 million infections could be prevented! And a cost-effectiveness analysis suggests that in sub-Saharan Africa this could also save money in the long run.

So ... what do we make of all this? Should we start mass circumcision programs in countries with low circumcision rates and high HIV prevalence, such as Namibia, Zimbabwe and Botswana? Are there any other factors that should influence our decision?

The epidemiological benefits of circumcision as a public health policy are becoming quite clear, and the World Health Organization endorses it as an "efficacious intervention for HIV prevention". There are, however, a few issues that still need clarification, such as risk compensation of individuals who are circumcised, and how to deal with this. Risk compensation is the potential increase in risky behavior that individuals have when they feel their vulnerability to a disease reduced. In this case for example, this could mean the decrease in condom use amongst circumcised individuals, or the increase in the number of sexual partners, since the risk of HIV infection is thought to be no longer present or drastically reduced.

The problem is that it will be difficult to create public health campaigns that at the same time induce men to get circumcised and continue using condoms. However, this should not be a sufficient reason to completely halt the development of public health policies, but should point to efforts in developing novel risk reduction interventions and messages that are consistent with this kind of intervention.

The biggest problem however with a public health policy of mass circumcision is not on the epidemiological data, but on the ethical issues that may arise from such a policy. Circumcision is a normal procedure in the United States, where approximately 58% of newborns are circumcised. It is also a common procedure in the Jewish population, since it symbolizes a covenant with god and is mandated by him, and of course also in Muslim populations, where although it is not present in the Koran it is part of the sunnah (the laws based on the life of the Prophet) and is further justified as a hygienic procedure. However, by WHO estimates, the procedure is far from common in the rest of the world (certainly not common in Latin America!), and apart from the possible prevention of HIV and STDs, there is no medical reason for routine circumcision.

Ethical issues arising from such a policy need to be extensively debated before starting a massive intervention. Ideals of bodily integrity should be taken into account when the institution of such a policy is planned. Circumcision may be considered a violation of the human being's wholeness, and the integrity of the body is something that should be respected. The studies that have been conducted to provide the data on the effectiveness of circumcision only involved individuals who were 18 or older, so an informed consent took place and they accepted the procedure. However, it is not hard to imagine a situation like in the United States, where for supposed hygienic reasons circumcision is done to many newborns. Circumcision in the United States has become a cultural procedure, since no medical society endorses routine circumcision.

The situation here in Chile is quite different. The permanent removal of tissue from an individual that does not consent to this is not easily justifiable without falling into religious or cultural arguments There are many men who were circumcised as children that object to this practice, and there are increasingly more organizations raising awareness that circumcision is a violation of a child's human rights (see for example the work of the National Organization of Restoring Men, Doctors Opposing Circumcision and even a petition to the International Court of Justice in The Hague which includes it as torture and mutilation of children).

It is hard to disregard the importance that an intervention that has long term effectiveness and is not dependant on behavioral change could have; the confirmation of a health benefit alters the ethical perspective, since it is no longer a routine procedure with no scientific reasoning behind it. In my opinion, there is enough evidence to move forward regarding male circumcision as a public health policy, although careful monitoring of risk compensation should take place, and an open debate that involves the communities where this will happen should be started. This should not be only a top-down strategy to stop HIV transmission, but the ethical and cultural issues attached to it should also be addressed.

There is much to discuss on how such a policy should be implemented, what age groups will be part of the intervention, and of course, where the funds will come from. This last point is extremely important. Funds for such an intervention should not come from other preventive strategies already in place, or from funds dedicated to researching new strategies. We should not forget that even though male circumcision may save money in the long term, two thirds of the African population is already circumcised, and HIV continues to batter the continent.

Mexico on the Way to Make Things Right

2007-04-18T08:50:00-04:00

After years of advocacy from human rights organizations and feminist groups, a bill that would make abortion legal on request for any woman in Mexico City during the first trimester of pregnancy is scheduled for a vote soon by the state legislature of Mexico City. With a population of over 8 million people, the new law will make Mexico one of the most progressive countries in Latin America regarding abortion laws. The only other countries in the region that have liberal abortion laws are Puerto Rico, Cuba and Guyana

For the moment, the situation is looking good. Although the usual suspects have begun their efforts to try to stop the law from being enacted, their efforts may be futile. The state legislature in Mexico City has a liberal majority, which is expected to vote in favor of the new law. However, it does not cease to amaze me how in the same sentence, without even taking a breath to clear their windpipes of so many lies, conservative speakers make a "defense of life" (not women's lives that's for sure) and warnings of how such a law may incite violence against doctors who perform abortions. It is revolting to see them move their misogynist machinery of repression in order to maintain a status quo of women being subjected to the humiliating and life endangering conditions of unsafe abortions.

In a ridiculous attempt to frustrate the imminent approval of the bill, the Green Party in Mexico has introduced a proposal to raise the number of years in jail for a woman who consents to an abortion or for a person who performs an abortion. I have nothing but contempt for the people who promote such an initiative. How does further punishment of women improve the situation? What obscene pleasure do they get from the pain of women who clandestinely run the risk of botched abortions? How do they protect life by throwing women in jail while at the same time opposing comprehensive sexuality education? Conservatism in Latin America seems more a perverse cult than a political position.

On the sidelines of the debate has been Mexican president Felipe Calderon. Apart from a few comments of how he is "for life" (yeah right...), he has pretty much stayed away from the fray. Although some media has hypothesized that he is trying to steer free from the red hot debate, it seems to me he is just making the wise choice of not losing any more legitimacy. After all, he won the elections very similarly to how George Bush won them the first time ... that is to say, he didn't.

The Catholic Church deserves special attention. Not only have they been directly meddling with political affairs of a lay country (not that they have ever cared ...), but they have even let one of their Bishops ramble how voting in favor of the law would mean "automatic excommunication." Has the canonic code changed in the past few months that he thinks this can actually happen? Or does he just have no shame in lying to catholic people in Mexico? I think the latter. Not only does the canonic code say nothing with respect to enacting abortion laws, but even for women who exercise their right to an abortion there is no such thing as "automatic excommunication." Did the Mexican Church forget to read the part where there are exceptions to excommunication, such as acting because of fear or to avoid a greater evil? Have all the paragraphs on the role of the conscience been erased lately? There is absolutely no contradiction between being a good catholic and supporting a law that saves women's lives and dignity.

However, this is a time of rejoicing for those of us who believe in women's rights, which include the right to a safe abortion. Even if the bill is rejected, feminist and progressive organizations in Mexico have succeeded in putting the abortion debate on the frontlines, and by that they have started a process that is unstoppable. Under oppression, against repression and even when there seems to be no possibility of moving forward, people break through to claim their inalienable rights.

Chile: a Democracy Without Debate?

2007-04-10T08:50:00-04:00

Editor's note: Today we welcome Dr. Moisés Russo, writing from Chile. He has experience in healthcare and bioethics, and will be reporting on reproductive health in South America.

Is not Chile the country in Latina America that sets an example of a working democracy after a military regime? Isn't Chile the country where the government and opposition coalitions have provided stability for the past 16 years? Perhaps it is, although we may realize today that the price for stability that Chilean parliamentarians are willing to pay is far too much: women's lives.

Abortion is illegal in Chile since the last year of Augusto Pinochet's dictatorship (1989), where it was banned even if it is medically required to save the mother's life. The tragedy of unsafe abortion in Chile, where an estimated 150,000 illegal abortions --- 1/3 of the total pregnancies take place every year, was finally brought cautiously forward by parliamentarians of the ruling political coalition. Being mindful of how the abortion debate stirs immediate self-righteous right wing folly, they presented a project that would make induced abortion legal until 12 weeks if the mother's life is in danger or if the pregnancy is the result of rape. Incomprehensibly, the proposed law didn't stir any debate, not because it was approved, but because it wasn't even discussed! An alliance of right wing politicians, including the Christian Democrats (who are part of the governmental left-wing coalition), voted to not to discuss the bill at all. Conservative parliamentarians have effectively undermined one of the pillars of democracy, the possibility of debate. Although more than 50% of the population agrees with having some form of abortion legalized, parliamentarians have decided that even though unsafe abortion is a recognized problem, they will not even discuss the matter.

Although the Chilean government has been setting some public health examples on how to address some sexual and reproductive health problems (President Michele Bachelet recently approved the distribution of free emergency contraception for minors 14 years or older), the legislative branch is not living up to the challenge to maintain a legitimate democracy. If problems like unsafe abortion not only are kept secret, but can't even be debated, how can the Chilean congress claim to be representing the Chilean people? What is the purpose of parliamentarians if not to debate the most important problems in society? Apparently, Chilean women will have to wait longer for their voices to have even a chance of being heard.