Making family planning accessible in resource-poor settings

It is imperative to make family planning more accessible in low resource settings. The poorest couples have the highest fertility, the lowest contraceptive use and the highest unmet need for contraception. It is also in the low resource settings where maternal and child mortality is the highest. Family planning can contribute to improvements in maternal and child health, especially in low resource settings where overall access to health services is limited. Four critical steps should be taken to increase access to family planning in resource-poor settings: (i) increase knowledge about the safety of family planning methods; (ii) ensure contraception is genuinely affordable to the poorest families; (iii) ensure supply of contraceptives by making family planning a permanent line item in healthcare system''s budgets and (iv) take immediate action to remove barriers hindering access to family planning methods. In Africa, there are more women with an unmet need for family planning than women currently using modern methods. Making family planning accessible in low resource settings will help decrease the existing inequities in achieving desired fertility at individual and country level. In addition, it could help slow population growth within a human rights framework. The United Nations Population Division projections for the year 2050 vary between a high of 10.6 and a low of 7.4 billion. Given that most of the growth is expected to come from today''s resource-poor settings, easy access to family planning could make a difference of billions in the world in 2050.     

Problems of value in medicine and the humanities, or will the real doctor please stand up?

After a general discussion of the need for physicians to concern themselves with questions of human ethics, this paper considers genetics, the population explosion, abortion, curing patients of psychological problems which are perfectly normal (such as masturbation), and behavior modification. The population explosion is the outgrowth of the understandable desire to reduce disease and death. Now births must be reduced immediately or the world will eliminate starvation among infants only to have starvation among adults. The 2nd problem is preventing births. Contraception is not caught up in moral problems but abortion pits 1 set of ethics against another. Here, again, the physician must have a broad world view. The humanist theory holds that procedures that enhance human freedom are both natural and desirable while procedures that suppress it are unnatural and undesirable. This also applies to medical procedures. An understanding of the humanist point of view is important to the physician in his work.     

Demographic and contraceptive patterns among women in Northern Mindanao, the Philippines

Desired family size and contraceptive behavior of 986 ever-married women aged 15-54 from Northern Mindanao, the Philippines, are described. Using the Dow and Werner typology of demographic and contraceptive patterns, it was found that a majority of the women were traditional in their demographic attitude and contraceptive behavior. A substantial proportion of the women desired medium to large families. In consistency in attitude and behavior was also manifested by women who desired small families but have never used efficient family planning methods. Sociodemographic characteristics of these women are described. A majority of the women who have never used efficient contraception also never practiced family planning. Rhythm was the primary method of birth control among demographic innovators and traditionals who have ever used inefficient methods; the pill was popular among contraceptive innovators and moderns. A considerable proportion of the demographic innovators and the traditionals were not currently using any family planning method; a lesser proportion of contraceptive innovators and moderns were also not using birth control methods. Relevance of the findings to family planning programs is pointed out. Recommendations are given. Motivation for a small family is a prerequisite for a successful family planning program. Without motivation, what family planning programs do is reduce the number of unwanted births. Family planning programs should reach out to those who are sufficiently motivated to have small families but have never used efficient family planning methods. A major finding of this research is that a majority of the women who never used efficient contraception also never used inefficient or traditional methods. Efforts should be made to change this. Additionally, efforts should be made to bring those modern and contraceptive innovators who had stopped using any family planning method to practice contraception again.     

Community Psychiatry and the Population Explosion

Although excessive population has long been a dilemma in certain areas of the world, current rates of growth present a global threat to all nations. Arguments based on economics, world peace, individual freedom, humanism and the preservation of life''s amenities all point to the urgent need for programs to control birth rates. This applies to the United States also, although we have the advantage of a relatively high cultural and economic level from which to attack the problem.Modern psychiatry is increasingly committed to the Community Mental Health concept, which in part implies greater involvement with the element of the population that is socially and economically at a disadvantage. Effective treatment cannot ignore the effects on the patient of intolerable reality situations, often produced by successive unwanted pregnancies. In addition, a positive approach to family planning by psychiatrists and social workers will provide the structure needed for truly preventive psychiatry; as our knowledge of the determinants of psychosis, delinquency and mental retardation expands, selective counseling can do much to prevent these family and social tragedies.Both as world citizens and as practitioners of a profession, psychiatrists cannot afford to delay pledging their resources to the solution of so compelling a problem.     

Where next?

This paper provides a personal perspective on the rich discussions at the Bixby Forum. The size, rate of growth and age structure of the human population interact with many other key factors, from environmental change to governance. While the details of future interactions are sometimes difficult to predict, taken together they pose sombre threats to a socially and economically sustainable future for the rich and to any realistic possibility of lifting the world''s bottom two billion people out of poverty. Adaptive changes will be needed to cope with an ageing population in countries with low fertility or below, but these are achievable. More worrying, continued rapid population growth in many of the least developed countries could lead to hunger, a failure of education to keep pace with growing numbers, and conflict. The assumption that the demographic transition from high to low birth rates occurs as a result of exogenous social and economic forces is being replaced by a clearer understanding of the many barriers that separate women from the knowledge and technologies they need to manage their childbearing within a human rights framework. The forum ended with a clear consensus that much more emphasis needs to be given to meeting the need for family planning and to investing in education.     

Are husbands a barrier to women's family planning use? The case of Morocco

Little is known about men's role in the adoption of family planning. Recent studies suggest that men may be a barrier to women's use of family planning. However, it is not clear whether husbands represent a true or a perceived barrier. Using the 1992 Morocco Demographic and Health Survey data, this study examines (1) whether women and men report concordant fertility desires, discussions, and contraceptive use; (2) the accuracy of women's perceptions of their husbands' fertility desires; and (3) whether husbands are a barrier to women's family planning use. The results demonstrate that, controlling for women's own fertility desires, husbands' true fertility desires are associated with family planning use. Likewise, women who perceive their husbands to want fewer children than they want are more likely to use family planning. Future fertility and family planning programs need to include men to reduce their role as both perceived and true barriers to family planning use.     

公共卫生伦理学简论

试图阐述公共卫生伦理学的基本概念、基本原则和概念框架,并通过例举多个公共卫生伦理的具体案例来阐明如何利用道德推理来解决公共卫生研究和实践中出现的伦理冲突,制定有效的公共卫生政策和措施。     

Gonococcal infection and human fertility in sub-Saharan Africa.

An analysis is presented of the influence of Neisseria gonorrhoeae on human population growth in regions of sub-Saharan Africa where gonococcal infections are prevalent in sexually active adults. Combining epidemiological and demographic data within the framework of a mathematical model, we show that gonorrhoea has a major impact on fertility and, concomitantly, on net population growth in areas with a high prevalence of untreated infections. Specifically, a 20% prevalence in sexually active adults is predicted to induce a 50% reduction in net population growth. Model predictions are in good agreement with observed data from Uganda, and the sensitivity of the prediction to various complications, such as heterogeneity in sexual behaviour, is assessed. The analysis suggests that the predicted increase in fertility arising from expanded sexually transmitted disease (STD) control programmes in Africa to help combat the spread of human immunodeficiency viruses (HIV-1 and HIV-2) will help to offset the predicted demographic impact of AIDS in the worst afflicted areas. In other areas the rise in fertility associated with effective STD control will need to be countered by the linkage of STD control programmes with family planning initiatives.     

Considerations for a Human Rights Impact Assessment of a Population Wide Treatment for HIV Prevention Intervention

Increasing attention is being paid to the potential of anti‐retroviral treatment (ART) for HIV prevention. The possibility of eliminating HIV from a population through a universal test and treat intervention, where all people within a population are tested for HIV and all positive people immediately initiated on ART, as part of a wider prevention intervention, was first proposed in 2009. Several clinical trials testing this idea are now in inception phase. An intervention which relies on universally testing the entire population for HIV will pose challenges to human rights, including obtaining genuine consent to testing and treatment. It also requires a context in which people can live free from fear of stigma, discrimination and violence, and can access services they require. These challenges are distinct from the field of medical ethics which has traditionally governed clinical trials and focuses primarily on patient researcher relationship. This paper sets out the potential impact of a population wide treatment as prevention intervention on human rights. It identifies five human right principles of particular relevance: participation, accountability, the right to health, non‐discrimination and equality, and consent and confidentiality. The paper proposes that explicit attention to human rights can strengthen a treatment as prevention intervention, contribute to mediating likely health systems challenges and offer insights on how to reach all sections of the population.     

Differences in Moral Judgment on Animal and Human Ethics Issues between University Students in Animal-Related,Human Medical and Arts Programs

Moral judgment in relation to animal ethics issues has rarely been investigated. Among the research that has been conducted, studies of veterinary students have shown greater use of reasoning based on universal principles for animal than human ethics issues. This study aimed to identify if this was unique to students of veterinary and other animal-related professions. The moral reasoning of first year students of veterinary medicine, veterinary technology, and production animal science was compared with that of students in non-animal related disciplines of human medicine and arts. All students (n = 531) completed a moral reasoning test, the VetDIT, with animal and human scenarios. When compared with reasoning on human ethics issues, the combined group of students evaluating animal ethics issues showed higher levels of Universal Principles reasoning, lower levels of Personal Interest reasoning and similar levels of Maintaining Norms reasoning. Arts students showed more personal interest reasoning than students in most animal-related programs on both animal and human ethics issues, and less norms-based reasoning on animal ethics issues. Medical students showed more norms-based reasoning on animal ethics issues than all of the animal-related groups. There were no differences in principled reasoning on animal ethics issues between program groups. This has implications for animal-related professions and education programs showing that students’ preference for principled reasoning on animal ethics issues is not unique to animal-related disciplines, and highlighting the need to develop student (and professional) capacity to apply principled reasoning to address ethics issues in animal industries to reduce the risk of moral distress.     

Contraceptive knowledge and attitudes in urban Ilorin, Nigeria

In Nigeria as in other African countries, population growth negatively affects economic development, and high parity affects maternal health. Breastfeeding, a common practice traditionally, is declining in some situations. This study was carried out in Ilorin, Nigeria. A sample population of 932 households stratified to represent different socioeconomic groups was used. 913 currently married women aged 15-35, who were in their prime childbearing ages, were interviewed on their contraceptive knowledge and on their attitudes towards modern contraception. In a bivariate statistical analysis, of 8 variables examined (i.e. ownership of a television, radio, religion, and other) only the woman's education, age, and area of residence within the city have significant independent effects on contraceptive knowledge. A linear logistic regression technic was also applied. 90% of the women interviewed thought that women should be free to practise family planning. Also, 95% of all the women believed that too frequent births could endanger the health of the mother and her children. Only the women with previous contraceptive knowledge overwhelmingly (80%) thought that the best way to prevent too frequent births is by family planning. 66.5% of those without previous contraceptive knowledge before this study suggested that traditional abstinence should be used and only 28.9% suggested family planning. Adequate awareness of the availability and usefulness of family planning methods can influence attitudes of women towards contraception and may also enhance contraceptive use. Better use can be made of broadcasting media, and efforts should be made to target younger, more fecund women, since there was evidence that more knowledge of family planning existed among women 30+ years old.     

Predicting restoration outcomes based on organizational and ecological factors

For restoration to be an effective strategy to reverse large‐scale habitat loss and land degradation, funding programs need policies that promote selection of and commitment to projects that can reasonably be expected to succeed. Programmatic project selection practices have received minimal formal evaluation, despite their importance. In this study, we considered the extent to which a program needs to consider both ecological and organizational factors during project selection in order to minimize the incidence of project failure. Our assessment of a long‐term program that funds ecological restoration efforts across Minnesota (U.S.A.), based on project records, manager surveys, and field surveys, yielded several broadly relevant insights. First, factors well understood to confer ecological resilience (level of landscape alteration and starting condition) were clearly associated with restoration outcomes, regardless of time‐since‐initiation of restoration. Second, restoration of low‐resilience ecosystems is typically a labor‐ and skill‐intensive enterprise for organizations that undertake them. Our analysis revealed four organizational limitations, in addition to insufficient funds, that hindered capacity to keep projects on‐track: lack of planning and goal‐setting, inadequate staffing, leadership change, and incomplete records. Third, to reduce risk, programs do not necessarily need to avoid challenging projects, but do need to consider whether organizations proposing restorations have adequate internal capacity to competently plan and to sustain actions for a duration sufficient to restore ecological resilience. If a restoration is degraded enough to require human intervention to recover, the outcome of a project is as likely to reflect its organizational reality as much as its ecological circumstances.     

Men's approval of family planning in Bangladesh

This article attempts to evaluate men's approval of family planning in Bangladesh using the couple data set from the recent Bangladesh Demographic and Health Survey (BDHS), 1999-2000. Family planning approval is addressed both from individual and couple perspectives. Analysis of BDHS data shows that about 85% of the wives report that their husbands approve of family planning, which is lower than the wives' own approval rate (95%). Using the couple data set, husbands' characteristics were matched to the wives' responses on family planning approval. Regression analyses show that age, education, access to TV, inter-spousal communication, current use of family planning and the number of living children significantly determine family planning approval among both men as well as couples. Family planning approval was found to be much lower in Sylhet than in the other administrative divisions. Multilevel modelling analysis suggests almost negligible variation at the community level. The findings indicate the need for careful evaluation of the DHS questions in order to measure appropriately men's family planning attitudes.     

The rise of research ethics committees in Western Europe: some concomitant problems

The rise of research ethics committees in Western Europe has accelerated since 1975 when the World Medical Association recommended that protocols for experiments involving human subjects be submitted to independent committees for consideration, comment, and guidance. This article describes the numbers, types, composition, function, authority, and problems of institutional, regional, and national research ethics committees in the Netherlands, Great Britain, West Germany, France, Switzerland, and Sweden. Among the problems are lack of authority to require ethical review, underrepresentation of nonmedical members, inconsistencies in definitions of and standards for human experimentation, and nonconsideration of the rights of investigators as well as subjects. The author urges legislation to strengthen the self regulating mechanism of research ethics committees.     

Microbial rights?

Our ability to disrupt habitats and manipulate living organisms requires a discussion of the ethics of microbiology, even if we argue that microbes themselves have no rights.Synthetic biology and the increasing complexity of molecular biology have brought us to the stage at which we can synthesize new microorganisms. This has generated pressing questions about whether these new organisms have any place in our system of ethics and how we should treat them.The idea that microbes might have some moral claims on us beyond their practical uses or instrumental value is not a new question. Microbiologist Bernard Dixon (1976) presciently asked whether it was ethical to take the smallpox virus to extinction at the height of the attempts of the World Health Organization in the 1970s to eradicate it. There is no unambiguous answer. Today, we might still ask this question, but we might extend it to ask whether the destruction or extinction of a synthetic microbe that was made by humans is also ethically questionable or is such an entity—in that it is designed—more like a machine, which we have no compunction in terminating? Would two lethal pathogens, one of them synthetic and one of them natural, but otherwise identical, command the same moral claims?In a colloquial way, we might ask whether microbes have rights. In previous papers (Cockell, 2004) I have discussed the ‘rights'' of microbes and further explored some issues about the ethics we apply to them (Cockell, 2008). Julian Davies, in a recent opinion article in EMBO reports (Davies, 2010) described my assertion that they should have constitutional rights as ‘ridiculous''. Although I did suggest that environmental law could be changed to recognize the protection of microbial ecosystems—which would imply statutory rights or protection—nowhere have I claimed that microbes should have ‘constitutional'' rights. Nevertheless, this misattribution provides a useful demonstration of the confusion that exists about exactly how we should treat microbes.Few people are in any doubt that microbes should be conserved for their direct uses to humans, for example, in food and drug production, and their indirect uses such as the crucial role they have in the health of ecosystems. Indeed, these motivations can be used to prioritize microbial conservation and protection efforts (Cockell & Jones, 2009). The crucial question is whether microbes have ‘intrinsic value'' beyond their practical uses. If the answer is ‘no'', then we should have no guilt about deliberately driving microbes to extinction for our benefit. However, there are people who feel uneasy with this conclusion, a feeling that calls forth more complex ethical questions.The question is whether microbes have some sort of ‘interests'' that make demands on our treatment of them that go beyond a mere utilitarian calculation. These arguments themselves question what we define as ‘interests'' and whether interests make demands on us. A microbe has no future plans or thought processes; the sorts of interests that are accepted as being of sufficient scope to place demands on our treatment of other human beings, for instance. However, microbes do have biological interests. A halophilic microbe might eventually die if it is dropped into freshwater. Does our knowledge of what is in the biological interests of a microbe mean that we must show it any consideration beyond practical uses? The answer is not obviously negative (Taylor, 1981), but even if we decide that it is, this does not let us off the hook quite yet.There are other intrinsic value arguments that are more obscure, particularly those around the notion of ‘respect''; the idea that we should show empathy towards the trajectory, however deterministic, of other life forms. These unquantifiable and controversial arguments might, nevertheless, partly explain any unease that we have in watching a group of people smash up and destroy some exquisite microbial mats, just because they were bored.Clearly, human instrumental needs do trump microbes at some level. If they did not, we could not use bleach in our houses, an absurd end-point raised in a 1970s science fiction story that explored the futuristic ramifications of full microbial rights, in which household bleaches and deodorants are banned (Patrouch, 1977).However, we should not be so quick to ridicule ideas about microbial ethics and rights. Although it might be true that phages kill a large percentage of the bacterial population of the world every few days, as Julian Davies points out, human society has achieved an unprecedented capacity for destruction and creation. Our ability to poison and disrupt habitats has been unquantified, with respect to the loss of microbial species. Both synthetic biology and bioterrorism raise the spectre of creating new organisms, including pathogens, which we might need to control or deliberately pursue to extinction. Dixon''s dilemma about the smallpox virus, raised more than 30 years ago, has become an urgent point of discussion in the ethics of molecular biology and microbiology.     

Applications of terminating nonhomogeneous renewal processes in family planning evaluation

A terminating nonhomogeneous renewal process is formulated and studied in relation to the development of quantitative methods in family planning evaluation. The motivation underlying the results presented here was to satisfy a need, which arose during computer studies, to complete and extend a stochastic model of human reproduction reported previously. The paper is divided into seven sections detailing the nature of changes made in previous work. Two novel developments in the paper are the formulation of the waiting time between live births in terms of an absorbing semi-Markov process and the waiting time to conception in populations utilizing several methods of contraception as an absorbing Markov chain. These formulations not only permit the accommodation of many family planning variables but also lead to greater conceptual simplification than formulations used in previous work.     

中国丹霞的世界遗产价值及其保护与管理

2010年8月1日,世界遗产委员会批准了贵州赤水、福建泰宁、湖南崀山、广东丹霞山、江西龙虎山和浙江江郎山6个国家级风景名胜区以＂中国丹霞＂系列提名的形式列入世界遗产名录;同时,在中国诞生和发展起来的丹霞地貌获得了国际认可,填补了世界遗产在地貌类型上的空白。在中国丹霞申报阶段,规划提出6省组建＂中国丹霞世界遗产保护管理委员会＂、＂中国丹霞世界遗产专家委员会＂和＂顾问委员会＂;同时,制定了遗产地突出普遍价值的保护、分级与分区保护、环境保护、旅游管理、居民参与和社区发展、宣传与展示、科学研究、遗产地监测等保护与利用方案,提出了财政与法律保障、行动计划和预算方案等。上述规划在遗产申报和申报成功之后陆续得到实施。     

Sexually transmitted diseases (STDs) in the world.

Sexually transmitted diseases (STDs) represent a major public health problem in the world and the advent and increase of human immunodeficiency virus infection during the last decade has highlighted the importance of infections spread by the sexual route. The World Health Organization estimates that the global incidence in 1995 of new cases of selected curable STDs, which are gonorrhea, chlamydial infection, syphilis and trichomoniasis, was 333 million. Control programs for STDs must prevent the acquisition of STDs, their complications and sequelae and interrupt and reduce transmission.     

Application of Ethical Principles to Research using Public Health Data in The Global South: Perspectives from Africa

Existing ethics guidelines, influential literature and policies on ethical research generally focus on real‐time data collection from humans. They enforce individual rights and liberties, thereby lowering need for aggregate protections. Although dependable, emerging public health research paradigms like research using public health data (RUPD) raise new challenges to their application. Unlike traditional research, RUPD is population‐based, aligned to public health activities, and often reliant on pre‐collected longitudinal data. These characteristics, when considered in relation to the generally lower protective ethico‐legal frameworks of the Global South, including Africa, highlight ethical gaps. Health and demographic surveillance systems are examples of public health programs that accommodate RUPD in these contexts. We set out to explore the perspectives of professionals with a working knowledge of these systems to determine practical ways of appropriating the foundational principles of health research to advance the ever growing opportunities in RUPD. We present their perspectives and in relation to the literature and our ethical analysis, make context relevant recommendations. We further argue for the development of a framework founded on the discussions and recommendations as a minimum base for achieving optimal ethics for optimal RUPD in the Global South.     

Integrated pest management of dipteran pests in the New World

Although the screwworm eradication program, so successful at ridding much of North America from this pest, was not called an IPM program as such when first initiated, it nevertheless met the current definition of such a program. Considering the enormous success and the unbelievable numbers of insects reared for sterile release, this eradication program is one of the most outstanding entomological feats in history.Similar programs for other livestock pests are not yet assured of the same success. Hypoderma eradication may become a definite reality provided in vitro rearing methods can be developed to provide large numbers of sterile males. This development would not only indicate another possible international control effort but could also provide impetus for a Dermatobia hominis control program in the subtropics of Mexico, Central America and South America.The cost/benefit analysis of a number of the major pests needs to be completed to determine if their control is beneficial to the health of the host or provides a profitable return on the producer's investment. Greater knowledge of the pest biology-ecology, including dispersion, migration, rate of population increases, and behaviour is needed. Pest population models used to simulate the effect of weather, host density and pest density on outbreak situations need to be developed. Insecticide resistance in insect populations now needs to be considered in these models. Even sampling procedures are inadequate for most pests.Also, alternative methods to insecticide control are needed for many of the dipterous pests. Some pests cannot be controlled with current delivery systems. For instance, flies of the family Tabanidae cannot be controlled because of lack of information on their biology-ecology; also, methods of chemical application to effect their control are not available.Much effort has been made to control the dipterous and myiasis-causing pests in the new world. For the most part, chemicals have been effective, and until recently, resistance has not been a problem. Although control has been satisfactory for most pests, the implementation of IPM programs against some pests could make control more permanent and cost effective. Many parts of an IPM program are available for use but need to be put together in a control system and validated. Only after a system has been shown to be cost effective can the technology be transferred to the producer. A few pests of the New World can be controlled within the concept of IPM, but by and large, operational programs remain something to be achieved.