Claudio Csillag

Appeal court bans use of emergency contraceptive in Chile

A Appeal Court ruled on April 2 that an emergency contraceptive, levonorgestrel, cannot be sold or distributed in the country. The courts decision reverses a ruling made in the previous week when a request to prevent the sale of the drug by the Institute for Research and Advocacy for Women, the World Mothers Movement, and the International Institute for the Study of Human Life was turned down. The court has now reversed the ruling in light of further evidence submitted by that group with two other abortion groups, Front for Life and Solidarity Action, indicates that the drug induces abortion and is not a contraceptive. The decision means that no changes to the sale or distribution of the contraceptive can be made until May 14 when there will be more hearings. The debate surrounding the drug began in March when the Ministry of Health announced that it had authorised a pharmaceutical laboratory to sell levonorgestrel as an emergency contraceptive. This decision, bearing in mind that abortion is not legal in Chile, prompted an intense debate among clinicians, patients, religious organisations, and antiabortion groups across the country. In the past several antiabortion organisations and the Catholic Church have made clear their opposition to the “day after pill”. However the Minister of Health, Michelle Bachelet, and Chile’s President, Ricardo Lagos, have declared their support for the pill after taking advice from the Institute of Public Health, which stated in a recent report that the drug is a contraceptive and does not induce abortion. The government’s decision has been backed by the Medical College of Chile. Critics state that the country’s constitution protects the right to life from the moment of conception and therefore the drug does induce abortion. In an effort to side step the ethical argument, Bachelet stressed the public health importance of the government’s decision in an interview with the El Mercurio newspaper. “We cannot deny the choice to one part of the population because of the view that another part of the population might have”, she said. The drug was to be sold under prescription in emergency cases, such as rape and failed birth control, for about US

Data show Brazilian Indians' unmet health needs

5 for a two dose treatment. According to Gonzalo Navarrete, director of the Institute of Public Health, last week’s court decision will have little practical impact at the moment. He explained that the company that received authorisation to sell the pill will not complete the development of the final product before hearings on May 14.

Sex education is key to combatting AIDS in Brazil

Brazils indigenous Indian population numbers 330000 persons which is triple the number in 1970 but considerably lower than the 4 million existing during the European invasions. The indigenous population is 0.2% of total Brazilian population. Life expectancy is very low at 48 years compared to 65 years for the average Brazilian. Data are unavailable in many regions and for some indicators. Until 1991 the Indian National Foundation (Funai) was in charge of Indian health services. In 1994 the Ministry of Health lost all responsibility for provision of health services. The relationship between the two agencies is poor but there is a great need for collaborative action. The Ministry of Health should deliver immunization programs personnel training endemic disease control and sanitation services. Funai should be in charge of health care delivery and should coordinate activities with the Ministry of Health. Funai has a shortage of doctors. There are only 16 doctors serving 330000 people and the 667 health professionals are insufficiently trained. The main causes of death are respiratory diseases and diarrhea. Over 43% of total mortality occurs among children aged under 5 years. The lowest life expectancy is in the Amazon region and is 42.8 years. The lack of complete data even on government reserves hampers evaluations of any program impact.

São Paulo's health assistance plan restored

About 60,000 children in Brazil were born from an AIDS-affected mother, and 16,000 were orphaned by AIDS. These stark figures were released by the Global Orphan Project and the Instituto Promundo at the EducAids conference. About 90% of childhood AIDS cases were a result of perinatal exposure, and the other 10% from unknown exposure. In response to these prevalences, the EducAids initiative, which aims to promote AIDS education in schools, was considering sex education for preschool children. The coordinator of the governments AIDS prevention program, Pedro Chequer, believes sex education for children as young as 4 years old would reduce AIDS among teenagers and help avoid unwanted pregnancies. The Minister of Health supported this concept. Jose Serra, the Minister of Health declared that it was not the aim of the ministry to avoid teenage pregnancy but to prevent early sexual intercourse. In 1997 the number of deliveries by girls aged 15-19 years had risen to 25.27%, from 21.41% in 1993. However, the number of deliveries for women over age 20 are falling. Pedro Chequer, EducAids coordinator, stated that despite these facts, campaigns for sex education would be opposed by the Roman Catholic Church.

Sterilisation in São Paulo

the main criticism made by major medical organisations, such as the Paulista Association of Medicine, Sao Paulo’s Regional Council of Medicine, and the doctors’ union. In addition, many critics believe that the plan is no more than the mayor’s personal political marketing device. Resistance by these and other medical organisations forced the Municipal Health Secretary to step down last November (see Lancet 1995; 346: 1418). The new secretary, Roberto Richter, is pushing the project forward and managed to implement it in one hospital in the Pirituba-region. Though the plan has been functioning since the beginning of January, the director of the Pirituba hospital said it is early to assess the plan’s efficiency. Late in January a request by the Paulista Association of Medicine, the National Federation of Doctors, and Sao Paulo’s doctors’ union

Better nutrition of Brazilian children

Illegal in Brazil until last year voluntary sterilization operations are to become free and available in the public health system in the countrys largest city Sao Paulo by the end of this month. Hospitals in the city have started to register patients willing to undergo sterilization. The patient has to put in a formal request for the procedure and the case has to be approved by a technical commission. Last year the Church had opposed the legislation of sterilization (see Lancet 1994; 344: 325). It is now opposing sterilization as a contraceptive method. Professional bodies such as Sao Paulos Physicians Union and its Regional Council of Medicine have also criticized the new law which although widely welcomed by the public does not lift charges for other contraceptive methods. The citys mayor Paulo Maluf has stated that the procedure will not be encouraged among the poor merely made available to them. Rio de Janeiros mayor Cesar Maia is defending a similar bill. (full text)

Sterilisation to be legal in Brazil

The prevalence of child malnutrition in Brazil declined 60% over the period 1974-89. This decline was not however uniform across the country causing regional differences to therefore widen. These findings are based upon a 1975 national survey of 55000 families and a 1989 survey of 14000 families. More specifically the overall prevalence of undernourished children in Brazil fell from 18.4% to 7.1% over the period. Among those aged 4-5 years a 68% reduction was experienced but only 47% among infants. Prevalence in the northeast region was sliced in half from 27%; this decline is in striking contrast to the more pronounced drop in prevalence in the south from 11.7% to 2.5% over the period. Socioeconomically the prevalence of malnutrition among the poorest 25% of the population increased from 5 times to 10 times the prevalence among the richest 25%. The authors conclude by asserting that this rapid improvement in child nutrition was due to the rapid economic growth experienced in the 1970s in the country the expansion of health and education services and declines in the national birth rate and the number of families living in rural areas.

Project held up in Mozambique

Brazils lower house of Congress has passed a bill that legalizes voluntary sterilization for both sexes. According to the bill introduced by Eduardo Jorge of the Workers Party the public health system is obliged to offer all contraceptive methods with the exception of abortion. The bill if approved by the Senate will enable people to do legally something they have always done. Female sterilization is one of the most commonly used methods of contraception (42% of all cases) second only to the pill (43%). Around a third of Brazilian women have undergone surgical sterilization and in some regions the figure reaches 70%. These operations have contributed to the decline in birth rates. In 1970 the number of children per woman was 5.7 whereas in 1991 it was 2.5. Many of the sterilizations have been done at the same time as cesarean sections which account for a third of all births in the country. To avoid a sharp rise in the number of cesarean births the bill forbids sterilization during deliveries. If the man or woman agrees to the operation he or she has to sign a conscience clause. The doctor that performs sterilization surgery without the document will be subject to up to eight years in prison. The bill according to Jorge will cut down on the clandestine mass sterilization programs taking place around the country. The Church has declared its intention to block approval of the bill by the Senate. (full text)

Fibromyalgia: the Copenhagen declaration

The UK is the only English-speaking nation where the regulation of chiropractic is by voluntary arrangements rather than by statute, says a King’s Fund working partyl that has made recommendations on the scope and content of a statutory register to regulate the education, training, and practice of this form of therapy. Chiropractic, the second commonest form of complementary therapy in the UK, is statutorily regulated in 17 other countries. The practice originated in the US and was based on the premise that reduced nerve flow led to disease. In the UK there are about 800 practitioners; the number has doubled in the past 5 years and is expected to double again in the next 5 years. The Anglo-European College of Chiropractic, Bournemouth-the first school to offer training in the UK-was opened in 1965, and in 1988 it became the first complementary medicine college to offer an accredited (4-year) degree course in the UK. Since 1992, graduates have had to undertake an additional year of postgraduate training in clinical practice with a recognised principal to qualify for full registration by the British Chiropractic Association. The Institute for Pure Chiropractic registers graduates of the McTimoney School of Chiropractic in Oxford and The British Association of Applied Chiropractic those from the Witney School of Chiropractic, Oxford. These two schools run part-time diploma courses. The three organisations, which formed the Chiropractic Registration Steering Group in 1991, differ in emphasis on education and