This journal issue has at least two themes. The originally announced theme is about strategies for taking on the opposition to sexual and reproductive health and rights. Not surprisingly, abortion is the subject of several of the papers. Interestingly, the issues of support and opposition in relation to abortion law and policy are analysed from the point of view of Islam in the Middle East and North Africa (Hessini), the role of the parliament in reforming the abortion law from a gender and political perspective in democratic Spain (Cambronero-Saiz et al), knowledge and perceptions of ordinary people vs. the churches and government in Trinidad & Tobago (Martin et al), the stories of women who had unsafe abortions in Australia prior to legal reform (Wainer) and the process of taking a case to liberalise the abortion law to the Constitutional Court in Colombia (Cook).
But abortion is not the only subject of papers for this theme. Opposition to emergency contraception in Latin America is the focus of two papers, one about the changing political stance of different governments and the influence of that and of right-wing lobbyists on a major donor in Peru (Chávez and Coe) and the other about the opposition of the Catholic church in Latin America to emergency contraception, with examples from Peru, Brazil and Chile, and a scientific and conceptual analysis of the origins of that opposition (Faúndes et al).
Three other papers also contribute to this theme, all of them about rights, advocacy and provision of health services for some of the most vulnerable women in the countries concerned. One is about the efforts of two feminist NGOs to provide sexual and reproductive health services for sex workers in Brazil in a context of stigma and discrimination (Chacham et al). One is about building coalitions to support the health and rights of poor and minority women in two southern US states (McGovern). The third is an interview with a member of parliament who led a successful campaign to pass a law against sexual violence in Kenya, supported by women lawyers and other women's NGOs, and the opposition they met (Association for Women's Rights in Development).
Ironically, even when the issue of the campaigns described in these papers was not about abortion, abortion was a constant stick that the opposition waved about to try and discredit the efforts of those working for these other aspects of women's health and rights. Speaking of waving sticks about, in line with our main theme, we hope you will enjoy our journal cover, taken at an anti-globalisation demonstration in France in 2006. The photograph depicts an effigy of George W Bush, whose administration was aptly described in an article published on International Women's Day this year as someone for whom sabotaging programmes for women has become “something of a sport”.Footnote*
Speaking of political footballs, sexual and reproductive health matters are often described (and sometimes dismissed) by politicians and the media as “controversial”. In fact, many other public health and scientific issues are considered controversial as well, and popular “debates” in the press can sometimes generate more heat than light as a result. Differing interpretations of facts and figures, differing perceptions of what is moral and ethical, hidden and sometimes not so hidden agendas (such as wanting women's lives to be controlled and limited by childbearing), all contribute to the politicisation of sexual and reproductive health policy and practice. There is a strong belief that all “sides” must be aired in the name of “balance”, even when there is evidence that the information being put out by the opposition (who are not always the same people) is inaccurate and sometimes a deliberate distortion of fact, which they persist in putting forward even in the face of incontrovertible evidence that it is wrong. Why journalists feel forced to give space to such inaccurate information, in spite of the increasing level of education of people all over the world, who want and have a right to accurate news and information, is beyond comprehension.
Sex worker, Caracas, Venezuela, 2004
However, until journalists are in a position to stop feeding the public distorted information, access to information will suffer, and the anti-scientific claims made by the opposition to sexual and reproductive health and rights (such as that abortion causes breast cancer or that emergency contraception causes an abortion), will continue to get far more coverage than they deserve. And unfortunately, coverage of any ilk confers credibility, even where there is none to confer. Our job in the field in the coming years will be to convince politicians, ministers of health, development and finance, and parliamentarians and judges that they must not continue to take account of, be intimidated by or legislate on the basis of these views precisely because of the damage to the public health and human rights that they engender.
There are a number of features on other themes in this journal issue, including papers on the commodification of obstetric ultrasound and quality of care in abortion services in Viet Nam, (Gammeltoft et al; Nguyen et al). There is a paper on giving contraception more prominence in international policy again (Bernstein and Edouard). There is a wonderful perspective on the question of whether monthly menstrual periods are becoming optional (Aubeny) (oh, what a terrific thought, lucky young women!!) and a letter by Jayawardena about unsafe use of safe condoms (male clients of sex workers slipping them off in the middle of intercourse, is there no end to wickedness?).
Human papillomavirus vaccination
A Round Up section on vaccines against human papillomavirus seemed to be in order, to call attention to this new prevention technology, which could contribute so much to reducing the incidence of cervical cancer if it is made widely accessible in the developing world. The only concern worth mentioning as regards these vaccines, which on public health grounds should receive our full support and no opposition at all, is their high cost, especially for developing countries. The private sector price is very high by any measure, (e.g. US $550 in Poland for the three injections), and it is unlikely, even on a purely manufacturing-cost basis, that the price for the public sector would come anywhere near what countries are used to for vaccine costs (a pentavalent vaccine for infants costs about US $3.50–$3.75 per doseFootnote*, for example). Apparently, although both firms manufacturing HPV vaccines say they are committed to tiered pricing, neither has as yet put any concrete figures forward. Because very little public money was invested in the research on these products, public health bodies are not in a strong position to have influence over the price now. Moreover, as long as the companies can expand in the profit-making sector and need all their production capacity to serve that sector, there will be little motivation for them to start thinking seriously about tiered pricing to benefit the public sector in developing countries. Hopefully, WHO, UNICEF and UNFPA, among many others with influence, will pursue this as a matter of urgency, since the most pressing need for this vaccine from a public health point of view is in the developing world, where the greatest burden of cervical cancer exists – more than 80% of cases and more than 90% of deaths – due to the continuing, unconscionable lack of screening and treatment.
Roundtable on male circumcision
An unexpected addition to the journal appeared only a month before we should have gone to press,Footnote† as a result of a WHO/UNAIDS consultation on policy and programming on male circumcision for HIV prevention in Montreux, Switzerland. There, the published results of three randomised clinical trials were presented, which showed a substantial reduction in acquisition of HIV through vaginal sex during up to 24 months of follow-up by men who had been circumcised as compared to men who had not. Conclusions and recommendations regarding policy and programming were developed by WHO and UNAIDS thereafter, and can be found on their website.Footnote** It is thought that near-universal male circumcision would have a high impact in high prevalence HIV settings where there are currently low circumcision rates, primarily in sub-Saharan Africa. A 50–80% adult male population coverage rate would, according to modelling based on the trial results, reduce the risk of transmission of HIV to men substantially over an estimated 10–20 years. In the interim, although men's individual risk of female-to-male transmission would be reduced, no protective effect has as yet been shown for circumcised men's sexual partners, male or female. Equally importantly, protection for circumcised men would only ever be partial – condoms and/or other forms of safer sex will still be needed. Although the research evidence is clear, consensus on many other aspects of this matter is far from being achieved, starting with whether or not to promote this intervention and provide services and if so, where and to whom. Many points of view are emerging – clinical, public health, sociological, anthropological and cultural; in relation to priority setting in HIV prevention and delivery of health services; and in relation to sexuality, ethics, gender and rights.
Some of the participants at the Montreux consultation and several other colleagues agreed to contribute to a roundtable of views for RHM, and we are pleased to publish these papers in this journal issue. The WHO/UNAIDS conclusions and recommendations are excerpted to start off the roundtable, to set the context for the papers. The papers have had to be prepared at speed, and the authors deserve credit for their commitment in doing so. In fact, male circumcision is generating debate across the globe, which can only be a good thing, as it is a complex matter and far more than a straightforward public health intervention. We hope these papers will help to inform that debate. The papers are an excellent example of the breadth of analysis that should inform sexual health and rights issues. It is no surprise that the debate is heated – men's sexuality and penises (not just their foreskins) are suddenly being put under a bright light for examination. Whether or not this surgery will be the answer to reducing men's sexual risk of HIV infection remains to be seen.
Acknowledgements
Many thanks to Paul Van Look, Department of Reproductive Health and Research, WHO, for information on the cost of human papillomavirus vaccines and the Federation for Women and Family Planning in Warsaw for the price in Poland. Thanks also to Kevin DeCock and Kim Dickson of the WHO Department of HIV/AIDS for permission to print excerpts from the WHO/UNAIDS conclusions and recommendations on male circumcision.
Notes
* Wokusch H. War on terror, war on women. 8 March 2007. At: <www.commondreams.org/cgi-bin/print.cgi?file=/views07/0308-26.htm>.
* At: <www.unicef.org/supply/files/Product_Menu_2007.PDF>. Accessed April 2007.
† Apologies that the journal is late in arriving as a result, but we think it will have been worth the delay.