Women's Health Action Trust
Women's
Health Watch
Women's Health Watch
edited by Jo Fitzpatrick/Kristen Berger
Selected articles from Women's Health Watch newsletter in June 2006
- Prescription Pills
- What Women’s Health Action has done
- Courageous Women
- Stem cell research is a women’s issue
- Politics & positivist science
- Welcome to Kristen Berger
- Storm in a D cup
- Gender equity & health sector reforms
- Unethical trials in the third world
- Depressed about abortion
- Watch this Space
- Ready to serve you? The Lynx effect
- Cheering for pharmaceuticals
- DIY Healthcare
- The Hype over Herceptin
- Legal &
Ethical Watch
- Sperm Shortage
- More Vioxx dramas
- Drug trials gone wrong
- Ethical dilemmas over frozen embryos
- Fake study on oral cancer
- Pharmaceutical funding for patient advocacy groups
- Medical Journal
Watch
- Calcium supplements & hip fractures
- Better meal times later on for breastfed children
- HRT & lung cancer survival
- Gender differences in lung cancer
- Abnormal smear results and anxiety
- Are working mothers healthier?
- Maori youth and contraception
- Hot items
Prescription medicines
are a hot topic. The impetus for the debate is the proposed trans Tasman
Agency to regulate therapeutic products which has been under discussion
and development since 2001. As the Agency comes closer to reality, the
debate is heating up. Jo Fitzpatrick reports on topical aspects of recent
debates drawing on the Inaugural Diseasemongering Conference in Australia;
the Ministry of Health consultation on direct to consumer drug advertising,
an NGO Advertising symposium and the recent New Zealand Future Medicines
Policy Summit.
agency project is charged with looking at the establishment of a joint
agency to regulate therapeutic products (medicines, medical devices
and complementary medicines/dietary supplements that have therapeutic
uses) in New Zealand and Australia.
Discussions have been ongoing with a view to ‘harmonisation’
which would put a regulatory framework in place for these products to
serve both countries. The joint agency would replace the TGA in Australia
and Medsafe in New Zealand. Tentatively named ANZTPA (Australia New
Zealand Therapeutics products Agency), the Agency was due to come into
operation in July this year but delays are probable. A new round of
Stakeholder meetings has only just begun, meetings are scheduled throughout
June and submissions don’t close until August. For details of
the meetings and copies of the Consultation papers, see http://www.tgamedsafe.org/consult/meetings0606.htm
What are the areas to watch?
The process hasn’t been straightforward. The ‘hotpoints’
to date have been in two principal areas – complementary products
and direct to consumer advertising (DTC) of prescription medicines.
There are major differences in the two countries in these areas. Australia
has standards for complementary products while, except for products
used in the eyes, New Zealand does not specifically mandate standards.
The New Zealand complementary medicines industry has argued that a regulatory
framework similar to that required for pharmaceuticals would cripple
the lively local industry. New Zealand allows DTC advertising; Australia
bans it but does allow ‘disease state advertising’ (DSA).
At its worst, DSA is essentially DTC without mention of the specific
drug name.
New Zealand and the United States are the only two countries in the
world to allow prescription drug advertising directly to consumers.
The Ministry of Health has recently run another consultation asking
for input on DTCA so that it can advise the new Minister of Health on
DTCA policy options as we head towards trans-Tasman harmonisation.
So, what is DTCA?
DTCA is any advertising directly to consumers and is generally understood
to be for drugs, medical treatments and medical devices (asthma inhalers
and IUDs). The Ministry’s discussion paper confines discussion
on DTCA to prescription drugs and treatments. DTCA ads campaigns in
New Zealand have targeted lifestyle diseases. Some examples include:
weight reduction (Reductil, Xenical), asthma inhalers (Flixotide and
Serevent), pain relievers (Vioxx and Celebrex); the impotence drugs
(Viagra, Cialis and Levitra) and contraception (see the current campaign
for Yasmin in women’s magazines, and Mirena on Family Health Diary).
Another recent and worrying New Zealand trend is advertising for boutique’
breast cancer drugs.
The advertising is typically long on information about lifestyle and
appearance enhancement, and very short on actual health benefits, drug
action, potential risks and side effects of medication. Most prey on
fears and insecurities around attractiveness and appearance. This is
a feature of the advertising for non-prescription products as well.
The ‘It’s my choice’ advertisements take an old feminist
credo and apply it to an elderly male surfer. The latest ad for breast
cancer patients has tag lines which ask women to ‘explore the
options, improve the odds’ and offers ‘fresh hope after
breast cancer.’ Women with breast cancer are a vulnerable population
group and the advertising preys on their vulnerabilities. The print
ad does, in very small print list contraindications, side effects and
the fact that the medicine and the visit to the doctor to discuss it
will cost money. A visit to the website, where the ‘fresh hope’
tagline looms large, assures patients that this medicine is fully funded
for a number of indications. If women don’t fall into one of the
fully funded categories, then ‘a patient sample programme is available
through selected pharmacies around the country. This programme will
continue as long as the current partial subsidy is in place. This
removes any part charge on
Arimidex making it free to patients,’
DTCA is big business. Figures and details are difficult to obtain from
the industry but the MoH report does give some industry supplied figures.
DTCA expenditure in New Zealand in 2004 was $38 million. A graph suggests
this may have doubled since 1999 but exact figures are not given for
the other years. This is accompanied by a note that this figure does
not include the weight products (eg Xenical and Reductil) as they are
classified under ‘Diet/Slimming, Health Clinics.’ This is
convenient as these are big DTCA products and would certainly take the
total spend to well over $40 million. Estimates based on US studies
are that every dollar spent on DTCA returns a profit of $2.50 back to
the drug companies.
The arguments for and against DTCA
DTCA incites passionate debate but is a difficult area to argue from
an evidence base. The industry has control over much of the information
and seems reluctant to share. The principle arguments cited in the discussion
paper are around provision of health care information to consumers;
the impact on the pharmaceutical budget; the medicalisation of normal
body processes and the impact on doctor-patient relationships. The full
discussion paper and list of submitters is available at: http://www.moh.govt.nz/moh.nsf/238fd5fb4fd051844c256669006aed57/8daa2bc24bcff5d9cc25712400778549?OpenDocument8daa2bc24bcff5d9cc25712400778549?OpenDocumentThe
DTCA consultations
The current consultation is the second in the last five years. The first
in 2000-2001 changed nothing. There were only 43 submissions and the
option of a ban on DTCA was offered. The summary of submissions stated
that the result was essentially a tie – without mentioning that
most of those supporting the status quo and opposing the ban were industry
based – from either the drug or advertising industries.
This latest discussion paper offers three options – two which
allow DTCA and the third offering a ban but tying it to regulated ‘disease
state advertising.’ There were over twice as many submitters to
this consultation (115). Two things stand out this time. The first is
the large number of overseas submitters opposing DTCA which reflects
concerns about the push to promote DTCA internationally. Submissions
came from the International Society of Drug Bulletins, Health International
and Medicines International in Europe, from Healthy Skepticism and the
Consumers Organisation in Australia, from Medwatcher and Informed Prescriber
in Japan, from Canada and from Public Citizens Research in the US. Most
of the international submissions oppose DTCA.
The second feature of this process is the increased number of submissions
from consumer groups and organisations. For the most part these oppose
DTCA. The exceptions are interesting. It is tempting to speculate that
the more drug company likely it is to see no problem with DTCA or to
support it.
Women’s Health Action submissions can be found at here.
The Advertising Framework
Industry self regulation is seen as practicable and cost-effective and
is the NZ standard. This has been widely touted as being effective and
acceptable. It is for both the industries involved – advertising
and pharmaceuticals. During the early consultations on the trans Tasman
Agency, this system was widely lauded and actively promoted as the model
which should be adopted by the Agency. Women’s Health Action made
itself extremely unpopular pointing out the limitations of the system
but it was to no avail.
The regulators work in tandem with the industry to ‘teach’
them acceptable standards of behaviour. Drug companies are very slow
learners. Despite a number of identified
inadequacies (lack of balance, poor presentation of risk info etc) these
problems remain. In response to concerns about the size of font for
risk information, we noted an increase in font size – which was
heartening. However, as time passes, the original font sizes reassert
themselves. The current system reinforces bad behaviour – ads
which have been successfully complained against have been given ad industry
awards. The ‘work with them’ approach taken by the regulators
is to some extent a response to poor resourcing. In an industry based
system, much of the work is funded by the drug companies ( product registration,
pre-vetting of ads etc). It is difficult to effectively police the hand
that feeds.
It is not possible to develop appropriate and proper standards to meet
the information needs of consumers as part of an advertising regime.
Any appropriate and proper standards attempted are subject to boundary
push by the drug companies and advertisers who delight in finding loopholes
and pushing limits. The standards are policed by industry pre-vetters
before release and the general public after release. The complaints
system is cumbersome for the general public and the rewards small. The
result of a successful complaint is an abject oops from the drug company
and a reassurance that they have withdrawn or modified the ad. They
withdraw if the ad campaign is over, they modify if they think there
is still some life left in it. A complaints based system is always problematic:
it closes the stable door after the horse has bolted. For a detailed
description of the frustrations involved on the complaints process,
see Coney, 2002 which is available here
The PHA Advertising Forum confirmed that public health workers in the
fields of food, alcohol, tobacco and gambling all share the same frustrations
with the advertising regime.
Diseasemongering
A related problem is diseasemongering. Diseasemongering is the ‘selling
of sickness that widens the boundaries of illness and grows the market
for those who sell and
deliver treatments.’ Examples discussed at the Inaugural Diseasemongering
conference in Australia (See; www.diseasemongering.org)
included erectile dysfunction, female sexual disorder, sadness and depression,
overactive bladder, restless legs, andropause, menopause, baldness and
nail fungal infections. A particularly startling example was the extension
of Attention Deficit Hyperactivity Disorder into adulthood (a symptom
of which is difficulty locating your keys!) and into the womb (is your
baby kicking too much). The process is to extend the boundaries of existing
condition or create entirely new conditions out of normal life experience.
In both cases a key strategy is the tyranny of measurement. If you can
define a condition using ‘objective’ measurement criteria,
then it is easy to extend the boundaries by creating a ‘pre’
disease state and use drugs to catch it early. The conference illustrated
how easy it is to create a new condition. The first session introduced
‘Motivational Deficiency Disorder’. (See
here) This totally fictitious condition, created by conference organisers,
generated international media and, by the end of the conference, a number
of inquiries as to the availability of the drug to treat it. For a comprehensive
discussion of diseasemongering and some of the papers from this fascinating
conference see: www.plosmedicine.org.
April 2006. Vol 3. Issue 4.
A National Medicines Strategy for New Zealand
The New Zealand Future Medicines Policy Summit in late April this year
brought together key players to look at developing a National Medicines
Strategy for New Zealand. This is another area of difference between
Australia and New Zealand. The strategy aims to identify where improvements
can be made to the existing system to ensure the best health and disability
outcomes from medicines. The three key areas identified as important
are: access to medicines, quality of medicines and the rational use
of medicines. A discussion document, due in November, is expected to
describe the current system; summarise trends and their potential impact;
propose a set of high level objectives; and address a number of more
specific issues.
The issues discussed at the summit
included the role of PHARMAC which has an enviable record in New Zealand
for keeping the pharmaceutical budget within tight constraints. Discussions
of the ways in which PHARMAC negotiates with the drug companies occasioned
some lively debate. The industry views budget restrictions and the PHARMAC
negotiating ‘toolbox’ as contributing to a hostile environment
for them in New Zealand. There was much debate at the summit as to whether
PHARMAC policy limits treatments and contributes to access to fewer
drugs to an extent which compromises our health. However, PHARMAC described
robust processes and criteria to evaluate medicines and argued the toss
on matters of access. PHARMAC is the global darling of the world’s
regulators but the universal enemy of international pharma.
Another interesting feature was the emphasis by a number of speakers
on the economic contribution of drug company engagement. Lesley Clarke
from the Researched Medicines Industry stated clearly that: ‘The
National Medicines Policy is not just about health. In addition to pharmaceutical
management and funding policies we are advocating that the strategy
integrates with and supports economic and industry development.’
The discussion here focussed on the impact on research and development
and our scientific place in the world. Industry is withdrawing research
funding support from New Zealand and we are missing out on our fair
share of internationally available funds from this source. We are also
facing the potential loss of opportunity from the bourgeoning biotech
industry.
The Australian Medicines Policy has four key platforms and is based
on four central objectives: The first three mirror those set for New
Zealand but the fourth is more controversial : to maintain a responsible
and viable medicines industry. By including this, the Australian government
has signalled its desire to work alongside industry. The question for
both New Zealand and Australia as we head towards ‘harmonisation’
is the extent to which constructive engagement for the common good is
possible with industry. The challenge for industry is to rise to the
opportunity offered by the Australians. Early indications are that this
is proving the most challenging aspect of the Australian Medicines Policy.
The
BMJ ‘ April Fool’s day’ article: Australian Scientists
Discover New Disease
BMJ on Mar 31 2006 07:19:58
Motivational deficiency disorder
Extreme laziness may have a medical basis, say a group of Australian
scientists in this week's BMJ, as they describe a new condition called
motivational deficiency disorder (MoDeD).
The condition is claimed to affect up to one in five Australians and
is characterised by overwhelming and debilitating apathy. Neuroscientists
at the University of Newcastle in Australia say that in severe cases
motivational deficiency disorder can be fatal, because the condition
reduces the motivation to breathe.
Neurologist Leth Argos is part of the team that has identified the disorder.
‘This disorder is poorly understood,’ he says. ‘It
is underdiagnosed and undertreated.’
Trials of indolebant, a drug to help combat this condition, are underway
and initial results are promising. ‘Indolebant is effective and
well tolerated,’ adds Professor Argos. ‘One young man who
could not leave his sofa is now working as an investment adviser in
Sydney.’
But some doctors are concerned that ordinary laziness is being medicalised,
and have organised a conference on ‘disease mongering’ at
Newcastle University on 11-13 April 2006 (www.diseasemongering.org).
A study of the economic impacts of motivational deficiency disorder
estimates the condition may be costing the Australian economy $A2.4bn
(£970m; €1.4bn; $1.7bn) a year in lost productivity. This
has prompted calls from industry and advocacy groups for a fast tracking
of the regulatory assessment of indolebant in Australia and world wide.
A Google search in March 2006 found no entries for Motivational Deficiency
Disorder. After the April Fools day release the Google hits on ‘motivational
deficiency disorder’ were Friday 9; Sunday 101; Monday 245; Wednesday
452. Two months later on June 2nd there were 93,600
Why
stem cell research is a women’s issue
Genetic technology is presented as the new miracle cure,
a way to eradicate disease and prolong life, a technology with the ability
to control the creation of life itself. Research and use of genetic
technology continues to expand world wide including the use in biotechnology,
genetic engineering and genetically modified food. Kristen Berger, Women’s
Health Action policy analyst, explores some of the wider issues around
gene technology and explores some of the issues raised for women in
embryonic stem cell research.
The Impossible Dream?
Dramatic cures are far from simple. The South Korean stamp was designed
to celebrate the accomplishments of Dr. Hwang Woo-suk. Dr. Hwang gained
international accolades for his genetic research. He and his team created
Snuppy last August, the world’s first cloned puppy. In May 2005
he appeared to be way ahead of the pack publishing a study in the journal
Science which claimed that he and his research team were now able to
produce tailor-made embryonic stem cell lines. Unfortunately, it simply
wasn’t true. This study, which grabbed world attention, has subsequently
been debunked as a fabrication. The article has been retracted, and
Dr. Hwang has resigned in disgrace. This has left much of the scientific
community questioning how research is presented and verified. It has
raised serious questions about the ways institutions and academics respond
to research pressures.
Many of the potential uses of stem cells remain just that, potential.
There are many health issues around the use of genetic knowledge and
stem cell research. The reality is that we still don’t know the
limitations of this research and are a long way off any practical health
interventions from them.
A clear set of issues arising from the Dr Hwang case are around the
integrity of scientific research today. Questions around these are being
asked and debated but
another more fundamental set of questions remain unasked and unanswered.
If we ask about the role of women in the case and what this means for
women everywhere, a very different set of issues emerge. The egregious
breaches of research practice have overshadowed the very real ethical
issues that have yet to be considered from this particular story.
In November 2005, just as stories began to emerge around Dr. Hwang and
his research team, a member of his team confessed to paying women for
their eggs to use in this research. The confession of this ‘lesser’
breach may have been a smokescreen to divert attention from the fabrication
of data in the study. Journal reports that Hwang’s research ‘used
research assistants’ stem cell lines’ cloud the fact that
the eggs of two research assistants were used. After one of Hwang’s
doctoral students told Nature that she was a donor, Hwang argued that
the report was false and it was a miscommunication exacerbated by broken
English.
Women in Stem Cell Research
How are women impacted by stem cell research? How are they included
in current research and what does genetic technology mean for women?
There are a number of questions here. First, in the case of the Hwang
research we can see clear concerns for women in the practice of genetic
research. All stem cell research requires the use of women’s eggs.
This raises serious concerns around women’s role as producers
of the basic materials used in this research. A second set of questions
evaluates the uses of genetic technologies and what this means for women
in a gendered world.
To get back to the infamous stem cell research carried out by Dr. Hwang
and colleagues at Seoul National University. His research assistants
and students donated their own eggs to the research. It is a shocking
abuse of power to have students donating their own body parts for research.
This research requires the donation of a woman’s eggs- ova, ovum,
oocytes - what ever part of the egg being used still requires the extraction
of eggs (many!) from actual women. This has a wide range of implications
and the possibility of the commodification of women is particularly
disturbing.
The well understood power gradient between professor and student has
been completely disregarded in Hwang’s research. Perhaps the students
willingly donated their eggs, they are after all part of the research
team, but this ignores the crucial ethical concerns surrounding any
situation where one party holds so much power and sway over another.
The report that in one instance of egg donation ‘professor Hwang
accompanied the student to the hospital himself’ seriously questions
the student’s ability to say no to this so-called ‘donation’.
The other issue in this piece of research is that the research team
also paid women to donate their eggs. Numerous international standards,
and particularly those dealing with reproduction and reproductive capabilities,
specifically forbid or censure the practice of paying for any body parts
in research.
Despite insisting for months that the research relied on donated eggs,
a key member of the research team admitted in November 2005 to paying
women for their eggs. At least three women were paid $1,400 for their
eggs. The potential exploitation of the poor in genetic trade is clear.
All three of these women told Korean television that they were in dire
financial circumstances and two stated that they had not been informed
of the potential risks involved in the process.
‘Harvesting’ Eggs
All embryonic stem cell research requires the use of women’s eggs.
Some stem cells are derived from both egg and sperm (embryos created
for the purpose of fertility treatment), others require only women’s
egg (SCNT). Even the newest technologies for stem cell production, like
‘biological artefacts’ require large numbers of women’s
eggs. Obtaining eggs from women is not straightforward – it is
a difficult and risky process.
Large numbers of eggs are required to produce embryonic stem cells.
As a women’s natural cycle only produces one egg per month, it
is more efficient to get the women to produce multiple eggs. To obtain
the necessary number of eggs to make the ‘harvest’ worthwhile
a woman’s ovaries must first be “shut down” and then
hyperstimulated. Both parts of this practice have potential dangers,
most notably ovarian hyperstimulation syndrome (OHSS) which in the worst
case scenario can lead to death.
If the vast research demands for eggs are to be met, literally millions
of eggs will be needed for this purpose. For example, one study using
cloned embryos required 176 human eggs to produce just one embryo. The
many grand plans that abound in embryonic stem cell research will require
vast numbers of eggs and large numbers of women to produce them.
The very serious potential side effects need to be off-set by the potential
benefits of research. Although a “cure” for neurological
diseases is seductive, research participants must weigh up their reasons
for taking a completely avoidable risk. In addition to the known problems
associated with OHSS and Lupron, (the drug used in the “shut down”
part of the ovary stimulation), there remains a large potential for
unknown risks. Dr. Ahuja from the Cornwall Fertility Centre notes that
“we don’t know the long term consequences…we are not
in a position yet to reassure women”
Women for sale
Payment for egg donations are a clear commodification of this ‘product’.
In many countries, including New Zealand, payment for donations is banned.
This seems like a fairly straight forward way to avoid commodification.
However it is somewhat simplistic. The problem is that the only people
who can make any money in the stem cell trade are then the researchers
and institutions which hold the cell lines, while the women who donated
their eggs and their bodies receive nothing.
Because embryonic stem cells can be cultured for very long periods of
time, there is the potential to use one stem line for multiple research
projects. The danger here is that once an approved research use is completed,
these stem cell lines may now be given or traded with another researcher
or institution. Even if the cell line remains with the same researcher
the value of this limited commodity certainly represents an asset to
that institution.
Currently, there is no international regulation around stem cells and
regulations vary greatly from country to country. Embryonic stem cells
may be traded internationally and processing or use in a third country
further clouds the cell lines origins. Even if a country like New Zealand
has very tight regulation around egg donation, there is the opportunity
to use and support unethically obtained cells from countries with less
stringent regulation. In fact as embryonic stem cell regulation becomes
more stringent in some countries it may encourage others to be less
rigorous as demand outstrips supply. To be an exporter of these valuable
cells, or to attract research, some countries may well be tempted to
put lax regulation in place. This could exacerbate the North South divide
and encourage further exploitation of women from the developing world.
A particularly repugnant aspect of this sort of trade is that the poor
women, who are the most likely egg donors, are the ones least likely
to benefit from new and expensive gene technology when and if it is
found.
Even for women in the developed world, women’s role in research
and their ability to benefit from it exhibits the same gendered discrimination
evident in so many other areas of life. For many years women were left
out of research which impacted on both men and women. The hypothesis
that if it worked for men it would work for women was assumed. In 1985,
a US Public Health Service task force concluded that the exclusion of
women from clinical research was detrimental to women's health. This
resulted in the adoption of guidelines by the National Institutes of
Health (NIH) urging the inclusion of women in NIH sponsored medical
research. In 1990, and again in 2000, General Accounting Office audits
revealed that guidelines are not being followed and that even when women
are included, gender analyses are rare. The impacts of this are examined
in the recently released 10Q report which looks at the differential
treatment and higher morbidity of women with heart disease, and belatedly
attempts to address this.
Further issues are raised about what constitutes informed consent for
women whose eggs created this bounty for sale. These issues were raised
by Women’s Health Action in a recent submission on genetic research
in New Zealand. Consent given for one purpose can not be assumed to
be valid for the many various uses for the resulting stem line.
Women’s response
Internationally women’s organizations have responded to stem cell
research with calls for banning embryonic research. In many places feminist
ethicists and women’s organizations have decried the potential
abuses in such research. However, we still lack international regulation.
The type of regulation that can assure international trade is controlled
and the divide between developed and developing nation is not exploited.
The use of high profile figures to promote and add emotive power to
stem cell research potential is invidious. Superman and President Ronald
Reagan are two high profile figures whose tragic lives have been widely
promoted as a reason for us to use this new wonder science. These serve
to cloud the fact that genetic technology is not inevitable, it is a
choice that we make and we can choose not to go there. If the majority
of people are informed about the implications of this research, they
may well choose not have to go in a direction so fraught with danger.
It is not good enough to devalue and minimise women’s concerns
as a luddite response. It is not that women’s groups want to avoid
technological innovation, it is that we choose to avoid exploitive technology
that puts us up for sale. It is not insignificant that the Korean stamp
features a man rising from his wheelchair!
References
1 Newsweek 12/5/05
2 New Zealand Herald 11/01/06
3 Galpern, E and M. Darnovsky The Nation 29/11/05
4 BBC News 30/06/05
5 See: http://www.womenshealthresearch.org/
6 See http://www.womenshealthresearch.org/press/10QReport.pdf
Women’s
Health Action World Breastfeeding Week posters have developed a reputation
for being controversial and edgy. As we work on our poster for this
year, breastfeeding advocate
Louise James looks at some of the issues raised by last years poster.
A simple beginning
A quiet morning in the park with a mother, her breastfeeding toddler,
a banana and a top class photographer. Mother and daughter look fantastic
and all is going well when the photographer asks the mother to take
her breast out from the neck of her red top rather than lift it up from
the waist. The resulting photograph is elegant, less clumsy and certainly
less ungainly. All are pleased with the result. However, the repercussions
of that decision were to reverberate again and again as the poster developed
and ventured into the public domain.
The theme for World Breastfeeding Week internationally is set by the
World Alliance for Breastfeeding Action (WABA). In 2005 the theme was
Breastfeeding and Family Foods: Loving and Healthy. The focus was on
the continuation of breastfeeding after solids have been introduced.
Women’s Health Action workshopped this theme with a small working
group which grew out of an initial community consultation. The decision
was to develop a poster which depicted a mother breastfeeding her toddler.
It was agreed, though not unanimously, to have the toddler hold a healthy
nutritious food to demonstrate that breastfeeding could happily co-exist
with first foods. Across all cultures, the most common first food for
young New Zealanders was a banana. It suited the theme beautifully,
being easily recognisable, portable, non commercial and healthy.
The resulting photograph was great and mother, photographer and Women’s
Health Action were happy with the result. Off it went to the working
group. These were all people who supported breastfeeding and the WHO
Global Strategy supporting breastfeeding exclusively for the first six
months and on up to two years and beyond. For some of these people the
translation of the words into a real life image proved challenging.
There is one right way
Everybody loves a breastfeeding image when the baby is small and the
mother is in a Madonna pose gazing adoringly at her progeny. An older
child however is more
challenging and the new poster was an affront to the set of unspoken
rules and assumptions that many people carry
unconsciously in their heads. The revelations started with the working
group, but were confirmed by the wider community once the poster was
released. The process uncovered a number of unwritten rules and assumptions
that form real barriers to mothers breastfeeding older children and
they are fascinating. We discuss some of them here.
The unwritten rules for breastfeeding older children in public:
- If the child being breastfed is not a baby then the child should be ‘a little toddler’, ‘a younger child’, ‘a 9-10 month child’, ‘I have a problem with a child breastfeeding when they can ask for it’.
- The act of breastfeeding needs to be: ‘discrete’, ‘private’, ‘less exposed’, ‘top pulled up’ and ‘tasteful’.
- The breastfeeding mother and child should be ‘loving’, ‘arm wrapped around the child’, ‘a more likely feeding posture’, ‘baby on lap’, ‘motherly’, ‘held in mother’s arms’, ‘the child cuddling up on mum’s knees’ and ‘don’t sit with legs apart’.
- Everybody should breastfeed in the same way so the image has to conform to personal experiences of breastfeeding: ‘some of us have breastfed our own children through to toddlerhood but at no time found it necessary to pull our shirts down’, ‘We have never in all our years, seen anyone breastfeeding their toddler in this position.’ ‘We are all mothers who have breastfeed our own babies and have nothing against breastfeeding in public if it is done in a sensitive and tasteful way’.
- Can’t have the child holding a banana: ‘the banana can be seen as a phallic symbol’, ‘a banana milk shake?’
Thanks
for the mammaries
The reaction to the poster was indeed mixed: the ‘Outstandingly
Healthy’ breastfeeding poster proved overwhelmingly popular with
many: WABA from Penang wrote, ‘Thank you very much for sending
us the posters. They are beautiful and the
message comes out loud and clear’. James Akre formerly of the
World Health Organisation wrote, ‘Splendid new breastfeeding promotion
poster. It superbly places the expression ‘complementary feeding’
into appropriate perspective.’ Positive comments came from far
and wide recognising the great shot that it was, ‘I think this
poster is just wonderful.’ ‘Beautiful photo’, ‘looks
good’ and ‘She looks gorgeous’.
However, given the high level of negative comment, the focus testing
was important and would determine whether the poster saw the light of
day. We took the image to numerous different places outside of the health
profession and asked them what they thought the messages were. While
some in the working group, and particularly health professionals, felt
it ‘Could discourage rather than promote breastfeeding’,
‘is not appropriate’ and ‘would put many people off’,
the take home messages from the focus group were exactly what we were
hoping for and more:
- Breastfeeding is nothing to be ashamed of.
- Fresh air, fresh food and fresh breast milk.
- It is OK to feed in public.
- The longer you breastfed the better.
- Breastfeeding makes mother and child happy and healthy.
- Breastfeeding is not difficult or problematic.
- Should feed whenever the child needs to.
- It’s a normal and natural thing to do.
- Breast milk is the best.
- Doesn’t matter where you breastfeed.
- Breastfeeding doesn’t have to stop with babies.
- Women’s breasts are put on their bodies to feed babies.
- Breastfeeding is clearly part of a healthy diet.
- Breastfeeding is just part of life.
We had a second
picture up our sleeve for focus testing. In this one the child was on
the mother’s knee in the more traditionally seen Madonna pose.
We ran this image through our focus groups as well: The ‘safe’
alternative ‘doesn’t grab you’, is a ‘friendlier
image’, is probably ‘acceptable to society’ and ‘it
looks more of an effort’. Surprisingly, and happily, when choosing
between the two, focus group participants liked the edgier, challenging
version.
What lies beneath?
What was going on for many people? Even those who agreed it was a lovely
photo and supported breastfeeding, said they would not display it. A
childbirth educator said, ‘Cool, but I wouldn’t put it up
in my classes.’ And a nurse felt ‘it would be demeaning
to even ask mums to look at the poster.’
Different people reacted to different aspects of the poster. For some,
it was the size of the breast. With the growing popularity and acceptance
of breast augmentation, with magazines and movies showing large breasts
in skimpy clothing it is amazing that naturally full breast is seen
as somehow remarkable and obscene. ‘What a big boob!’ said
some and ‘The exposed breast is obviously enlarged.’ And
some accused us of digitally enhancing it to make our point. Just for
the record, we didn’t.
Some disliked the poster at some incoherent level and were then asked
to say just what their problem with it was. The most violently opposed
immediately seized on the age of the child and inflated that. With no
evidence at all, they decided the child was at least three years old
and maybe as old as four or five. Again, without any evidence they were
also more likely to assume the child was a boy. In fact, the child is
20 months old and a girl.
Clearly the poster brought out some deep seated barriers in attitude
that can’t help but hinder the widespread freedom to breastfeeding
with in our society. A couple of comments on an internet forum about
the poster sums it up nicely, ‘…it’s important to
realise that our discomfort is about US not about what that child is
doing. Breastfeeding isn’t a ‘glorious act’ –
it’s a way to nurture a young child, both physically and psychologically.’
‘I am guilty of feeling a
little uncomfortable by the poster as it doesn’t portray what
I thought breastfeeding was about for me.’ ‘…it’s
a societal issue with women’s bodies in Western culture being
viewed as sex objects…’
Breastfeeding Week 2005 presented New Zealanders with a new image of
breastfeeding to begin breaking down the barriers of stereotypes that
have been infiltrating us through the years. Taking a look back in history
at the images of the Madonna breastfeeding her child, there has been
a variety of images. Continuing to only portray breastfeeding in one
way, the romantic Madonna look, does not help the acceptance of breastfeeding
as a normal and natural function that has many different looks.
Getting Over it
From the amount of debate and dialogue that has occurred from the release
of the poster it became apparent that the image presented challenges
to some peoples’ way of thinking about breastfeeding. ‘At
least it has promoted discussion, which is very healthy for our Public
Health Unit.’ ‘…has created a lot of discussion about
breastfeeding which is a good achievement.’
Many people who were first taken back by the image, on reflection came
to see its value: ‘Well done, at first I thought too much breast
was showing, but you can almost see that amount on some people so I
say go for it.’ ‘Throws you back a bit at first, but hey
it’s natural, it’s acceptable to show the breast.’
One mother of a young baby suggested that the image should have been
more discrete then went on to ask, ‘any tips for being able to
feed that long?’
Just like me!
There was a wonderful unanticipated reward from the release of the image
- the validation that small talking breastfeeding children received.
The image remains of one such child excitedly tugging her mother to
see the poster and beaming at her as she pointed to it with a big smile
on her face saying ‘like me’. Another child was determined
to know the name of the child in the photo - the little girl breastfeeding
in the park was her hero. A mother related; ‘Two and a half year
old Clayton (still breastfeeding) saw the
toddler breastfeeding poster and immediately said ‘Nana and Nan-na’.
He had no trouble seeing it as an advertisement for food with his breastmilk.
Getting On with it
Breastfeeding is the biological norm. However success is at least as
reliant on the many non-biological social factors in our modern society.
One of those factors is people’s views, expectations and tolerance
for what is seen as normal. The focus on breasts as sex symbols and
their extensive use in selling almost everything is seen as normal by
most and desirable by many. At the same time, the tendency to hide breastfeeding
away and portray it as normal only for babies who are held in a Madonna
pose, creates a situation where breasts are seen as indecent when they
are being used for their designated purpose and decent when their display
is gratuitous.
Variety is normal. Some mothers’ breastfeed by lifting their tops
up, others by pulling them down, both are acceptable. Mothers breastfeed
two year olds, two month old babies and sometimes tandem feed new babies
alongside pre-schoolers. All are acceptable practices. Babies feed comfortably
in their mother’s arms. Toddlers however are active and curious.
Many feed ‘on the run’ and most have a wandering eye –
they just hate to miss anything! Many a mother breastfeeding a toddler
will testify to the fact that few breastfeeding toddlers focus entirely
on the job at hand. Mothers sometimes look adoringly at their infants
when they feed. Other times they take no notice of the child at the
breast as they talk freely to friends. In this they are not unusual
- most animals with suckling young pay them little heed as they get
older!
For breastfeeding to move from a biological norm to a widespread and
accepted cultural norm, we all need to look at how we react to the different
breastfeeding styles and images that we see. When it is no big deal
or nothing out of the ordinary we will have made progress. While we
still gape and uncomfortably shift and shuffle at the exposed breast
or the feeding child (in any position), we still have a way to go. And
while we still have a way to go, children miss being breastfed and gaining
major health benefits. Every one of us has a role in creating a breastfeeding
society.
Gender Equity and Health Sector Reforms
Sweeping health
care reforms have shifted the structure of health care throughout the
world in the past twenty years.
Largely, health care has become more market oriented. In much of the
developing world this has been dictated by international financial institutions
and put in place through structural adjustment policies. In the developed
world nations have responded to the wants of the international financial
institutions such as the World Trade Organisation and the World Bank
by increasing the tendency toward decentralisation and privatisation
or a refocus in financing.
In New Zealand we have seen a shift in policy toward more market friendly
reforms across government. In health care this has been reflected in
the restructuring of regional health boards into the 21 District Health
Boards, and an attempt to meet more of the community and public health
needs through the development of Primary Health Organisations. As far
as WHA is aware these shifts in health care structure have not analysed
from a gender perspective.
The World Health Organisation has however done an evidence report on
the effects of health care reforms on gender equity. The 2005 report
found that health sector reform programmes affect women and men differently
due to their respective positions as users and producers of health care.
However most reform programmes do not take gender equity into account
when designing changes to the health care system and may lead to increasing
inequalities.
The evidence report, based on a systematic review of the literature,
looked at four key health care reforms (decentralisation, financing,
privatisation and priority setting). The review looked at the literature
examining reforms in both developed and developing countries, although
it noted that most articles looking explicitly at gender and health
care reform were in developing countries.
This is a summary of the report findings:
Decentralisation
A growing trend toward decentralisation is characterised by the transfer
of authority for decision making and management from the national level
to agencies and organisations on the sub-national level. A problem with
decentralisation is the devolution of responsibilities without a corresponding
devolution of resources and authority. This lack of resources frequently
leads to difficulties in providing adequate services. This may affect
women’s health more as any decrease in available service or service
quality is disproportionately felt by women as they need more health
care, particularly during childbearing years.
The decentralisation of decision making may be a challenge for providing
adequate gender representation and gender awareness at different policy
making levels. Evidence from Canada shows that the regionalisation of
health care can make it more difficult for women’s organisations
to address policies at varying levels. Some studies show that decentralisation
may inadvertently support more conservative agendas in reproductive
health.
Financing
There is substantive evidence from both high-income and low-income countries
that taxes and social insurance schemes provide the most equitable basis
for health financing. Other schemes, such as private insurance or direct
out of pocket payment are likely to increase inequalities, particularly
in access to care and health-seeking behaviour. This generally affects
women more, as they tend to have fewer financial resources and less
access to them.
Additionally, women form the majority of lower-tier health workers and
are the primary informal carers in the household. As a result cuts in
health and social sectors can lead to higher levels of unemployment
among women health workers, as well as increased burdens in informal
home care.
Evidence has shown that a well functioning and wide ranging system of
public health, especially when gender-sensitive, is the best guarantee
of equitable and affordable services for the less privileged.
Privatisation
Privatisation is the transfer of ownership and function from government
(public) organisations to private ones. The hallmark of health care
privatisation has been the increased reliance on user fees or private
insurance.
Privatisation has an important impact on gender equity in access to
health care and financial protection for those who are ill.
Privatisation may lead to increased emphasis on reducing costs and maximizing
efficiency. The negative consequences of these policies affect women
more than men since women are over-represented among both patients and
personnel.
Priority-setting
Throughout the 1990s health care planning and priority setting were
increasingly influenced by Global Burden of Disease (GBD) methodologies.
These methodologies rely on gender disaggregated data to determine the
needs and successes of different health care policies. One of the most
common methodologies is the use of DALYs
(disability adjusted life years). A range of gender biases have been
revealed in some priority-setting methodologies, which seriously underestimate
women’s burden of disease and in turn affects resource allocation
and priority setting.
The report concludes there is a clear need for gender equity considerations
to be taken into account when planning health care reforms. Unfortunately,
there is little evidence of this occurring in the past. Policy considerations
need to look at gender equity needs in planning and services at national,
regional and local levels. It concludes that a well functioning and
wide-ranging system of public health services is the best guarantee
of equitable and affordable services for those less privileged, many
of whom are women.
References
Ostlin, Piroska (2005) What evidence is there about the effects of health
care reforms on gender equity, particularly in health? World Health
Organisation Europe
Available at: http://www.euro.who.int/HEN/Syntheses/genderEquity/20051027_1
News headlines
highlighting New Zealand research pointing to a link between abortion
and depression ushered in the new year.
The source was Professor Fergusson who published his analysis from the
Christchurch Health and Development Study (CHDS) in the Journal of Child
Psychology and Psychiatry. While saying he ‘regretted’ the
finding, he also admitted that a number of confounding factors may be
involved and his strongest conclusion is that further studies are needed
on the topic.
The debate and study around the links between abortion and depression
have been circulating for quite some time and they
continue to have varying findings. It is crucial that we maintain access
to safe legal abortions for women who choose them. What we know is that
when they are denied, women seek abortion in ways that put not only
their sanity but their lives at risk.
The current study is based on the ongoing Christchurch Health and Disability
Study, a longitudinal study of a birth cohort of 1265 New Zealand children
born in 1977. In this latest analysis of the cohort, 301 women had never
been pregnant, 205 women had been pregnant at least once and of these
women 74 had at least one abortion. The study looked at the incidence
of subsequent mental health problems including depression, anxiety,
suicidal behaviours and substance abuse disorders. The study concluded
that ‘young women reporting abortions had elevated rates of mental
health problems when compared with those becoming pregnant without abortion
and those not becoming pregnant’.
The greatest difficulty in any study of this type is examining the contextual
factors. The Ferguson study attempts to control for some of the confounding
factors by using the data already collected in the CHDS longitudinal
study. These factors included looking at available data on childhood
social and economic disadvantage, measures of family dysfunction and
individual adjustment problems. Unfortunately the study of confounding
factors was limited by the data already available.
Wanted pregnancies and level of support?
The primary difficulty might be in the study design. Studies in the
past have frequently compared women who have children with women who
had abortions. The Ferguson study expands on this and includes women
who have never been pregnant. Unfortunately, this continues to tell
only half the story and the most relevant pieces of information may
well be whether the pregnancy was wanted or not and whether the women
had levels of social support sufficient to support any choice she may
have made.
The Ferguson study did not include data on whether the pregnancy was
wanted or not nor whether she had social support for the choices made.
These are important confounding factors. It is probable that unwanted
pregnancies and a lack of social and emotional support are more likely
to be linked to depression rather than the abortion.
The Christchurch study builds upon a US study linking abortion and depression.
The Reardon study has subsequently been re-analysed with different conclusions.
Schmiege and Russo looked at the same data set as the Reardon study
but used different coding and sampling approaches to information and
concluded that ‘there is no credible evidence that choosing to
terminate an unwanted pregnancy puts women at a higher risk of subsequent
depression than does choosing to deliver an unwanted first pregnancy’.
Relevant studies need to look at the effects of unwanted pregnancies
and use abortion or birth as variable factors. This research could also
look at the outcomes of wanted and unwanted pregnancies and the levels
of social and emotional support.
A further limitation is that there is evidence of under-reporting. The
expected rate of abortion for this cohort was 81% of that expected from
general population figures available for the cohort. This raises the
possibility that almost 20% of the women chose not to disclose their
abortion history. This difference is statistically significant.
Correlations versus explanations
Most studies on abortion and mental health are correlational. Abortion
is related to poorer mental health outcomes. There is seldom any real
attempt at examining the mechanisms that might link the two. The assumption
behind these persistent studies on abortion and depression is rooted
in a widely held societal notion of guilt. It is argued that abortion
inevitably makes one feel guilty, and it is this unresolved guilt that
manifests itself in depression.
Although there appears to be a correlation between guilt and depression,
there is no convincing evidence explaining the link
between abortion and guilt. If having an abortion induces guilt, then
guilt is the problem . If guilt is the problem could that aspect of
abortion be removed? Guilt is ‘an emotional state produced by
the knowledge that one has violated moral standards’ (The
Penguin Dictionary of Psychology 1995) , Perhaps it is the imposition
of these moral standards that eventually leads to depression. There
has yet to be a study which seriously deals with the emotional baggage
society visits on abortion. Removal of this may solve the depression
argument. Which is why the questions around wanted versus unwanted pregnancy
and levels of social support are such important confounding factors.
Sustaining women’s choices
It is crucial that we maintain access to safe legal abortions. The issue
providing choice for young women and supporting them in those choices
is too important to yield. The risks associated with lack of access
to abortion have consequences that endanger women’s lives.
References
1 Fergusson et al Journal of Child Psychology and Psychiatry
47(1):16-24.
2 Raerdon, D.C and J.R. Cougle BMJ 324:151-52
3 Schmiege, S and N.F. Russo BMJ 331:1303-08.
| The previous relation between termination of unwanted first pregnancy3 and risk of depression was not found |
| Abortion may be indirectly associated with a lower risk of depression through beneficial effects on education, income, and control of family size |
| Women who are willing to disclose abortion may also be more willing to disclose depressive symptoms, exhibiting a form of ‘over-reporting bias’ |
| Under-reporting of abortion may occur, but does not seem to account for lack of detection of a relation between abortion and depression |
Abortion
pill use doubles in 12 months
Demand for the abortion
pill in Britain has reached an all time high with 10,000 pregnant women
undergoing the procedure last year. BPAS, formerly known as the British
Pregnancy Advisory Service, said the number of women, which it treated
with early medical abortion (EMA), rose from 56 per cent to 65 per cent
of its case load last year.
Use of the drug, which can legally be prescribed only within nine weeks
of conception, has taken off since BPAS began offering the abortion
pill in 2003. That year, 3,500 women went to the organisation for the
treatment. The following year the figure rose to 5,000 and that number
doubled last year.
Ann Furedi, the chief executive of BPAS, said: ‘Women's demand
for the early medical abortion service is at an all time high. We're
glad that it has been recognised that the best option for women needing
abortion is earlier access.
‘With EMA it's the woman having the abortion rather than the doctor
doing it to them. This is what makes it attractive to women, as opposed
to a surgical abortion involving a general anaesthetic.’
About 77 per cent of 50,000 treatments carried out by BPAS last year
were conducted on behalf of the National Health Service. The abortion
pill works by blocking pregnancy hormones and making the uterus contract.
The first oral dose of the drug called mifepristone is taken in a clinic.
This blocks the pregnancy hormones. Two days later, the woman returns
for a second drug which triggers the miscarriage. Patients are sent
away after the second dose so the miscarriage takes place at home.
Great Britain.Daily Telegraph report. 29 April 2006
Cheering
for pharmaceuticals
The sparkling, smiley and ‘perky’ disposition of cheerleaders
is the new hiring criteria in the US pharmaceutical sales force. Sex
sells, so it should come as no surprise that the pharmaceutical industry
is using sex
appeal in their unending push for more sales. A New York Times article
in November 2005 highlighted the disproportionate number of cheerleaders
working as pharmaceutical sales reps. Increasing scrutiny on the way
the pharmaceuticals promote their products has led to mounting restrictions
on the gifts given to doctors which is exploring innovative sales approaches.
Although it may appear that a useful drug should be able to sell itself
by virtue of its’ effects the glut of ‘me-too’ drugs
means that there is frequently very little difference in the effectiveness
of similar drugs put out by different companies. Now, more than ever
the industry is reliant on the face- to-face contact between sales reps
and doctors. The perky enthusiastic cheerleader seems to be just the
trick, the industry thinks, in convincing doctors to prescribe more.
The New York Times concludes ‘known for their athleticism, postage-stamp
skirts and persuasive enthusiasm, cheerleaders have many qualities the
drug industry is looking for in their sales force’. Exactly what
those qualities are is still under debate. One cheerleading coach noted
that cheerleaders ‘are really capable high-profile people’
while another advisor at the university said that the industry doesn’t
care what their major is they just want ‘exaggerated motions,
exaggerated smiles, exaggerated enthusiasm- [cheerleaders] learn those
things, and they can get people to do what they want’.
The industry denies that sex appeal has anything to do with hiring but
some doctors complain that seduction appears to be a deliberate industry
strategy. Jamie Reidy a former drug rep who wrote the tell-all book
‘Hard Sell: The Evolution of a Viagra Salesman’ discussed
the ways in which women reps are able to persuade doctors to buy their
products. A female drug rep is suing Novartis alleging that she was
encouraged to exploit a personal relationship, Novartis denies the accusation.
Despite the industry’s argument that it is cheerleading skills,
not looks they are after one doctor noted ‘there’s a saying
that you’ll never meet an ugly drug rep’. In the US federal
law bans employment discrimination based on factors like race and gender,
but omits appearance from the list. In West Virginia a bill has been
introduced to require drug reps to have science degrees. Dr. Foster
who introduced the bill was concerned about the attractive, but sometimes
ill-informed drug reps. A quick perusal through café pharma,
a chat room for drug reps, shows that the debate rages, with reps writing
in the most florid language to either defend the current state of affairs
or lament that lack of academic requirements tarnishing the images of
all pharmaceutical sales people.
Let’s give a cheer that drug sales reps don’t have the swaying
power in New Zealand over individual prescribing as they do elsewhere.
The poor pharma industry would have to search hard to find enough cheerleaders
to fill the role.
DIY
Healthcare
Recent
developments in DIY healthcare are verging on the ridiculous. WHA has
been approached by a group selling a DIY cervical smear kit. Coming
in a video type case, the leg crossing kit comes with a fearsome looking
brush and some utterly hilarious instructions. It is hard to figure
out just how you ensure that the guiding tube is lined up with your
cervix and once having accomplished this rather unlikely feat, you then
keep it in place - while you insert the brush into to give it a twirl.
Even a relatively athletic woman would find this a challenge but try
being older with a little bit of middle age spread and an elusive cervix.
Truly an exercise in frustration. We say stick to WONS and Family Planning
for this one.
Then there’s this little gem from the Herald on Sunday. For a
mere $6,000, you can plug in to your computer and keep tabs on your
baby in utero. It’s not clear whether this is for internal or
external application but both are equally ridiculous. What do you think
the poor little blighter is trying to get away with in there? For a
balanced approach to untrasound scans in pregnancy, try reading our
WHA pamphlet.
More
Vioxx dramas
Merck’s arthritis drug Vioxx was removed from the market in 2004
after it was found to increase risk of heart problems.
One of Merck’s defenses has been that Vioxx only causes heart
disease after long term use. In 2005 they released a study in the New
England Journal of Medicine claiming that it caused heart problems only
after 18 months. However the company has just acknowledged that the
statistical analysis does not support this claim. The company now admits
that there is a seven percent chance that Vioxx has an equally high
risk of causing heart problems before 18 months of use. Although a seven
percent chance may sound small this is a significant turn around from
the ‘almost certain’ stance Merck claimed before. Merck
faces at least 11,500 lawsuits from patients who used Vioxx and say
it caused their heart attacks or strokes. Five cases have gone to court
so far in the States and Merck was found guilty in three of them.
New York Times 31 May 2006
Ethical
dilemmas over frozen embryos
IVF has been plagued with the issue of who has rights and control over
frozen embryos. Frozen embryos are in a complex legal, ethical and emotional
limbo and have an almost infinite shelf life. The Fertility Society
of Australia announced in February that Australia and New Zealand have
over 100,000 frozen embryos stored. Recently a British woman lost her
legal case to use the frozen embryos fertilised by a former partner.
Natalie Evans and her then partner, Howard Johnson, fertilised and froze
embryos in 2001 after Ms. Evans was diagnosed with cancer. They subsequently
broke up but the embryos remained in a fertility clinic. Ms. Evans wanted
to use the embryos to try to have a child. Mr. Johnson refused consent
arguing that he does not want to become a father. The European Court
has ruled that the frozen embryos should be destroyed, recognising the
need for consent from both partners throughout the process.
Pharmaceutical
Funding for Patient Advocacy Groups
There has been increasing concern over the funding of patient advocacy
groups by pharmaceutical companies. Many patient advocacy groups started
at a grassroots level to argue for support and recognition for groups
of patients. Pharmaceutical companies have found these groups to be
a particularly useful way to market their products to specific patient
groups. Increasing amounts of financial support for patient advocacy
groups comes directly from pharmaceutical companies.
The Association of the British Pharmaceutical Industry issued a new
Code of Practice in January. The Code states that pharmaceutical companies
may work with patient advocacy groups but that they must make their
involvement clear and declare sponsorship. The changes in this ‘self-regulatory’
code are a reaction to report on the influence of the pharmaceutical
industry produced by the UK parliamentary health select committee in
2005
The ABPI code is available at: www.abpi.org.uk/press/press_releases_05/051116b.asp
The Health Select Committee report is available at: http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf
Calcium
supplements don’t prevent hip fractures
The Women’s Health Initiative (WHI), who ran the large US study
that uncovered the risks of HRT has recently found that calcium and
vitamin D supplements do not prevent broken bones or colorectal cancer
and increase the incidence of kidney stones in middle-age and elderly
women
It was thought that post-menopausal women should take supplements since
calcium and vitamin D are need for healthy bones, and women’s
bones normally start to thin after menopause. Observational studies
had also suggested that people taking calcium supplements had less incidence
of colorectal cancer.
The WHI study looked for the outcomes of supplement taking ie- the actual
number of fractures rather than focusing on bone density (an intermediate
measure that may not reflect increased fractures).
36,282 healthy postmenopausal women aged 50-79 participated and were
randomly assigned either an intervention group, who took 1000 milligrams
of calcium and 400 units of vitamin D a day or to a control group who
took placebos. Both groups were followed for a mean of seven years.
A subgroup of 2431 women had their bone mineral density monitored and
all participants were contacted by their clinic every six months to
assure their safety and assess health.
The study found that the use of calcium and vitamin D supplements diminished
bone loss at the hip (as measured by bone mineral density). However
despite this, there was not a statistically significant increase in
hip fractures.
During the trial the women in the calcium/vitamin D group had a fracture
rate of 14 per 10,000 cases per year while the placebo group had 16
per 10,000. This difference is not statistically significant. The calcium/vitamin
D group had a 1 percent higher hip bone density than those in the placebo
group.
The supplements provided no detectable effect on the incidence of colorectal
cancer. There were similar rates of cancer in both groups. There was
a 17 per cent increase in kidney stones among the calcium/ vitamin D
group (34 per 10,000 per year) compared to the placebo group (29 per
10,000).
This study challenges common knowledge that ‘more of a good thing,
is a good thing’, in this case more of a good thing, may mean
more kidney stones. It seems that the combined calcium and vitamin D
supplements do not reduce colorectal cancer. Further, it has become
clear that the sweeping recommendation that all women over 50 should
take supplements is not longer accurate. The debate continues over whether
to recommend these supplements for specific groups of women.
The WHI study has not examined what these findings mean for the reliance
on bone mineral density as a measure of osteoporosis or as an accurate
predictor of fractures. However since such a large study did not find
a connection between the two factors it raises questions over the heavy
reliance on bone mineral density in other studies.
References:
Jackson, RD et al (2006) “Calcium plus vitamin D supplementation
and the risk of factures” New England Journal of Medicine
354(7):669-83.
Kolata,
G (2006) “Study finds calcium supplements don’t prevent
broken bones” New York Times 15 February 2006.
HRT
and lung cancer survival
Further risks associated with hormone replacement therapy. A US study
of 500 women with lung cancer found that women who had taken HRT had
worse survival rates than women who had never taken HRT. The women with
a history of HRT use (took HRT for at least 6 weeks) had an average
survival rate of 39 months compared to 79 months for women with no HRT
history. The differences in survival rates were even more pronounced
for women who smoked and used HRT. The study concludes that this difference
suggests a possible interaction between estrogens and the carcinogens
present in cigarette smoke.
Ganti, A.P. et al. (2006) Hormone Replacement Therapy is associated
with decreased survival in women with lung cancer. Journal of Clinical
Oncology. Early online publication. November 28, 2005
Abnormal
smear results and anxiety
This study examined the psychological effects of low-grade abnormal
cervical smear results. Most studies of anxiety of cervical smear results
have included women with high grade abnormalities but the UK study of
3500 participants with low grade abnormalities found that these women
experienced increased risk of anxiety as well. This was particularly
true if they were young, had children, were current smokers or had the
highest levels of physical activity. The study points to potential interventions
to decrease women’s anxiety such as directly addressing their
fears about cancer, treatment and fertility.
British Journal of Cancer 2006 94:1253-62.
Maori
youth and contraception
How refreshing to read a sexual health article about what people are
doing right! This secondary analysis of the Youth2000 survey sets out
to identify the factors that have a positive impact on consistent contraceptive
use among Maori youth. Most of the sexually active youth in the survey
consistently used contraception. The study identifies protective factors
that promote good outcomes or resilience, and looks at ways of reducing
risk factors. The protective factors associated with consistent contraceptive
use were getting enough time with parents, feeling teachers cared about
them, feeling their neighbourhood was safe and having an adult to talk
to.
This data is the largest randomly selected sample of young Maori ever
surveyed on their health and wellbeing. The Youth2000 study was a national
population based survey of secondary school students taken in 2001.
The current study is a secondary analysis of 2340 Maori students from
the original study. Most sexually active Maori students in the survey
consistently used contraceptives (70%). Condoms were the most common
form of contraception (82%) interestingly Depo-Provera, once touted
as the next great form of contraception was near the bottom of the list
with only 6% of respondents using this. There were no significant differences
by age or gender. The study compared hypothesised protective factors
and risk factors to contraception use. The risk factor associated with
lack of consistent contraceptive use was weekly marijuana use.
As the Youth2000 study only surveyed secondary school students it is
possible that it did not capture the needs of those groups of young
people not attending school and those who missed school on the survey
day. This study supports the need for a broad strategy of promoting
protective factors that takes a holistic approach recognising the interconnectedness
of health and the broader environment.
Clark, T et al (2006) Contraceptive use by Maori youth in New Zealand:
associated protective factors NZMJ 119(1228)
