T he extraordinary pro-gress of biomedical sciences and medical technology during the last three decades and its application in medical practice con- front our societies with new ethical dilemmas. The numbers of articles in daily and professional journals bear witness to the importance of the subject and society's preoccupation with it. The terms "medical ethics," "bioethics" and "health policy ethics" appear more and more often - and usually in confusing contexts. Before going further, it may be useful to provide some definitions. Health is a state of complete physi- cal, mental and social well-being and not merely the absence of disease or infirmity. Ethics is a set of principles of right conduct, such as those governing the actions of an individual or of a profes- sional group, or the philosophy under- lying such principles. Medical ethics deals with those ethi- cal principles that govern professional conduct in medicine. Medical ethics implies obligations of the physician toward the patient as well as some obligations towards other physicians. Bioethics is the term used to distin- 2 guish traditional medical ethics from ethical issues that arise from recent progress in biology and medicine. Health policy ethics concerns ethical issues relevant to the organizing, finan- cing and delivering of health care services. Medical ethics The central role of ethics in the practice of medicine cannot be too highly rated. Medicine presupposes certain fundamental values such as the preservation of life and the relief of suffering. These values distinguish medicine from other sciences and imply some special responsibilities, particularly for the physician and other members of the health professions. Dr Zbigniew Bankowski is ·Executive Secretary of the Counci I for International Organizations of Medical Sciences (CIOMS). In colla- boration with WHO. CIOMS has conducted a series of international conferences dealing with ethics. human values and he-alth pol The most important obligations of the physician toward the patient are fidelity to the patient's interest, truth- telling of physicians and confidentiality of patient information. In a physician- patient relationship where there are emotional and physical intimacies, patients often entrust their bodies and sometimes even their lives to physi- cians, and therefore trust must exist. Medical ethics provides the basis for this trust. To assure patients that their interests are the most important, to promise to keep their confidences, and to deal honestly with them are fun- damental values of medicine to which physicians must adhere. Ethical problems arise when these values conflict with one another or with other interests. For example, there may be conflict between fidelity to the patient's best interest and the physi- cian's financial interests, or conflict between the obligation to tell the truth and the obligation to protect the patient's well-being - in a case where the physician fears that an honest description of a hopeless prognosis would seriously upset the patient. Because of the physicians' central role as decision-makers about the health and welfare of their patients, the dilemmas they face are the primary WoRLD HEALTH, April 1989 concern of medical ethics. This role of decision-maker has created a degree of paternalism, in that the physicians are qualified by their expertise and are obligated by this relationship to their patients to take the responsibility for decision-making. The patient expects his physician to possess both technical knowledge and ethical wisdom. Bioethics Recent progress in biomedical science, the resulting development of new medical technology and the grow- ing possibility of its applications pro- voke a certain anxiety. In order to explain society's concern it may be useful to describe briefly the methods of biomedical experimental research and their application. Investigation begins with the construction of hypotheses which are tested in a laboratory and with experimental animals. For the findings to be clinically useful, experiments must be done on human subjects and, even when carefully designed, such research entails some risk to the subjects. This risk is justified not by any personal benefit to the researcher or the institu- tion at which research is conducted, but by its benefit to the human subject involved, its potential contribution to human knowledge, to the relief of suffering or to the prolongation of life. Long-term, the benefits are likely to be collective. In the remote Tunisian countryside or in a crowded hospital in Sri Lanka, wherever people gather to talk health, certain fundamental values hold true about the preservation of life and the relief of suffering. WORLD HEALTH, April 1989 Society, together with the medical profession, is developing measures aimed at protecting against possible abuses. Thus, immediately following the Second World War, the judge- ments passed by the Nuremburg Tribu- nal on those who ran the Nazi concentration camps articulated the standard for carrying out human experimentation, emphasising the subject's voluntary consent. Repre- sented by the World Medical Associa- tion, the medical profession took an important step further to reassure society: the Helsinki Declaration of 1964, elaborated and revised in 1975 and 1983, provides ethical principles for research involving human subjects. It adheres entirely to the concept of voluntary informed consent and imposes other protective measures such as a review of research protocols by independent ethical review com- mittees. These issues were further expanded by the Council for International Organizations of Medical Sciences (CIOMS) and WHO, which published international ethical guidelines for such research. Besides prior review of research protocols, the ethical review committee at the hospital, university or other facility where the research is conducted may only approve research when the expected ratio of benefit is favourable compared with the risk to the subjects, and when the subjects' informed consent has been obtained. New and very complicated bio- ethical questions arise today. For example, the resuscitation of patients whose hearts and respiration have stopped functioning. Is an unconscious body in which respiration and blood circulation are artificially maintained still a living person or merely a corpse WHO/ J Mohr Cover: Co llaborat ion or confrontati on? - the "little theatre" w here eth ics and the heal th profess ions meet. as seen by Peter Dav ies. lt~-.... ....... ..,_-'l'~ IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organizat ion. Editor: Joh n Bland Deputy Editor: Christiane Vi edma Art Editor: Peter Davies News Page Editor: Philippe Stroot World Health appears ten times a year in English. French. Portuguese. Russian and Spanish. and four times a year in Arabic and Farsi. The German edition is obtainable from: German Green Cross. Schuhmarkt 4. 3550 Marburg. FRG . Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessari ly reflect WHO's views. World Health. WHO. Av. Appia. 1211 Geneva 27. Swi tzerl and. Contents Ethics and Health by Zbigniew Bankowski Family planning and the law 2 by Anne-Marie Dourlen Rollier . . . 7 Medical confidentiality . . . . . . . 9 Health ethics and the law by Susan Scholle Connor and Hernan L. Fuenzalida- Puelma 10 AIDS and discrimination by Jonathan M. Mann ......... . 14 The doctor's dilemma . . . ... 16-17 Research in human reproduction by Jose Barzelatto .. . ..... . .. . .. 18 Islam and family planning by Maher Mahran . . . . . . . . . . . . . . 22 They condone tortune by Cesar A. Chelala . . . . . . . . . . . . . 24 The Ethical Grid . . . . . . . . . . . . . . 25 World's 2nd No-Tobacco Day by Peter Ozorio . . . . . . . . . . . . . . . . . 26 Food irradiation - scientists' toy or everyman's joy? by Valery Abramov . . . . . . . . . . . . . . 28 News Page .... ... .. . ...... . 30-31 The doctor-patient relationship has required patients to entrust their bodies and even their lives to the physician. Medical ethics prollidf:?S the basis for this trust. Ethics and health with the appearance of life? Likewise, methods of artificial reproduction offer the possibility of child-bearing to infer- tile couples. But who are the parents of a child resulting from in vitro fertilisation of the egg taken from Mrs A and sperm from Mr B, implanted into the uterus of Mrs C and then offered to Mr D and Mrs E upon birth? The sperm and the ovum, and the fertilised ovum resulting from their in vitro union, can be manipulated to a hitherto unknown extent. Artificial insemination by donor other than the husband is an established procedure; a ~ husband's sperm can be frozen and ~ stored for future use, even after his ~ death; similarly, the fertilised ovum can ~ be frozen and stored for later use; and women "lease" their wombs to carry other women's embyros. Genetic engineering is already capable of changing some inherited characteris- tics, and genetic selection is feasible, based on prenatal diagnosis. Research at present under way on molecular genetics, and particularly on human genome mapping and sequencing (as described in the December 1988 issue of World Health) , presages a new scientific era, perhaps a revolution, in the medicine of the 21st century. It opens up the possibility of changing the ways in which certain genes function in order to prevent or to treat many diseases and disorders. The particular dilemmas raised by genetic screening and counselling are: the ownership of gen- etic information, and the advantages and pitfalls associated with genetic counselling and engineering. Who owns genetic information? The traditional moral viewpoint has been that professional secrecy is in both the patient's and the doctor's interests. But today, ought we not to be concerned to make genetic information available to the relatives (or the potential spouse) of the patient? If the health and well-being of relatives or of future offspring are at issue, does the obliga- tion to keep a secret then turn into an obligation to tell? It now seems that the totality of one's physical existence exceeds the limits of one's body, and consequently the traditional right to secrecy may turn into a duty to share information with the family or even with others in society. The burden of knowledge ~-~r---~~ _ There is also a right not to know. ~ For one reason, false-positive test :ii results give inaccurate predictions. •---.---.'l._-l ~ Then, some people are unable to cope ~ with the burden of knowledge. Thirdly, ~r;..._....l..,_ _ ..Jiw._.....J § information obtained from predictive ~ testing can be misused. A fundamental s principle of patient autonomy would WORLD HEALTH, April 1989 WHO/T Farkas seem to be that it is the basic right of the person to be tested or not to be tested, and to choose to be informed fully or only in part. Here is an area of interaction between the developments in biomedical science, ethics and health policy-making that cries out for further elaboration. What are the advantages and pitfalls of genetic screening and engineering? Both geneticists and the public must know clearly that prenatal diagnosis, as one of the options in genetic counsel- ling, does not lead to a "handicap- free" society; and that, even when used to the maximum, there would not be a significant reduction in the percentage of congenital handicaps and diseases. Predictive screening is warranted only if a free and informed decision is possible, and if adequate facilities are available for long-term follow-up of those identified as disease-gene carriers at an early age. Another reason for concern is the risk of social discrimination by employers, insurance companies and so on against someone known to have some genetic pre- disposition. These and similar questions seem to go beyond the terms of reference of the medical profession alone. Can we consider that the neurologist or the cardiologist is the only person to decide who is alive and who is dead? Are the geneticists, obstetricians and embryologists the only people to WORLD HEALTH, April 1989 answer the questions about the moral status of human germinal material, eggs, sperm and embryos, whether in the human body, in the laboratory test tube or even frozen in laboratory containers? Society is largely unprepared for, and unconcerned about, such rapid scientific and technological develop- ments. The ethical issues to which they give rise need to be examined thoroughly in the light of social norms, legal codes and human values. Health policy ethics The ways in which health policy, ethics and human values interrelate are described by the American physi- cian and philosopher, Edmund Pelle- grino: "The health policy of a nation or a community is its strategy for control- ling and optimising the social uses of its medical knowledge and resources. Human values are the guides and justifications that people use for choosing the goals, priorities and means that make up that strategy. Ethics acts as the bridge between health policy and values. It examines the moral validity of the choices that must be made, and seeks to resolve conflicts between values which inevit- ably occur in making those choices. Ethics, therefore, orders human choices in accordance with normative principles." Many, perhaps most, health policy Laboratory in Singapore specialising in sexually transmitted diseases. The tradi- tional right to medical secrecy may turn into a duty to share information with the family. decisions raise ethical questions. Poli- cies having to do with who shall receive health care, what resources should be allocated, what criteria should be used in setting priorities, what constitutes an acceptable form of health care, when should health care begin or end, and even the matter of who should be involved in making policy decisions, all have inherent ethical components. Different national, cultural and religious traditions yield different ethical value-systems, and their interaction with health policy- makers will therefore vary from country to country. Three general considerations should motivate health policies: First, to attempt to control the social and economic impact of the unrestrained use of advanced medical technology in treating individual patients; second, to achieve a more equitable distribution of the benefits of medical knowledge; and third, to use the medical know- ledge in an anticipatory way for the collective good of present and future generations. Let us try to identify the levels of moral responsibility that physicians 5 Ethics and health , ' ,~ Photo W HO/J Schytte 6 The poor man's medicine; a street- vendor offers drugs in Nepal. One goal of health policies should be to achieve a more equitable distribution of the bene- fits of medical knowledge. should exercise in making the judge- ments and choices essential to policy formation and operation: - The physician as the patient's advo- cate. The physician who offers to treat or help a sick person is bonded in a special way with the patient. He (or she) invites the patient's trust that he will be competent and will place that competence at the patient's disposal. - The physician as technical expert When not locked into a trust relation with a particular patient, the physician is obliged to partici- pate in policy formulation as a person with the technical know- ledge which policy-makers need to make rational choices among alter- natives. This is an obligation owed to society since that knowledge is not proprietary. - The physician as citizen. The duty to act as a technical witness in policy formation does not exempt the physician from obligations as a citizen. Thus, he must favour poli- cies that are morally sound, and oppose those that are immoral. - The physician implementing health policies. Sooner or later, health policies must be applied to the care of individual patients. It is here that the physician faces the most diffi- cult moral conflicts and the most direct challenge to the traditional ethic of beneficence. - The physician as moral agent. The physician, like any other person, is morally accountable and therefore cannot carry out a health policy - for example, mandatory sterilisation of carriers of genetic disorders, or refusal of care because of inability to pay - that he considers fun- damentally immoral. The complexity of these role rela- tionships illustrates the urgent need for careful reconstruction of professional ethics so as to address the new dilemmas and conflicts that medical technology and evolving health poli- cies introduce into the physician's role. Today, it is possible, and indeed necessary, to examine these questions not only as the ethics of care but much more extensively as the ethics of health policy and biotechnology as a whole. The intention is not to under-value moral and ethical aspects at the indi- vidual level, but rather to view them within a wider frame of reference. • WORLD HEALTH, April 1989 Family planning and the law by Anne-Marie Dourlen-Rollier y first reflection is that science moves forward more quickly than man- kind. The second is that we live in a world which, from a political, ethical and consequently legal point of view, is pluralistic. The nations order the interrelations between state, religion and citizens in different and sometimes opposing ways, so that discrepancies between countries are on the increase. As regards access to modern con- traceptives and their use, voluntary sterilisation and abortion, most coun- tries have formulated laws, some liberal, others still repressive. But arti- ficial reproduction technologies are new, and consequently there is no legislation to regulate the delicate problems they pose. The issue of surrogate motherhood, for instance, has so far only been addressed by 26 states of the United States and by the United Kingdom, where the Surrogacy Arrangement Act was enforced in 1986. The right to family planning and health services has become recognised by all as a social and legal right, but nevertheless the quality of services and access to them vary greatly between countries, as well as between geogra- phic areas in the same country. In Europe and North America, where contraceptives and advice about their use are available to every individ- ual, there is no consensus on whether unmarried minors should have access to the services without parental know- ledge or consent. The best family planning services and information in the developing world are available in East Asia. This is not the case in Latin America, where the only method accepted as a regulator of fertility has traditionally been periodic abstinence, although the use of other methods is becoming increasingly common in some countries. Africa presents special problems with regard to the acceptability of A Colombian lather seeks confidential advice on family planning. WORLD HEALTH, April1989 family planning, but its promotion as a basic human right has become increas- ingly acceptable during the last decade. Some 26 sub-Saharan countries now provide government family planning services to improve the health of mothers and children. In the Middle East, there is a major consensus on not prohibiting contraception but, in the context of Islamic moral views, it should not inhibit the procreative func- tion of marriage. uu '"' Mrs Anne-Marie Dour/en Rollier is President of the French National Association !'"'" for the Study of Voluntary Sterilisation. based in Paris. Male and female voluntary sterili- sation for family planning purposes has increased in importance during the last two decades. At present it is worldwide the most widespread fertility control method, used by 130 million couples. The legality of this procedure - which has to be considered as p erman e nt - is not admitted everywhere. It is available and included in national family planning programmes in Bangladesh, Korea, Malaysia, but is only allowed on medical grounds in Latin America. This procedure is rarely used in most African countries, and some doctors refuse to discuss the question , even for highly fertile couples. On the other hand, it is very popular in the United Kingdom (21 per cent of all contraceptive use) and in the United States, where it is the leading method (33 per cent) . Recently, in Western Europe, many countries have legalised this pro- cedure, (Austria, Federal Republic of Germany, Italy, Portugal, Scandinavia, Spain, Switzerland). In France the situation is still unclear, and physicians are uncomfortable about performing voluntary sterilisation, while many Catholic countries recognise it as legal. The abortion policies best illustrate the many relationships among laws, WHO/ J Li tt lewood 7 religion, social and medical policies. Around 24 per cent of the world population live in countries where abortion is permitted only to save the woman's life, or is utterly prohibited (Muslim countries of Asia, two-thirds of the Latin American nations, half the countries of Africa, Belgium, Ireland and Malta). Nearly 13 per cent live in countries under statutes authorising abortion on medical grounds, includ- ing protection of the woman's health and some fetal indications. In 24 per cent social factors are taken into account (India, Japan, most of the states of Eastern Europe, the Federal Republic of Germany, the United King- dom). But the interpretation of "social factors" varies a lot from one country to another. And 39 per cent live in countries whose laws permit abortion on request, limited to the first trimester of pregnancy (China, France, Italy, the Netherlands, the Scandinavian coun- tries, the Soviet Union, the United States). The issue of supporting abortion 8 services remains very controversial, and opposition stems particularly from religious groups, who insist on the right to life of the fetus. The facts show that restrictive laws do not prevent abor- tion, but lead women to resort to back-street illegal abortions. One-third of the maternal mortality in the world is due to septicaemia and other complications following illegal abor- tion. The example of Romania is very significant. In order to increase the low birth rate, a restrictive statute was enacted in 1966; the maternal morta- lity per million women aged 15 to 44 rose from 14.3 in 1965 to 97.5 in 1978. New techniques In view of the advances in con- traceptive and abortion technologies, laws and regulations need to be reviewed and updated. The boundary between a contraceptive and an aborti- facient needs to be pr-ecisely drawn, and a new terminology found for defining some new methods. New technologies have also been Therapeutic abortion under ideal condi- tions. Only 39 per cent of the world's population live in countries where laws permit abortion on request. Facing page: Elsewhere, the facts show that restrictive laws do not prevent abortion, but lead women to resort to illegal and risky back-street abortion. Photos: L. Sirman © developed which enable infertile couples to have a child. Unfortunately, because of the expertise and cost involved, their use is limited to the wealthy developed world. Elsewhere, most countries cannot afford the high cost of specialist centres for infertility diagnosis and treatment. Because of the complex ethical and legal problems, the developed world is confused about the measures to be taken to enact directives or regulations. Countries have hesitated to legislate on those topics, as shown by the large number of committees appointed by governments to study these extremely delicate matters. Since 1979, at least 85 statements have been issued by WOR LD HEALTH, April 1989 committees representing some 25 countries, most of them in North America and Western Europe. If we examine 15 statements from eight nations, Australia, Canada, Fed- eral Republic of Germany, France, the Netherlands, Spain, the United King- dom, the United States, we find that they unanimously concluded that in vitro fertilisation is in principle accept- able, but some would restrict this to heterosexual married couples with a medical need. Eleven of the 15 com- mittees include couples living together in stable relationships, and only five regard either single women or members of homosexual couples as appropriate candidates for in vitro fertilisation in some circumstances. All the committees accept the potential clinical usefulness of embryo freezing, but they regard the technique as experimental and consider that a time limit should be set for the cryo-preservation of frozen embryos. They disagree on the appropriate length of time. Of the 15 committees, 12 find ovum WORLD HEALTH, April 1989 donation to be acceptable without qualification . A more cautious approach is taken to embryo donation; they agree that donation should be genuine, but some draw distinctions between reimbursement of donor expenses, payment for time and incon- venience. But there is a fear that this may open the door to commercial- isation. The committees also disagree on the question of donor anonymity, and express strong opposition to surrogate motherhood. Eleven com- mittees approved some kinds of research with early embryos remaining from clinical abortion. The problems posed by the new reproduction technologies cannot be left for ever to health professionals, who, after all, represent only part of society. Nations will have to promul- gate laws, but they are right to be cautious, as no legislation can be enacted unless the basic ethical agreement of the population con- cerned is reached. Up to now no consensus could be obtained on some of the main issues, and each country should be prepared to pass legislation according to its own moral values. At the same time, there should not be too many disparities between statutes. In view of the increasing interdependence between countries it is essential that an international dia- logue be initiated. On such intimate matters, legislation invariably lags behind the evolution of mental atti- tudes. These attitudes will have to attune themselves to new concepts that overtake traditional ways of thinking. Science moves forward more quickly than mankind evolves; the laws will follow. • }['~!~~r;ec: ~oe~fc~~i:~a~~f~~~~ of prospectiv~. clients who _seek life insurance~ and . recently they have started asking doctors whether or not tt)eir patient is :at risk from .AIDS . . A general _ prac- tit!oner writ!p9 in the .British Medical Journal commented: "Obviol!sly, if:a patient h~s been testectforHIV '(the AIDS virus) and tqund · positivE:1r that information Is legitimately of. real concern to potential insure~s. E;lut we are .mov!pgJo aJidiculous_ position in .. which patients who have been AIDS tested think that they have to conceal this from.their physici~ns; rE:1gardless of,the result, because doctors may hot be safe holders o~ that information." . The GP ahd his colleagues d.ecided that insurance com- panies ought to rely on their plients to answer quesUons about h~w they live, and should restrict questions addressed to physi~ cians to matters that are strictly medical. He wrqt~: "To put our policy intp pra,ctiqe we have hada r!Jbber stamp made that reads: 'We are not willing . to .(lnswer questions about /ife$tyles ', and we apply it Jreely to insurance questionnaires." '' • .What the doctor bears uin the consulting room is intend~ to be confidential. · 9 Health ethics and the law Why does WHO not deal more forthrightly with the searing issues of biotechnology and medicine that confront today's world? The authors argue that the Organization should play a much more positive role by Susan Scholle Connor and Herm)n L. Fuenzalida-Puelma A n international agenda for Health Ethics and Law must begin by defining the issues. What is health? What are health ethics? What is health law? How do they relate to each other? What are the international concerns? The questions are simple, answers are complex. First what is health? The Preamble to the WHO Constitution defines health as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". It is an all-inclusive, positive state, a social index. Although not precise, this definition - by its breadth - encompasses virtually every sphere of social and personal activity. The WHO Constitution proclaims that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. This view is now virtually uni- versal. Health is everywhere seen as crucial to individual and societal well- being. Health ethics can be categorised into two headings: bioethics and medical ethics. Bioethics is a field which originated during the last four decades, and applies ethical principles to the new and unsettling questions presented by scientific and technologi- cal advances that probe into the deepest secrets of biology. In part, it resulted from the scientific self-doubt that accompanied the development of the atomic bomb in World War II, and was precipitated by the discovery of DNA (the genetic code) in 1959. One of its main concerns is to determine whether there are unacceptable risks in technological development and scienti- fic expertise. Bioethics also looks into such social aspects as the equitable distribution of 10 the fruits of scientific achievement and, in the health field, considers the principles for allocating scarce health resources, whether high-tech (organ transplants or in vitro fertilisation), medium-tech (kidney dialysis) or low- tech (primary health care). The issues are most dramatic at the beginning and end of life - in-vitro fertilisation, genetic manipulation, arti- ficial respiratory and feeding devices, artificial organs. Hallmarks of bioethics at this level are the belief that a human being has a certain autonomy over his or her own body, and that the doctor alone does not have the right to take decisions about whether life should be created or prolonged. Dr Susan Scholle Connor is Special Legal Counsel. and Dr Hernlm L. Fuenza/ida- Puelma is General Counsel and Chief. Office of ~~gal Affairs. WHO Regional Office for the Americas/Pan Amer- ican Sanitary Bureau. Washington D.C. Medical ethics traditionally ad- dressed issues related to the collegial practice of medicine (such as intra- professional relations) that are not covered within the field of bioethics. It was enshrined in such codes as the Greek Hippocratic Oath (sixth century B.C. to the first century AD.) or the Indian Oath of Initiation ( Carak Samhita, first century AD.) These codes deal with the conduct of physi- cians with patients, with the relation of physicians to each other, whether as peers, teachers or students. The codes of other health care professionals, for instance nurses and dentists, are similar. Not all of health ethics is translated into health law. Certain ethical stand- ards remain simply moral guidelines, without legal consequences. But increasingly, ethical standards are enforced by law. This is not a new development - the Protomedicata of the Middle Ages were a quasi-legal body, with authority over doctor- patient disputes, licensing, and allega- tions of unauthorised practice. Government licensing of health profes- sionals has been common for over 100 years. But as technology has advanced, so has its regulation and control - health law now encompasses over 22 subjects. The area of overlap between health ethics - both bioethics and medical ethics and health law - has grown and will continue to grow. International public health law can be seen to have begun in 1851, with the adoption by the First International Sanitary Conference (largely European) of the first international sanitary regulations dealing with cholera, plague and yellow fever. The International Sanitary Conferences, and their successor assemblies (the Office International d'Hygi(me Pub- lique, the Health Organization of the League of Nations, the World Health Organization and such regional health bodies as the Pan American Health Organization) were all governmental bodies. Health ethics - and particularly medical ethics - was left to the professional societies, which began meeting internationally with the Inter- national Medical Congress of 1867, or to the initiatives of other non- governmental organizations. Particu- larly notable is the work of the Interna- tional Red Cross, involved in drafting the first Geneva Convention of 1864 (revised in 1949) on the treatment of the sick and wounded, as well as prisoners, in time of war. It was World War II, however, that created the climate for the "interna- tionalisation" of human rights, in gen- eral, and for health ethics, in particular. The Universal Declaration of Human Rights, adopted in 1948, marks the first recognition that the manner in which a state treats its nationals is a subject of international concern. Since World War II, health ethics, like human rights in general, has increasingly become the subject of international activity - largely, however, conducted outside the auspices of WHO. In the field of medical ethics, the World Medical Association adopted an International Code of Medical Ethics in 1949, and CIOMS - the Council for International Organizations of Medical Sciences, proposed International WORLD HEALTH, April 1989 " E <i' ~ 0 ~--~ Posters and puppets: two ways of putting across family planning messages - in Costa Rica and Indonesia. Bioethics holds that all human beings have autonomy over their own bodies, and that the doctor alone may not take decisions about whether life should be created or prolonged. Guidelines for Biomedical Research Involving Human Subjects in 1982. The latter were drafted in conjunction with WHO, but have never been officially adopted by the World Health Assembly. The fate of those guidelines seems to illustrate the reluctance that WHO has shown in entering the field of health ethics. While the list of World Health Assembly resolutions includes a category of "medical law, ethics and humanitarian questions", the pattern has not been of a leadership role, but rather one of reaction to suggestions from particular governments, or initia- tives of other institutions. In 1962, the Assembly reiterated the WHO constitutional provision that health is a fundamental condition for peace and security. Some five years later, and for several years thereafter, the Assembly expressed its alarm over the problem of chemical and bacteriological weapons. And it was by invitation of another group - the United Nations- that Wi-IO's Executive Board responded to the issue of the need for a medical code of ethics for physicians concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment. Instead of taking the lead on the issue, the Executive Board and the Assembly referred the topic to CIOMS and the World Medical Association (both non- governmental organizations of profes- sional societies, and both accredited to the WHO as such) . Medical code of ethics On humanitarian law, the only issue on which the World Health Assembly has shown consistent concern through the years is based on the WHO Consti- tution's preambulatory statement that the health of all peoples is fundamen- tal to the attainment of peace and security. That principle was reaffirmed by a World Health Assembly resolution in 1962, and again in 1979, 1981 and 1983 (the latter in connection with the report on the effects of nuclear war) . Activities on health legislation have generally been confined to publishing summaries of national health laws, especially in the International Digest of Health Legislation, an outstanding contribution to the field, but far less active than the legislative activities of other international bodies such as the International Labour Organisation and the Food and Agriculture Organi- zation. The authors have puzzled over the reasons for this. Certainly the WHO Constitution contains no prohibition of active involvement in the field of health and ethics and the law. In areas of an ethical nature, as 11 Another concern for bioethics. A man lies dying after a road accident. Would doctors be justified in taking organs from his body to save other lives? discussed above, even guidelines have been relatively few, although this trend may be changing. The 41st World Health Assembly adopted last May a resolution entitled "Ethical criteria for medicinal drug promotion." A much more assertive role on ethical/legal issues has been taken by the Global Programme on AIDS, which has adopted consensus statements and issued guidelines on such policies as informed consent for testing , avoidance of mass screening, need for confidentiality, respect for human rights, and condemnation of discrimi- nation. A controversial arena Should the Assembly follow the lead of the Global Programme on AJDS, and deal more forthrightly with the searing issues of biotechnology and medicine facing the world today? The authors can only guess at the reasons for WHO's traditional reluctance to enter into such an arena, which is inevitably controversial. First, the belief that the 12 Organization should not become involved in the internal affairs of its member states is very strong, dates back virtually to the First International Sanitary Conference, and is generally the rule for public international bodies. Secondly, there is a common institu- tional antipathy to and concern about politicising the Organization. While any public international organization, whose members are sovereign states, is inevitably a political body, WHO has walked an uneasy line between politics and science. Executive Board Members are selected, accord- ing to the WHO Constitution, not only with regard to equitable geographic distribution, but as persons "technically qualified in the field of health", and they are required to vote on behalf of the whole, and not as representatives of governments. Moreover, at WHO the typical international concern for achieving consensus is exceptionally strong. These factors, plus the generally technical or scientific training of the secretariat, militate for a "hands off" attitude towards matters not subject to scientific proof, or towards controversy, where national political views or cultu- ral diversity could lead to deep-seated differences of opinion. Health law is WHO/ T Urban largely ignored because of concerns over meddling in national politics; health ethics are avoided due to their relationship to morality which, barring certain general principles (do not kill) , can cause emotional and heated debate (is abortion a killing?) . Debate at a high level The authors do not suggest that WHO should adopt an international agenda for conventions, agreements or regulations on health law and health ethics. But they do believe that the Organization has a duty to foster exchanges of information, and pro- mote debate at a high level on such issues. To ignore them is to neglect reality: the concerns of regulation of biotechnology and regulation of health ethics exist, and there is now no international forum that deals with these concerns in a truly global way. International consensus may not be achievable, but international debate is. Genetics, genetic engineering, clinical medicine, cancer and AJDS research, human reproduction techno- logies, control of death - all these are not only scientific and technical mat- ters; they have deep ethical, legal, social, cultural and political conse- quences. Hence, participation should WORLD HEALTH , April 1989 be made available to a broad represen- tation of interests and disciplines. There is also a growing need to discuss, to evaluate and to regulate clinical research conducted in less developed countries. Important issues on the ethics of biomedical research have been raised concerning the appli- cation of ethical standards of developed countries to developing nations. The rights of the subjects of biomedical research, the doctrine and practice of informed consent, the shar- ing and disclosure of research results - these are matters in need of an open forum and of regulation, both institu- tional and governmental. The eager- ness to find cures to a particular disease and the availability of resources towards this end should not lead, in spite of good intentions, to double ethical standards. The issue of social ethics, of equity in the access to health care services, universalisation of health care, the dichotomy of health as a right versus health as a commodity, the diverse models in the search for a fair health system compatible with scarce resources, privatisation versus public or mixed economy schemes, social security/ ministry of health/ private medicine - these are among the issues in which the rhetoric and the reality of health care appear in stark opposition. Discussion, exchange of information and evaluation of improvements in the health and well-being of the people should be encouraged. The issues of health are national, in that they belong to everyone - as individuals and as members of society. There is no official ethics, there is no official health; there are ethical prin- ciples, values and standards; there is health as a state of decent, just well-being, with access to care and to the enjoyment of healthy living con- ditions. WHO can and must play a leading role in the discussions to come. One of the main justifications for the existence of international organizations is that they constitute the specialised forum, the institutional umbrella under which studies, research and discussion can take place on a basis of sound data and with respect for all. Health ethics and law provide WHO with a comprehensive, intelligent and rich opening from which to work humanis- tically for the health for all mankind. • A young bride in Indonesia receives advice on the contraceptive pill. Last year's World Health Assembly adopted a resolution on "ethical criteria for medicinal drug promotion., WOR LD HEALTH , April 1989 Health ethics and the law World Council of Churches/ J . Taylor 13 AIDS and discrimination by Jonathan M. Mann HO has taken a series of strong and proactive stands to help protect the rights of, and prevent discrimination against, persons infected with the human immunodeficiency virus (HN). This position was reinforced last year in Geneva by the 41st World Health Assembly, which adopted a resolution entitled: "AIDS: avoidance of discrimi- nation in relation to HN-infected people and people with AIDS." This revolution started by urging the Organization's 166 member states to "foster a spirit of understanding and compassion for HN-infected people and people with AIDS through information, education and social support programmes." Experience with national and local AIDS programmes has suggested that, as public informa- tion and education increases in quan- tity and quality, irrational fears about HN and its transmission tend to diminish. Nevertheless, while people may understand that HN cannot be spread through casual contact, the specific and individual instance of an HN-infected child in a school or an HN-infected adult in the workplace can still provoke unwarranted but substantial anxiety and can unveil deep-seated prejudices. Dr Jonathan M. Mann is Director of WHO 's Global Pro - gramme on AI OS. The Assembly resolution urges countries "to protect the human rights and dignity of HN-infected people and people with AIDS and of members of population groups, and to avoid dis- criminatory action against and stigma- tisation of them in the provision of services, employment and travel." In addition, member states are urged "to ensure the confidentiality of HN testing and to promote the availability of confidential counselling and other support services to HIV-infected people and people with AIDS." There is a strong and clear public health rationale for this emphasis on protecting the human rights and the dignity of HN-infected persons, includ- ing people with AIDS. In fact, the World Health Assembly has stated that this policy is critical to the success of national and international AIDS pre- vention programmes. It follows that the protection of the rights and dignity of HN-infected persons has become an integral part of the Global AIDS Strategy. In Kenya, a former prostitute now trains health workers in conveying the mes- sage of "safe sex". In Beijing, cam- paigners warn that "AIDS is knocking at the gates of Asia." Photos WHO / H Anenden and WHO This strategy's first objective is to prevent HN transmission, which spreads almost entirely through identi- fiable behaviours and specific actions (sexual intercourse, self-injecting be- haviour) which are generally - though not always - subject to individual control. In most instances, HN trans- mission involves the behaviour of two persons; a change in behaviour of either the HN-infected or the uninfec- ted person will be sufficient to prevent HN transmission. But it must be remembered that HN is transmitted mainly through behaviours which are private, secret, hidden from society and illegal in some societies. For these reasons, the following are critical elements in the design of programmes to prevent HN infection: - The keystone of HN prevention is information and education, as HN transmission can be prevented through informed and responsible behaviour. - Each person, HN-infected or unin- fected, must bear in mind the responsibility not to put themselves or other persons at risk of infection with HN. - In addition to information and education, specific health and social services will be required to support risk-reducing behaviour changes. Nevertheless, if HN infection, or suspicion of HN infection, leads to stigmatisation and discrimination (e.g. loss of employment, forced separation from family, loss of education or housing), persons already HN-infected and those who are concerned that they may be infected will actively avoid detection, and contact with health and social services will be lost. Those needing information , education, counselling or other support services will be "driven underground". The person who fears he or she may be infected will be reluctant to seek assistance out of fear of being reported - with severe personal consequences. The net result would be to seriously jeopardise educational outreach and thereby exacerbate the difficulty of preventing HIV infection. To prevent HIV infection effectively, persons whose behaviours place them at increased risk of exposure to HN must be informed, educated and pro- vided with health and social support. Persons suspected or known to be HN-infected should remain integrated with society to the maximum possible extent and should be helped to assume responsibility for preventing HN transmission to others. Exclusion of these persons would be unjustified in public health terms and would undermine the public health pro- gramme to prevent HIV infection. WORLD HEALTH, April 1989 ItiAV Please hu 5 me I cant ma e you Sick AIDS HOT LINE FOR KIDS CENTER FOR ATIITUDINAL HEALING 19 MAIN ST., TIBURON, CA 94920, (415) 435-5022 Discrimination may actually endanger public health; stigmatisation may itself represent a threat to public health. The World Health Assembly resolu- tion therefore directed WHO "to stress to Member States and to all others concerned the dangers to the health of everyone of discriminatory action against and stigmatisation of HN- infected people and people with AIDS and members of population groups . .. " Protecting the human rights and dignity of HIV-infected people, including people with AIDS and members of at-risk groups, is not a luxury - it is a necessity. It is not a question of the "rights of the many" against the "rights of the few"; the protection of the uninfected majority depends upon and is inextricably bound with the protection of the rights and dignity of the infected persons. WHO believes it is essential to involve the international human rights network to help prevent discrimination against HIV-infected people, persons with \'IIHO In the USA, a poster appeals for people not to discriminate against AIDS cases. AIDS or stigmatised population groups. WHO has stressed the need for human rights organizations, non- governmental and governmental, to play an active role in this area, particu- larly at the national and local levels. WHO has been given the mandate to direct and coordinate the global fight against AIDS and stands ready to continue providing the human rights networks with the credible information upon which all effective public health and human rights action related to AIDS must depend. At the national level, organizations concerned with human rights must link with AIDS- related organizations - governmental and non-governmental - and work with national AIDS committees to help broaden understanding and seek effective alliances against AIDS-related discrimination. • 15 The Hippocratic Oath ][ swear by Apoll. o the physician, by Aescula- pius, Hygeia and Panacea, and all the gods and goddesses, to keep to the best of my ability and judgment the following Oath: To reckon him who taught me this Art (of medicine) as dear to me as my own parents; to share my goods with him; to look upon his children as my own brothers; to teach them this Art if they so desire without fee or written promise; to impart a knowledge of the Art to my sons and the sons of the master who taught me, and to such disciples as have bound themselves to the rules of the profession - but to no others. I will prescribe regimen for the good of my patients to the best of my ability and judgment, and do harm to nobody. I will give no deadly medicine to anyone, even if it is requested, nor give advice that might result in death. Nor will I give a woman a pessary to produce abortion. With purity and holiness will I practise my Art. I will not cut persons suffering from kidney stone but will leave this to be done by specialists in that Art. Whatever houses I visit, I shall enter only for the good of my patients, abstaining from any wilful evil-doing and corruption, and especially from the seduction of women or men, whether they be free or slaves. All that may come to my know!edge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal. If I keep this Oath faithfully, may I long enjoy life and the practice of my Art, respected by all men in all times. But should I swerve from it or violate it, may the reverse be my lot! the doctor's dile01D1a JE orn on the Greek island of Cos, Hippocrates seems to have been a practising physician in the years around 400 B.C. There is some doubt whether he personally penned the Oath, which was written for a small select circle of doctors rather than having universal application. Nor was his either the first or the only Oath binding doctors to a certain code of conduct. But the Hippocratic Oath can stand as an archetypal statement of the basic ethics of medical practice. For instance, it enshrines the notion of doing harm to none, of prescribing no deadly potion, of not provoking abortion, of not abusing the professional relationship to achieve sexual ends, and of maintaining medical secrecy. But times change, and what was appropriate in ages long past may not necessarily hold good in all cultures today. As the reference to cutting out a stone shows, the profession of physician was regarded in Hippocrates' time as quite different from that of surgeon. And the enormous progress made by medicine in the past two centuries has outdated many aspects of those early Oaths. At a time when, in most countries, any young girl can go into a pharmacy or supermarket and buy contraceptive pills, the ban on procuring abortion has lost much of its meaning. Nevertheless, therapeutic abortion continues to be a highly controversial subject even today, particularly because of entrenched opposition to it by the Roman Catholic church. The article by Zbigniew Bankowski in this issue of World Health pinpoints some of the ethical dilemmas that face the health professions today or will face them in the coming years. For these and a host of other problems there can be no simple, all-purpose answers. The questions posed here are examples of real-life situations which we hope will provoke readers to think about, and talk about, the ethical ' aspects of health. • Surgery in the Arab world. WHO W ORLD HEALTH, April 1989 The beginning of a new life - one of the points of intersection between ethics and health. Artificial kidney machines like this (below) keep alive the lucky few who have access to them. Matters of life and death • Should there be legislation to control experiments on aborted human fetuses? Or should research be formally banned on fetuses after the first weeks of embryonic life? How many weeks after? • Should a doctor comply with the request from parents to switch oH life-support equipment which is keeping alive a road accident victim who is undoubtedly "brain-dead"? Would the doctor be correct in seeking the parents' permission to remove organs from such a patient for transplant? • A midwife attends the difficult delivery of a child who is struggling to live but is visibly severely deformed or mentally handicapped: should she make every eHort to keep the child alive, or concentrate on saving the mother? • A 90-year-o/d patient dying from a painful disease and heavily medicated requests the doctor to put an end to the suffering: how should the doctor respond? • A health department's budget permits either the purchase of a renal dialysis machine (which will maintain life for several sick people) or the employment of two more nurses (who may serve all the community)- but not both. What is the right choice for the health policy-makers? • Is it ethical for young volunteers to be oHered money if they agree to be injected with an experimental drug for treating epilepsy and schizophrenia? Conversely, would it be ethical to withhold from a sufferer from such diseases a drug known to relieve that condition yet also known to entail a risk of side-eHects? • Supposing medical science discovers a vaccine against conception, which operates by preventing fertilisation of the ovum by the sperm, will that vaccine be regarded as an abortifacient and therefore still be proscribed by religious groups? • A young mental patient confined in hospital shows signs of sexual maturity: should such a patient be subjected to sterilisation even though he or she is incapable of giving informed consent for the operation? • When we can identify and locate defective genes responsible for specific hereditary diseases, will selective abortion of affected fetuses be ethical? In fact, will it be ethical not to abort such fetuses when science has perfected the technique of predicting a defective conception? • What should be the ethical approaches to in vitro fertilisation -test-tube babies? To womb-leasing- where a fertilised ovum is "grafted, into the womb of an otherwise infertile woman? To surrogate motherhood - where a young woman accepts sperm from a husband whose wife cannot herself conceive and hands over the baby to husband and wife? To the imminent likelihood of producing a viable fetus in an artificial womb? • Another imminent breakthrough will be to successfully transplant an animal's organ (such as a pig's kidney) to temporarily replace a failing human kidney until a human kidney becomes available. Will such transplants be "ethical"? • The AIDS epidemic raises a host of new dilemmas. Should there be compulsory screening for the AIDS virus before marriage (as there is already in some countries for syphilis)? Random screening for AIDS of anonymous individuals - perhaps those who have had blood-tests for other reasons - is already being suggested in some countries: this means that sero-positive individuals will be detected in a given community but cannot be warned of their condition. Has every individual a right to know when such screening is carried out, and/or to know if such tests prove positive? Or a right not to know the result? A physician treating a young couple for unimportant medical problems discovers that one of them is sero-positive: is it ethical for the physician not to tell the other partner? 17 Research in human reproduction by Jose Barzelatto T he work of WHO in the field of human reproduc-tion covers an extremely sensitive and controver-sial field which also includes research directed to the medical termination of pregnancy. Some time ago this was considered "an issue that is dependant upon national legislation and religious and cultural precepts and, therefore, does not lend itself to an international recommendation" in the "Proposed international guidelines for biomedical research involving human subjects," endorsed by WHO and the Council for International Organizations of Medical Sciences (CIOMS) . Although a correct reflection of the state of a controversial subject at the time, that statement is not very helpful today when many research issues involving human subjects are faced with the same criteria. In fact, recent progress in the field of human reproduction, namely the synthesis of progesterone antago- nists, has blurred the distinction between "late contraception" and "early abortion". Dr Jose Barzelatto is Director of WHO's Special Programme of Research. OeyeiOpment and Researsh Trai11ing in Human Repro- duction. WHO's Special Programme of Research, Development and Research Training in Human Reproduction (HRP) conducts this type of research in countries where medical termination of pregnancy is legal , and where governments and scientists have expressed an interest in participating in such studies because they believe that safety of induced abortion is a public health factor of considerable signifi- cance. In order to support these studies, the Special Programme only uses funds provided by governments that recognise the importance of this type of research for improving the 18 reproductive health of women. Prob- ably no other field of biomedical research reveals the tensions more dramatically between the rights and responsibilities of individuals (couples in this case) and those of society. HRP is a truly global programme. To date, scientists and institutions in 85 countries have participated in the research projects it has sponsored, involving a great variety of cultures, religions and political systems. Its research into and development of improved and safe new contraceptive methods has resulted in the introduc- tion of completely new forms of inter- vention in the reproductive process, and in new explanations of the mechanisms of action of existing methods. Individuals and societies are therefore required to take a fresh look at the consequent ethical concepts and implications. To take just one example, the mechanism of action of intrauter- ine devices (IUDs) had been believed to interfere mainly with implantation of the ovum but now seems to be mainly through interference with fertilisation. The Special Programme incorpo- rates activities that represent three different decision-making levels in biomedical research, all of which have ethical implications of a different nature . At the " society and government" level, decisions relate to what should be done and the ethical concerns are about politics, priorities relevance to society, and so on. Deci- sions at the "professional" level relate to what can be done; the main ethical concerns relate to research projects, WHO/ Zafar WHO promotes research aimed at improving the reproductive health of women. No other field of biomedical research reveals the tensions more dramatically between the rights and responsibilities of individuals and those of society. and include the quality and feasibility of the research as well as the expected effect on relatively small population groups. And at the "researcher" level, decisions relate to how to do it; here the interplay between the investigator and the person that is the subject of the research dominates the ethical concerns. The inclusion of human reproduc- tion under WHO's aegis stemmed from a political decision taken by a few "leaders" who had society's authority to argue that research on fertility regulation (including contraception and infertility problems) was justified both in terms of health and of develop- ment. With the provision of new, safe and improved methods of fertility regulation, the quality of life could be improved, especially in developing countries. During its 17 years of opera- tion, the Special Programme has accu- WORLD HEALTH, April 1989 mulated scientific evidence to indicate that the need for improved methods of fertility regulation is an essential component of maternal and child health. Indeed, there is also a growing consensus that family planning is an important aspect of the multifaceted strategy that developing countries must adopt, regardless of demographic poli- cies, in order to accelerate their devel- opment. The mandate of HRP explicitly states that all activities should be oriented towards the needs of developing coun- tries, a guideline that is strictly fol- lowed. Two-thirds of the operational budget is devoted to the direct support of research projects; one-third is dedicated to assisting developing countries in achieving self-reliance in research. Around 70 per cent of the total operational budget is allocated to funding scientists from and working in developing countries. Policy and budgetary decisions are guided technically by the Scientific and Technical Advisory Group (STAG), a group of 15 to 18 ·independent and knowledgeable scientists from all over the world who represent different disciplines and do not participate in any other HRP activities. They meet World Council o f Churches/ J Taylor annually to review the strategic plans, analyse their technical feasibility, advise on priorities and systematically evalu- ate the activities. So STAG has to face fundamental ethical issues in the choice of research topics to be pursued in the context of an international effort oriented towards the needs of developing countries. Ethical Dilemma One appropriate example is the problem of continued research on the injectable contraceptive Depo-Provera. There has been a heated (and not always scientific) debate about this drug in the mass media around the world. The debate has emphasised that the Food and Drug Administra- tion of the USA, the drug's country of origin, refused its registration for con- traceptive purposes as a result of studies conducted on animals. The ethical dilemma exposed is that there is no such thing as 100 per cent certainty. The different levels of decision-making in the Special Pro- gramme agreed that the risk/benefit ratio was strongly in favour of Depo- Provera. Since to date all follow-up human studies conducted by HRP worldwide provide affirmative evidence 19 in favour of this view, the Programme continues to support and conduct research on this drug. All projects submitted to the Special Programme must first show evidence of approval by institutional and national ethical review mechanisms. In fact, in countries where no such review mechanism exists, HRP has made it mandatory to create an ethical com- mittee at the institutional level. Guidelines agreed During the past decade, tacit guidelines have been agreed upon. These include severe restrictions on the use of incentives offered to per- sons who volunteer to participate in clinical research, other than reimburse- ment of transport expenses or loss of income. Particular care is given to control groups, and the use of pla- cebos (substances which, unknown to the user, have no effect at all) is usually not permitted; protocols are designed to compare a new method with an established one, even if this rule makes 20 it at times difficult to interpret results. In early clinical trials, safety issues are resolved before efficacy is tested; thus, a new contraceptive steroid will be tested initially in women who are sterilised or protected by another method. Last but not least, each approved protocol must state pre-set termination levels in terms of contraceptive failures and the frequency of side-effects. These are carefully monitored at WHO headquarters and, if such indices are reached, the study is terminated prematurely. For instance, when a long-acting injectable preparation, norethisterone enanthate (NET-EN), was compared with Depo-Provera in a multicentre study as a three-monthly injectable, the study had to be termin- ated because the preset termination index for contraceptive failure was reached in the former group. The data suggested that the duration of effect of NET-EN is two, rather than three, months . Subsequent large-scale studies conducted in India and else- Two of the devices developed by MIOs research programme: the vaginal ring and a one-time only syringe for an injectable contraceptive. Left: Animal studies - a vital step in studies that will ensure safe and eHective fertility or anti-fertility drugs. Right: Sex education in schools; another key stage in making such drugs universally acceptable. With the advent of new, safe and improved methods of fertility regulation, the qual- ity of life can itself be improved. es- pecially in developing countries. where revealed that NET-EN is a suit- able two-monthly injectable. The fact that contraceptives are intended for use by large numbers of mainly healthy individuals during pro- longed periods of their reproductive lives requires particularly strict criteria to properly assess the balance of risks and benefits to justify their use. In particular, rare side-effects, either bene- ficial or undesirable but of public health significance, cannot be assessed until many thousands of healthy subjects have used the method over a substantial period of time. And, after the product is on the market, it would be unethical not to continue the follow-up of the subjects who had used it. WHO recommends to governments that, in future, the submission of a plan to this effect should be a requirement for registration of a drug. If this practice had been followed in the past, we would perhaps not be debating today - after 25 years of use by 100 million women - whether or not the contraceptive pill increases the risk of WORLD HEALTH, April 1989 certain genital cancers (e.g. breast and cenncal cancer) even though it has been established that it significantly decreases the risk of other cancers (e.g. ovarian and endometrial cancers). Since the Special Programme was established in 1972, it has developed for biomedical research a worldwide network of centres collaborating in a global research and development effort to facilitate and improve the conduct of clinical studies of fertility regulation and infertility. So far, the Programme has conducted close to 200 multicentred trials involving approximately 200,000 subjects in 150 clinical centres in over 50 countries. Principal objectives One of the two main objectives of HRP is to increase, through research, access to new and improved methods of fertility regulation that are safe, effective, cost-effective and acceptable. It is too early to have reached this goal, especially since we now know that the development of a new contraceptive WORLD HEALTH , April 1989 agent usually takes more than 15 years before it can be put on the market. Nevertheless, the Programme has developed a variety of new fertility regulating methods that are expected to be available to family planning programmes in the foreseeable future: - Two new "once-a-month" injectable contraceptives and a levonorgestrol- releasing vaginal ring of three months' duration will very shortly come on to the market. - Others, farther back in the pipeline, include a sequential antiprogestin/ prostaglandin combination for post- ovulatory fertility regulation, a three- monthly injectable progestogen, a single biodegradable implant releasing levonorgestrel with an expected life- time of two years, and an injectable androgen/ progestogen contraceptive for men. - We can look forward in the mid- 1990s to having a genuine "birth control" vaccine. The second main objective is to promote and support national self- reliance in human reproduction research in developing countries through institutional development, including research training. The global network of centres collaborating with the Programme includes a majority of centres located in developing coun- tries. During its 17 years of existence, the Programme has provided research training grants and visiting scientist grants to more than 1,000 scientists from 60 countries; more than 90 per cent of these grants went to developing country scientists. So far, the Programme has spent over US$ 30 million on providing equip- ment, reagents and supplies to institu- tions located predominantly in developing countries. • (An expanded version of this article has recently been published in ''T awards an institutional ethic for Research in Human Beings," documents of the International Summit Conference on Bioethics, Medical Research Council of Canada, Ottawa.) 21 Islam and family planning by Maher Mahran K n the time of the prophet Mahomet, Moslems - both men and women - were never shy to ask the prophet about all affairs, including such private matters as sexual life, so as to know the teachings and rulings of their religion concerning them. As Aisha, the wife of the prophet testified: "Blessed are the women of the Anser (the citizens of Medina). Shyness did not stand in their way of seeking knowledge about their religion." The way the women asked the prophet - directly or through his wives - is a proof that sexual matters were not taboo but were fully acknowledged and respected. "Shyness is part of the faith" as the prophet taught, but he also taught "There is no shyness in matters of religion" . .. even entailing the most delicate aspects of sexual life. Professor Dr<Maher Mah- . ran <, is Secr~tary.-Gyne ral ?f the Egyptian National f>opt.r~ latiorr"councit in<Cairo . ''· It is our firm belief that facts about sex should be taught to children in a way commensurate with their age as they grow up - both by the family and by the school. We emphasise that this should be done within the total context of Islamic ideology and Islamic teaching, so that young people - besides getting the correct physio- logical knowledge - become fully aware of the sanctity of sexual relations in Islam and the grave sin of blemishing such sanctity, whether under Islamic law or - far more important - in the sight of God. Provided the Islamic conscience is developed, we see no reason to shun sex education (as is unfortunately the rule in many Moslem countries). We "We emphasise that the facts about sex should be taught within the total con- text of Islamic ideology. , A religious leader in Egypt discusses family plan- ning with a women's group. 22 believe it is better to give the correct teaching than to leave this to chance and to incorrect sources, and to the concomitant feeling of guilt resulting from the hush-hush atmosphere in which this is done. Teaching about sex should also have its place in the curricula of medical schools, as it has in Kuwait and in Egypt. There should be no difficulty whatsoever with our religious and rather conservative men and women students, since the subject is taught within an Islamic perspective. There is no doubt that family plan- ning is a sexual problem. The aim of using contraception is to have safe sex, sex which is free from the risk of unwanted pregnancy. However, an ideal contraceptive should not interfere with the act of sex. Proper counselling is essential for couples who want a happy family. Some contraceptive methods may create sexual problems by their side- effects. In the case of steroids, for instance, breakthrough bleeding is a common complaint among users of low-dose pills, injectables and subder- mal implants. In our culture, sex is usually not practised if the woman is bleeding. Breakthrough bleeding is an important reason for dropout because the husband does not want any con- straint on his sexual activity. In rare cases steroid contraception may also cause diminished libido, or affect the woman's attractive feminine appear- ance by causing obesity, acne and breast atrophy. The intrauterine device (IUD) , if not WHO / UN / K Muldoon correctly fitted, may cause pain to the husband during intercourse. Break- through bleeding and a higher inci- dence of menorrhagia and polymenorrhea can be a sexual drawback, diminishing the sexual availability of the wife. Leucorrhea, frequently associated with IUD, may interfere with sexual pleasure, especi- ally that of the husband, whose wife may worry because she cannot meet her husband's sexual needs. Methods which are directly related to the act of sexual intercourse include coitus interruptus, coitus reservatus, coitus interfemora, or the use of condom and diaphragm. These methods interfere with normal physio- logical sexual relations. They call for very high self-control in the case of physiological methods, and good training in the case of the diaphragm and the condom. They are not as reliable as the pill or the IUD. More- over these techniques cannot be recommended at the beginning of marriage when there should be no constraint on sexual relations. The advantages Despite these potential problems, the use of effective contraceptive methods will relieve all the worries of an unwanted pregnancy, and con- sequently the wife usually participates more actively in sexual relations. Some women react towards unprotected sexual relations by vaginismus or spasmodic contraction of the sphincter vaginae muscle, causing painful or difficult intercourse. WORLD HEALTH, April1989 There are other advantages. Some contraceptives such as the pill can regulate the woman's cycle and normalise the menstrual blood loss, making her available for sexual rela- tions for the longest possible time. The use of steroid contraception will also, in the majority of cases, improve sexual appetite and give the woman a feeling of well-being which will contribute to a better sexual relation. Condom use can improve or even cure the occur- rence of premature ejaculation by the husband by slightly diminishing sexual sensitivity. And condoms, of course, play a major role in the prevention of sexually transmitted disease, particu- larly AIDS. Counselling is one of the main pillars of family health and an import- ant component of family life edu- cation. Indeed, family planning services cannot be effective without good counselling, and a woman who comes for this service should not be regarded as a patient. Lack of counselling is a major cause behind the failure of many family planning programmes. But this in turn calls for a counsellor who is well informed about reproduc- tion, human sexuality, methods of contraception, mechanism of action, side-effects, contra-indications and how to recognise them. He or she should be interested in people, sym- pathetic and a good listener. The couple should be taught to recognise the side-effects, and should know when to come for consultation and when to stop using a given method. The counsellor should help them to Family planning services cannot be eHective without good counselling, and a woman who comes for this service should not be regarded as a "patient". choose the best method and encour- age them to persist in its use. Some methods of family planning need education and training for both clients, doctors and nurses. Doctors need to be properly trained in how to insert an IUD, otherwise there could be a risk of it perforating the uterus, or they might position the device outside the uterine cavity where it loses its contraceptive effect. They should also be trained in how to take it out properly, otherwise complications may develop. More training for doctors is needed in the insertion and removal of subdermal implants. And nurses in developing countries must be trained to give properly an intramuscular con- traceptive injection. As for the clients, women particu- larly need to have good information about the physiology and anatomy of the reproductive system. A knowledge of physiology is needed if natural family planning methods such as checking the viscosity of the cervical mucus or the calendar method are used. Women should be trained to locate the cervix in order to be able to insert a diaphragm or a cervical cap properly, to detect the IUD thread after every menstrual cycle, to detect the tip of the IUD if it is partially expelled, or to get a sample of cervical mucus for assessment. • 23 They condone to~ by Cesar A. Chelala y friend's profes- sion (he is a pianist) was con- sidered unusual when he went to prison in a South American capital city. And unusual was his punishment. He was repeatedly beaten on his hands, and threatened that they would be chopped off - a spiritual if not a physical death for a pianist. Miguel Angel Estrella, then already a pianist of world renown, had been abducted and imprisoned by the military regime, unjustly accused of being a guerrilla from a neighbouring country. After his release from prison - following an unprecedented interna- tional campaign of support - he said: "They (the torturers) concentrated on my hands like sadists. They applied electricity under my nails without stop- ping, and later they hanged me from my arms. After two days of torture I hurt all over, and didn't have any sensibility left in my hands. I touched Maintaining law and order poses special problems in the modem world. Never- theless, it is no part of a doctor's duties to be an accomplice in the systematic torture of prisoners. things and didn't feel anything. The last time that I was tortured they threatened to chop off my hands with an electric saw, and told me "We are going to chop your hands off, finger by finger, and then we are going to kill you, just like Victor Jara." (A famous South American folk singer and guitarist, Jara was killed after being tortured, his fingers being brutally smashed before his death.) My friend's torture, like that of many others, was carefully orchestrated, carefully planned and carried out so as to lower the prisoner's defences, his self-esteem, his hope. Such a complex system of brutality cannot exist without the advice of medical and para- medical personnel - including psycho- logists - on how to carry it out. After his liberation, Estrella testified against the involvement of medical personnel in torture. The presence of the doctor in the torture chamber is not a new phenom- enon. In many countries worldwide - especially those under military rule - it is still practised. In 1532, when Charles V of Spain was Holy Roman Emperor, the Constitutio Criminalis Carolinia listed the first recorded reference to "medical complicity" in torture. Until it was prohibited in many European countries by the Napoleonic Code d'instruction criminelle of 1808, tor- ture was an accepted part of the legal process. Unfortunately "medical complicity" is not an extinct phenomenon. The role of medical personnel can take several forms, ranging from assessing the prisoners' health status before they are tortured or determin- ing how much longer it is possible to do it without killing them, to reviving prisoners made unconscious by pain and punishment or even actively parti- cipating in the interrogation process: a catalogue of horrors that one usually Dr Cesar A. Chelala. an m. Argentine medical scientist living in New York, is a winner of an Overseas Press n Club of America a\IVard . assumes had ended with Germany's Nazi regime. That professionals who are trained to do eveything in their power to alleviate suffering might contribute instead to perpetrate torture is one of the most tragic perversions of the medical mandate. This fundamental problem highlights a critical aspect of medical ethics that is rarely treated in the textbooks. Alvaro Jaume, an architectural student who had been in the same prison as Estrella, expressed outraged astonishment when speaking about the role of a doctor in this process. In a testimony given to the human rights W HO/ C. Blackwell Pianist Miguel Angel Estrella with his two children; as a prisoner, he was threatened with having his hands chop- ped oH. body Amnesty International, he said: "I was thoroughly examined by a doctor. He asked me about my family, any chronic or present illnesses, and about parts of my body which might be delicate because of previous sickness. I thought that giving that information might reduce the torture. Hours later I realised the real reason for the doctor's interest. I heard his voice, unmistak- ably, saying: 'That's O.K, you can carry ' on. "I felt angry and impotent. Here was an individual trained by society to save lives, dedicating himself to inflicting pain. Mostly I was angry with myself for being so naive as to believe that a doctor who worked in such a place could possess a trace of humanity. These doctors are saving lives, but in a perverse way. The aim of torture is thwarted if the victim cannot support the interminable ordeal. The doctor is needed to prevent you from dying for your convictions." Although there may be multiple interpretations of doctors' behaviour in these circumstances, one situation on which there must be widespread agreement is on the need to eliminate doctors' participation in these actions. That will only be possible, however, WORLD HEALTH , April 1989 Photo WHO /C. Chelala when everybody is aware of its occur- rence, when nobody can claim ignor- ance about it. Keeping the memory of those events alive thus becomes fundamen- tal. That same need for collective memory, with reference to the victims of the Nazis, was expressed by the late Italian writer Primo Levi in his book "If this is a man:" You who live safe In your warm houses, You who find, returning in the evening, Hot food and friendly faces: Consider if this is a man Who works in the mud Who does not know peace Who fights for a scrap of bread Who dies because of a yes or a no. Consider if this is a woman, Without hair and without name With no more strength to remember, Her eyes empty and her womb cold Like a frog in winter Meditate that this came about, I commend these words to you. Carve them in your hearts At home, in the street, Going to bed, rising; Repeat them to your children Or may your house fall apart, May illness impede you, May your children turn their faces from you. • The Ethical Grid . Health workers are con-stantly faced with the kind of ethical dilemmas of which we give a few examples on page 17 -dilemmas which are more complex today than in past ages when few people questioned the "moral certain- ties". In an attempt to help health professionals. patients and potential patients to under- stand more readily the prin- ciples and processes of moral reasoning. a community health specialist at Liverpool Uni- versity has develpped what he calls The Ethical Grid. Or David Seedhouse explains that the Grid is divided into four different coloured layers. rep- resenting the primary con- siderations that any health worker who wishes to reason morally must take into account. These are the basic raison d'etre of health care (blue). the idea of duty (red). the requirement to analyse the consequences of action (green), and a range of practical considerations (black). The layers are in turn divided into separate "boxes" contain- ing brief statements which act as reminders of the content of moral thinking at a deeper level. They include the phrases create autonomy (blue). truth-telling (red). increase of social good (green). and effectiveness and efficiency of action (black). Its inventor stresses that the Grid is not a pocket calculator. but rather provides a guide through a jungle of factors and. because it asks that the decision-maker ultimately select a small number of boxes. it can be of significant help in making highly complex judgements. For further information write to: Or David Seedhouse. Department of Community Health and Gen- eral Practice. Liverpool Uni- versity. Liverpool. U K. • @) -s E <J) ci u.: 0 0 "" 0.. When tender loving care is not enough: the Ethical Grid is a device to help health professionals to make highly complex judgements. Now the World's 2nd No-Tobacco Day HO is planning a repeat perform- ance of a day without tobacco - an event which it first sponsored last year. An evaluation report of the World's 1st No-Tobacco Day showed that at least 60 countries staged special events, and that "only WHO can undertake the sensitising of public opinion worldwide to the need for tobacco-free societies and for the decrease of tobacco-induced diseases." That day was observed on 7 April 1988, following a decision of the World Health Assembly to link it to WHO's 40th anniversary. It was deemed an appropriate occasion to launch an initiative with worldwide implications. For the observance of the World's 2nd No-Tobacco Day this year, and for by Peter Ozorio the years ahead, the date will be 31 May- in recognition of the Assembly's decision which was taken in May. This year a slogan has been chosen for the day. It is "The female smoker: At added risk." For good reason was this topic selected. Faced with increasing public opposition to tobacco and a decline in the number of smokers - particularly among men - in the developed world, the tobacco industry is now seeking new markets and setting its sights on women, on youth but above all on the developing countries. In the industrialised world, women began smoking during World War II. But mainly as a result of advertising which linked smoking to women's rights and success in the business world, women are lighting up more than men. One ad that promoted The female Smoker: At Added Risk 26 World's lnd No.Jobacco Day 31 May1989 World Health Organization cigarettes through such an appeal told upwardly mobile women: "You've come a long way, baby." They have indeed - most specifically in their lung cancer rates. Between 1960 and 1980, the mor- tality rate for women from lung cancer doubled in 28 industrialised countries. Since the mid-1980s, in parts of the United States, lung cancer has been overtaking breast cancer as the most common form of female cancer. It is the first country to show this trend. Lung cancer is projected to be the No. 1 form of cancer for women in the United Kingdom by the year 2010. An Italian campaign against smoking- related cancers offered apples in exchange for cigarettes_ WOR LD HEA LTH , April 1989 The female smoker may add further risks to her health. If she is using oral contraceptives she increases her risk of heart attack, stroke or blood clot in the leg veins. For instance, the risk of a heart attack is ten times greater for smokers than for non-smokers. The health risks are further increased if her blood pressure and cholesterol levels are above normal. Moreover, her menopause will occur from one to three years earlier. When a pregnant woman smokes, her unborn child does so too. In addition, her new-born baby is likely to be premature or underweight; and her toddler will be more frequently ill. The risks are greatest for women in the Third World because they are likely to be poor and anaemic, and to have had many children. In the days when few women smoked they were thought to be im- mune froin lung cancer or cardiovas- cular diseases. The experience of the last 40 years has shown that women who smoke as men die from the same tobacco-induced diseases as men. Mr Peter Ozorio. until receQtly a Public .• Information QJfic>er with Wl-fO .and .. World [lealth's News Page Editor, is wor.!<i.ng as ,a,wHo con"• sliltant 011. smoking and health. · That a world day without tobacco is now established in the calendar of annual, international events is due in large part to the response from coun- tries to such an occasion. Special events to mark the World's 1st No- Tobacco Day were arranged all around the globe, either by governments, by citizen groups or jointly. Among the events reported to WHO: • In Australia, some 1,000 new-born babies received aT-shirt saying "Brand new non-smoker" as part of the cancer society's programme. • Brazil observed the world no- tobacco day even though it later held its own national no-smoking day, on 29 August. • In Costa Rica, there was no cigarette advertising on 7 April as a result of an agreement between the health ministry and the tobacco industry. • In Ethiopia, rooms at the Addis Ababa Conference Centre were declared smoke-free zones as the Organisation of African Unity met. • In Mauritius, a top-level citizen com- mittee recommended that insurance companies should reduce premiums on life insurance for non-smokers. • WORLD HEALTH, April 1989 Food irradiation - scientists' toy or everyman's joy? JHI ardly any other issue related to public health has caused as much heated debate in recent years as the subject of food irradiation, which is still, however wrongly, associated in many people's minds with radioactivity. The scientific community, tradi- tionally conservative in addressing the world outside its own Ivory Tower, has been reluctant to come forward and explain to the public at large the essence and the advantages of a new technology. Other voices, though somewhat less qualified to pass a learned judgement, have been raised in a scare-mongering campaign void of scientific argument. What's so special about food irradi- ation? Well, consider the following: Earlier this year the world's popu- lation passed the five billion mark, but according to UN projections a further three to nine billion human beings will be added before the population of our planet stabilises. Will we be able to feed ourselves in the future, given this tremendous population growth and the ever-increasing global environment problems that accompany it? Not only will natural disasters, such as floods and droughts, progressively affect more and more millions of people throughout the world every decade. Desertification too, steadily gobbling up arable lands to the tune of six million hectares per year, will turn productive soil into arid desert beyond practical hope of reclamation. Another form of land degradation, defores- tation, is directly linked to soil erosion. The fact that two mighty rivers of the Indian sub-continent - the Ganges and Brahmaputra - flush three billion tons of what once was fertile top soil into the ocean each year should serve as a grim warning, when we consider that it During a conference on irradiated food in Geneva, participants were served an entire, tasty meal whose ingredients had all been safeguarded by this means. 28 by Valery Abramov takes anything between 200 and 1,000 years for a mere inch of soil to form. According to the Washington-based Worldwatch Institute, "agricultural lands are degrading on every con- tinent. Apart from growing scarcity of fresh water, the productivity of perhaps one-third of the world's irrigated land is being adversely affected by severe waterlogging and salting. Worldwide, an estimated 25 billion tons of topsoil are being lost from available crop- Mr Valery Abramov is a Public Information Off icer with WHO's Divisionof Public Information and Public Relations. land each year." All this affects the availability of food. But there is another angle. The sad fact is that, all too often, the food never gets to the consumer due to spoilage and microbial contamination. This is a world problem of enormous dimensions, especially in the developing countries with warm climates, where the losses of veget- ables, fruits and non-grain staple foods can reach a staggering 50 per cent of the total output. The story does not end there either. Food safety and food-borne diseases rarely get into the limelight of the international media. Yet several years ago a joint FAO/WHO Expert Com- mittee on Food Safety concluded that "food-borne disease, while not well documented, is one of the most Photo WHO/V. Abramov WORLD HEALTH, April 1989 widespread threats to human health and an important cause of reduced economic productivity." We still know too little about the true scale of this problem, but here is some food for thought: - 1,000 million US dollars is the price paid each year by the United States alone in lost productivity and health care resulting from only four food- borne diseases spread by contami- nated meat and poultry. A recent much-publicised chicken- and-egg story in the United Kingdom has highlighted an intriguing aspect of food safety so far confined mainly to the developed countries: the sal- monella contamination of perfectly good-looking eggs and nicely wrapped poultry. This is one of the paradoxes of our time. We explore outer space and bisect primordial cells by means of genetic engineering, but can't success- fully cope with a serious health risk presented by these minute bacteria. Luckily, there is a relatively new technology called food irradiation, which can effectively render salmonella-contaminated poultry harmless. And not only that. Besides bacteria, the process can tackle such food spoilage organisms as moulds and yeast. It can prolong the shelf-life of fresh fruits and vegetables, delaying the ripening of many fruits, keeping strawberries at the very peak of ripeness for up to two weeks, inhibiting the sprouting of onions and potatoes. It can also destroy parasitic worms and insect pests, thus preventing damage of grain-stocks, for example. Meals in space American and Soviet space explorers habitually take irradiated foods with them, not in order to conduct intricate tests, but simply to eat them. And there have been Soviet cosmonauts staying in orbit for months on end! Any specific reason for this novel treatment of their food? Yes, there is enough risk-taking in their profession without adding the worry of possible food poisoning. But why then, given such an impressive track record, is the process not used on a universal scale? Why are a number of consumer unions dead against it? Why are some governments reluctant to adopt and use the tech- nique, while others have gone success- fully ahead with it? There is no single answer, but what appears to be at the root of the acceptance problem is the rather ir- rational fear of anything connected with nuclear power. Because of the much-publicized Three Mile Island (USA) and Chernobyl (USSR) acci- dents, few people vvill readily acknow- WORLD HEALTH, April 1989 Photo WHO / Zafar ledge that the safety and environ- mental record of the nuclear industry is far superior to that of the chemical, oil and coal industries. Yet this is the case. No voices are raised against hospi- tals that regularly use x-ray machines or more sophisticated radiological equipment for diagnosis and treatment. We have simply got used to these devices. Not so in the case of food irradiation. The public at large has not yet accepted it for what it is: yet another wonder of 20th century technology bringing a better and safer quality of life for all of us. Already 35 countries throughout the world have given approval for the introduction of food irradiation tech- nology. At a recent UN-sponsored International Conference on the Acceptance, Control of and Trade in Irradiated Food held in Geneva, WHO roundly declared itself "satisfied regarding the safety of irradiating any food commodity up to an overall average dose of 10 kilogray. Since the availability and safety of food . . . are important components of the primary health care approaches, WHO is con- cerned that the unwarranted rejection of the process, often based on a lack of understanding of what food irradiation "Unwarranted rejection of the process may hamper its use in those countries which may benefit most." entails, may hamper its use in those countries which may benefit most." So the issue of safety is not really an issue, at least for the scientific com- munity. But it is still a very hot issue for some "activists" of the International Organization of Consumer Unions who seem to know better. In the course of the conference, all scientific evidence was promptly disregarded by the self-styled "vigilantes" and all that remained was pure emotionalism. Earlier this century there was pro- tracted and entrenched opposition to milk pasteurisation - a process that is taken for granted today. In fact many new ideas and inventions have had a rough time trying to establish them- selves in our world. The only hitch is that the world is becoming too fragile an ecosystem to support its swelling human cargo. In the circumstances we can hardly afford to toss away a sound and proven food preservation tech- nique, just to appease a number of vociferous opponents obsessed with an idee fixe. • 29 ...... ....... ... ... ... .... .... ..... . .......... . ...... ....... ... ... ... . .... .... . ....... . ........... . ...... ....... ... ... ... . .... .... . ....... . ........... . ... .. ... ... ... ... . ... . ............. . ... .. ....... ... ... ... . ... .... . ... ... .. . ..... . ... .. ....... ... ... ... . .... .... . ... ... . ........... . ... .. ....... ... ... ... .... .... . .................. . ... .. ... ... ... ... ... ... . ............. . ... .. ....... ........... ....... ... ....... . ........... . ... .. ....... ........... ....... ... . ................. . ... .. ....... .......... ...... ... . ................ . Editor: Philippe Stroot Health in Africa: a pioneer's point of view When. in 1946. the United Nations passed a resolution to create an international health organization. only one representative from Black Africa participated in the dis- cussions he was Professor J . N. Togba. of Liberia. Rewarded for his services to international public health by a commemorative medal dur- ing the 38th session of the WHO Regional Committee for Africa. this distinguished pioneer offered his impres - sions on the state of Africa and on the progress that WHO has achieved there during its 40 years of existence. "More and more people from the Third World today participate actively in the effi - cient running of the Organi- zation." he commented. "But the governments of the developing countries must make hea lth a major priority. so that their populations can live better and longer lives. and can contribute to devel - opment and peace in the world." Whi le Professor Togba appeared confident that WHO. one day. w ill manage to eradicate malaria as it did sma ll pox. he declared himself very worried about A ID S. "We have got rid of sma ll pox. we are trying to eliminate the other infectious diseases. and sudden ly there appears something we know nothing about" he said. and added " I am sure that when we have vanquished AIDS something else wi ll come up." Asked about any direct link between AIDS and promiscuity. the dean of all the African members of the WH 0 Executive Board pro- posed a new way of looking at things " I think that Afri- cans can avo id the practice of promiscuity because our ancestors did not practise it I think that polygamy as it was practised by our forefathers had its justification in that it prevented th em from changing partners indiscrimi- nately. outside the sma ll group of 'housewives· This is how it happens st ill among rura l popu lations and I do not think that A IDS is so wide- spread outs ide the urban regions. This is why I do not believe that AIDS orig inated in Africa The typical African does not traditiona lly practise promiscuity. He has several w ives. certain ly. and he goes from one to the other. but always within this little group that he knows well. " Grave though it may be. AIDS is on ly one problem among many that affect the African continent "I hope." Professor Togba concluded. "that health wi ll occupy a more and more preponderant place among the priorities of the African governments south of the Sahara. Through better health. we shall have better education. greater economic progress and increased productivity If a population is in good health. it wi ll be in a better position to work for the real develop- ment of the country. I shou ld like my own people to under- stand this very clearly." • Or Monekosso, WHO Regional Director for Africa, presents a commemorative medal to Professor J. N . Togba of Liberia. 30 No need to die in giving life. Mother and child are doing wel l ... A banal phrase in the developed countries. where it is rare for someth ing to go so badly wrong during a confinement that the mother loses her life. This is much less true in the Third World. especially in Africa. Every time a woman in Africa becomes pregnant she runs a risk of dying as a result which is over 100 times greater than for a woman in the industria lised world . South of the Sahara. an estimated 1 50.000 women die every year from the effects of pregnancy. In order to try to stop this waste of life. public health off icials. midwives. doctors and representatives of non- governmenta l organizations from 22 French-speaking African countries met recently in Niamey. cap ital of Niger. at a major conference on safe motherhood. Even though the sca le of the problem became clear on ly recently. as a result of ep idemiologica l stud ies. African governments decided to act rapidly to reduce maternal mortality. Apart from such specific causes as excessive blood loss. difficult confinements. infections and other complications. certain additiona l factors make the situation even worse - malnutrition. anaemia. malaria or simply overwork. Many Afr ican women toil from 1 2 to 14 hours a day But the heavy price that African women pay for maternity is not inevitable. Efficient cheap methods exist to put a stop to this si lent tragedy The most important are family planning. pre- and post-natal care. supervision of the confinement and recourse to well - equipped and well-staffed primary health care centres. As Dr Gottlieb Monekosso. WHO Regional Director for Africa. told the N iamey con feren ce: "Safe motherhood requires the setting up of adequate and efficient services at all levels. and both geographic and financial access to these services. In order to ach ieve this. there must be a considerable mobilisation of resources. and this can on ly be provided by a real national commitment and the impetus of international solidarity in an understanding partnership .. WHO. UNICEF. UNDP and the World Bank financed the conference whose aim was to ass ist countries to draw up their respective national plans of action. The government of N iger hosted the con ference. and the flags displayed in Niamey asserted "Motherhood if I want it and when I want it" Th is speaks volumes about the growi ng awareness aroused in that country. as in others. about the need to plan and space births fo r the sake of the health of both mother and ch ild • WOR LD HEALTH, April 1989 Health at Sea What should be done if d isease or injury occurs in a ship at sea? From now on. all seafarers wi ll be able to con- su lt the second ed ition of the International Medical Guide for Ships published by WHO . This Guide pro- vides com plete informat ion and advice of special value to seafa rers. even if they have had no medical training. on w hat to do in case a hea lth problem arises on board This new ed iti on has been com pl ete ly revised and updated in th e l ight of scienti fic progress and devel- opments in seafaring. The numerous illustrations enable users to find immed iately the advice they may need on how to manage a given eme rg ency Other new features include chapters on preg nancy and gynaecolog i- ca l problems. on medical care of castaways and rescued persons. and on how to obta in externa l assistance in case of serious health prob- lems at sea. lt also includes informat ion on d iseases occu rring in fi shermen. Some 60 diseases and medical problems have been selected and listed in alpha - betical order The new edi- tion also features medica l advice for sh ips carry ing toxic chemica ls. including first-aid treatment of po ison ing. and a completely updated list of medicines and su rgica l supplies for the ship's medi - cine chest INTERNATIONAL MEDICAL GUIDE FOR SHIPS Thi s 368 -page Guide with its 152 illustrations an d 14 tables is cu rrentl y avai lable in English . French and Spanish edit ions are in preparation and shou ld be ava il able dur- ing the second half of 1989 . The Guide may be obtained from Distribution and Sa les. WHO. Geneva. Switzerland. for 60 Swiss francs or US$ 48 (Order No. 1152078) • WORLD HEALTH, April 1989 Nevvsbriefs AIDS- the scientific and social challenge. This is the theme of the Fifth International Conference on AIDS. to be held in Montreal. Canada in June. Sponsored bv WHO. the Canadian In ternational Development Research Centre and the Canadian Ministrv of National Health and Welfare. this conference will be attended bv specialists from all over the world Thev will tackle such aspects as AIDS and the individual. AIDS. societv and behaviour. ethics and the law. and the international implications and economic repercuss- ions of the disease The epidemiological. clinical and basic research aspects will also be reviewed in detail. For further information. contact the conference secretariat. Kenness Canad. Inc. 1010 ouest. rue Ste-Catherine. Suite 628. Montreal. Quebec. Canada. H3B 1 G7 Telephone. (5 14) 874- 1532 Sports and AIDS. The first -ever consultation on AIDS and sport. organized recentlv in Geneva bv WHO and the International Federation of Sports Medicine (IFSM) . con - cluded that the risk of transmitting the AIDS virus during even violent sporting activities is extremelv low In the presence of members of the Medical Commission of the International Olvmpic Committee (IOC) and of several sporting federations. Or Jonathan Mann. Director of WHO's Global Programme on AIDS. stressed that these conclusions "should go far towards putting to rest concerns on this issue in the sporting world" So as to avoid anv direct contact between two bleeding wounds. it was recommended that injured sportsmen's partiCipation should stop until the bleeding ceases and their wounds have been cleansed with an antiseptic and carefullv dressed legionnaires' disease. During the 83rd session of the WHO Executive Board. Or Hiroshi Nakajima. Director- General. announced that he would convene a meeting of experts on legionellosis this vear to discuss the epidemiologv and biologv of this respiratorv tract disease. Appearing mvsteriouslv in 1976. it is now known to be caused bv a bacterium called Leg/one/la pneumophilia The source of infection is usuallv in air-conditioning and air-circulating svstems in the interior of buildings. Because of the importance of the problems caused bv legionellosis. WHO is alreadv assisting its member states in the fields of vocational training and diagnosis. and this effort will be continued and increased in the future. Personalities. Mr Edward Uhde (United States) has been appointed Director of WHO 's Division of Budget and Finance to succeed Mr Adriano lmbruglia (ltalv) who has retired Mr Uhde first joined WHO 20 vears ago. and worked successivelv in the Regional Office for Africa in Brazzaville and that of the Western Pacific in Manila Former D.-G . Or Halfdan Mahler. Director-General Emeritus of WHO. has been appointed Secretarv-General of the International Planned Parenthood Federation (IPPF). a non-governmental organization which is based in London and maintains official relations with WHO He succeeds Mr Bradman Weerakoon of Sri Lanka. who had held that post since 1984 The poem bv Prima Levi appearing on page 25 is quoted bv kind permission of Andre Deutsch Ltd. London. In the next issue Particularly in those parts of developing count ries that are far removed from the ca pital city, the District Level Health System is the foca l po int for such hea lth services as exist The May issue of World Health exam in es the role and the funct ions of th is cruc ial sector of the infrast ru ctu re. and the ways in wh ich it operates in diffe rent cou ntries. 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Всемирная организация здравоохранения (ВОЗ / WHO) · Journal articles
World Health: the magazine of the World Health Organization: April 1989 [full issue]: ethics and health
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