Law and Policy

Developed countries neglect poverty and social development

The goal of the International Conference on Financing for Development held in Monterrey, Mexico last year was to devise a strategy to eradicate poverty, strengthen economic growth and promote sustainable development. However, talk of greater resolve and stronger partnerships failed to make any changes. This failure was made worse by the extraordinary hopes created by the Millennium Development Goals and the pledges made by G8 leaders at the Okinawa summit in 2000. There, politicians wanted to cut cases of HIV/AIDS by 25%, TB deaths by 50% and the burden of malaria by 50%, all by 2010. The ambitious agenda called for a sizeable scaling up of action by the world's financial institutions. Recognising that their dismal record of loans would be under scrutiny in Monterrey, these institutions embarked on a public relations offensive to quell inevitable criticism of their work. Prior to Monterrey, the World Bank, in an assessment of the role and effectiveness of development assistance, claimed that overall progress has been remarkable. Yet 1.2 billion people still live on less that US$1 a day. The Bank calculated that $1 billion of efficiently targeted aid can lift 434,000 people above the poverty line. The US government promised an extra US$5 billion over three years from 2004, contingent on economic reforms in countries seeking aid. Using World Bank figures, this translates to only two million people brought out of poverty by 2006. To reach the target of 600 million people lifted out of poverty by 2015, the world's richest countries need to give US$1,382 billion or US$106 billion annually from 2003 to 2015. Current aid spending, however, is only US$6 billion a year. Even the World Bank points out that when inflation is taken into account, aid allocations by developed countries have fallen in the past decade. The politics of Monterrey were unusually destructive. The US government blocked efforts by some donor countries such as the UK to use the Millennium Development Goals to kickstart the debate. It also resisted discussing how countries might reach the UN target of 0.7% of national income spent on aid (the US spends about 0.1% of its GDP).

The obligation to advocate for and act on behalf of the poor rests not only with politicians but also with health professionals. Organisations representing doctors and other health workers—from the most local to WHO—should be on the front line of this work. Yet the societies, centres, colleges, offices, clubs, institutes and councils of medicine have largely abandoned the poor, preferring instead to advocate for themselves. Where are the arguments supporting the wider responsibilities of medicine for the health and development agenda? Why are they not calling their political leaders to account? Most egregious, given its vast budget, resources and the international respect it commands, is the silence from the US National Institutes of Health (NIH) and its Fogarty International Center. On human development, NIH, whose budget has been increased by over a billion dollars for bioterrorism research, is quiet at a time when it has unprecedented political responsibility. The fact is that without substantial additional aid, there will be more deaths among the poor than the conscience of the rich should be able to bear.¹

Addressing health inequalities

A focus on health inequalities with the aim of promoting equity in health and health services is growing apace in the developed world. Yet views on the differences in health between populations can sometimes betray a lack of clarity about when inequality matters (e.g. across groups defined by income, sex or race) and how inequality should be measured. The formulation of such policies requires that inequality is measured appropriately, and the data presented fairly. Thus, an argument based only on a ratio (e.g. that a particular problem has increased by 100%) hides the absolute difference (e.g. whether the increase was from one per million to two per million, or from five in 20 to ten in 20) and therefore how serious the increase actually is and whether it deserves additional resources. Not all health inequalities are inherently inequitable and therefore require or deserve public intervention, and the implementation of public interventions, whatever the cost, may be at the expense of other valid health needs. These authors therefore argue that governments should not agree to alleviate health inequalities as an agenda on its own without due consideration to other health-related policy objectives.

Instead, policymakers need a coherent ethical framework to establish which health inequalities lead to inequitable outcomes. This should form the basis for seeking to achieve a fair distribution of health, whilst accepting that some health inequalities will always exist in any society where people have the freedom to choose how they live, e.g. to eat unhealthily. Policymakers will then need to assess any proposed health inequality policies and interventions in terms of their value for money. It is undesirable that health inequality should take precedence over all other considerations or that health inequalities should be addressed at all costs.¹

Guidelines for public–private partnerships in health

Partnerships between the private and public sectors have expanded over the past decade and will continue to do so. Although such links may be broadly welcomed, there is considerable potential for conflicts of interest which can affect areas such as research priorities, the quality, outcome and dissemination of results, and public trust in science and research. The London School of Hygiene and Tropical Medicine has addressed this problem by drawing up a set of guidelines which provides a framework for fulfilling its mission whilst collaborating with the private sector. These guidelines advise staff on judging the suitability of private sector partners while protecting academic independence. These include: feeling comfortable with the partner's broad mission and public image, not just in the area of mutual concern; preferring multiple partners where issues are controversial so as to represent a broad spectrum of opinion and interests; avoiding working with companies whose interests threaten public health; ensuring that independence and objectivity of scientific judgement are paramount in conferences, publications and intellectual property rights; ensuring that agreements on such issues form part of a signed contract; and making the partnership a matter of public record.¹

Argentina: new National Programme of Sexual Health and Responsible Parenthood

A new National Programme of Sexual Health and Responsible Parenthood was passed in October 2002 in Argentina and will be established within the National Ministry of Health. It will include sexual education in schools nationally and free access to sexual and reproductive health services in public hospitals and under certain medical insurance schemes. The policy commits the country to spending US$14 million per year to provide free contraceptives through its public hospitals, including IUDs, condoms and oral contraception. However, private and religious schools can exempt themselves from providing sexual education, and health services run by religious organisations are not obliged to provide services. In mid-January 2003, the President had not yet signed the law. The Minister of Health, Ginés González Garcı́a, urging him to do so, announced that the number of abortions in Argentina had increased to more than half a million per year, and that in the last five years hospitalisations for abortion complications had risen by 46%, mostly among adolescents, who lacked access to contraception.^{1 2 3}

China amends one-child policy

According to China's revised one-child policy, families with unauthorised births will have to pay a “social compensation fee” instead of a fine. The new measure is meant to reflect the collective cost rather than punish individual couples for bearing children, and is considered a step towards a more gentle family planning policy that acknowledges the transformations in Chinese society and seeks to improve China's image in the world. The one-child policy, begun in the early 1980s, has been widely criticised as a draconian exercise in social engineering with stories of infanticide, forced abortions and sterilisations. In practice, the policy has been unevenly implemented. While it significantly altered urban birth rates, it barely made a dent in the countryside, where the majority of Chinese live, and although penalties ranging from stiff fines to confiscation of land were rampant up to the early 1990s, it has become much easier to have more than one child through loopholes and lax enforcement. Even official figures show that as many as 80% of Chinese children under age 14 have siblings.

Rural families and ethnic minorities can legi-timately have more than one child, especially if the first is a girl. Some have more than two in the quest for a male heir, and either pay the fines if they can afford it or become migrants. City dwellers can also have a second child if both parents were only children. Some local officials have encouraged unplanned births to collect the fees. Under the new law, local officials will no longer be able to pocket these fees and must turn the money over to the central government.

This is the first time the policy has been legislated; in the past, there were only government directives and targets. Demographic changes in China may make the policy redundant in future. Increased wealth and education have resulted in negative population growth in some parts of the country, while larger cities worry about their elderly population, who have no children to care for them. However, China's population will remain extremely large and a population policy will still be needed. The figures are elusive due in part to large, uncounted numbers of internal migrants with “unauthorised” children who are overlooked in the official census. The UNFPA is credited with helping China to re-orient its family planning policy.¹

Philippines reproductive health programme blocked

A Reproductive Health Care Programme has been proposed in the Philippines parliament that would educate women about their reproductive rights and provide them with accurate information, including on family planning. However, the bill is threatened by the Roman Catholic church and the lack of political will. The Church maintains a strong political base, especially through supporting politicians like former President Corazon Aquino and current President Gloria Macapagal-Arroyo. Their antagonism has made it hard to resuscitate other proposals on population and reproductive health that have languished in previous legislatures. Of 2.6 million pregnancies each year in the country, 53% are unintended, forced or unwanted, and complications of pregnancy, delivery and abortion lead to about 4,000 deaths annually. One in six pregnancies in the Philippines ends in abortion, and some 300,000–400,000 illegal abortions take place annually. Advocates of the bill argue that it is about reproductive rights, not just legalising abortion, as the Church makes it out to be. However, the government has already slashed next year's budget for the purchase of condoms and contraceptives, citing lack of funds. Foreign aid for family planning has also apparently been withdrawn.¹

Women's reproductive rights under attack in Peru

Following the release of a congressional report exposing forced sterilisations in Peru during the Fujimori presidency,¹ conservative officials in the Peruvian government are seeking to ban sterilisation, the fourth most popular birth control method in the country, which has only been legal since 1995 under Fujimori. The report itself could be viewed as a thinly-veiled attempt to generate opposition against sterilisation itself. The Minister of Health, Fernando Carbone, claimed that 200,000 women were sterilised without their consent from 1996 to 2000. However, most sources, including official Ministry records, the national ombudsman's office and women's groups, recognise 450–500 cases. Advocates of a ban on sterilisation, such as congressman Hector Chavez, are accusing Fujimori of genocide, claiming that indigenous Andean women were the primary targets, even though most data show that the programme was carried out nationwide. It is believed that among the leaders of this campaign are individuals associated with the Roman Catholic church and other conservative bodies. Chavez has worked with a US-based anti-abortion group, and Carbone with a Peruvian anti-abortion organisation with links to Human Life International, another US-based anti-abortion group. A high-ranking official of the Catholic church in Peru has publicly denounced emergency contraception as a crime, while Chavez has accused UNFPA and USAID of complicity in the forced sterilisations.

There is evidence that during Fujimori's rule, some state-sponsored health care providers coerced women into sterilisations with threats and insults, bribed them with money and food, or failed to provide accurate information or adequate care. These violations were well documented by women's groups, and attempts have been made to seek compensation for the women, some of whom died as a result of poor treatment. Few perpetrators have been brought to court, however, and virtually none of the women or their families have received any form of compensation as yet. Women's groups are concerned that if the Peruvian government is using these violations as a tactic to diminish women's contraception options, low-income and indigenous women's rights will be violated for a second time. Reproductive choices are already limited in Peru, with conscience clauses allowing physicians to opt out of giving care they deem offensive, including emergency contraception and post-abortion care. Abortion is illegal in Peru except when the life or health of the woman is at risk and physicians in Peru are required by law to report any woman they suspect of having had an abortion to the police.¹

Nine-year-old Nicaraguan girl has an abortion amid controversy

A nine-year-old Nicaraguan girl who became pregnant after she was raped in Costa Rica was refused a second trimester abortion there as, under Costa Rican law, abortion is not permitted after 12 weeks. The family returned home to Nicaragua and requested permission for an abortion. This sparked furious public debate, with the Cardinal and other Catholic church officials opposed and women's and children's rights groups supporting the girl's parents. A government medical board ruled (erroneously) that the risks to the child of continuing the pregnancy or having an abortion were equal, thus in legal terms failing to give a clear indication whether or not an abortion was required to save her life. The parents decided to take their daughter abroad for a legal abortion, but were told they would not be permitted to leave the country. The immediate situation was resolved when the abortion was carried out at a private clinic. Cardinal Obando y Bravo and others pressured the Nicaraguan government to investigate whether a crime had been committed. The attorney general ruled that the abortion had been necessary to save the girl's life and was therefore legal. The Archbishop declared that the girl's parents and the doctor had ex-communicated themselves from the Church ipso facto for going ahead with the abortion, whereupon 26,000 people signed a petition, originating from Spain, in which they demanded to be ex-communicated as well, for having “contributed actively in making the termination of the girl's pregnancy possible”. In the face of such a massive task, the authorities in Managua backtracked and the ex-communication was withdrawn. An estimated 15,000 women are treated for abortion complications in Nicaragua annually.^{1 2 3}

Namibian Health Minister says no to abortion

The Abortion and Sterilisation Act of 1975 in Namibia outlaws abortion in most circumstances. Attempts to pass a draft Abortion and Sterilisation Bill in 1996 were shelved because of pressure from church groups and other anti-abortionists. Now statistics show that backstreet abortions are increasing and that every month around 40 Namibian women travel to South Africa for abortions. Research found that over 7,000 women with abortion-related complications were dealt with in hospitals over a three-year period. Despite this evidence, Health Minister Libertina Amathila said that abortion would not be legalised in Namibia for at least ten more years and proposed research on why women were not using contraception. About half of legal abortions were on the grounds of the woman's HIV-positive status.¹

Canberra: first territory to decriminalise abortion in Australia

After nearly a decade-long campaign, the Australian Capital Territory (ACT), which contains the capital Canberra, became the first federal territory in Australia to remove abortion from its criminal code. The bill decriminalising the procedure for both women and doctors passed by nine votes to eight. The pivotal vote came from an MP who considered abortion as a crime to be an archaic notion. Requirements that women seeking abortion must have a 72-hour waiting period and look at pictures of fetuses were also repealed. This bill was built on abortion reforms in Western Australia and Tasmania.¹

Peruvian woman goes to UNHRC for justice

Peruvian law allows abortion for therapeutic reasons, yet a Peruvian women diagnosed with an anencephalic baby at 14 weeks of pregnancy was forced to carry it to term and breastfeed it until its inevitable death four days later. The Centre for Reproductive Rights (CRR), Latin American and Caribbean Committee for the Defence of Women's Rights and Counselling Centre for the Defence of Women's Rights filed a complaint on the woman's behalf to the UN Human Rights Committee, asking for recognition that Peruvian public health officials failed to comply with their own laws, and for compensation from the government.¹

Women to be punished for antenatal sex tests in India

Amendments to the Pre-Natal Diagnostics Techniques Act 1994 mean that mothers in India can now receive up to three years imprisonment and a fine of Rs 50,000 if they undergo a fetal sex determination test. This change in the law, supported by the National Committee on Empowerment of Women, has angered other women's groups, who argue that women are often forced by family pressures to be tested and abort a female fetus.¹

Adverse effects, compensation and the role of the courts

An action against three pharmaceutical companies by women who had suffered thrombo-embolisms which they claimed were caused by third-generation oral contraceptives lost their case recently in a UK High Court. It had been agreed that the action could only proceed if the relative risk was proved to be greater than 2.0, so that each woman's adversity was more likely than not to be due to the type of pill prescribed. Millions of pounds spent, 42 days of evidence and submissions, and complex arguments about statistics on relative risk all resulted in a legal judgement considered by this author to have failed to get to the heart of the matter, i.e. the extent of additional risk of thromboembolism with these particular pills. Two recently published meta-analyses put the summary risk of thromboembolism in users of third-generation oral contraceptives at 1.7. However, there was a dichotomy between the relative risk estimated for studies funded by pharmaceutical companies (1.3) and that for all other studies (2.3), the significance of which the judge failed to take into account. The author concludes that consumers might receive fairer treatment from a system of no-fault compensation, as scientific consensus is unlikely to emerge from court cases such as this one.¹

Kenya struggles with child prostitution

Worldwide, an estimated one million children are forced into prostitution each year, while the total number of prostituted children could be as high as 10 million. Kenya reports 10,000 to 30,000 child prostitutes, although experts claim the figure is much higher. The situation is such that most people may be alarmed to see a 14-year-old prostitute, but not a 16-year-old, who is no longer considered under-aged. In parts of the country, pimps have set up bureaux to supply men in Nairobi hotels with under-aged girls, while farm supervisors often demand sexual favours in exchange for money. Such practices are rarely exposed. The increasing problem of child prostitution can be attributed to poverty, child poverty and the growing population of AIDS orphans. In efforts to address these problems, Kenya has initiated new laws and campaigns to prevent child prostitution.¹

Wanting “a baby like me”: ethics and freedom in reproductive decision-making

Prompted by a deaf lesbian couple who deliberately sought to have a deaf child via in vitro fertilisation with the sperm of a deaf man, this article discusses ethics and freedom in reproductive decision-making. The women had a right to procreate with whomever they wanted. Although some couples with a disability seek to have a child that also has their disability, or a child like them in other ways (e.g. mixed race) others deliberately do the opposite. Many people would see deliberately creating deaf babies as a perverse manifestation of what they consider a broader “designer baby syndrome”. However, selecting an embryo for deafness does not harm the resulting child since that child is not worse off and deafness is not so bad that its life would not be worth living. While this author argues that with the use of genetic tests, couples have the moral obligation to select the child with “the best prospects”, what constitutes the best prospects is not always the same for everyone. Individuals need the freedom to act on their own value judgements, even if those judgements are disagreeable to others. Interference in reproductive decisions should only be considered acceptable to prevent important detrimental impacts of such choices.

Savulescu J. Deaf lesbians, “designer disability”, and the future of medicine (Education and debate). BMJ 2002;325:771–73.

Notes

1. Horton R. The health (and wealth) of nations. At: 〈www.thelancet.com/search/search.isa 〉, 26 September 2002.

1. Oliver A, Healey A, le Grand J. Addressing health inequalities. Lancet 2002;360: 565–67.

1. Walt G, Brugha R, Haines A. Working with the private sector: the need for institutitional guidelines. BMJ 2002;325:432–35.

1. EFE News Service. 20 January 2003.

2. Paginá 12. 21 January 2003. At: 〈http://dfn.org/news/americas/news-summaries030122.htm#statistics〉.

3. Mabel Bianco, Fundación para Estudio e Investigación de la Mujer, Buenos Aires, personal communication, 1 November 2002.

1. Ni CC. China redefines extra offspring as burden rather than offence. Los Angeles Times. 23 August 2002.

1. Sison M. Furore over Philippine reproductive bill. At: 〈www.atimes.com〉, 7 September 2002.

1. Loder A. Peru looks to ban popular birth control method. 〈www.womenseenews.com〉 30 August 2002.

1. 〈www.itechnology.co.za/index.php?click_id=122&art_id=qw10446917417 09B223&set_id=1〉

2. 〈http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/2789279.stm〉

3. Tremlett G, Widdicombe R. Rebellion forces Vatican u-turn in child rape case. Guardian (UK). 7 March 2003.

1. Maletsky C. Abortion ruled out. The Namibian. 28 November 2002. At: 〈http://allafrica.com/stories/printable/200211280273.html〉.

1. Canberra Times. 22 August 2002.

1. Centre for Reproductive Rights. UN Human Rights Committee petitioned with reproductive right case (Peru). Press release, 26 November 2002.

1. Times News Network. 7 December 2002. At: 〈http://timesofindia.indiatimes.com/cms.dll/xml/comp/articleshow?artid=30 598992&prtPage=1〉.

1. Skegg DCG. Oral contraceptives, venous thromboembolism, and the courts (editorial). BMJ 2002;325:504–05.

1. Siringi S. East Africa to tackle high rates of child prostitution. Lancet 2002;359:1756.