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Pakistan: Safe motherhood
903
university administrators, grappling with deficits, generally regard the rates as unrealistically low.
a statute law forbidding vasectomy, although one doctor in Brisbane has done well over 16 000 male sterilisations. In March this year, the Labour party drafted legislation to remove any reference to abortion and sterilisation from the Criminal Code. State Premier Wayne Goss has ruled that MPs will be able to vote according to their conscience. The outcome will be watched with interest, and not only in
lab bench;
having
In any case, the indirect rates, computed as a percentage of direct research costs, are often startlingly high: Harvard Medical School, 77%; New York University Medical Center, 63 5%; and Mount Sinai School of Medicine (NY), 62 5%. On the books, it’s all for research, but whatever the nomenclature, NIH is a major subsidiser of a medicaleducation system that the Federal Government deems
Queensland.
overly productive. While medicine continues to attract a steady supply of young recruits, woeful lamentations are to be heard from those in the profession. In a survey conducted last year for the American Medical Association, 1004 physicians were asked, "If you knew then what you know now, would you go to medical school?". 14% responded "definitely not" and 25% "probably not". Only 24% said they would "definitely go", and 36% said they would "probably go". Among the regretful, 27% cited as the reason "Government/thirdparty payer regulations interfere with doing my job; lack of autonomy", and 12 % chose "Rewards are not great for effort/time/risks/overhead". 72% said the public today has less respect for physicians than it did ten years ago. In a companion poll of 1500 laymen, 67 % agreed with the statement "Doctors are too interested in making money", and 57% agreed with "Doctors don’t care about people as much as they used to". 42% thought that medicine today was a worse career than it was ten years ago. Given these sentiments on both sides of the doctorpatient relationship, along with the loss of direct federal assistance for students, it may be that the medical wonder of our time is that outstanding young people continue to flock to the profession.
Daniel S.
Greenberg
Round the World Australia: Abortion legislation The debate over abortion in Australia, like the popular television soap opera Neighbours, is immediately understandable in Britain, although there are some interesting differences in style and detail. Abortion legislation in Australia has always been made at the level of the State parliaments and, with the exception of South Australia, the States are where Britain was before the 1967 Abortion Act. Restrictive laws derived from the 19th century Offences against the Person Act remain in force but are interpreted in the light of more liberal case-precedents. Where Britain had the McNaughten ruling on the 1938 Bourne trial, New South Wales has the Levine (1971) and Victoria the Menhennitt (1969) precedents. In 1970, the then Labour Government of South Australia adopted a reform law with many similarities to the British law. Since then doctors in other states, relying on the case-precedents, have carried out many abortions, and the federally funded Medicare system has been reimbursing termination of pregnancy throughout the country. In Queensland, which had 35 years of very conservative government under Bjelke Peterson, the debate over abortion has been particularly intense. In 1985, Dr Peter Bayliss of Brisbane was arraigned and subsequently acquitted of breaking the law. In addition, Queensland is unusual in
A
correspondent
Pakistan: Safe motherhood The chance of a woman dying from childbirth, pregnancy, or abortion during the course of her fertile years is over 60 times higher in the Indian subcontinent than in the west. Although only a quarter of the world’s births occur in Pakistan, India, Bangladesh, and Nepal, this area accounts for almost half of all maternal deaths world wide. In an effort to highlight this appalling statistic, the International Planned Parenthood Federation, with the cooperation of the Government of Pakistan, sponsored a Safe Motherhood South Asia Conference in Lahore last month. Death in childbirth was recognised as the outcome of a lifelong chain of adverse events that in many cases can be traced back to discrimination against females from the very moment of their delivery. Consequently maternal deaths tend to be concentrated among the poorest women in the most remote parts of the region. In the long run, maternal mortality will only approach western levels as women enjoy more education, better nutrition, and improved social status. In the short term, however, much could be achieved by some simple and more readily attainable measures. Anovulation associated with long intervals of breast feeding remains the single most important factor in spacing pregnancies in rural areas of South Asia and must be preserved. Education of health professionals and vigorous prosecution of the World Health Organisation code on milk substitutes are essential. Contraceptive practice saves maternal lives because it reduces the number of unintended pregnancies and of dangerous abortions (which account for a third or more of all maternal deaths) and is preferentially adopted by older high-parity women, who are most at risk of death. For example, in Bangladesh, where desired family size has fallen as low as 29, improved access to contraceptive pills, injectable preparations, intrauterine contraceptive devices, voluntary sterilisation, and condoms would more than halve the current maternal mortality rate (estimated at 560 per 100 000 live births). The conference underscored the need for more investment in family planning, noting that possible shortages of funds to buy contraceptives for very poor people threaten to undermine all efforts to improve health and family planning. Moreover, family planning indirectly improves educational opportunities and also gives women essential autonomy. Unfortunately, unlike interventions to reduce infant deaths, high-level skills and facilities are needed to treat obstetric complications. Traditional midwives can be trained to refer high-risk pregnancies, but such a strategy only works when the formal health system provides a place where women with complications can be referred.
904
Nevertheless, Dr Altaf Bashir, from Faisalabad, Pakistan,
inspired the conference with her record of reducing maternal mortality from 10 per 1000 to 09 per 1000 through 14 years of careful attention to the complex of factors that affect mortality. She adopted every tack from hospital conferences on maternal deaths to health messages in the local cinemas. The Safe Motherhood conference emphasised that women provide much of the basic capital available to any country for development, sometimes providing over half the economic output of a subsistence economy. Governments and international agencies were asked to provide the resources needed to turn childbirth from one of the most dangerous occupations in South Asia into a time of joy and security. Dr Mahmoud Fathalla, Director of the WHO Human Reproduction Programme, characterised the look that comes into the eyes of a woman dying in delivery as "difficult to describe but impossible to forget". Malcolm Potts
adjustment disorder, and post-traumatic stress disorder. A large proportion of women from both seriously and mildly affected
areas
still have menstrual disturbances.
Sathyamala et al claim that the scoring system used for assessing personal injury is based on inadequate information, is arbitrary, and works against the interests of the gas victims. Moreover, a claimant is designated gas exposed only if he or she produces medical documents for the post-exposure period. Sathyamala et al say that this overlooks the fact that hospitals and emergency camps were initially overwhelmed and failed to hand out documents to all the victims who attended. The scoring system weighs the effects on different body systems, with the respiratory system leading the hierarchy. This works against claimants who have serious disorders in other systems. To be categorised as suffering "permanent injury", claimants have to have a higher injury/disability score currently than in the immediate post-exposure period. Sathyamala et al also point out that the information contained on the personal injury evaluation forms does not
adequately assess disability. According to Sathyamala et al, these and other flaws mean that the assessment as carried out by the Madhya Pradesh
India: Health of the Five years after the
Bhopal survivors
explosion at the Union Carbide Bhopal exposed hundreds of
in
Corporation’s plant people to a mixture of toxic gases, an independent study coordinated by three Indian health workers has suggested that the authorities have grossly underestimated the scale of the disaster.l According to the study a faulty assessment system adopted by the Madhya Pradesh Government means that the injuries of more than 90% of the victims have been "defmed away". Only a small proportion of the disaster’s victims are likely to be compensated. The Indian Supreme Court used figures provided by the Directorate of Claims for Bhopal when it settled the case of thousands of
the Union of India
versus UCC for$470 million in last A clarification order of the Supreme February year. Court in May, 1989, said that calculations for compensation were based on 3000 deaths, 30 000 cases of permanent total or partial disability, 20 000 of temporary total or partial disability, and 50 000 of minor injuries. In August, 1989, the Madhya Pradesh Government filed an affidavit in the Supreme Court stating that out of a total of 204 000 cases evaluated, just over half had been categorised. Out of these only 19 were in the category of permanent total disablement and 762 were in the category of permanent partial disablement. Sathyamala et all say that if these figures are extrapolated only 4000 of the 600 000 claimants are likely to be categorised as having permanent partial or total disability. The new study carried out by Sathyamala and colleagues shows that 80% of the population in the seriously affected areas of Bhopal continue to have gas-related disorders. The study was based on a follow-up of 572 individuals examined soon after the gas leak and a separate sample of 680 women. By attempting to diagnose gas-related diseases, it presents a much clearer picture of the damage than that so far presented by the Government. For instance, it shows that half of those reporting breathlessness due to respiratory illness have allergic alveolitis or chronic obstructive lung disease. It also identifies previously unrecognised morbidity. The disaster has had a serious, widespread effect on the mental health of victims, resulting in depression,
Government should not form the basis for interim relief or final damages. In the absence of a just and scientific method for assessing injuries interim relief, they say, should be distributed on the basis of proof of residence in one of the gas-affected localities. 1.
Odds: Continuing Effects of the Toxic Gases on the Health Status of the Surviving Population in Bhopal. By C. Sathyamala, N. Vohra, and K. Satish. Copies available (Rs 15 per copy plus postage) from C.E.C. F-20 (GF) Jangpura Extn, New Delhi-110014, India.
Against All
A
Human
correspondent
Rights
Amputations in Saudi Arabia Amnesty International reports that four Filipino nationals had their right hands amputated on March 2 in Al-Khubar, in the Eastern Province of Saudi Arabia, after they had been convicted of theft from a number of companies. Islamic law (Shari’a), as practised in Saudi Arabia, imposes amputation of the right hand as the punishment for repeated theft where there are no mitigating circumstances. The amputations were announced by the Ministry of the Interior after the sentences had been upheld on appeal and finally ratified by royal decree. The United Nations Universal Declaration of Human the UN Torture Convention, the International Covenant of Civil and Political Rights, and other international human-rights organisations condemn amputation as a cruel, inhumane, and degrading punishment. In Saudi Arabia most amputations are carried out in public, and an ambulance is generally present to transfer the amputee to hospital for aftercare. Amnesty International does not have details of the role of doctors in training those who carry out the amputations but believes that some medical instruction may be given. Any use of medical skill by physicians to assist in the infliction of amputation as a punishment clearly runs contrary to international codes of medical ethics.
Rights,
university administrators, grappling with deficits, generally regard the rates as unrealistically low.
a statute law forbidding vasectomy, although one doctor in Brisbane has done well over 16 000 male sterilisations. In March this year, the Labour party drafted legislation to remove any reference to abortion and sterilisation from the Criminal Code. State Premier Wayne Goss has ruled that MPs will be able to vote according to their conscience. The outcome will be watched with interest, and not only in
lab bench;
having
In any case, the indirect rates, computed as a percentage of direct research costs, are often startlingly high: Harvard Medical School, 77%; New York University Medical Center, 63 5%; and Mount Sinai School of Medicine (NY), 62 5%. On the books, it’s all for research, but whatever the nomenclature, NIH is a major subsidiser of a medicaleducation system that the Federal Government deems
Queensland.
overly productive. While medicine continues to attract a steady supply of young recruits, woeful lamentations are to be heard from those in the profession. In a survey conducted last year for the American Medical Association, 1004 physicians were asked, "If you knew then what you know now, would you go to medical school?". 14% responded "definitely not" and 25% "probably not". Only 24% said they would "definitely go", and 36% said they would "probably go". Among the regretful, 27% cited as the reason "Government/thirdparty payer regulations interfere with doing my job; lack of autonomy", and 12 % chose "Rewards are not great for effort/time/risks/overhead". 72% said the public today has less respect for physicians than it did ten years ago. In a companion poll of 1500 laymen, 67 % agreed with the statement "Doctors are too interested in making money", and 57% agreed with "Doctors don’t care about people as much as they used to". 42% thought that medicine today was a worse career than it was ten years ago. Given these sentiments on both sides of the doctorpatient relationship, along with the loss of direct federal assistance for students, it may be that the medical wonder of our time is that outstanding young people continue to flock to the profession.
Daniel S.
Greenberg
Round the World Australia: Abortion legislation The debate over abortion in Australia, like the popular television soap opera Neighbours, is immediately understandable in Britain, although there are some interesting differences in style and detail. Abortion legislation in Australia has always been made at the level of the State parliaments and, with the exception of South Australia, the States are where Britain was before the 1967 Abortion Act. Restrictive laws derived from the 19th century Offences against the Person Act remain in force but are interpreted in the light of more liberal case-precedents. Where Britain had the McNaughten ruling on the 1938 Bourne trial, New South Wales has the Levine (1971) and Victoria the Menhennitt (1969) precedents. In 1970, the then Labour Government of South Australia adopted a reform law with many similarities to the British law. Since then doctors in other states, relying on the case-precedents, have carried out many abortions, and the federally funded Medicare system has been reimbursing termination of pregnancy throughout the country. In Queensland, which had 35 years of very conservative government under Bjelke Peterson, the debate over abortion has been particularly intense. In 1985, Dr Peter Bayliss of Brisbane was arraigned and subsequently acquitted of breaking the law. In addition, Queensland is unusual in
A
correspondent
Pakistan: Safe motherhood The chance of a woman dying from childbirth, pregnancy, or abortion during the course of her fertile years is over 60 times higher in the Indian subcontinent than in the west. Although only a quarter of the world’s births occur in Pakistan, India, Bangladesh, and Nepal, this area accounts for almost half of all maternal deaths world wide. In an effort to highlight this appalling statistic, the International Planned Parenthood Federation, with the cooperation of the Government of Pakistan, sponsored a Safe Motherhood South Asia Conference in Lahore last month. Death in childbirth was recognised as the outcome of a lifelong chain of adverse events that in many cases can be traced back to discrimination against females from the very moment of their delivery. Consequently maternal deaths tend to be concentrated among the poorest women in the most remote parts of the region. In the long run, maternal mortality will only approach western levels as women enjoy more education, better nutrition, and improved social status. In the short term, however, much could be achieved by some simple and more readily attainable measures. Anovulation associated with long intervals of breast feeding remains the single most important factor in spacing pregnancies in rural areas of South Asia and must be preserved. Education of health professionals and vigorous prosecution of the World Health Organisation code on milk substitutes are essential. Contraceptive practice saves maternal lives because it reduces the number of unintended pregnancies and of dangerous abortions (which account for a third or more of all maternal deaths) and is preferentially adopted by older high-parity women, who are most at risk of death. For example, in Bangladesh, where desired family size has fallen as low as 29, improved access to contraceptive pills, injectable preparations, intrauterine contraceptive devices, voluntary sterilisation, and condoms would more than halve the current maternal mortality rate (estimated at 560 per 100 000 live births). The conference underscored the need for more investment in family planning, noting that possible shortages of funds to buy contraceptives for very poor people threaten to undermine all efforts to improve health and family planning. Moreover, family planning indirectly improves educational opportunities and also gives women essential autonomy. Unfortunately, unlike interventions to reduce infant deaths, high-level skills and facilities are needed to treat obstetric complications. Traditional midwives can be trained to refer high-risk pregnancies, but such a strategy only works when the formal health system provides a place where women with complications can be referred.
904
Nevertheless, Dr Altaf Bashir, from Faisalabad, Pakistan,
inspired the conference with her record of reducing maternal mortality from 10 per 1000 to 09 per 1000 through 14 years of careful attention to the complex of factors that affect mortality. She adopted every tack from hospital conferences on maternal deaths to health messages in the local cinemas. The Safe Motherhood conference emphasised that women provide much of the basic capital available to any country for development, sometimes providing over half the economic output of a subsistence economy. Governments and international agencies were asked to provide the resources needed to turn childbirth from one of the most dangerous occupations in South Asia into a time of joy and security. Dr Mahmoud Fathalla, Director of the WHO Human Reproduction Programme, characterised the look that comes into the eyes of a woman dying in delivery as "difficult to describe but impossible to forget". Malcolm Potts
adjustment disorder, and post-traumatic stress disorder. A large proportion of women from both seriously and mildly affected
areas
still have menstrual disturbances.
Sathyamala et al claim that the scoring system used for assessing personal injury is based on inadequate information, is arbitrary, and works against the interests of the gas victims. Moreover, a claimant is designated gas exposed only if he or she produces medical documents for the post-exposure period. Sathyamala et al say that this overlooks the fact that hospitals and emergency camps were initially overwhelmed and failed to hand out documents to all the victims who attended. The scoring system weighs the effects on different body systems, with the respiratory system leading the hierarchy. This works against claimants who have serious disorders in other systems. To be categorised as suffering "permanent injury", claimants have to have a higher injury/disability score currently than in the immediate post-exposure period. Sathyamala et al also point out that the information contained on the personal injury evaluation forms does not
adequately assess disability. According to Sathyamala et al, these and other flaws mean that the assessment as carried out by the Madhya Pradesh
India: Health of the Five years after the
Bhopal survivors
explosion at the Union Carbide Bhopal exposed hundreds of
in
Corporation’s plant people to a mixture of toxic gases, an independent study coordinated by three Indian health workers has suggested that the authorities have grossly underestimated the scale of the disaster.l According to the study a faulty assessment system adopted by the Madhya Pradesh Government means that the injuries of more than 90% of the victims have been "defmed away". Only a small proportion of the disaster’s victims are likely to be compensated. The Indian Supreme Court used figures provided by the Directorate of Claims for Bhopal when it settled the case of thousands of
the Union of India
versus UCC for$470 million in last A clarification order of the Supreme February year. Court in May, 1989, said that calculations for compensation were based on 3000 deaths, 30 000 cases of permanent total or partial disability, 20 000 of temporary total or partial disability, and 50 000 of minor injuries. In August, 1989, the Madhya Pradesh Government filed an affidavit in the Supreme Court stating that out of a total of 204 000 cases evaluated, just over half had been categorised. Out of these only 19 were in the category of permanent total disablement and 762 were in the category of permanent partial disablement. Sathyamala et all say that if these figures are extrapolated only 4000 of the 600 000 claimants are likely to be categorised as having permanent partial or total disability. The new study carried out by Sathyamala and colleagues shows that 80% of the population in the seriously affected areas of Bhopal continue to have gas-related disorders. The study was based on a follow-up of 572 individuals examined soon after the gas leak and a separate sample of 680 women. By attempting to diagnose gas-related diseases, it presents a much clearer picture of the damage than that so far presented by the Government. For instance, it shows that half of those reporting breathlessness due to respiratory illness have allergic alveolitis or chronic obstructive lung disease. It also identifies previously unrecognised morbidity. The disaster has had a serious, widespread effect on the mental health of victims, resulting in depression,
Government should not form the basis for interim relief or final damages. In the absence of a just and scientific method for assessing injuries interim relief, they say, should be distributed on the basis of proof of residence in one of the gas-affected localities. 1.
Odds: Continuing Effects of the Toxic Gases on the Health Status of the Surviving Population in Bhopal. By C. Sathyamala, N. Vohra, and K. Satish. Copies available (Rs 15 per copy plus postage) from C.E.C. F-20 (GF) Jangpura Extn, New Delhi-110014, India.
Against All
A
Human
correspondent
Rights
Amputations in Saudi Arabia Amnesty International reports that four Filipino nationals had their right hands amputated on March 2 in Al-Khubar, in the Eastern Province of Saudi Arabia, after they had been convicted of theft from a number of companies. Islamic law (Shari’a), as practised in Saudi Arabia, imposes amputation of the right hand as the punishment for repeated theft where there are no mitigating circumstances. The amputations were announced by the Ministry of the Interior after the sentences had been upheld on appeal and finally ratified by royal decree. The United Nations Universal Declaration of Human the UN Torture Convention, the International Covenant of Civil and Political Rights, and other international human-rights organisations condemn amputation as a cruel, inhumane, and degrading punishment. In Saudi Arabia most amputations are carried out in public, and an ambulance is generally present to transfer the amputee to hospital for aftercare. Amnesty International does not have details of the role of doctors in training those who carry out the amputations but believes that some medical instruction may be given. Any use of medical skill by physicians to assist in the infliction of amputation as a punishment clearly runs contrary to international codes of medical ethics.
Rights,