Round-Up

Measuring inequalities in health

G OVERNMENTS are looking for effective poli- cies to reduce health inequalities yet there are

no standard definitions, indicators or measure- ments of these inequalities. In this critical reflec- tion, the authors ask whether health inequalities or social group health differences should be meas- ured and present arguments for and against each approach, recognising that both are important. Focusing on average levels of health is mean- ingless in the context of large variations in health within populations. Measuring social group health differences has many advantages, including ease of measurement. Measuring inequalities across individuals would lead to an interesting debate about the pros and cons of the numerous summary indicators of the distribution of hea1th.l

It is not known whether the many interven- tions and polities to reduce inequalities in health are effective at al1 or by how much. A set of guidelines developed by an expert group in the Netherlands are useful for evaluating specific interventions, such as the provision of free milk to disadvantaged children. They may also be useful for evaluating broader polities, e.g. the effects of pricing polities upon inequalities in cigarette smoking by socio-economie group, but are likely to be complicated and expensive exer- cises. Such methods may be the only way to demonstrate that interventions have achieved their outcomes, however. Alternatively, policy- makers must rely on common sense and not expect such evidente before making and imple- menting rational polities.”

Another paper explores some of the issues to consider when developing targets for reducing inequalities in health. Two types of targets are described: those with a symbolic purpose, which inspire and motivate, and those with a practica1 purpose, which measure progress towards equity and improve accountability in the use of resources. #en setting the more practica1 targets, four principles are listed: (1) the target should specify a levelling up, so that the health gap is closed by an improvement in the health status of the least healthy group rather than a

deterioration in the health status of the healthiest group; (2) the target should be set for the more disadvantaged groups in society, not the healthier, more prosperous ones: (3) targets should focus on the wider socio-economie causes of health inequalities such as access to affordable, nutritious food rather than on disease-based outcomes; and (4) differential targets should be set, appropriate to the sex, ethnic group and socio-economie status of each population group. If the targets are based on these principles, the authors believe they wil1 have a higher chance of success.3

Murray CJL, Gakidou EE, Frenk J, 1999. Health inequalities and social group differences: what should we measure? Bulletin of World Health Organization 77(7):537-41. Mackenback JP, Gunning-Schepers LJ, 1997. How should interventions to reduce inequalities in health be evaluated? Journal of Epidemiology and Community Health 51:359-64. Whitehead M, Scott-Samuel A, Dahlgren G, 1998. Setting targets to address inequalities in health. Lancet 351:1279-82.

Cost-effectiveness analysis

@ OST-effectiveness analysis (CEA) in health care is a way of analysing how much health

benefit is likely to be produced by different investments. It converts effectiveness of inter- ventions into common units such as QALYs (quality-adjusted-life-years). This article explains how CEA obtains its single unit of value for comparing widely different effects. The main criticisms of CEA are that it does not pay enough attention to the individual and is insensitive to issues of distributive justice for the disadvant- aged. The authors argue that social values should be incorporated into CEA, most importantly the severity of the illness, life-saving measures and treatment in the face of death (i.e. the ‘rule of rescue’) and the leve1 of health potential. Other factors to be considered are maintenance of hope, assurance of treatment and age. Health economists must recognise the relevante of

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these social values and ethicists must help to make them as precise and usable as possible.’

1. Memel P, Gold MR, Nord E, et al, 1999. Toward a broader view of values in tost-effectiveness analysis of health. Hastings CenterReport20(3):7-15.

‘Sustainability’ and donor fatigue

?D ONORS supporting public health pro- grammes speak of the need for preventive

health services to be made ‘sustainable’, by which they mean that donor support should eventually be able to be phased out. This paper argues that this is not realistic and that there are no preventive health interventions that can operate effectively and consistently without financial support from the public sector. Instead of focus- ing on long-term ‘sustainability’, he proposes that donors think about the feasibility of large-scale implementation, the most efficient use of avail- able resources and the levels of subsidy needed.’

1. Lengeler C, 1999. From Rio to Iragua: sustainability versus efficiency and equity for preventive health interventions. Tropical Medicine and International Health 4(6):409-11.

Disease burden not the only criterion in US research funding allocations

A study published in the NEJM (1999:340:1881- 86) examined the criteria used by the US

National Institutes of Health to allocate funding for health research. It compared estimates of disease-specific funding for 29 conditions with six measures of the burden of disease. The meas- ures that predicted disease-specific spending were disability-adjusted life years (DALYs), the degree of disability and the number of deaths. Prevalente, incidence and relative financial burden of a disease were not significant as measures. Some diseases, e.g. AIDS and breast cancer, were allocated more than their predicted funding while others, e.g. perinatal conditions, were allocated less. Clearly, other criteria were also considered; the researchers themselves recommend that disease burden should not be considered the only important criterion.’

1. Rovner J, 1999. NIH allocates tïmding by burden of disease. Lancet 353(9):9171.

Japan finally approves the pil1

1 N June 1999, the Japanese Ministry of Health and Welfare officially approved the import,

manufacture and sale of low-dose oral contra- ception in Japan, nine years after the initial application for approval was made. The pill came onto the market in September 1999.l

1. The pil1 gets a green light! Yokohama Women’s Forum Newsletter 1999; 14(Aug):5.

Proposed amendments to US laws attack and support reproductive freedom

s EVERAL bills affecting reproductive freedom are going through the US Congress. The ‘global

gag rule’ is an amendment to a bill providing funds for family planning programmes overseas, which has just been passed. It bars non-US NGOs (hut not foreign governments) from receiving US funds if they engage in activities to change their own countries’ abortion laws.l,* A second is an amendment to the Child Custody Protection Act, which would make it a federal crime for any person other than a parent to take a minor to another state for an abortion. A third would grant contraceptive coverage to all federal employees, and a fourth, on equity in prescription insurance and contraceptive coverage, would prohibit private health insurance plans from excluding prescription c0ntraceptives.l

To achieve contraceptive equity, a law should stipulate that health insurance must provide coverage for al1 contraceptive needs, including medical appointments and all approved methods, and must not allow employers or insurers to refuse coverage based on a religious objection. Currently, only 15 per cent of large group health insurance plans in the USA cover the five most commonly used contraceptives, and half do not routinely cover any contraceptives. Yet two-thirds of women of reproductive age in the USA use private, employer-related plans.*

1. Kilborn PT, 1999. Definition of abortion is found to vary abroad. New York Times 24 November.

2. Kawadler W, 1999. Capitol gang still attacking reproductive freedoms. Reproductive Freedom News 8(8):6.

3. Contraceptive equity bik gain momentum in state legislatures (leaflet). Centre forReprodu&veLaw and Policy. 1 September 1999.

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NZ Pap smear results re-examinecl

F E New Zealand Health Funding Authority

announced in May that it would review 30,000 existing cervical smear slides, as wel1 as offer free Pap smears, counselling and support ser- vices for women in one area of the country. This announcement comes in the wake of a contro- versial High Court case in which a woman with cervical cancer lost her claim for damages against a pathologist who had misread or mis- reported a series of smear tests between 1990 and 1994. The case has focused attention on the New Zealand screening programme, which has not been formally evaluated since its inception in 1990. Questions have been raised about how an unaccredited pathologist was allowed to practise on his own, with few quality standards in place.’

1. Coney S, 1999.30,OOO smear-test results re- examined in New Zealand. Lancet 353:1775.

Lesbian couple in Israel seek official parental recognition

A lesbian couple are seeking state recognition of the fact that their three-year-old son has

two mothers, a birth mother and an adoptive mother. The women are dual US-Israeli citizens. Their son was born in the USA, where he was adopted by the birth mother’s woman partner. They returned to Israel two years ago and tried to register their son with both of them named as his mothers, but were told that this was impossible. In April, the High Court of Justice gave the Interior Ministry three months to explain its position in refusing to acknowledge the US adoption order.*,*

1. Lesbian mothers sue for parental recognition, Women Envision 68, April 1999.

2. High Court orders State to show cause for refusing to acknowledge lesbian adoption, Israelwire.com. 15 October 1999.

Islamic dress code imposed in Sudan and Afghanistan

Under a law dating from 1991, women must wear a headscarf and a long flowing robe or dress covering the arms and legs. Dresses and gown are to be provided to non-Muslim women at entry

points like airports and railway stations. Many north Sudanese women are Muslim and have complied with the new code, but in the South, women are hostile to it and are expected to resist. Special police have been deployed to make sure the code is observed.

In Kabul, Afghanistan, religieus police are en- forcing a similar code. They have been seen beat- ing women for showing their ankles, and in one incident a policeman jumped off a van in order to lash two passing women on the back wlth a tree branch. He then went into a clothes shop and lashed two other women in a similar way.’

1. Sudan to require Islamic attire for al1 women; and Taliban beat women for showing ankles. Women Living UnderMuslim Laws Newsheet. 1999; 11(1):21.

Pakistan Senate fails to condemn ‘honour killings’

N 1

1998, 286 women were killed in the name of family honour in Pakistan. Pressure from

human rights activists resulted in a resolution going before the Senate on 2 August 1999 con- demning the practice of killing of women in the name of family honour. Although the resolution appeared to have the support of various politica1 parties, it was not passed by the Senate. Human rights advocates had been hoping that a positive outcome would help to end the practice and send a strong message that women’s human rights are to be protected in Pakistan.l

1. Violente Against Women, Second follow up case PAK 120499. VAW, Geneva. 13 September 1999.

Catholic pregnancy advice centres to close in Germany

‘s” E Pope has intervened to disband the

Catholic Church’s pregnancy advice services in Germany, which are used by more than a third of al1 German women seeking compulsory counselling prior to abortion under German law. The Pope’s intervention has caused anger within the Church and the media. Some lay Catholic organisations have pledged to set up a privately funded service when the existing ones close.’

1. Paterson, 1999. Pope stops pregnancy advice in Germany. Guardian. 22 September.

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Law and Policy

Latin America: News Shorts

In Paraguay, a group of parliamentarians met to discuss population, health and development policy, including reproductive health, and the country’s attitude to reproductive rights and its legislation. As a result, the parliamentarians agreed to enter into a dialogue with NGOs and state-funded concerns active in the field.’

1. Mujer/Fempress, NO 212, July 1999,13.

The Senate in Uruguay has finalised a four-year effort to draft a law regulating the practice of assisted reproduction, based on a Spanish policy from 1988. It also regulates the preservation of pre- embryos, and forbids human cloning. Its most controversial features includes extending access to these techniques to single women. The Catholic Church argues that this would open doors for homosexual couples to seek the repeal of res- trictions on adoption (currently available only to heterosexual married couples) as wel1 as becoming parents by assisted conception techniques.’

1. Mujer/Fempress No. 214, September 1999,3.

Uruguay has the highest mortality rate in Latin America for women with breast cancer. A pro- gramme for the early detection of breast cancer began operation in May 1998 throughout the country, offering free mammograms primarily to women over the age of 40. Since its inception, the programme has reached 28,000 women. 1

1. Mujer/Fempress No. 215, October 1999,6.

Costa Rica has created an Inter-institutional Commission on Health and Sexual and Repro- ductive Rights’ to organise training for govern- ment health workers in the basic human rights of men and women over 18 as regards sexual and reproductive health, to implement the commit- ments made at international conferences on these issues, and to inform the population about fertility control methods available and their right to decide. 1

1. MujerYFempress No. 215, October 1999,9.

The Rio de Janeiro City Council in Brazil approved a bil1 requiring municipal workers to inform rape victims that they have a legal right to

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obtain an abortion. The bil1 awaits the Attorney General’s signature; if it is rejected, it will be returned to the City Counci1.l

A recent survey by BemFam in collaboration with UNICEF and the Health Minister of Brazil into the sexual activity of women aged 15-24 in Brazil has revealed that 48.1 per cent of respondents engaged in sexual relations before marriage and 49 per cent used some form of contraceptive. In 1986 a similar survey found that barely 4 per cent of adolescents and young women interviewed were using contraceptives.l

UNFPA has entered into a collaborative effort with the Health Minister of Brazil to develop and implement a family planning programme through the public health system, including contraceptives (birth control pill, diaphragms, other reversible methods) and professional training. The government has also announced that Germany wil1 provide Brazil with financial and technical assistance to diagnose and treat sexually transmitted diseases.’

1. Boletim Eletronico Saude Reprodutiva na Imprensa, 1-15 October 1999.

New quinacrine sterilisation ‘trials’ halted by international women’s health movement protests

A non-surgical sterilisation method using the former malaria drug quinacrine, which has

been performed on over 100,000 women in 19 countries but approved for use in none, has once again been at the centre of controversy. There has been renewed attention to this method of sterilisation in the USA, including an article in the Wal1 Street JournaP and television coverage on the programme Sixty Minutes in 1998. Earlier this year, the National Medical Committee of the Planned Parenthood Federation of America (PPFA) began an evaluation of the method by setting up an Ad Hoc Committee to review the literature and what is known about the drug. In July 1999 the committee held a meeting where presentations were given by a number of quina- crine’s supporters from different countries (as we11 as by others). From the evidente they con- sidered, the Ad Hoc Committee recommended that a ‘full-scale investigational study of the safety and efficacy of quinacrine sterilisation be

conducted in the United States, and that similar studies be done in several foreign countries.‘* This recommendation was put forward to PPFA’s board at a meeting on 13 November, at which time additional presentations were heard.

Following international protest, just prior to the November meeting, PPFA approved a revised resolution, as fellows, with only one vote against and one abstention:

‘RESOLVED THAT: the Board of PPFA.. . whole- heartedly supports the principles stated by the NMC that research studies on the safety and efhcacy of quinacrine sterilization (or any other method) should be methodologically rigorous, designed for FDA approval, and sensitive to the social and ethica1 issues surrounding the introduction of a new method of sterilization, in the spirit of the Cairo agreement.

FURTHER RESOLVED THAT: participation of affiliates in clinical trials for quinacrine steriliza- tion may be considered if and only when the FDA signifies that the toxicological studies permit the initiation ofphase II and/orphase IR clinical trials.

AND FURTHER RESOLVED THAT: the board recommends that during this period of time the national office work with afhliates, women’s groups, other stakeholder groups, and with the public to determine:

women’s need for simple transcervical sterilization methods, means for preventing abuse of contraceptive and sterilization methods, and alternate methods of long-term contraception/ sterilization.O

This resolution was much to the relief of women’s health advocates around the world who had signed on to an e-mail letter to PPFA on 11 November 1999, urging them not to proceed with clinical trials4 There had been some confusion as to when the Ad Hoc Committee had intended PPFA to initiate clinical trials.

As far back as 1991, the World Health Organization Toxicology Panel had advised that no clinical trials of quinacrine as a method of female sterilisation should be undertaken until full toxicology studies, including studies on carcinogenicity, mutagenicity and teratogen- icity, as we11 as pharmacokinetic studies, had been carried out and completed.5 NO such studies have yet been completed; WHO them-

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selves decided against fukher work on this drug at around that time.

On 18 November, the president of PPFA stated that ‘PPFA is not considering clinical trials at this time, nor was there ever any intention to consider such trials until toxicology studies are complete and further research into the socio- politica1 impacts have been accomplished.‘”

The drug’s supporters, meanwhile, were distributing quinacrine to individual practition- ers in developing countries until on 14 October 1998, the US Food and Drug Administration wrote to Steven Mumford, one of the drug’s promoters: ‘We request that you immediately halt the distribution of any and al1 quinacrine under your control, identify its location and voluntarily destroy it under FDA supervision.‘7

Further, use of quinacrine as a female sterili- sation agent was banned by the Supreme Court of India in 1998, following the submission of an extensive brief that documented the lack of in- formed consent and violation of ethica1 prin- ciples in its use on Indian women,* mainly very poor women in slums and rural areas.

The promoters of quinacrine sterilisation have said that toxicology studies in animals would tost over eight million US dollars9 Family Health International in the USA has been seeking to raise funding to proceed with these studies in animals for several years now, and funding has apparently been secured by them from a private foundation. According to David Sokal of FHI, preliminary results have already been submitted to the FDA, who have given the go-ahead to proceed with remaining studies on carcino- genicity in neo-natal mice and reproductive toxicity in rats. These are supposed to take another two years to complete, and FHI them- selves are not planning to conduct clinical trials until these results are known.1°

In Chile, meanwhile, women’s health advo- cates recently received information that the Ministry of Health might be planning a new study with quinacrine sterilisation in public hospitals. Last year, the Public Health Institute of Chile determined that female sterilisations with quinacrine must be stopped because the drug had not been approved in Chile. Feminists heard that the Ministry had sent letters to several public hospitals, inviting their participation in new research on the drug on 1,000 women. About 5,000 Chilean women have been sterilised with

quinacrine in previous years.” On 29 November, the Chilean Under-Secre-

tary of Health held a press conference and announced that no research with quinacrine would be initiated in Chile until the toxicology studies in the USA had been completed. In the meantime, the 1998 prohibition on importing the drug would continue to be enforced. He also recognised the significant contributions of the Chilean women’s health movement.*z

As one women’s health advocate wrote to RHM in response to these events: ‘There is no doubt that a safe and efficacious non-surgical method of sterilisation could prove to be useful- if it is truly safe and efficacious. However, the potential for abuse is not only hypothetical but real. If women’s reproductive rights are to be respected, then they must be protected from unethical experimentation, even when it is carried out in the name of greater choice.‘t3

1. Freedman A, 1998. Quinacrine sterilization. Wal1 StreetJournaJ. 19 June.

2. Summary findings of the PPFA Ad Hoc Committee on Quinacrine Sterlization (undated).

3. From the minutes of the PPFA Board meeting, 13 November 1999.

4. From: quinacrine_alert@hotmail.com 5. World Health Organization, 1991. Female

sterilisation: quinacrine pellet study. WHO Toxicology Panel Report 4.3.1. Summarised in Berer M, 1994. The quinacrine controversy one year on. Reproductive Health Matters. +fNov):99-106.

6. Letter to RHM from Gloria Feldt, President, PPFA, 18 November 1999.

7. Warning Letter from the US Food and Drug Agency, 18 October 1999. (In [lil below.)

8. Use of quinacrine as a contraceptive banned. The Hindu. 18 August 1998. (In [lil below.)

9. Kessel E, 1997. Overview of quinacrine sterilization. Presentation at Special Symposium on Quinacrine Sterilization, FIGO Conference, Copenhagen. (In [lil below.)

10. Dr David Sokal, FHI, personal communication to Shree Mulay. (In Illl below.)

ll. Gomez A. Latin American and Caribbean Women’s Health Network, Santiago. E-mail announcement, mid-November 1999.

12. Matamala, MI. Latin American and Caribbean Women’s Health Network. E-mail announcement, 26 November 1999.

13. lnformation from Shree Mulay, associate professor, Department of Medicine, Directer, McCill Centre for Research and Teaching on Women. November 1999.

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