A Better Health Agenda for the Americas

Alexander Sanger

The new "Health Agenda for the Americas" is more significant for what it omits: sexuality education, safe abortion access, emergency contraception, and measures to combat domestic violence, than for what it addresses.

In June 2007 the Ministers of Health of all Latin American nations
issued a Health Agenda for the Americas: 2008-2015, (the "Agenda") a
supposedly comprehensive plan for improving the health of the people of
the Americas that was anything but comprehensive. It managed to leave
out many proven recommendations for improving the sexual and
reproductive health of the citizens of Latin America.

Infant and Maternal Mortality

If
the moral soundness of a society is measured by how it treats its
children, then Latin America, while better than Africa, does not
measure up. Infant mortality in Latin America is stubbornly high — averaging 23 per 1000 live births (versus 7 in the U.S.) — though an improvement
from 81 per 1,000 live births in the years 1970-1975. Maternal
mortality is far too high, with Bolivia and Peru leading at rates of
420 and 410 per 100,000 births respectively, as opposed to 17 in the
U.S. Uruguay has the low at 27. The major causes of high infant and
maternal mortality are well known: poverty, lack of skilled birth
attendants and deficiencies in emergency medical care. There are
underlying causes as well that lead to these medical emergencies, and
they all fall under the rubric of sexual and reproductive health.
Health experts, and mothers, know that contraception which enables
intended pregnancy can improve outcomes by 1) delaying first birth
until a woman has fully matured, 2) birth spacing, permitting a mother
to regain her health and to fully nurture the child she has before
giving birth to the next, and 3) reduction in absolute number of
births, allowing the mother to give more care to the children she has.
The Agenda, to its credit, called access to contraceptives
"indispensable," and called for continuous care to mothers before,
during and after pregnancy, for increased efforts to prevent
transmission of STI’s and for stronger men’s roles in all these.

While a good start, this is insufficient.

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Contraceptive and Fertility Rates

The
issue in Latin America is not contraceptive use; it is getting the
contraceptives to those at risk for unintended pregnancy. Contraceptive
prevalence in Latin America is the highest in the developing world, on
average, with 75 percent of women in South America and 66 percent in
Central America having access to a method (the corresponding figure in
Africa is 27 percent and in the U.S. 73 percent). These rates are far
less in rural and poorer areas, and thus the rate of unintended
pregnancy there is higher. Increase in contraceptive prevalence (the
rate was 60 percent for Latin America and the Caribbean in 1998) though
has not translated into birth rate or abortion rate declines. The
reason is a combination of lack of contraceptive access in vulnerable
populations, along with higher intended childbearing desires. In some
Latin countries overall birth rates, including teen birth rates,
increased during the 1990’s, while in the rest of the world they
declined. On average, 20 percent of teens give birth in Latin America.
The fertility rate for ages 15-19 is currently 78 in South America. In
1996, the South American rate was 75, indicating a 4 percent rise since
then. A comparison with the U.S. is instructive. The fertility rate for
Hispanic teens in the U.S. is about 82 for 2005, or slightly higher
than the overall fertility rate for teens in Latin America (about 76).
The U.S. figure disguises ethnic variations among immigrant
populations, with the fertility rate for teens of Mexican origin in the
U.S. being 93. However, interestingly, the teen fertility rate in
Mexico is 63, about a third less than for Mexican teens in the U.S.
Hispanic teens in the U.S. in general have a higher fertility rate than
Hispanic teens in their country of origin. The reasons could include
lack of access in the U.S. to contraception or more teen sexual
activity. Also Hispanic culture meeting with more prosperity in the
U.S. (as well as in those Latin countries that have prospered) could
have led to increased teen birth rates. There are no figures, though,
that I have seen as to the intentionality of these teen pregnancies.
Though adolescents especially were recognized in the Agenda as needing
special attention, there was, however, no specific call for renewed
sexuality education efforts and increased availability of
contraceptives for adolescents. This is not dissimilar to the silence
in official circles in the U.S. Government around teen sexual activity,
except for calls for abstinence education.

One sure way to
decrease unintended pregnancy for teens and adults alike is emergency
contraception. In many Latin countries there are battles over the
legality of emergency contraception, which is characterized,
mistakenly, as an abortifacient. In Chile and Ecuador, cases
challenging distribution of emergency contraception recently went up to
their respective Supreme Courts where, alas, EC opponents prevailed.
The Agenda makes no mention of emergency contraception.

Abortion

An
abortion rate about 50 percent higher than the North American level
predominates throughout Latin America, along with attendant maternal
mortality and morbidity. This would indicate pregnancy rates are higher
than the desired childbearing rates. Still, women in Latin America have about one more child than they say they want.

Abortion is proscribed virtually everywhere in Latin America, except
Cuba, Guyana and Mexico City. Four of the five countries of the world
which prohibit abortion in all cases, even to save the mother’s life,
are in Latin America: Honduras, Chile, Nicaragua and El Salvador. There
are about 4 million illegal abortions a year, 95 percent of which are
unsafe. About 5,000 women die a year, resulting in 20 percent of all maternal deaths being from unsafe abortion.

There
has been progress during the last year in decriminalization. Colombia’s
Constitutional Court decriminalized abortion in three cases: rape, for
the life or health of the woman and for fetal deformity. The Mexico
City legislature also decriminalized abortion, by a vote of 46 votes in
favor and 19 against, despite a threat of excommunication.

The Agenda made no mention of de-criminalizing abortion or providing post-abortion care.

STD’s and HIV/AIDS

While
HIV/AIDS levels are below those of sub-Saharan Africa, HIV is still at
serious levels. The prevalence rate is at or below 1 percent in every
South American country, similar to most Asian countries, compared to
rates of 25 percent in southern Africa. Condom use
in Latin America is low — just 4 percent of women in Brazil and Mexico
report using condoms, compared with 13 percent in the U.S. according to
PAHO (other sources show a higher rate of condom use of 18 percent in
the U.S.).

Approximately one-third of Latin women have never
had a Pap smear. In the U.S. about 84 percent of women had a Pap smear
within the last three years (including 81 percent of Hispanics),
indicating that Hispanic women are not disproportionately marginalized
from the U.S. health care system. The Agenda made no specific
recommendations for increasing condom use and the availability of Pap
smears.

Violence Against Women

Violence
against women is apparently more prevalent in Latin America than in the
United States, though comparable and accurate statistics are hard to
come by. In the U.S. there has been a steady decline in what the U.S.
Department of Justice calls "intimate partner non-fatal victimization"
(a gender neutral term) which had declined from 6 per 1000 persons to
about 2 per 1000 from 1993 to 2005. The rate of violence
against both Hispanic and non-Hispanic females in the U.S. declined as
well and averaged about 4.2 per 1000 annually during the period 2001-5.

In
Latin America, the few surveys that have been done show, for example,
that over 40 percent of women ages 15 to 49, who have ever been in a
union in Peru (42 percent) and Colombia (44 percent), have been victims
of partner violence. This is a cumulative figure, but it would appear
that violence against women is higher in Latin America than among
Hispanics in the U.S. DHS surveys in Latin America reveal that, for
instance, in Nicaragua 11.9 percent of women experienced domestic violence in the year preceding the survey.

There was not a single mention of violence against women or domestic violence in Health Agenda for the Americas: 2008-2015.

The Americas’ Health Ministers’ Recommendations … and Omissions

So,
the Latin American Health Ministers made a less than sterling start in
addressing the sexual and reproductive health needs on their citizens,
leaving out sexuality education, teen access, condoms, safe abortion,
emergency contraception and measures to combat domestic violence.

Not
unexpectedly, they did call for increased spending on health. The
region spends 6.8 percent of its GDP on health care, or about $500 per
person (the U.S. figures are 16 percent and $7,600, respectively).

How
to pay for increased sexual and reproductive health care? First,
decriminalizing abortion will save health care dollars. So will
providing preventive health care, including family planning, emergency
contraception and condoms. Passing and enforcing domestic violence laws
too will reduce health care expenditures.

If funds are needed,
countries might consider increasing tax revenues. Latin American taxes
average 18 percent of GDP (in the U.S. it is about 25 percent and about
36 percent in Western Europe.

Finally,
the U.S. and other donor nations could also increase their ODA to the
agreed-upon level of 0.7 percent of GDP. The U.S. ODA in 2006 was at
0.17 percent. Only three Scandinavian nations, the Netherlands and Luxembourg exceeded 0.7 percent. Having healthy neighbors is in our national interest.

This article was first posted at Alternet.

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.