Mangano DT, Layug EI, Wallace A, Tateo I. Multicenter study of Perioperative Ischemia Research Group: effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713–20.
Investing in children Sir—In your Nov 1 Editorial (p 1427),1 you call for firm plans and commitments aimed specifically at children in national and international settings. “The future for our children” is the theme of the Fourth Ministerial Conference on Environment and Health, to be held in Budapest, Hungary, in June, 2004, by the WHO Regional Office for Europe.2 Out of this Conference will come a Children’s Environment and Health Action Plan for Europe. Ministers of both health and the environment will commit themselves to producing their own national plans and to a number of agreed regional priorities. This action is driven by a determination to tackle some of the familiar and obvious problems in the WHO European Region, for which there is enough evidence that associated interventions and publichealth strategies are effective. Children’s health is suffering from exposure to entirely avoidable risks. Children experience respiratory damage from pollution outdoors, much of it from traffic, and pollution indoors from tobacco smoke. In the European Union, an average of one in ten children has asthma. In our Region overall, allergic disease is the most common chronic illness of childhood, and in some areas is estimated to affect more than one child in four. Some childhood cancers show an upward trend, along with some neurological disorders, and more than 30 000 synthetic chemicals are on the market, most of them not tested for their effect on human health. Injuries are the single most important cause of death in children in most of the Region, and lack of exercise and junk food are causing a new epidemic of obesity. Children living in poverty are at the greatest risk: from contaminated water and air, malnutrition, unhealthy housing, and in some parts of Europe, child labour. About a third of the global burden of disease from birth to 18 years can be attributed to unsafe and unhealthy environments. In the Commonwealth of Independent States, children are six times more likely than children in the European Union to die before their 5th birthday; thousands of children die from diarrhoea. In one
Member State, 77% of schools and 44% of kindergartens have no sewage system. In addition to these traditional hazards, new concerns are arising owing to the wide use of new technologies and changing lifestyles. We have to find ways to protect children from damage that might not be fully scientifically clarified beyond reasonable doubt for many years, but that can be addressed with a precautionary approach. Children should be entitled to a life at least as healthy as ours, and in most of our Member States, a better one. This is why ministers of health and the environment will meet in Budapest next year. *Roberto Bertollini, Viv Taylor Gee *Division of Technical Support, Health Determinants (RB), and Environment and Health Coordination and Partnership (VTG), WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark (e-mail: [email protected]
) 1 2
The Lancet. Investing in children for a better future. Lancet 2003; 362: 1427. World Health Organization Regional Office for Europe. Fourth Ministerial Conference on Environment and Health: Budapest, Hungary, 23–25 June 2004. http://www. euro.who.int/budapest2004 (accessed Nov 24, 2003).
Effect of US policies on women’s health worldwide Sir—In your Nov 8 Editorial1 addressing the US abortion divide, you call on US policymakers to stop waging “war over abortion” and instead “provide comprehensive contraceptive services to the poor”, asserting that “it would do more to reduce abortion than passing bans”. The same suggestion holds for the White House itself, which 3 years ago reimposed the “global gag rule” banning abortion counselling and referral in US-subsidised nongovernmental family planning clinics around the world. But, in the developing world, unlike in the USA, such bans do more than restrict access to abortion services. Indeed, a new report, Access Denied: U.S. Restrictions on International Family Planning (http://www.globalgagrule.org, accessed Dec 22, 2003) shows that the global gag rule jeopardises the health of women and their families by impeding access to a wide array of life-affecting reproductive health services. Aimed at abortion, the gag rule eliminates access to family planning, AIDS-related services, and maternal care. The report, prepared by a coalition of organisations called the Global Gag
Rule Impact Project, was the result of research in Ethiopia, Kenya, Romania, and Zambia from July, 2002, to May, 2003. Research teams visited health facilities and interviewed health providers, policymakers, programme managers, and donors. The resulting case studies document that the gag rule reduces access to health services and contraception in each of the four countries investigated. In Kenya, for example, where 24% of married women lack access to family planning and 15% of all adults are infected with HIV/AIDS, the gag rule has had devastating effects. Kenya’s two most prominent family planning nongovernmental organisations (NGOs) closed five of their well established clinics, eliminating access to family planning, prenatal and postnatal obstetric care, well-baby care, cervical cancer screening, immunisations, and HIV/AIDS prevention services, including counselling and testing. Four of these clinics served nearly 24 000 clients each year and another was the only source of health care for a community of 300 000 people. In Ethiopia, where there are 1800 maternal deaths per 100 000 deliveries and just 8% of women use contraceptives, two NGOs have lost access to US-donated contraceptives, including male and female condoms. At the same time, evidence is replete, worldwide, that greater access to contraceptives reduces reliance on abortion. An analysis of 11 countries2 shows that increased contraceptive use and effectiveness leads to reduced abortion rates when other factors— such as fertility—are held constant. In an analysis of trends in Kazakhstan, for example, abortion decreased by 50% as contraceptive prevalence increased the same amount during the 1990s.3 In Turkey, where the abortion rate declined from a peak of 45 abortions per 1000 married women in 1988 to 25 per 1000 in 1998, an increased use of modern methods of contraception accounted for 87% of the decline in abortion.4 A study in Bangladesh found that lower abortion rates resulted from access to higherquality family planning services.5 These findings underscore how misplaced and heavy-handed such bans are, especially in the context of the realities of medical care in the poorest regions of the world. While US policymakers wage an ideological war in the ether, the restrictions imposed on international family planning erode the services that can prevent abortion on the ground.
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