Entre Nous: the European magazine for sexual and reproductive health: no. 47–48: networks

THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No. 47-48 - Autumn 2000 NET\NORKS Danmarks Natur-og Lmgevidenskabelige Bibliotek ~t II 1111111111 ~" ,1el• ENTRE NOUS The European Magazine for Sexual and Reproductive Health Entre Nous is published by: The Women's and Reproductive Health Unit WHO Regional Office for Europe Scherfigsvej 8 OK-2100 Copenhagen 0 Denmark TeL: (+45) 3917 1451 or 1426 Fax: (+45) 3917 1850 E-mail: entrenous@who.dk Chief Editor Dr Assia Brandrup-Lukanow Editor Jeffrey V. Lazarus Administrator & Editorial Assistant Dominique Gundelach French translator Yvon Prigent ISSN 1014-8485 Entre Nous is funded by the United Nations Population Fund (UNFPA), New York, with the assistance of the World Health Organization's Regional Office for Europe, Copenhagen. It is produced and distributed three times a year in English and French by the Women's and Reproductive Health Unit of the WHO Regional Office for Europe. Present distribu- tion figures stand at 5500 English, 2550 French, 2000 Spanish, 2000 Portuguese, 1000 Russian and 500 Hungarian. Entre Nous is produced in: Hungarian by the Department of Obstetrics and Gynaecology, University Medical School of Debrecen, P.O. Box 37, Debrecen, Hungary. Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, P-1056 Lisbon, Portugal. Russian by the WHO Information Centre for Health for the Central Asian Republics, Toktogoul str. 62, Bishkek 720021, Kyrgyzstan. Spanish by the Instituto de La Mujer, Ministe- rio de Trabajo y Asuntos Sociales, Almagro 36, 28010 Madrid, Spain. The Portuguese and Spanish issues are dis- tributed through UNFPA representatives and WHO Regional Offices to Portuguese and Spanish-speaking countries in Africa and South America. Materia L from Entre Nous may be freely trans- Lated into any national Language and reprint- ed in journals, magazines and newspapers, provided due acknowledgement is made to Entre Nous, UNFPA and the WHO Regional Office for Europe. Articles appearing in Entre Nous do not necessarily reflect the views of UNFPA or WHO. Please address enquiries to the authors of signed articles. For information on WHO-supported activities and WHO documents, contact the Women's and Reproductive Health Unit at the address given above. Please order WHO publications direct from the WHO sales agent in each country or from Marketing and Dissemination, WHO, 1211 Geneva 27, Switzerland. CONTENTS EDITORIAL .................................................................. 3 Kazakhstan and the Netherlands - Sexual and Reproductive Health Training Collaboration E. Ketting et al .............................................................. 4 Strategic Action Plan for the Health of Women In Europe: HEALTH21 for the Health of Women I. Yordi •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 6 Hungary - International Postgraduate Training Courses 1981-2000 - I. Batcir ...................................... 1 Why Increase lnteragency Cooperation on Adolescent Health? - R. Krech ........................................................ 8 Entre Nous - Networking on Sexual and Reproductive Health in Europe - D. Gundelach ................ 10 Central Asia and the Caucasus - Collaborative HIV/AIDS Awareness Activities - Shannon Berlin ............ 11 HIV/AIDS - How Great is the Danger for Young People?: The Case of the Conscripts - C. Fiala ................ 13 Sexuality And Aging - An Israeli Experience - G. Bronner 15 Medical Abortion - Where we are in Europe - C. Fiala .... 16 Turkmenistan - Reproductive Health Services Take Root - G. Khodjaeva et al ...................................... 18 Resources .................................................................. 20 Internet Resources - J. Lazarus .................................... 23 Cover Illustration: ©Mads Tunebjerg Photo page 6: ©Dr Mouazzama Jamalova Photos on pages 7 and 8: ©University Medical School of Debrecen Photos page 12 : ©Dr Vladimir Verbitski Illustration page 14: ©Deirdre Brennan The illustrations on pages 18 and 19 are taken from the UNFPA Calendar for 2000 devoted to the participants of the 1999 UN FPA International Poster Contest "The Day of Six Billion", held on 25 May 1999 in Ashgabat. ©Ministry of Health and Medical Industry of Turkmenistan and United Nations Population Fund of Turkmenistan. Page 6 Page 7 Page 12 Page 18 MEMBERS OF THE EDITORIAL BOARD Dr Alison BIGRIGG Clinical Director Family Planning and Sexual Health Directorate Glasgow, United Kingdom Dr Carlos HUEZO Medical Director International Planned Parenthood Federation (IPPF) London, United Kingdom Dr Malika LADJALI Senior Programme Specialist UNESCO Paris, France Mr Henning MIKKELSEN Program me Development Officer Department of Country Planning and Program me Development, Europe Desk Joint United Nations Programme on HIV/AIDS, (UNAIDS) Geneva, Switzerland Ms Elin RANNEBERG-NILSEN UN FPA Representative United Nations Population Fund (UNFPA) Bucharest, Romania Dr Katy J. SHROFF UNFPA Representative United Nations Population Fund (UNFPA) Tirana, Albania Ms Lyn THOMAS Regional Director International Planned Parenthood Federation - European Network Brussels, Belgium Dr Ketty P. TZITZIKOSTA President Association of Interbalkan Women's. Cooperation Societies (A.I.W.C.S.) Thessaloniki, Greece Entre Nous would Like to thank Dr William J. Hunter for his support as member of the Editorial Board and to wish him a happy retirement PAGE 2 - NO. 47-48 - AUT UMN 2000 © World Health Organization 2000 EDITORIAL NETWORKIN~ :.., ~h .,.,1 ~ .. l:ieyoiiu a.-J e ,~ ie ... oric Since 1989, the field of sexual and reproductive health has expanded in the WHO European Region, in large part due to the increased sensitivity of policymakers to this priority issue. In particular, the new countries which emerged from the former Soviet Union found themselves in need of donor sup- port with regard to funding of the public health care system. To break their isola- tion a forum for peer review and ex- change had to be created. Compounded with the change in government in the eastern European countries, the World Health Organization faced the task of fill- ing in the information vacuum . In 1990, WHO approached UNFPA and together they decided to launch a family planning magazine for the entire WHO European Region, but aware that the greatest need would be in the central and eastern countries. Entre Nous is now in its tenth year and while the sexual and reproductive health situation is improving in many countries, the recent violence against women re- sulting from the conflicts in the Balkans and in more eastern parts of the Region is a reminder of the importance of a reg- ular source of information that deals with these issues for health care workers in the field, ministries of health and non-governmental and intergovernmental organizations. High rates of maternal mortality and morbidity in many central and eastern European countries, very high abortion rates in several countries, the reproduc- tive health of refugees and negative pop- ulation growth in a number of eastern European countries, in addition to issues like female genital mutilation among migrants, emergency contraception and the advent of medical abortion and via- gra have created a vigorous and often controversial debate. However, the Pro- gramme of Action of the International Conference on Population and Develop- ment (ICPD) in Cairo in 1994 and the ICPD+5 review in the Hague have provid- ed a forum for defining the issues and implementation strategies. While specific goals were set, to be achieved by the year 2015, general deci- sions were made to prioritise reproduc- tive health in national agendas and development aid budgets. And, in re- sponse to requests from countries, the Women's and Reproductive Health unit of the WHO Regional Office for Europe ex- panded activities by forming alliances with strategic partners and creating net- works. These collaborative efforts have had some sustainable effects in research, training and service delivery and bilateral assistance: • A scientific advisory group on training and research in reproductive health, with 20 members, was established to pinpoint key issues in the Region and help define programmes and policies. To implement these recommendations, a country network was created in coop- eration with UNFPA, UNICEF, the Euro- pean Union (EU}, the World Bank and bilateral donors; • A network of focal points in reproduc- tive and women's health provides a forum for peer review and exchange for all of the Region's Member States; • Women's and reproductive health has been a central element of the WHO Healthy Cities Programme network that works through mayors and urban administration bodies to improve health. See: http://www.who.dk/ hea [thy-cities/papers. htm; • Increased bilateral aid: the Netherlands School of Public Health, for example, has now trained more than 173 spe- cialists from the countries of central and eastern Europe and has helped the Kazakhstan School of Public Health to expand its reproductive health section (see article on pages 4-5). Collaboration with non-governmental organizations, like IPPF with its network of family planning associations, has been the crucial element for many of the sexu- al and reproductive networks. NGO con- tact with local players forms an impor- tant bridge for donors responding to problems derived from statistical analysis and reports. And while collaboration and discussion is the key to success, NGOs often remind the international communi- ty that there needs to be more than just talk. We, the editors of Entre Nous, have dis- cussed if the above initiatives are suffi- cient. Where are the gaps? What are the barriers? Networking itself is not just a good way to optimize resources and to support peer review and exchange, and the collection of comparative evidence, it must also result in "working" informa- tion . We hope that in this issue of Entre Nous the contributions about joint pro- grammes and projects with a number of donors such as UNFPA, UNICEF, WHO and the World Bank will spark more debate on the next steps to be taken. From central Asia to Hungary to the Netherlands, training programmes and the exchange of knowledge, organized by health experts, are slowly increasing networking with other sectors. But as the article entitled "Why Increase Interagency Cooperation on Adolescent Health?", on page 8, points out, health is intricately tied to a country's overall socio-economic context, which means that sexual and reproduc- tive health programmes must develop and strengthen new alliances with donors such as the World Bank and/or ministries such as the ministry of finance. In addition to the focus on networking and collaboration, this issue of Entre Nous includes articles on sexuality and aging in an Israeli context, AIDS testing among military conscripts in Austria and the state of medical abortion in Europe. As always, we welcome and look forward to your feedback. Assia Brandrup-Lukanow [abr@who.dk] Chief Editor, Entre Nous Jeffrey II. Lazarus ULa@who.dk] Editor, Entre Nous Women's and Reproductive Health Networks in the WHO European Region • Scientific advisory group on training & research in reproductive health Network for strengthening reproductive health Q at the country Level in cooperation with UN FPA, UNICEF, EU, World Bank & bilateral donors • CARAK: Strengthening maternal & child health at district Level (with Child Health Development) Q Multi city action plan on women's health (with Healthy Cities) NO. 47-48 - AUTUMN 2000 - PAGE POLICY AND PRACTICE KAZAKHSTAN ~A\\§? a~l=Jvl;'ffi~~;lollaboration The sexual and reproductive health needs in the central and Eastern European countries and newly indus- trialized states (CCEE/NIS) are very seri- ous and still largely underestimated. Although many initiatives have been taken over the past decade to improve the situation in these countries, progress has been slow, for the most part, in large parts of the region. Major causes for the relative lack of progress are the persis- tent economic crisis in several countries in the region, leading to a general lack of resources; a rather low political priori- ty given to sexual and reproductive health (SRH}, often caused by a misun- derstanding of the issues at stake; health care systems that lack a tradition of prevention and health promotion; and health providers not having had suffi- cient training in modern approaches to SRH. In addition, cultural factors often make it hard to openly address issues that are perceived as sensitive, in partic- ular sexuality and sexual behaviour. And, finally, international assistance for pro- moting and implementing the Cairo Pro- gramme of Action in central and eastern Europe, including the central Asian republics, has been far too limited given the severity of the situation and the size of the area. As a result, the SRH situation in the region is still characterized by: • high maternal and infant mortality and morbidity; • high abortion incidence; • a very high prevalence of sexually transmitted infections (STis), includ- ing rapidly rising HIV infection rates; • increasing adolescent pregnancy rates; and • poor knowledge of sexuality and sexual health among the population. A variety of different responses is needed to improve the SRH status of the popula- tion, one of them being building national professional capacity. In the past decade, the Netherlands School of Public Health (NSPH) in Utrecht, the Netherlands, has tried to contribute to such national capacity in CCEE/NIS countries, especial- ly Kazakhstan. Collaborative training efforts: NSPH experience In 1993, the Netherlands School of Pub- lic Health initiated a family planning, sexual and reproductive health (FP/SRH) training programme, designed especially for health professionals and policy mak- ers working in these fields in CCEE/NIS countries. The initiative was partly trig- gered by the WHO Regional Office for Europe (Women's and Reproductive Health unit, at that time called "Sexuali- ty and Family Planning unit"). This unit had suggested better coordination of the different ad-hoc training activities that had been initiated by specialized Dutch agencies in some central and eastern European countries. By bringing together specialized knowledge and experience, available in different institutions, a com- prehensive three-week intensive training course was developed by NSPH. Being a typical "network institution" that is accustomed to hiring expertise from different specialized organizations for its educational programmes, it was not unusual for NSPH to involve several external agencies in the development and implementation of this training pro- gramme. Expertise on family planning and sexual health was provided by the Rutgers Foundation (Dutch Family Plan- ning Association), on STis by the Dutch Foundation for STD Control, and on pro- ject development and management by the World Population Foundation (an international reproductive health agency). The private sector was also involved, contributing specialized exper- tise on contraception and on service management. Each of these organizations was already active in central and eastern Europe, and, therefore, all the core facili - tators of the training course had practi- cal experience in working with specialists from this part of Europe. The effort turned out to be very viable; from the end of 1993 until early 2000 a total of nine training courses were given in which 173 specialists from almost all CCEE countries (including some from cen- tral Asia) have participated. Feedback from participants, either directly or dur- ing follow-up meetings and through fol- low-up questionnaires, has been over- whelmingly positive, indicating that there is a widespread need to learn how to develop and implement projects and programmes in this field. It should be stressed that the highly interactive approach, through which participants have the opportunity to learn from each other's experience and develop practical skills has been valued most. Many former course participants are still working in key positions in the field of sexual and reproductive health in their respective countries, in the government, in universities, in health (promotion) institutions and in non-governmental organizations (NGOs). Through follow-up contacts and meetings, NSPH has been able to build several networks of SRH specialists and institutions in CCEE/NIS countries. The training programme has been financially supported by the United PAGE 4 - NO. 47-48 - AUTUMN 2000 Nations Population Fund (UNFPA} Divi- sion for Arab States and Europe and by the Dutch Government, and in some indi- vidual cases also by other agencies. An important factor contributing to the success of this training programme has been the close collaboration, not only nationally with Dutch specialized agen- cies, but also internationally with a variety of organizations and institutions. The WHO Regional Office for Europe has been closely involved in the process of identifying and assisting in the selection of suitable candidates for the course. It also actively participated in the course itself, and it has been instrumental in supplying some of the course materials, as was the Special Programme on Human Reproduction at WHO headquarters in Geneva. Moreover, the WHO Regional Office for Europe has played an impor- tant coordinating role in training for reproductive health by organizing and hosting annual meetings attended by representatives of different European institutions that are involved in this field and that are active in the CCEE countries. Similarly, collaboration with the Interna- tional Planned Parenthood Federation (IPPF) European network has been very useful as well. This network has vast experience in working with the NGO sec- tor in the region, and, therefore, it has helped in the process of the selection of suitable course candidates, the supplying of course materials and more. Collaboration with UNFPA, both the headquarters in New York and regional and national offices, has also been use- ful. It should be stressed that UNFPA is not only a potential source of financial support, but also has extensive knowl- edge of the reproductive health situation in the large number of countries where it is represented, and it has extensive net- works of national experts that can be used. For example, in the process of the identification and selection of course candidates from the Russian Federation, the UNFPA office in Moscow has always played a crucial role, but it has also been very helpful in solving the practical prob- lems of course participants (such as obtaining a visa) . Furthermore, NSPH has built up solid working relationships with ministries of health in most CCEE/NIS countries, which is important for stimu- lating government commitment to sexual and reproductive health. The course programme primarily covers the areas of contraception and abortion, sexuality and sexual education, STI con- trol and project/programme management. The objectives are to familiarize partici- pants with the content and philosophy of the International Conference on Popula- tion and Development (ICPD) Programme of Action (Cairo 1994) and to motivate and enable them to implement the pro- gramme in their own national or local context. The NSPH "Working Group on FP/SRH", which implemented the courses, has also initiated a range of related activities in CCEE/NIS countries, including follow-up meetings of the courses to evaluate their impact and to give additional sup- port to the former trainees. In some cas- es, these follow-up contacts with course participants gained a more permanent character. The collaboration between the Kazakhstan School of Public Health (KSPH) and NSPH is a good example of this. Four reproductive health specialists from Kazakhstan have participated in the NSPH course on FP/SRH, three of them work in the reproductive health unit of KSPH. The Kazakhstan School of Public Health KSPH is a relatively new institution. It was established in Almaty in July 1997, with extensive support from WHO Europe. Because it is the only school of public health in central Asia, it has the poten- tial and the intention to become a regional expert, research and training centre. KSPH has quickly developed and now has a staff of 85, of whom 28 are involved in training. The school has five teaching departments: • Department of Health Policy and Management; • Department of Health Economics and Finance; • Department of Environmental Health and Occupational Hygiene; • Department of Health Promotion and Social Sciences; and • Department of Epidemiology, Biostatis- tics and Information Systems. The reproductive health unit is part of the Department of Health Promotion and Social Sciences. In Kazakhstan, and the other central Asian republics as well, there is an extensive need for training in public health in general, including repro- ductive health. Traditionally, medical doctors are the principal health profes- sionals for public health and manage- ment related positions in the entire health system, and practically all of them have only a clinical orientation. More- over, the public health function is almost exclusively focused on the control of communicable diseases, and approaches in these areas need to be modernized. For instance, methods to investigate and control outbreaks of communicable diseases are narrowly based on laboratory tests, with Little epidemiological investi- gation and few policies to eliminate risk factors for infection. Also, few profes- sionals are involved in preventive activi- ties, intersectoral action and promotion POLICY AND PRACTICE ~ of healthy Lifestyles. Therefore, there is an urgent need to create a real focus on public health in Kazakhstan and in its neighbouring countries. In several respects sexual and reproduc- tive health are areas of particular con- cern in this region. In Kazakhstan, the maternal mortality ratio has increased in recent years to 77:100,000 Live births {1997), but according to UNFPA the actu- al ratio is much higher because Kazakh- stan does not use internationally recog- nized measures. A substantial number of the maternal deaths are probably due to illegal, unsafe abortions, particu- larly among young (unmarried) women. Although national statistics indicate a substantial decline in the number of abortions, the current official rate of 40:1,000 women of fertile age (1997) is still very high. However, it is doubtful that all abortions are reported to the authorities. Furthermore, the prevalence of STis is increasing alarmingly. In 1997, the incidence of syphilis had risen to 270:100,000 population. This high inci- dence has severe implications for the health of infants and children. The high STI rates also increase vulnerability to HIV and eventually AIDS. Adolescent SRH is another serious concern. A significant proportion of young people are sexually active, but sex education is almost com- pletely absent in the country, as are youth oriented sexual health services. One crucial requirement to effectively deal with these and related SRH problems is the availability of committed profes- sional and managerial staff, both at cen- tral and regional (oblast) levels. To meet these needs, KSPH has started to develop an SRH training programme, assisted by WHO Europe and by NSPH. Collaboration between KSPH and NSPH Starting from the participation of three KSPH reproductive health staff members in a 3-week NSPH training course, KSPH an NSPH signed an agreement to collabo- rate in November 1999. The agreement focuses on collaboration in developing a training programme at KSPH in reproduc- tive health management, policy develop- ment and administration. Apart from this, the agreement also includes intend- ed future collaboration in the areas of research and consultancy services. As a first step in this process of collabo- ration, the reproductive health staff at KSPH has developed a two-week training course, which is largely based on the course given by NSPH. Both the training methodology and the contents and back- ground materials of the NSPH course are used, after having been partly adapted to the specific needs and context in Kazakh- stan. The course concentrates on improv- ing quality of care in reproductive health service delivery. In late 1999 and early 2000, the course was held twice, for 20 participants each, and initial feed- back from the participants has been posi- tive. KSPH now plans to organize a series of these courses in different oblasts of the country in the near future. In addi- tion, possibilities are being explored to make this course available to participants from other central Asian countries, or to implement the course in those countries. Concluding remarks There is not only a need to develop and strengthen technical capacity in the field of sexual and reproductive health in CCEE/ NIS countries but also a need to create national and regional training capacity in these countries. Participation of health professionals from CCEE/NIS countries in training activities in western European countries is generally much more expen- sive, and, therefore, these training activi- ties should focus on training of trainers programmes, which is also the current policy of UNFPA. However, the collabora- tive experience of NSPH and KSPH indi- cates that, particularly at the initial stages, there is need for technical sup- port to institutions Like KSPH in develop- ing training programmes and curricula. Support is particularly needed in the areas of modern training methods and in designing curricula that are appropriate for different target groups. Therefore, it would be advisable for international funding agencies to shift gradually from funding participation in training activi- ties abroad to supporting the develop- ment of national and regional training capacity. Promoting and supporting collaboration between specialized training agencies, as has been described here, is a useful mechanism in making national or region- al training initiatives in CCEE/NIS countries meet international quality standards. Evert Ketting [ e.ketting@tip.nl] Co-ordinator of Family Planning, Sexual and Reproductive Health, Netherlands School of Public Health (NSPH) Maksut Kulzhanov [mkk_ksph@nursat.kz] Rector of the Kazakhstan School of Public Health (KSPH) [http://www.ksph.kz] Soule Nukusheva Head, Reproductive Health Unit, Kazakhstan School of Public Health (KSPH) NO. 47-48 - AUTUMN 2000 - PAGE 5 -~ WOMEN'S HEALTH AND DEVELOPMENT STRATEGIC ACTION PLAN FOR THE HEALTH OF WOMEN IN EUROPE HEALTH21for-the Heal-ti, ofWome,1 Women in Europe enjoy better health than ever before, and bet-ter than that of women in other regions. However, not all health targets set by the World Health Organization for the year 2000 regarding women's health have been achieved, and there has even been significant deterioration in some women's health indicators such as can- cers of the reproductive tract, cardiovas- cular disease, mental ill health and depression, and maternal morbidity and mortality. Even in the richest countries in the Region, there are differences and differentials in health for women and men, which are not taken into account. Although women live longer than men, they suffer a greater burden of morbidity. Women are over-represented amongst the poor and female income is on average only 70% of male income. Women utilize the public health care system more than men do. Women are more likely to experi- ence depression and stress linked to their experience of inequality and discrimina- tion, to experience chronic conditions such as arthritis and osteoporosis and to suffer ill health and death as the result of abuse against them. Recognizing the need to address these issues more intensively, the Member States of the European Region of WHO are embarking upon the implementation of the Strategic Action Plan for the Health of Women in Europe. The initiative was developed by the reproductive health unit of the WHO Regional Office for Europe, which, in Feb- ruary 2000, gathered a group of experts, representatives from WHO collaborating centres and members of the WHO Stand- ing Committee for the Regional Commit- tee to discuss the need for, and the con- tent of, a future European women's health action plan. Participants brought perspectives from nine countries of the region. The outcome of this two-day meeting was the Strategic Action Plan for the Health of Women in Europe. The action plan is being circulated in its draft ver- sion and will be presented during the Regional Committee of WHO, to be held in September 2000. The action plan revises the 21 health targets for the twenty-first century, endorsed by the Regional Committee of WHO in 1999, identifying their implica- tions for the health of women. It demands to make women's needs explicit in any strategies to address inequities in health across the Region. There have been repeated calls through international conventions to ensure greater equality and less discrimination against women with little or partial effect. There is considerable expertise across the Region as to how the impact of these can be improved. The Action Plan requests each European Member State to have a system to ensure that an exchange of this expertise can take place. The Action Plan aims to assist Member States and local governments in their efforts to achieve greater gender equity in health, health care and in the imple- mentation of HEALTH21, and thus contribute to improving the status of women in society. The Action Plan recognizes the key role of WHO, working together with its Mem- ber States and non-governmental organi- zations (NGOs), in achieving the goals of improving women's status and women's health throughout the Region. The Strategic Action Plan for the Health of Women in Europe builds upon the rele- vant recommendations of the World Health Assembly, the recommendations of the International Conference on Popu- lation and Development (ICPD) held in 1994 and the Declaration and Platform for Action from the Fourth World Confer- ence on Women held in Beijing, in Sep- tember 1995. PAGE 6 - NO. 47-48 - AUTUMN 2000 Before these UN conferences were held, the WHO Regional Office for Europe orga- nized in Vienna, in 1994, the first Euro- pean conference on women's health, Investing in Women's Health, which resulted in a set of recommendations to Member States concerning data collec- tion on women's health and priority actions to reduce women's morbidity and mortality in the Region. In 1995, the UN Economic Commission for Europe (UNECE) developed a Regional Platform for Action to improve the status of women in Europe, including a section on action to improve the health of girls, women of reproductive age and elderly women, and specifically addressing the ill-health effects of trafficking and vio- lence. The action plan contains a Resolution addressed to Member States, WHO, NGOs and international governmental organiza- tions where specific political, financial and structural demands for the imple- mentation of the plan of action are made. For more information about the action plan contact Dr Assia Brandrup-Lukanow at the WHO Regional Office for Europe: abr@who.dk Isabel Yordi [ i sabelya@vi p.cybercity.d k] WHO technical consultant POLICY AND PRACTICE tl~Ystgraduare Training- Courses 1981-2000 Family planning services have existed in Hungary since 1973, when a new population policy came into effect. However, since 1981, the Department of Obstetrics and Gynaecology at the Uni- versity Medical School of Debrecen (UMSD) has carried out international training courses, in English, funded by the United Nations Population Fund (UNFPA) and executed by the World Health Organization (WHO). There have been three phases in the history of the training programme: 1. Between 1981 and 1987, nearly 90 partici- pants from around 40 countries attended the courses in Hungary. The one to three-week courses focused on basic family planning. 2. In 1988, after a one-week evaluation meeting was organized by UNFPA and WHO in Debrecen, it was decided that the pro- gramme should become more special- ized. Instead of deal- ; ng with basic i nfor- mation on contracep- tion and abortion issues, specific sub- jects like adolescence, infertility and steriliza- tion were selected. Based on these recom- mendations, four one- month courses were held in Debrecen in 1990/1991. These were attended by some 60 participants from all over the world. 3) The UMSD then decided to submit a proposal to renew the training pro- gramme that was discontinued in 1992 due to financial shortcomings and policy changes. Since the conditions were again found to be acceptable to Launch a new programme, and the project proposal was accepted by UNFPA with some modifica- tion of the budget, a four-year project was agreed on in 1995. The aim was to organize international postgraduate training courses for service providers from countries with economies in transi- tion (the countries of central and eastern Europe (CCEE) and the newly independent states (NIS)). Project objectives The Long-term objective was to con- tribute to improving reproductive health care/family planning services in coun- tries with economies in transition, and thereby diminish reliance on induced abortion and decrease maternal mortality and morbidity. The immediate objectives of the project were: • to upgrade reproductive health/family planning knowledge and the technical and counselling skills of 140 RH/FP service providers from countries with economies in transition in a four- year period (basic courses); • to improve the knowledge and skills of 30 obstetricians/gynaecologists and surgeons in advanced FP techniques by the end of 1999 (advanced training); and • to strengthen the capacity of the department to conduct international reproductive health training courses in the context of intra-eastern European cooperation. Basic Course Between October 1996 and November 1999, seven courses were held in Debrecen. They were attended by 143 participants from the following 16 countries: Albania (13), Armenia (15), Belarus (15), Bosnia & Herzegovina (2), Bulgaria (9), China (1), Georgia (6), Hun- gary (2), Kazakhstan (3), Latvia {21), Lithuania (6), Moldavia (8), Poland (2), Romania (20), Russia (6) and the Ukraine (14). Parallel with this pro- gramme, a special one- week course on the same topic was organized for Bosnia & Herzegovina for ten doctors in December 1997, at the request of the WHO Regional Office for Europe. Based on the opinions reported on the evalua- tion forms, the five-week programme, which includ- ed 16 lecture modules and 20 practical training sessions, was very useful for both the present and planned jobs of the majority of the partici- pants. Both the theoretical and the practical portions of the course activities received the highest marks from more than the half of the participants. There was great interest in this programme. At the end of the project, 14 candidates were still on the waiting list. Advanced Training There was an overbooking for this type of course from the very beginning. Ulti- mately, 30 participants were selected from the following 11 countries: Albania (1), Armenia (3), Belarus (1), Bulgaria (3), Georgia (1), Latvia (4), Lithuania (5), Moldavia (1), Poland (5), Romania (4) and the Ukraine (2). Only three days were devoted to lectures and the rest of the programme was left for practical work, primarily carried out in the operating room. The total number of operations the trainees participated in ranged from 40 to 60. The majority of them were laparoscopies including steril- NO. 47-48 - AUTUMN 2000 - PAGE 7 POLICY AND PRACTICE ization and hysteroscopies, but they also included infertility operations (diag- nostic and curative) and microsurgical refertilization procedures as well. By request, abdominal and vaginal hys- terectomies, Wertheim operations and other delicate gynaecological surgeries as well as delivery room programmes and participation in obstetrical surgeries were also scheduled. New programmes The aim of the projects held over the last two decades has been successfully ful- filled. The large number of trainees who attended the courses (and the long wait- ing list) and their positive evaluations attest to the importance of training in family planning and reproductive health. As a result, the involved international organizations have decided to continue financing training programmes, though with some modifications. New topics (emergency obstetrics, neonatal care, management of unsafe abortions), as a result of unfavourable changes (increas- ing morbidity and mortality of both infants and mothers) in the target countries (NIS), have been included to broaden the coverage of the previous programmes. Moreover, a new possibility has recently been presented by the WHO Regional Office for Europe for training in research. This programme intends to provide train- ing in learning different aspects of clini- cal research work. Trainees attending this programme will gain practice in planning, PAGE 8 - NO. 47-48 - AUTUMN 2000 designing, conducting and evaluating clinical studies. In addition to technical aspects, the modules will deal with ethi- cal considerations, preparation of the results for publications and other rele- vant research-related topics. Istvan Bator, MD, PhD [ibatar@obgyn.dote.hu] Associate Professor Head, Family Planning Centre Director of Training, Department of Obstetrics and Gynaecology University Medical School of Debrecen (Hungary) ADOLESCENT HEALTH WHY INCREASE INTERAGENCV COOPERATION ON ADOLESCENT HEALTH? M ember States of the United Nations have repeatedly asked the secretariat and the specialized agencies, including the Bretton Woods organizations, to increase their coopera- tion and to reduce any duplication of efforts. Working within the United Nations system, this plea is very much welcomed. The issue of intersectoral working at the international level is accompanied by a variety of challenges, sometimes barriers, but also tremendous opportunities. An economist has a differ- ent approach to health than a sociolo- gist, a medical doctor, a psychologist or a policy analyst. Thus, we have a for- midable task in coordinating and plan- ning international health work. An initiative was started in early 1999 to better coordinate adolescent health work. Based on the recommendation from the international meeting on pilot approaches in adolescent reproductive health, kindly hosted by the Ministry of Health of Portugal in April of that year, WHO, UNICEF and UNFPA started to review the potential of increased cooper- ation in pilot countries. A major role that the international organizations have is to draw governments' attention to the determinants of health risks which lie, to a great extent, outside the health sector. A first task that the newly established Interagency Group on Adolescent Health and Development gave itself was to clarify the respective roles of each of the organizations to advocate for adolescent health and address the risk conditions that affect the health of young people. How can we create synergies? And for what use? Taking the example of children and ado- lescents, it is clear that comprehensible and sustainable social and economic Liv- ing conditions are decisive for the healthy development of children. Their life situation in today's social world is comparable to that of adults in that it is characterized by a considerable degree of tension. While on the one hand, children and adolescents have a great degree of freedom to organize their own individual lifestyles, on the other, one price to be paid for these greater opportunities for individuality is a corresponding loosen- ing of social and cultural ties, effecting greater insecurity and an uncertain future. Given the fundamental changes, especially in central and eastern parts of the WHO European Region, children and adolescents, in particular, also have to face contradictory moral and ethical val- ues. The changing situation raises potentially new forms of stress. However, there is currently no comprehensive scientific evi- dence on the level of ill health produced through unfavourable changing condi- tions of societies in central and eastern Europe; the international scientific com- munity so far has been satisfied to study the health behaviour of youths. Like adults, children and adolescents pay a price for the international trends of industrialization, u rba nizatio n, com mer- cialisation and individualization of every- day Life. However, children and adoles- cents have to pay that price during a period of their Lives that is characterized by rapid physical growth and personal development. The changing situation in Eastern Europe since the early 1990s reveals the problem most clearly: The rapid changes in the social macro-struc- tures have been accompanied by changes at the micro-level of social structures and personal relationships. However, these are important for healthy develop- ment. Tense relationships between the parents or partners, financial problems, job insecurity of the father or mother or alcohol problems of one of the parents influence directly or indirectly (via the insecure behaviour of one of the parents) the development of coping skills, behav- ioural competence and self-esteem. As the role of the family as the principal socializing authority in moulding health related attitudes and modes of behaviour during childhood changes with regard to cultural heritage, the value system and the social environment, adolescents are particularly affected. The health impacts of divorce on children, for example, - a relatively well documented topic - is compounded by other changes in society. Changes in the living conditions of chil- dren, however, are not limited to "split" families. They also concern so-called nor- mal families. An important feature of today's cohabitation of the parents and their children can be described as the relationship of negotiating options and a partnership structure instead of parental disciplinary measures. These "sunny sides" of a great number of freedoms stand opposite many "shady sides": chil- dren are confronted with a growing num- ber of behavioural expectations and pos- sible emotional diffusions. This instabili- ty is fostered by increasing spatial mobil- ity. Thus, children and adolescents have to cope with an increasing combination of social orientation problems, increas- ingly unstable family lives. The individual and social protective factors that the family provides must be strengthened if sustainable health improvement is to be achieved. Whereas this is the case in all societies, the example of the Russian Federation is a striking one, as especially here, these protective factors for adolescent health, by and large, were dismantled. This also had economic consequences which Joseph Stiglitz, a former World Bank chief economist, described very well. Stiglitz argues that "the failures of the reforms that were widely advocated ... [can be explained by] ... a misunder- standing of the very foundations of a market economy, as well as a failure to grasp the fundamentals of reform processes". He argues that at least part of the problem was an excessive reliance on textbook models of economics, espe- cially the neo-classic model. And since adolescent health has much to do with the overall societal contexts in which health can be produced, economic adjustments, which have caused social adjustments, have taken their toll on children and adolescents. Currently, there are around 300,000 street children in the area of St. Petersburg alone. A strategic and well coordinated World Bank, UNICEF, UNFPA and WHO programme, designed to increase social cohesion, economic security and social safety, would have effects on the health of young people and on positive economic and social development as a whole. There is much at stake and it is high time for the individual players of the international health, economic and social development community to broaden their outlook and increasingly coordinate activities. Dr Rudiger Krech [rkr@who.dk] Technical Adviser World Health Organization Regional Office For Europe Scherfigsvej 8 DK-2100 Copenhagen 0 Denmark Tel: (+45} 39 17 12 69 Fax: (+45) 39 17 18 18 NO. 47-48 - AUTUMN 2000 - PAGE 9 ~~ POLICY AND PRACTICE ENTRE N~M§rking-on Sexual and Reproductive Health in Ettrope Entre Nous started in 1982 as a four-page bilingual newsletter, and since 1990, it has been published as a proper magazine, now in seven languages. Entre Nous pro- vides a forum for the exchange of opinions and experiences between sexual and repro- ductive health professionals in Europe, and the growing readership reflects an increasing interest in the magazine. We now reach well over 14,000 readers in the European Region and beyond. • A forum for debate Entre Nous serves as a forum for debate on delicate subjects like abortion , emergency contraception, violence against women and sexually transmitted infections (STis) includ- ing HIV/AIDS. • Editorial board Members of the Editorial Board of Entre Nous represent the leading United Nations agencies, the European Union and non-governmental organizations (NGOs) working in the field of sexual and reproductive health and women 's health. • A voice for UNFPA and WHO policies and programmes In Entre Nous you can read about new initiatives and ongoing UNFPA and WHO projects. • Networking with other WHO units Entre Nous has served as an informa- tion vehicle for the promotion of sev- eral WHO Regional Office for Europe as well as WHO headquarters units. We report on the entire span of reproduc- tive health issues, on women's health, adolescent health, STis/AIDS, safe motherhood, reproductive health research and more. • Best practice Positive lessons learned are distributed across the Region on integrated RH services, youth centres, sexual education, educa- tional campaigns and the prevention of STis/HIV/ AIDS. These lessons are then converted into training courses and materials by professionals. • European network on training Details on training opportuni- ties are regular features in Entre Nous, since the Women's and Reproductive Health Unit acts as a clearing-house for research and training on RH. The advertisement of courses on sexual and reproductive , health (SRH) and adolescents' and women's health also contributes to the promotion of European training cen- tres, like the Dutch centre featured in this issue, and to strengthening national capacity-building . • Networking of professionals throughout the Region and beyond By ensuring that all articles are signed and by giving all contact details, pro- fessionals have been able to contact each other, either directly or some- times through the maga- zine. ·t 2000 Petersen , la~er, is ~pn t,\ette t,1ornrne ~soc\at\on Letter to oan\sh UN t,1ernber of the c/ o (ntre Nous D ar Ms Petersen. . l •changing e 0rt,c e . l . interest your ale Genito !just read wit~ h Approach to Fe~ Jor sexual and . . A oanis Magazine tar Trad1t10~ • • ·n the Europ~an receive on a regu Mutilation 1 [th which we Reproductive Hea ' from you abouttan~n . d to heor es e c. basis. · tereste rograrnlll ' I would be in educational~ lly prograrnrnes . . . rneosures, d spee1fico act1V1t1es, d·ng FGM on l oenrnork regor I . migrants- and I arn enc os- . h/for sarnall 1111 WHO on FGM the subJect. wit d ·sor to ks on I was an a v1 ts of rnY two boo . our quarterly in9 onnouncerne~or section on FGM in I publish o rig:EWS. journal, WI signed: p 11os\(en, fran · N£'NS £d\tor /'NlN - PAGE 10 - NO. 47-48 - AUTUMN 2000 • Promotion of publications Entre Nous receives review copies and advertises hundreds of documents and publications on RH and related issues, both from WHO and UNFPA, but also publications from other United Nations agencies and from many NGOs. • Internet sites Information on Internet resources has been added since 1999, and Entre Nous itself will be accessible on the Internet this autumn. • Free source of information Because of its free distribution, in countries in transition Entre Nous is one of the only sources of information on sexual and reproductive health. The fact that it is available in English, French, Hungarian, Portuguese, Russian, Spanish and from the next issue in Bulgarian makes it accessible to the entire WHO European Region. Dominique Gundelach [drm@who.dk] Editorial Assistant, Entre Nous Tel.: (+45} 39 17 14 51 HIV/STis ~ CENTRAL ASIA AND THE CAUCA§MJ§rative HIV/AIDS Awareness Activities HIV/ AIDS affects everyone, everywhere. The disease has had catastrophic effects in Asia and Africa. Globally, it has been recognized that prevention through edu- cation is essential. The United Nations Educational, Scientific and Cultural Orga- nization (UNESCO), working closely with other United Nations agencies, govern- ments and non-governmental organiza- tions (NGOs), has been active in develop- ing and implementing informational and educational HIV/AIDS awareness activi- ties and campaigns in central Asia and the Caucasus. The central Asian and Caucasian region presents a unique opportunity in terms of prevention of the spread of HIV/ AIDS. To date, the countries, on a global level, have low rates of incidence. However, there is a risk of a rapid increase of infected people. Studies show that intra- venous drug use is common throughout the region and that the incidence of sex- ually transmitted infections (STis) is increasing at a frightening rate. The most affected are youth. When compounding these factors with the socio-economic difficulties posed to youth today, a bleak picture is painted. Governments cannot afford to allocate sufficient resources to the education and health sectors and, with the collapse of the Soviet system, a number of gaps have been created. With a long history of cultural, social and economic commonal- ties, the countries face a number of simi- lar difficulties during the process of tran- sition. Prevention through education is the most effective way to fight HIV/ AIDS. As an integral part of its mandate, UNESCO is concerned with education. "HIV prevalence in Kazakhstan grew 163 fold from 1 995· 199811 In Central Asia (Kazakhstan, Kyrgystan, Tajikistan, Turkmenistan and Uzbekistan) the outbreak of HIV is already known. In 1996, it became evident that HIV infec- tion was rapidly becoming a problem in the city of Temirtau in the Karaganda oblast, Kazakhstan. This period saw a drastic rise in injecting drug use among young people who were unemployed. Estimates indicate that over 10% of the youth in Temirtau inject drugs. Due pri- marily to the outbreak in Temirtau, HIV prevalence in Kazakhstan grew 163 fold from 1995-1998. Recognizing the potential gravity of the situation, the UN system, governments, NGOs and the private sector joined efforts to work together. In July 1998, UNESCO, WHO and UNAIDS held a region- al seminar for the central Asian and Cau- casian republics. In keeping with the UNAIDS World AIDS Campaign for 1998, the title of the workshop was "Force for Change - Improvement of Preventive Education and Health Care Services with- in the School System". The primary goal of the seminar was to assist governments and NGOs to develop preventive educa- tion curricula and to improve health care services for adolescents. Representatives from the government, education special- ists and NGOs active in the field of HIV/AIDS education or adolescent health care from Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgystan, Mongolia, Tajik- istan and Uzbekistan gathered in Almaty, Kazakhstan, for the five-day participatory meeting. This seminar has been a cata- lyst for a number of activities in central Asia. Partially as a result of the seminar, gov- ernments in the central Asian republics have begun to recognize the importance of promotion of the health sector, specif- ically in areas of prevention and STI and HIV/AIDS awareness. National action plans on HIV/AIDS have been developed in each of the republics. Plans have iden- tified a number of priority areas includ- ing research, training and development and use of information, education, com- munication (IEC) techniques to help inform both vulnerable groups and the general public. UN agencies have been active in assist- ; ng governments to identify priorities and have been instrumental in working with relevant ministries, including educa- tion and health, in the design, develop- ment and implementation of school cur- ricula. As a direct follow up to the July 1998 workshop, UNESCO Almaty worked with the department of education and youth to develop a curriculum addressing healthy lifestyle issues. The curriculum has been integrated into classrooms in Temirtau, Karaganda. In Kyrgystan, UNF- PA has actively worked with the govern- ment, NGOs, youth, teachers and health specialists in the development of a cur- riculum. In Tajikistan UNESCO and UNFPA have been working with the government to develop a curriculum. UNESCO, along- side UNFPA and the government, have developed a curriculum in Uzbekistan. And a manual for biology teachers of grade nine students has been developed by UNFPA in Turkmenistan. Teacher train- ing in its use was on-going throughout 1999. It was piloted in 17 school, and is to be integrated into 80 schools in Sep- tember 2000. Since 1998, integrated multidonor pro- jects with an aim to fostering a healthy life have been developed regionally and in each of the five central Asian republics. Objectives and priority issues are the same: strengthening governmen- tal response, raising awareness of the general public and specifically among vulnerable groups, advocacy and the national capacity building of civil society organizations. HIV/AIDS has been recog- nized as a cross cutting issue, and thus UNAIDS, UNESCO, UNICEF, the United Nations Office for Drug Control and Crime Prevention (UNODCCP), UNFPA, the World Bank, WHO, NGOs, bilaterals and the pri- vate sector have actively worked togeth- er in providing financial and technical assistance to governments. "The project has nat only resulted in agencies commit· ting funds but has been a catalyst far the development af additional activities11 In 1998, UNESCO Almaty was awarded funding from UNAIDS to execute a regional IEC project entitled "STI, HIV/AIDS: A Regional IE( Initiative Along the Silk Roads of Central Asia". The project has had a number of positive results, including national capacity build- ing, generating additional funding, fos- tering innovative activities, awareness raising and increasing governmental response. In April 1999, UNICEF con- tributed financially to the project. The project has not only resulted in agencies committing funds but has been a catalyst NO. 47-48 - AUTUMN 2000 - PAGE 11 ~~ HIV/STis for the development of additional activi- ties. UNESCO Almaty has worked closely with national partners: relevant govern- ment ministries and republican and ob last AIDS centres, in providing technical assistance and in identifying national and regional priority areas in the area of HIV/AIDS prevention. Through the project, over 150 health care workers throughout central Asia were trained in communications techniques and over 150 media professionals were trained on HIV/AIDS issues and the sig- nificance the media can play to affect change. Networks among these two groups have been formed within each country and on a regional level. The project has supported the creation of a newsletter with the aim of informing the public and professionals working in the area of HIV/AIDS prevention on developments and to give a situational update of activities in Central Asia. The newsletter, INTO FOCUS, is issued quar- terly, in English and Russian, and is dis- seminated throughout central Asia. UNESCO Almaty, through its regional responsibility for education and commu- nication in central Asia, has built strong relationships with partners throughout the region. Collaboration has occurred on a number of different levels. Examples include awareness raising events and dis- cos in Kazakhstan, World AIDS Day cele- brations in Turkmenistan, media training and peer training in Turkmenistan, and the creation of the Jonathan Mann Award. Kazakhstan Through its extensive work with NGOs active in the field of HIV/AIDS preven- tion, UNESCO Almaty has been able to facilitate cost effective public awareness events on a regular basis. UNESCO was approached by the manager of a local club to see if we would conduct an event using their facilities, free of charge. We then decided to see if our partners were interested in working together - with no provision of funding. The response was positive, the National Healthy Lifestyle Centre, the Republican and City AIDS Centre, Doctors without Borders (MSF), the NGOs ANTI-NAR and "The Times of Change", and members of the artistic community - dancers and DJs - were all willing to participate. Si nee this first action, two other HIV/AIDS awareness programmes at popular clubs have taken place in Almaty this year. Tajikistan In celebration of the World AIDS Cam- paign in 1999, the Republican AIDS Cen- tre, the Ministry of Health, UNAIDS, UNDP and UNFPA organized an informa- tional campaign in Dushanbe. One of the highlights of the day was a bus with a loudspeaker that was driven around the city. A popular national figure rode on the bus and spoke on HIV/AIDS issues while distributing condoms, t-shirts and informational materials. "Within the framework af the Warld AIDS Campaign, 300,000 peaple were reached" Turkmenistan Collaborative public events included an event for youth in the Ashgabad stadium on World AIDS Day 1999. Within the framework of the World AIDS Campaign, 300,000 people were reached and 27 youth actions were conducted. Both formal and non-formal educational methods are employed in the process of educating the greatest number of people. UNESCO, working closely with the Repub- lican AIDS Centre and the Youth Union, a national NGO with a network throughout the country, conducted two communica- tion training workshops for youth union leaders outside of the capital. As a result, youths have gained knowledge on HIV/AIDS and contraception, and skills to encourage the sharing of this informa- tion have been developed. PAGE 12 - NO. 47-48 - AUTUMN 2000 Regional Award In March 1999, the UNAIDS Intercountry Regional Advisor for Central Asia, UNODC- CP, the Regional Office for Central Asia and the chairperson of the IE( Technical Group, Head of Office, UNESCO Almaty came together to establish the Jonathan Mann Award. The Award recognizes the most significant contributions by media, NGOs and national partners in the devel- opment of activities that aim to assist in the fight against the spread of HIV/AIDS. As a result of the success of the award, on World AIDS Day 1999, at the presentation of the award in Kaza- khstan, UNICEF CARK committed itself to joining in the award for 2000. It is evident that in a world where daily resources are becoming scarcer, we must find ways of sharing resources and skills in order to best affect change. The sig- nificant number and effect of efforts in central Asia are impressive. Governments are working towards the promotion of healthy nations, and UNESCO is commit- ted to assisting in the process. Shannon Berlin [sberlin@unesco.org] Head of IEC Unit UNESCO Almaty HIV/STis ~~ HIV I Al Dffl,w Grear is the Dan:[er for Youn:{ People?: I t has long been recognized that young people face a particular risk of HIV infection, which is why they have been a target group for numerous preventative information campaigns. If one attempts to define and assess the risk for young people more accurately, one surprisingly comes up against the problem that there is little or no precise data on the subject. Statements of age on positive HIV tests are by no means representative, since they only exist for some of the tests, and, moreover, it is not clear how many of these are repeat tests. In Germany, it is known that 38.9 is the average age of all those suffering from AIDS at the time of the diagnosis. In the last 15 years, there have been 506 cases of AIDS in the 13-24 age group (out of a population of 81 million). This age group represents 3.6% of all AIDS cases record- ed so far. Precise statements and conclu- sions on adolescents and AIDS are, how- ever, not possible. Nevertheless, the analysis of HIV tests for conscripts in the Austrian army is a reliable source of data. Austria is the only western country with an obligatory military service and HIV screening of its conscripts. The results have a high validi- ty as about three quarters of males aged 19-21 have been screened in this pro- gramme every year since 1985. "Since 1985 practically all of the 40,000 annual conscripts, cut cf a population of eight million, have been regularly tested far HIV" Although the HIV test is not part of the call-up in Austria, since 1985 practically all of the 40,000 annual conscripts, out of a population of eight million, have been regularly tested for HIV. The basis for this is an agreement between the army, which is seeking a cost-effective method of determining the blood type of its soldiers, and the Red Cross, which is prepared to determine the blood type of non-donors at no cost if it is guaranteed that the majority of conscripts take part in the blood-donor scheme. In order to ensure the motivation of the conscripts for this scheme, they are allowed to take leave for the weekend on Friday, once they have donated blood. Non-donors, The Case ofclie Co11scripcs however, have to wait until Saturday evening for their weekend leave, and often have no chance of travelling home by public transport. This procedure, which has been rejected in other European countries as being involuntary, has thus far ensured the almost total testing of Austrian con- scripts. As a result, there is now data on the frequency of HIV infection in three quarters of all males aged 19 to 21 for the last 12 years. A few points need to be taken into account when interpreting the data: Salzburg (Austria has nine provinces). In view of the fact that the surround- ing federal provinces of Tyrol and Upper Austria have so far not had a single HIV-positive blood donor from the barracks, and that their neighbour- ing province, Carinthia, has only had two, the reliability of this survey is only insignificantly affected by the absence of the Salzburg figures. All things considered, the data show that blood donors from the barracks are large- ly representative for heterosexually active, non-intravenous drug dependent male youths, after completion of schooling or apprenticeship. The propor- HIV positive blood donations from army barracks in Austria Year HIV- positive results number of recruits* 1985 3 49,000 1986 1 47,000 1987 1 45,000 1988 4 44,500 1989 3 43,000 1990 3 40,800 1991 4 39,400 1992 1 40,300 1993 2 41,500 1994 2 38,000 1995 1 32,300 1996 2 33,700 Total 27 494,500 *Defence Ministry figures No data are available from the Salzburg blood bank. • Members of the groups most affected, homosexuals and intravenous drug users, are, to some extent, in the course of the call up, exempted from military service, as are all haemophili- acs; • Conscripts who know they are HIV positive might resist the enormous pressure and refuse to take part in the blood donor scheme; • To a limited extent, professional sol- diers also give blood. Some of the positive tests could come from them; • Young men who have already tested positive for HIV may have attempted to avoid military service by applying for alternative community service instead; • It was unfortunately not possible to include findings from the province of tion of homosexuals or intravenous drug addicts seems to be rather limited. If one were to assume that HIV is spreading among the young heterosexual population, then a significant, and in recent years an increasing, number of HIV positive tests should manifest itself in the group tested. As is well known, unprotected passive/ receptive anal intercourse and the shar- ing of needles and syringes carries the greatest risk of infection with HIV. It can be assumed that only a small number of the conscripts were exposed to this risk situation. Thus, a low number of HIV positive tests was to be expected in this group, above all in the cities. The aver- age is 2.3 positive results per year. NO. 47-48 - AUTUMN 2000 - PAGE 13 ~~ HIV/STis Almost all cases, 25 of the total of 27, came from the Vienna blood bank, which also covers Lower Austria and Burgenland (Vienna is the only large city in Austria). In Carinthia, since 1985, there has been a total of two HIV-positive blood donors from army barracks. Since the survey began, in 1985, there has not been one single HIV-positive blood donor from army barracks in the other provinces: Upper Austria, Styria, Tyrol and Vorarl- berg . Assuming the participation of about 95% of the conscripts in the blood donor scheme, the result is a rate of six posi- tive HIV tests per 100,000 blood donors. (For all male first-time donors in Ger- many in 1993, the rate was 11.6). The studies published by the German and the French ministries of defence also show a similar result. The data there, however, are not as reliable, because conscripts' participation in the blood donor scheme was significantly lower due to its voluntary nature. The spread of HIV among young males not involved in the recognized risk behaviour cannot be observed on the basis of available data. In order to assess the risk for young women, it makes sense to draw on the anonymous, unconnected testing of new- born babies. After the birth, blood remaining in the umbilical cord is anonymously tested for HIV antibodies. The results provide information on HIV infection of the mother. Since 1993, this survey has been carried out in almost all births in Berlin, the German city with the greatest number of AIDS cases per capi- ta. In the meantime, similar surveys have been running in Lower Saxony and Bavaria. The Robert Koch Institute in Berlin, which is responsible for the eval- uation of the German figures, has come to the following conclusion: "The results - HIV prevalence significantly under one per thousand - among women giving birth confirm the assumption of a low distribution of HIV in the general hetero- sexual population so far". "It can hardly be productive, after 1 B years of HIV, to warn heterosexual, non intravenous drug-dependent young people by means of undifferentiated and alarmist information" Against this background, it would appear necessary to rethink sex education and AIDS prevention. It can hardly be pro- ductive, after 18 years of HIV, to warn heterosexual, non intravenous drug- dependent young people by means of PAGE 14 - NO. 47-48 - AUTUMN 2000 undifferentiated and alarmist information about a danger that does not exist to any subjectively or objectively provable degree. It is much more likely to endan- ger the credibility essential to all sex education. On the other hand, most pre- ventative information lacks explicit advice on the dangers of unprotected passive/ receptive anal intercourse, for women as much as for homosexual men. For sexually active people, contraception during sex was always an important sub- ject even before the arrival of AIDS. Pro- tection against unwanted pregnancies and sexually transmitted infections should thus be in the foreground of sex education. This should of course be done in a way that corresponds to young peo- ple's subjective experiences. Furthermore, any alarmism should be dispensed with, as it has already been shown that no lasting change in sexual behaviour can be achieved in this way. In this connection, it should be recalled that the Church also attempted to use alarmist information to impose a restric- tive sexual morality. The last major cam- paign of this type took place 35 years ago and was intended to hinder the introduction of the oral contraception pill. The horror scenario employed by the Church, purgatory, "going blind", loss of moral fibre and moral decay corresponded just as little to people's experience as the supposed AIDS epidemic among the heterosexual population today. The Church 's insistence on these empty threats has, as we now know after 2,000 years, neither changed our sexual behav- iour nor led us to Sodom and Gomorrah. Accordingly, the credibility of the Church and, as a consequence, its influence have shrunk to an extent that was unimagin- able at the time. This research would not have been possi- ble without the support of the Austrian Society for Family Planning and the blood banks of the Austrian Red Cross. I would like to thank them for their cooperation. References are available from the author. Christian Fiala, MD [ christian. fiala@aon.at] Dept. of Gynecology and Obstetrics General Public Hosptial Wiener Ring 3-5 A-2100 Korneuburg, Austria Tel.: (+43) 2262-780 6901 Fax: (+43) 2262-780 285 POLICY AND PRACTICE ~ ~ SEXUALITY AND AGl,.nf iraeli Experimce Widespread stereotypes, misconcep-tions and jokes about old age and sexuality affect negatively and powerfully older people's sexual experi- ence. Younger people sometimes find it difficult to accept that older people are still interested in sex, find one another attractive or enjoy sexual activity. When the elders internalise these attitudes, they function below their actual capaci- ties and their inner needs. "Younger people sometimes find it difficult ta accept that alder people are still interested in sex" Many Israeli healthcare professionals who work with elders share similar ideas and beliefs, thus neglecting sexual aspects of their older clientele. Therefore, they were chosen as the target population for change. This target group included health care professionals in nursing homes, geri- atric and psycho-geriatric institutes, sheltered housing and day care centers. In Israel there is an in-service govern- mental training programme designed for the professional and personal growth of health care workers. This training created a suitable framework for the insertion of a sexuality education programme, focus- ing on helping the participants under- stand and accept the sexual needs and rights of the elders. These rights were clearly defined by the IPPF in 1995: "IPPF recognises and believes that all persons have the right to be free to enjoy and control their sexual and repro- ductive life. No person should be discrim- inated against in their sexual and repro- ductive lives, in their access to health care and/or services on the grounds of race, color, sex, sexual orientation, mari- tal status, family position, age." During a period of ten years 1,880 staff members participated in the training. This group consisted of 315 directors or managers in geriatric institutes, 580 geriatric nurses, 390 geriatric social workers, 245 care workers and 350 family physicians. In addition, 6 teams (210 professionals in total) attended short training workshops designed to formulate solutions for specific problems regarding the sexual activities of the residents in their own institute. Through a 12-hour training in small groups, participants could learn about age-related changes in sexuality, practice assertive skills in discussing sexual issues and increase their ability to professional- ly and ethically confront the sexual behaviour of elders in the various insti- tutes. The objectives of the training were defined on the assumption that helping elders maintain the right to remain sexu- al human beings will contribute to their quality of life. During the training the participants were encouraged to raise problems and dilem- mas regarding sexuality, which they had to cope with in their daily work with the elders. Due to a strong taboo about speaking about sex, the training became a unique opportunity to talk, share and learn about various sexual problems and dilemmas as encountered by their col- leagues in the geriatric profession. "the training became a unique opportunity ta talk, share and learn about various sexual problems and dilemmas" The next step in the training comprised coping with sexuality at work, by using practical intervention modes. The PLISSIT model was used as a basic intervention model and adapted for the use of the health care professionals. The permission level and the limited information level, which are the first two levels of the PLIS- SIT model, were converted into two modes: direct permission and indirect permission. For example, a physician who discusses medical issues with an older client could choose to be open and direct in his/her sexual intervention by asking the elder whether there are any questions regarding sexuality or by simp- ly giving the client adequate sexual information regarding an illness or treat- ment. If the physician is too busy or embarrassed, he/she could choose indi- rect intervention by using non-verbal encouragement and by creating a posi- tive atmosphere for older clients to ask questions. This may be done by display- ing books or leaflets or by hanging posters on sexuality and aging. In the training participants spoke of problems and dilemmas that they had to face in their professional work with elders. These problems were analysed and solutions for intervention were discussed. The discussion included the following dilemmas: • Sexual expression in public areas; • Sexual expression in privacy; • Sexual expression within the client- professional relationship; • Concerns about sexual abuse of elders; • Sexual harassment at work; • Resistance of staff members, residents and family; • Dilemmas regarding moral issues. Conclusion There seems to be a change in awareness and understanding of professionals of the various issues with regard to sexuality and aging. For example, today there is almost no professional training in the domain of geriatrics which does not include a single lecture on this issue. However, there is still a long way to go until professionals will be able to per- ceive elders as sexual human beings and endow them with the right to have infor- mation, treatment or any other support regarding their sexual problems and questions. References can be obtained directly from the author. Gila Bronner [gilab@netvision.net.il] MPH MSW Sex Educator & Therapist Sex Therapist, The Tel-Aviv Sourasky Medical Center, Tel-Aviv Israel Neurologic Department & Psychiatric Services. Teacher, Tel-Aviv University, School of Health Professions, Sackler Faculty of Medicine and School of Education NO. 47-48 - AUTUMN 2000 - PAGE 15 POLICY AND PRACTICE MEDICAL ABORTION. .. "Wliere we are in Eitrope Eleven years after becoming commer-cially available in France, mifepris-tone (RU 486/Mifegyner) is still being withheld from most potential users peutical benefits from the population for commercial reasons (fear of boycott). US citizens died during the first six months of commercialisation in the US alone; see http://www.fda.gov/). The comparison between Mifegyne and Viagra is just another example of the double standard that continues to exist between men and women, and particularly women facing an unwanted pregnancy. in Europe (see Table 1). It is interesting to note that in 1988 the French govern- ment gave the pharmaceutical company Russel-Uclaff the choice to either market mifepristone or it would take away the rights and ask another company to pro- duce and sell the drug. The government argued it would be unlawful for a private company to withhold a drug with thera- And resistance to its use continues even 11 years after the first commercialisa- tion, although it has been proved to be safe and effective. By comparison, Viagra was available before its official authori- sation and received a licence quickly. It can also be used without medical super- vision and outside a hospital, despite a high number of deaths that have been reported in connection with its use (130 What is medical abortion? Mifepristone is a hormone that resembles the Luteal hormone progesterone and is taken by the woman as tablets. It binds Country Availability Limitations to access Austria Available only in a Approved only for hospitals and clinics, although most few institutions in the Vienna area abortions are performed in private practice by gynaecologists or GPs Belgium Available since June Centres have to obtain the product from a reference hos- pital with a pharmacy Denmark Available since April Some institutions have used it for over one year Finland Available in May France On the market since 1988 Strong regional differences in availability Germany Available in some institutions The Society of Gynaecologists imposed a "quality mainly to private paying standard": should be used only when cardiac women activity is visible (>42 DA); not fully covered by social security, in contrast to surgical abortion Greece Not yet available, although approved Approved for hospitals and clinics only, although most in October 1999 abortions are performed in private practice Ireland Not available No application Italy Not available No application Luxembourg Not yet available, although approved since December 1999 The Netherlands Not generally available although Abortion providers judge that women do not need it approved; two clinics are carrying out an acceptance study Norway Approved since February 2000 Not on the market yet, some institutions have used it the last year Portugal Not available No application Spain Available since February Centres must have a pharmacy or a responsible pharmacist Sweden On the market since 1992 Strong regional differences in availability Switzerland Available since December 1999 Marketing after a legal debate as to whether Mifegyne is a medical product or not UK On the market since 1991 Strong regional differences in availability Access to medical abortion still depends in all countries on the engagement of individual doctors and counsellors and therefore differs enormousely from region to region. DA: Days of amenorrhea PAGE 16 - NO. 47-48 - AUTUMN 2000 to the receptors in the uterus but exerts no effect. (This is similar to a wrong key blocking a padlock.) The progesterone is vital for the mucous membrane in the uterus for the continuation of the preg- nancy. Lack of progesterone or blockage of its receptors by mifepristone results in menstrual bleeding and loss of the preg- nancy. A second drug, a prostaglandin tablet is taken by the women two days later to make sure that expulsion takes place. The course of medical abortion In the General Public Hospital of Korneuburg, just outside Vienna, we have been carrying out terminations with Mif- egyne® since January 1999. We treat approximately 50 women per month, the demand being very high. Most of the women come from Vienna and its sur- rounding area. An (after) curettage was needed for three per cent of all women treated. After completion of the treat- ment, we asked the women, inter alia through a questionnaire, which method they would choose in any future termina- tion. Of those responding, over 90 per cent would choose this method again. 1. First telephone contact The first telephone contact usually begins with a detailed discussion of information on abortion itself, though also on the details of the various meth- ods. The discussion then proceeds rapidly - according to the situation - to a coun- selling session. This discussion is often of great importance in the Mifegyne (!) counselling, as it lays the foundation stone for the relationship and thus also the course of the process. The telephone calls are often long, or the woman rings several times within two or three days. It is therefore important that the same person also provides the continuing counselling and escort functions. As pre- viously mentioned, the counsellor must go through a selection process with the patient in relation to the medical and psychological criteria in order to choose the most suitable method. If the women seems to be sure of her decision we make an appointment. Often, however, we also provide information on other establish- ments that are either nearer or which carry out surgical terminations under local or full anaesthetic. Despite the surge of interest in Mifegyne and the fre- quent calls to our advice line, only approximately 20 per cent of the callers actually go on to termination with Mifeg- yne®. The period from first contact to the taking of Mifegyne® In this phase, women are confronted by unrealistic worries and illusions. Question repeatedly arise what is really going to happen to me, what have I let myself in POLICY AND PRACTICE ~ for, have I made the right decision? Seen as a whole it is the most uncertain and problematic phase. 2. Counselling at the hospital The first personal contact in the hospital is divided into the medical examination and the counselling. Teamwork between the doctor and the counsellor is crucial in this. They must divide the consulta- tion and reciprocally accept their compe- tences in order to guarantee the best possible care. Detailed information on the method and the process should, where possible, deal with any misconcep- tions. Women are particularly relieved when there are (still) no embryonic structures, and in particular no heart activity, visible on the ultrasound scan. Furthermore, it should be emphasised that the taking of Mifegyne JJ is the actu- al termination of the pregnancy. This is the point of no return. The prostaglandin two days later serves only to support the expulsion of the already terminated pregnancy. As already mentioned, an exact prediction of the further course of the process is not possible because of the great individual variations. The women should be advised of this. In par- ticular, the varying courses of the process do not allow any conclusions to be drawn on whether the method functions or not. In our experience it is particularly impor- tant and helpful for the woman if the partner or a contact person is integrated into the course of the process, so that he/she can have a supportive effect. Nat- urally, this can only happen with the agreement of the woman concerned. The period from the taking of Mifegyne to the taking of Prostaglandin In this phase, the problem with the body comes to the fore. The decision for termi- nation has already been implemented. Now, the uncertainty over the further course of the process and the waiting for the period are the main issues. 3. Care after the taking of Prostaglandin The atmosphere is now essentially more relaxed than at the previous contact. The woman knows the doctor and counsellor and knows at least theoretically what awaits her. Further, there is no longer any decision to be made, only the continuation of a process that has already been started. For some women, morning sickness has already receded and in a few cases the women have already ejected the amniotic sac and bring it with them (in these cases the treatment is thereby concluded). Most women are worried about possible pains after the taking of the Prostaglandin. The offer of an appropri- ate escort by a trusted person is there- fore very important. As far as possible this should, however, remain an offer, and not be seen as a compulsory measure. Some women are hardly affected by the termination and therefore have no need of an escort. This should also be taken into account in the organisation of the process. In this phase, medical care recedes into the background, in favour of escort by the counsellor and the part- ner/friend. Some 20-40% of the women require mild analgesics. From the taking of Prostaglandin to the check-up Heavy bleeding and cramps can occur in this phase. The main concern is the uncertainty as to whether the method has worked or not. Future fertility is sud- denly also an important issue again. 4. After-care The further medical check-up after a week to ten days is seen by most women as a great relief and the definitive con- clusion of the process. For many women the period up to the check up is stressful because of the uncertainty over whether the pregnancy has actually been termi- nated. Most women are thus all the more pleasantly surprised if everything has gone well. Occasionally, a second or third medical check-up is necessary, and in about three per cent of cases a curettage. For these women, too, appropriate counselling should be envisaged. As always, there is the question of psychological- psycho- therapeutic after-care, which is, however, only rarely taken up after a medicinal termination. Conclusion Medical abortion does not essentially change the counselling in the conflict case of an unwanted pregnancy. The pre- vious counselling only has to be supple- mented when it comes to the specific implementation. Here, good information and counselling with sufficient time are necessary, so that each woman can arrive at the best decision regarding the method for her. This makes medical ter- mination with Mifepristone a sensible alternative for many women. Moreover, we have the experience that the treat- ment proceeds essentially more calmly and less dramatically than the public debate. Christian Fiala, MO [ christian. fiala@aon.at] Dept. of Gynecology and Obstetrics General Public Hosptial Wiener Ring 3-5 A-2100 Korneuburg, Austria Tel.: (+4)32262-780 6901 Fax: (+43) 2262-780 285 NO. 47-48 - AUTUMN 2000 - PAGE 17 POLICY AND PRACTICE TURKMENISTA~ . - ~q,rodiicffve Health Services Take Root The UNFPA project TUK/96/P02 "Improving RH Services in Turk- menistan" was initiated in May 1997 and implemented by the Ministry of Health and the Medical Industry of Turkmenistan, and the World Health Organization. Long-term objectives of the project: • Improvement of reproductive health conditions; • Guarantees that pregnancy be made safer; • Improvement of national and fami- ly health, and the preservation of women's health; Immediate objectives of the project: • Increasing the birth space intervals from 1.5 years to 2 years for more than 20% of Turkmenistan's women; • Further upgrading performance and skills of health personnel after having trained approximately 300 specialists; • Ensuring a decrease in maternal and infant mortality rates by upgrading reproductive health services. A UNFPA project, implemented by the Ministry of Health (MOH) and the Medical Industry (MI) of Turkmenistan and WHO has: • Resulted in collaboration between the United Nations Population Fund (UNFPA), the MOH & MI of Turmenistan and WHO; • Established reproductive health services in Turkmenistan; • Improved the contraceptive supply system (determination of needs, conditions of storage, distribution, use control); • Trained twice as many specialists as originally intended; • Trained specialists so that they can train others; • Coordinated a system of supervisors; • Initiated research according to WHO standards; • Achieved the mutual understanding on basic directions of cooperation with organizations such as WHO, UNFPA and UNICEF; • Initiated the exchange of national personnel between regions; and • Established the necessary conditions for the successful beginning of a new programme cycle. Reproductive health services have existed in Turkmenistan since the beginning of 1997, when an order to establish six reproductive health centres (a centre in each velayat and in Ashkabad, the capi- tal of Turkmenistan) was issued. Repro- ductive health sub-centres were opened in each etrap. Today, there are 98 in total. In January 1999, an order of the Ministry of Health of Turkmenistan was issued calling for the establishment of affiliate branches of the reproductive health departments, the aim of which was to make reproductive health services avail- able to all of Turkmenistan's citizens, including those who live in remote areas of the country. Reproductive health centres in each velayat and in the city of Ashkabad were first established in mother's and chil- dren's hospitals. UNFPA provided both the principal reproductive health centres and their branches with the necessary equipment for holding training courses. In addition to training equipment, UNFPA equipped health-care institutions with gynaecological instruments, delivery beds, floor balances, heated infant's beds, etc. Since 1994, UNFPA has continuously pro- vided the population of the country with free contraceptives. In May 1999, the MOH of Turkmenistan established a national centre whose main tasks were defining needs, compiling orders and receiving, storing and distributing con- traceptives. Moreover, UNFPA has provid- ed the centre with storage facilities. PAGE 18 - NO. 47-48 - AUTUMN 2000 In 1998/1999, UNFPA financed two research projects reflecting the state of women's reproductive health, their atti- tudes to reproductive health and contra- ceptives, problems of teens and the structure of infection pathology in women. This research was vital for strate- gy implementation. From 1997 to 1999, contraceptive use among women increased from 14% to 29.2%. The birth space interval increased from 1.5 years in 1997 to 2.5 in 1999. The abortion rate has decreased and the maternal and infant mortality rate has also decreased: maternal mortality was 64.5 per 100 000 population in 1998 and 42.2 in 1999. Training of specialists in reproductive health issues The training of specialists in reproductive health has involved several stages. First, six heads of centres were trained in Hun- gary as master-trainers. Then, in collabo- ration with WHO, UNFPA and the MOH of Turkmenistan, training workshops were conducted in February and December 1998. As a result, there are 34 master- trainers in the country. In total, 500 spe- cialists (ob/gyns, family planners and midwives) have been trained. In 1999, UNFPA provided all the master- trainers with training programmes in Russian and Turkmen. Each training course is designed for 18 participants, the selection of which is conducted by the velayat health care departments with regard to regional requirements. During the whole training process a supervisor is present, a specialist from the first master-trainers, who monitors the training process and assists trainers in conducting courses. In addition to lec- tures, training courses include role games, which promote the better master- ing of the material. After finishing cours- es, the participants are tested and, if successful, receive certificates. Before 1999, UNFPA prepared and orga- nized training courses, and beginning from 1999, local coordinators were appointed to independently manage training courses. UNFPA is now only responsible for financing and providing curriculum materials. 340 gynaecologists, 108 family doctors and 108 nurses have been trained in RH issues. About 200 ob/gyns have been trained by local master-trainers. In total, more than 50% of all the obstetricians-gynaecologists have been trained in reproductive health issues, and the training of family doctors and paramedical personnel has started. Information work Besides informing large groups of the population of urgent reproductive health problems, advanced training courses for medical personnel are of considerable importance. Such courses were held at 16 short-term workshops {3-5 days) in 1997-99 at which doctors found the reproductive health issues to be the most interesting. In November 1999, WHO conducted a workshop in the rapid evalu- ation method of results for the improve- ment of evaluation methods and monitor- ing techniques. This workshop was of great use for supervisors and heads of health care departments providing regu- lar monitoring. Every year, with the help of an interna- tional expert, a workshop in the manage- ment of informational systems and the planning of procurement is held for heads of reproductive health centres and all specialists taking part in the process of preparation of orders for contracep- tives. These workshops have helped in the development of a system to manage procurements and collect information . At the end of each year, a national con- ference is held to sum up activities deal- ing with the reproductive service for the year and to define problems to be solved in the future. The conference allows the personnel of the reproductive health ser- vices to network. At each conference, an international expert is present. In addi- tion, UNFPA reports on new information sources from WHO and other organiza- tions. Monitoring In 1998, an evaluation of the reproduc- POLICY AND PRACTICE tive health service activities accompa- nied training courses. In 1999, a number of missions were conducted with specific aims: control of the work of the repro- ductive health sub-centres, stock-taking and storage of contraceptives and an evaluation of maternal and child health. During the monitoring mission, different international materials were distributed such as articles, posters, booklets and pamphlets. Future reproductive health work in Turkmenistan should seek to: • Collaborate with UNICEF on breast- feeding and reproductive health activities; • Improve the health of women by increasing the birth space interval (specific attention should be paid to infections of the genital tract, anaemia and other non-genital pathology). • Give specific attention to reproductive health during the perinatal period; • Establish effective RH services for adolescents; • Train RH master-trainers for adolescents; • Improve the system of compiling medical statistics; • Train specialists including specialists from MOH & MI and velayat depart- ments of health on medical statistics; • Develop activities for AIDS prevention jointly with UNFPA and UNAIDS; • Expand RH training courses for family doctors and paramedical personnel involving local coordinators; • Systemize reg- ular monitor- ing involving high level spe- cialists from MOH &MI; • Continue the practice of short-term (including field trips) seminars as an effective method of information distribution for doctors and middle Level staff. • Organize field trips for obste- tricia n-gynae- cologists from RH centres and sub-centres to study the experience of neighbouring countries; and • Strengthen the knowledge of project specialists by studying the experiences of different countries that have achieved positive results in improving the RH of their population. Gozel Khodjaeva [rh.unfpa@untuk.org] National Project Coordinator of the "Reproductive Health Services in Turkmenistan" project United Nation Population Fund (UNFPA} 40 Atabaeva str., Ashgabat, 744100 Turkmenistan Fax: (+99312) 35 26 75 Tel: (+99312} 41 97 76 Lola Babakulieva [ rh .unfpa@untuk.org] Project Assistant of the "Reproductive Health Services in Turkmenistan" project United Nation Population Fund (UNFPA) 40 Atabaeva str., Ashgabat, 744100 Turkmenistan Fax: (+99312) 35 26 75 Tel.: (+99312} 41 97 76 E. Khellenov [tuk96p02@un.cat.glasnet.ru] NO. 47-48 - AU TUMN 2000 - PAGE 19 RESOURCES UN Documents Charting the Progress of Populations ( Population Division, Economic and Social Affairs, ISBN 92-1-151344-8) pro- vides information on 12 key socio-eco- nomic indicators related to the goals of the UN global conferences held in the 1990s on economic and social issues of international concern. The indicators include access to health services, contra- ceptive prevalence, maternal mortality and infant and child mortality. The data are the latest available as of September 1999. Contact the director of the Population Division directly if you have questions (population@un.org). Contact United Nations Sales Section New York, NY, USA www.popin .org Findings of the Survey on the Repro- ductive Health of Women in some Towns and Rayons of Khatlon Oblast, Republic of Tajikistan (UNFPA, WHO, pp 46, 2000). The results of the RH sur- vey are based on the examination of 400 women and interviews with 3,000 women of different age groups. Survey results showed that nearly 22% of the respon- dents could not name at least one birth regulating method. The second survey showed that abortion remains a major means of birth regulation in Tajikistan. Finally, 72% of the surveyed women have little knowledge of what an STI is. Contact WHO Regional Office for Europe Women's and Reproductive Health Programme Scherigsvej 8 DK-2100 Copenhagen O Denmark Fax: (+45) 39 17 18 50 E-mail: entrenous@who.dk Handbook for Legislators on HIV/ AIDS, Law and Human Rights: Action to Com- bat HIV/ AIDS in View of its Devastating Human, Economic and Social Impact {1999, pp 152). More than 90% of the 33.6 million people living with HIV/AIDS at the end of 1999 were in the develop- ing world. The purpose of this handbook is to assist parliamentarians and other elected officials in promulgating and enacting effective legislation and under- taking appropriate law reform in the fight against AIDS. The handbook pro- vides examples of best legislative and regulatory practices gathered from around the world. Contact UNAIDS 20 avenue Appia CH-1211 Geneva 27 Switzerland E-mail: uanids@unaids.org www.unaids.org Health Issues of Minority Women Liv- ing in Europe {1999, pp 198, cost, USD 20). Based on a meeting in Gothenburg, Sweden, in November, 1999, this beauti- ful publication is the essential document on minority women and health. Well- written and interesting articles cover the spectrum on this subject, from FGM in Europe and justice and equality issues to country case studies and examples. The Gothenburg conference and this report are an example of a successful partner- ship between WHO, a "Healthy City" and a national public health institute. Contact Margareta Acherhans Gothenburg Healthy City Project Tel: (+46) 31 4000 885, or E-mail: marianne.hallbert@stadshuset.goteborg.se HIV in Pregnancy: A Review is a summa- ry of what is known about HIV during pregnancy, transmission of HIV from mother to child and interventions to pre- vent transmission. Appropriate manage- ment of HIV-positive women during preg- nancy delivery and postpartum is discussed. The publication includes guidelines for infection control and safe practices while working with HIV-positive women. Contact Documentation Centre Department of Reproductive Health and Research World Health Organization CH-1211 Geneva 27, Switzerland Tel: (+41) 2 791 4477 Fax: (+41) 22 791 4189 Programming for Adolescent Health and Development (Report of a WHO/ UNFPA/UNICEF Study Group on Program- ming for Adolescent Health, ISBN 92-4- 120886-4, price Sw. fr. 56-) describes the guiding concepts and major interventions that are necessary components for country programming for adolescent PAGE 20 - NO . 47-48 - AUTUMN 2000 health and development. The report makes it clear that there is value in col- laborating to address the health and development of adolescents simultane- ously. Most importantly, the report calls for all three international actors to col- laborate in helping adolescents. Contact Marketing and Dissemination World Health Organization CH-1211 Geneva 27, Switzerland Reduction of Maternal Mortality - A joint WHO/UNFPA/UNICEF/World Bank Statement identifies the issues involved in the selection of the appropri- ate interventions and outlines the poli- cies and legislative actions that are essential. One of the most significant conclusions of this joint effort is that it is possible to reduce maternal mortality significantly with Limited investment and effective programme and policy interven- tions. Contact Marketing and Dissemination World Health Organization CH-1211 Geneva 27, Switzerland Review and Appraisal of the Progress Made in Achieving the Goals and Objectives of the Programme of Action of the International Conference on Population and Development (Popula- tion Division, Economic and Social Affairs, ISBN 92-1-151339-1) contains the key actions adopted by the General Assembly at the special session and the opening statement of the Secretary General. The reproductive health section is 6 pages long with sections on repro- ductive rights, family planning, STDs/ AIDS and adolescents. Contact United Nations Sales Section New York, NY, USA www.popin.org The WHO Reproductive Health Library No. 2, the second issue of a WHO diskette on reproductive health in devel- oping countries, is now available. It updates many of the 27 reviews that appeared on the first diskette and also contains an additional 13 reviews as well as commentaries with practical rec- ommendations. The diskette, available in English and Spanish, is free to health workers in developing countries. Contact Jitendra Khanna World Health Organization E-mail: karnerc@who .ch Fax: (+41) 22 791 4171 Other Documents AVSC International publication series. AVSC's latest publication is a package of materials on voluntary sterilization. While working primarily in the field of reproductive health and family planning services, AVSC also retains a specialized expertise related to safe, voluntary steril- ization and counselling services. Contact AVSC International 440 Ninth Avenue New York, NY 10001 Fax: (+1) 212 561 8067 E-mail: info@avsc.org www.avsc.org Another cross-posting from health-l@hivnet.ch Moderators note: Distributed at no cost to policy makers and program planners worldwide. Helping Involve Men (HIM) USAID Working Group and Johns Hopkins Center for Communication Programs Releases "HIM" (Helping Involve Men) CD-ROM. The new Helping Involve Men (HIM) CD-ROM brings together for the first time hundreds of documents from around the world about men's participa- tion in reproductive health. Designed mainly for use by policy makers and pro- gram planners in developing countries, the CD provides easy access to an "essen- tial Library" of important research and programmatic findings and guidance. Documents on the CD are organized to address major aspects of men's involve- ment in reproductive health. Categories include: Gender, Couples, Men & Repro- ductive Health, !EC & Men, Institutional Influences and Future Research. Each category lists topic questions or state- ments to make it easy for the browser to seek out relevant documents. For exam- ple: What do we know about men's knowledge and opinion of family plan- ning? Adolescent males: What special attention do they need? What influence do men have on women's health? Com- munication to involve men in reproduc- tive health. What institutional obstacles prevent men from participating in healthy reproductive lives? Also, the CD-ROM features a resources section that lists materials, organiza- tions, LISTSERVs and web addresses for follow-up information. For example, the section on future research includes arti- cles about operations research, research gaps, indicators of men's participation, less-than-successful men's participation projects, lessons learned and recommen- dations from conferences and literature reviews. JHU/CCP will distribute the CD at no cost to people in developing countries. RESOURCES ~~ Contact Rick Glasby, CD-ROM manager, POPUNE Digital Services Center for Communication Programs, Johns Hopkins School of Public Health 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA Fax:(+1) 410 659-6266 E-mail: popline@jhuccp.org www.jhuccp.org The Holy See and Women's Rights: A Shadow Report on the Beijing Platform for Action is a response to an invitation to the NGO community to pre- pare shadow reports for the five-year review of the Fourth World Conference on Women. The report provides a review of the Holy See's activities regarding implementation of the Beijing Platform of Action. The report is critical of the Holy See's refusal to endorse modern methods of contraception in any context while condemning abortion. The report concludes that the Holy See has no intention of altering its stance on any issue that would force it to incorporate the promotion of women's reproductive health into its priorities. Contact Catholics for a Free Choice 1436 U Street, NW, Suite 301 Washington, DC 20009-3997 USA Fax : (+1 ) 202 332 7995 E-mail : cffc@ igc.apc.org www.cath4choice.org IPPF Medical Bulletin (Vol. 34, No. 1, February 2000). This issue focuses on progestagen implants, outlining the advantages and disadvantages of the implants. There is also an article featur- ing highlights from the International Medical Advisory Panel (IMAP) meeting in December 1999 where the non-Latex condom and male circumcision were dis- cussed. Contact International Planned Parenthood Federation Regents College, Inner Circle, Regent's Park London NWl 4NS England Tel: (+44) 171 487 7900 Fax: (+44) 171 487 7950 E-mail: info@i ppf.org www.ippf.org Meeting the Cairo Challenge: Progress in Sexual and Reproductive Health, Implementing the ICPD Programme of Action provides documentation that many of the 179 countries which took part in the 1994 International Confer- ence on Population and Development (!CPD) in Cairo are working to implement the gathering's Programme of Action. The report describes country-level progress and problems in each one. The main problems, however, are that donor coun- tries at large are not meeting funding commitments; women are still underval- ued and suffer ill health and the econom- ic and social effect of discrimination in many places; and poverty is hampering expansion of public health services. Developed in collaboration with the Lon- don School of Hygiene and Tropical Medicine and the Karolinska Institute. Contact Family Care International 588 Broadway, Suite 503 New York, NY 10012 Fax: (+1) 212 941 5563 E-mail: fcipubs@familycareint.org Network (Family Health International, Vol. 20, No. 1, 2000) focuses on intrauterine devices (IUDs) including a detailed article on how the Lev- onorgestrel contraceptive system offers several non-contraceptive benefits, for example a substantial decrease in men- strual blood loss and pain . It can also stop the development of endometriosis. Additional articles include IUD use and the risk of STis, how to minimize PID risks and the Copper T IUD, safe, effec- tive and reversible. The journal is avail- able in English, French and Spanish . Contact Family Health International PO Box 13950 Research Triangle Park, NC 27709, USA Tel: (+1) 919 544 7040 Fax: (+1) 919 544 7261 www.fhi.org Population Reports: Ending Violence Again Women (Series L, Number 11, pp 44). Around the world at least one woman in every three has been beaten , coerced into sex or otherwise abused in her Lifetime. Most often the abuse is a member of her own family. Gender-based violence is a major public health concern and the topic of this issue. This is with- out a doubt one of the most important documents on the subject. Contact Population Information Program Center for Communication Programs The John Hopkins University School of Public Health NO. 47-48 - AUTUMN 2000 - PAGE 21 111 Market Place, Suite 310 Baltimore, MD 21202 USA www.jhuccp.org/popline RESOURCES Sida Info Service, a European HIV/AIDS prevention network regarding women of southern European countries, was found- ed under the aegis of the European Com- mission. The "Mediterranean network listening to women" publishes a newslet- ter as a part of their efforts to improve the social, psychological and medical care of women confronted with HIV/AIDS. The newsletter is published in English and French. Contact Siege national 190, boulevard de Charonne F-75020 Paris E-mail: reseaufm@club-internet.fr www.sida-info-service.org WIN (Women's International Network, Vol. 27, No. 1 winter 2000) has a number of useful web sites as well as articles on women and health, FGM, Beijing + 5 and women and violence. Contact Women's International Network News 187 Grant St. Lexington, MA 02420-2126, USA Training/ Congresses 29th British Congress of Obstetrics and Gynaecology (10-13 July 2001) will be held at the International Convention Cen- tre, Birmingham, UK. Keynote lectures will be on: feta-maternal medicine, oncology and reproductive medicine. Contact 29th BCOG Secretariat, Congress House 65 West Drive, Cheam, Sutton Surrey SM2 7NB, UK Fax: (+44) 208 661 9036 E-mail: info@conforg.com European Institute of Women's Health: Promoting Gender Equity in Public Health in Europe (9-11 September, Dublin). Topics will include reproductive health, STis/AIDS and violence against women. Contact Conference Partners Limited 96 Haddington Road, Ballsbridge Dublin 4, Ireland Tel: (+353) 1 667 7188 E-mail: info@conferencepartners.ie The World Health Report 2000 is like no other WHR previously released. For the first time ever, a comprehensive analysis has been made of the world's health systems. Five performance indicators were used to measure the health systems in 191 member states. France, Italy, Spain, Andorra and Austria from the European Region all ranked at the top. The report presents an analysis of the four main functions of health systems and outlines a number of policies on provision, financing, input generation and stewardship that seem to be associ- ated with better performance. It also presents the main failings of health systems and provides recommendations. But what is truly unique with this report is that WHO broke new methodological ground by employing a technique not previously used for health systems. It compares each country's system to what the experts estimate to be the upper lim- it of what can be done with the level of resources available in the that country. It also measures what each country's system has accomplished in comparison with those of other countries. In Europe, for example, health systems in Mediterranean countries such as PAGE 22 - NO. 47-48 - AUTUMN 2000 France, Italy and Spain are rated higher than others in the continent. Norway is the highest Scandinavian country at 11th. Slovenia is the highest ranking Eastern European country at 38th, fol- lowed by Croatia at 43rd, and Kaza- khstan at 64th is the highest ranking NIS country. Responsiveness of health systems, fair- ness of financial contribution, overall level of health, distribution of health in the populations and distribution of financing were the performance indica- tors employed, and they are discussed in detail in the WHR. How do the country rankings reflect sex- ual and reproductive health care in your country? Send comments or feedback to Entre Nous. Contact World Health Report World Health Organization CH-1211 Geneva 27, Switzerland Fax: (+41) 22 791 4870 E-mail: whr@who.int Copies of the publication can be ordered from: bookorders@who.int Price: 15 Swiss francs (10.50 Swiss francs in developing countries) ISBN 92.4.156198 X The full report is available on www.who.int/whr/ http://www.agi-usa.org/ The Alan Guttmacher Institute site pro- vides information on sexual behaviour, pregnancy and birth, contraception, . abortion, STis, youth, and Law and public policy, both domestic and international. This site also contains select current vol- umes of the organization's publications including Family Planning Perspectives and International Family Planning Per- spectives, and the Guttmacher Report on Public Policy. Selected articles are full text. http://www.arhp.org/ The Association of Reproductive Health Professionals (ARHP) represents a group of professionals who provide reproductive health services or education, or conduct research or influence policy concerning reproductive health. The site provides information on future conferences. Recent editions of the organization's publications, including Health and Sexu- ality, Clinical Proceeding and the quarter- ly newsletter, ARHP Update, are available full-text online. http://europa.eu.int/comm/ development/aids HIV/AIDS - European Union is a new Web site. The primary goal is to raise global awareness of HIV/AIDS issues in developing countries and to facilitate the exchange of information. It also provides comprehensive information and relevant documentation relating to all aspects of the EU HIV/AIDS programme in develop- ing countries. http://www.hivatis.org/glossary/index. html This site, sponsored by the U.S. Depart- ment of Health and Human Services, provides definitions of HIV/AIDS-related terms, the pathogenesis of and associat- ed treatments for HIV/AIDS, and medical management of related conditions. http://www.intrah.org/~ofm.html . Compiled by INTRAH, this annotated bib- liography includes more than 1,200 items that are available free to individuals and organizations in developing countries. The list is organized into a number of sections, including reproductive health, maternal and newborn health, family planning, family and community health , reproduction and sexuality, STis/RTis and HIV/AIDS, and gender. The list of materi- als can be searched on line in English, French and Spanish. Information on ordering all of the materials is included. http://www.ippf.org/ IPPF's site contains an updated news RESOURCES section and a section on regional pro- jects. The resources section describes the available publications, including a Sex- wise Guide, the X-Press: The IPPF Newsletter for Young People, and bibli- ographies. IPPF also provides over 60 country profiles, and there are Links to IPPF affiliates all over the world, organi- zations concerned with family planning, population and reproductive health issues, other international organizations and other related sites. http://www.jhuccp.org/netlinks Johns Hopkins Center for Communica- tion Programs provides a searchable database of over 1, 100 Web sites of orga- nizations and government agencies that deal with issues of population, health and development. The site can be searched by country, subject or organiza- tion, and provides di rect Links to Web sites around the world. http://www.planetq.com/aidsvlfindex. html The AIDS Virtual Library provides Links to organizations concerned with social, political and/or medica l aspects of HIV/AIDS. www.safemotherhood.org/smguide Implementing the Safe Motherhood Action Agenda: A Resource Guide is a comprehensive annotated bibliogra- phy of publications, periodicals and web- based materials. Released by t he InterA- gency Group for Safe Motherhood (IAG), the guide Lists and describes a range of available materials and resources, includ- ing concise summaries of materials relat- ed to each of the ten Safe Motherhood Action Messages and a List of relevant journals focusing on topics relevant to reproductive health. This Web resource will help ensure that individuals and organizations responsible for supporting, designing and implementing safe mother- hood programmes in developing coun- tries are aware of the most effective and cost-effective strategies, and know-how to access existing resources that can help them implement these strategies. A CD- ROM version of the Guide will be avail- able in the autumn of 2000. www.rho.org Reproductive Health Outlook's (RHO) Web site, managed by PATH, is designed for reproductive health programme man- agers and decision-makers working in developing countries. The site provides summaries of recent research findings and programmatic information, including sections on adolescent reproductive health; gender and sexual health; HIV/ AIDS; infertility; reproductive tract infec- tions; and safe motherhood; links to other reproductive health information on the Web; and "community forums" through which users can ask questions of, post a notice for or discuss issues and exchange information with international experts and peers working on reproduc- tive and maternal health. http://www.who.int/hrp/RHL/index.html WHO. This Library offers reviews of evi- dence-based studies. It is a subset of the Cochrane Collaboration, which focuses on reproductive health problems in develop- ing countries. The Library is available on CD-ROM through WHO and portions may be available online by subscription. Abstracts are available free of charge. The Cochrane Library information can be found at: http://www.cochrane.dk/ cochrane/revabstr/ccabout.htm http://www.unaids.org/epidemic_upda te/report/index.html Report on the global HIV/AIDS epi- demic. UNAIDS's second comprehensive report is sobering reading indeed. For the first time, the impact of AIDS on young people has been calculated, and the report concludes that up to half of all fif- teen-year-olds in the most severely affected African countries (primarily sub-Saharan) will eventually die from HIV/AIDS regardless of whether rates drop substantially in the near future. Worldwide, the report finds that some 34 million people are infected and that life expectancy in the affected countries has been reduced by 20 to 30 years on aver- age. The full text of the 135-page report is available in .pdf format in its entirety or by chapter in English, Spanish, and French . Country-specific estimates and data are offered in Excel format, and a number of PowerPoint slides are also available. www.un.org/womenwatch/daw/ beijing/platform This United Nations Web site provides the full text of the Beijing Declaration and the Platform of Action. It treats compre- hensively all issues related to women and provides links to sites containing infor- mation about other UN conferences deal- ing with women. www.prb.org/pubs/wpds2000/ 2000 World Population Data Sheet. This publication contains the latest pop- ulation estimates, projections and other key indicators for all geographic entities with populations of 150,000 or more and all members of the United Nations. The data are broken down by standard vari- ables such as birth and death rates, infant mortality and total fertility rates, life expectancy, percentages of popula- tions with HIV/AIDS, population of rural vs. urban, increases in population rate, "doubling time" at current rate, projected population totals for 2010 and 2025, and more. These variables may also be exam- ined by region. NO. 47-48 - AUTUMN 2000 - PAGE 23 • I I