The government of Brazil is now beginning to face the possibility of an epidemic of Acquired Immune Deficiency Syndrome (AIDS). It has the 3rd most AIDS cases in the world and faces 2 hurdles, i.e., decontaminating blood supplies and informing the public. Doctors maintain that 3500 people suffer from AIDS, and some 350,000 could be infected with the virus that causes AIDS. It has taken almost 4 years for the government of Brazil to give the fight against AIDS priority. The government invests only 4% of its gross national product (GNP) in its health system, compared to 10% in many developed nations, and is not at all prepared for an AIDS epidemic. The government only just began to make it mandatory for blood banks to test donated blood and has a long way to go before it can eliminate blood transfusions as a means of contamination. By the end of 1988, the Health Ministry will provide about $400,000 to help watch over blood banks, pay for AIDS diagnostic kits, and implement its own public information programs. Due to the government's slow response to the AIDS threat, private entities and university hospitals have taken on much of the burden of treatment and education. The National Health and Social Security System will increase funding on treatment centers and plans to spend $26.6 million on AIDS patients. The Health and Education Ministries together intend to implement AIDS and sex education into the curriculum of public schools for the 1st time.
The use of depo-medroxyprogesterone acetate (DMPA), or Depo Provera, has been debated for the 20 years since it became available in 1967. The US Food and Drug Administration (FDA) refused to approve Depo Provera on the basis that it caused breast tumors in a controlled study of Beagle dogs and Rhesus monkeys conducted by Upjohn, the manufacturer. Depo Provera has been approved in over 60 other countries and is in use in 30 or 40 others with an estimated total of almost 5 million users. A natural hormone, progesterone, DMPA is injected intramuscularly and absorbed slowly. Common dosage is 150 mg every 3 months and usually is administered during the 1st week of the menstrual cycle. The pregnancy rate with Depo Provera is .44 pregnancies/100 women years for women receiving 100 mg every 3 months. No pregnancies were recorded in recent studies for women receiving 150 mg. Possible side effects include amenorrhea, weight gain, dizziness and headaches. The median time for contraception after the presumed duration of one's last injection is 5-1/2 months. Some countries only permit women who already have 1 child to use Depo Provera. The FDA in the US approves the use of Depo Provera for treatment of endometrial and renal cancer but accuses it of causing cancer in Beagles and Rhesus monkeys. The studies were conducted over 7 and 10-year periods, respectively, with extremely negative results including the death of 3 dogs due to "drug-induced diabetes," atrophication of adrenal glands, and malignant tumors. There were similar results for the monkey study. In the UK, the Committee for Safety in Medicine supports Upjohn's view that Beagles are unsuitable for comparison testing because "all dogs are acutely sensitive to progesterone." Groups such as the National Women's Health Network, the institute for Food and Development Policy, and "Mother Jones" have used the media to generate opposition to Depo Provera, citing a double standard for rich and poor women, developed and less developed countries. The proponents of Depo Provera criticize health activists for imposing their own standards on women in developing countries. Regarding concerns about greater risk of Acquired Immune Deficiency Syndrome (AIDS), Depo Provera can be injected with disposable needles. In response to the controversy, Upjohn withdrew its application to the FDA in September 1986 but intends to resubmit with new information from a World Health Organization report, which showed no evidence of an increased risk of cancers of the endometrium, liver, or breast.
Over 40% of all cohabiting women, in Asia and Latin America, are using contraceptives, most of them modern methods. In many countries, upper order births are disappearing, and rural birth rates in some regions have fallen nearly as much as urban ones. The average family size is diminishing sharply. It is close to 2 children in Thailand, and below 2 throughout urban China. 4/5 of the developing world's population live in only 17 countries, in which contraceptive use has risen from 41% to 52% of couples in 10 years. Moreover, family planning programs affect the overall health of the population: fewer births have meant fewer maternal deaths, and fewer orphans, fewer infant and child deaths, fewer high-risk births (especially at short intervals and upper parities), fewer children left unimmunized, and fewer unserved by the health services. The extent of this quiet social revolution has its limits. Mainly in the 50 struggling countries of sub-Saharan Africa, most of them with weak health ministries, as well as, among the largest 8 countries, Nigeria and Pakistan, which have changed little. But both are reactivating their family planning programs, and the concentration of 2/3 of the developing world's population in 8 large countries means that only 8 administrations can control the course of vital rates. The consequence of the great transformation induced by contraceptive use has begun to give developing world's women control over their own child bearing, adding freedom to their lives. Nevertheless, if the contraceptive revolution has enormously advanced the cause of international health, it still has a long way to go.
Nigeria has launched its 1st population policy, reflecting new approval on the part of policymakers of national efforts to curb population growth. Specifically, the policy seeks to reduce fertility from the present level of 6 children/family to an average of 4 children/family, suggests an optimum marriage age of 18 years for women and 24 years for men, and advocates that pregnancies be restricted to the 18-35-year range and at intervals of 2 years. US$100 million has been allocated for a national family planning program, $67 million of which is being provided by the US Agency for International Development (AID). The Nigeria program is AID's largest population program in Africa. Most of the funds will be used to bring family planning services to government-sponsored maternal-child health programs and for public education through the mass media, particularly radio. Without such an effort, Nigeria's population could be expected to double to 160 million by the year 2000.
Oral rehydration therapy (ORT) was hailed 10 years ago as potentially the most significant medical advance of the century. ORT is a simple and inexpensive means of treating diarrheal dehydration, which killed approximately 5 million children each year in the late 1970s. Today 25% of the world's children have access to ORT, and it is estimated that every year it saves 500,000 lives. Where ORT is not widely available, diarrheal dehydration remains the leading killer of children. It is still responsible for 25% of the 250,000 worldwide child deaths each week. Because there have been problems with acceptance of the ORT formula of salt, sugar, and water, researchers have been experimenting with cereal-based oral rehydration formulas that are much like traditional home remedies for diarrhea. In addition to relieving dehydration, these cereal-based formulas lessen severity and duration of diarrheal illness. Critics, however, claim that they fail to provide a child with sufficient calories, and call for a combination of ORT with early feeding--4-8 hours after completion of rehydration. Even with growing evidence of the benefits of early feeding, the practice of withholding food from children with diarrhea persists in the developing world and in the U.S. Problems in developing countries are greater, but each year 14 of every 1,000 American infants are hospitalized because of acute diarrhea. The major hurdle that ORT faces in the U.S. is that it is a simple form of therapy attempting to displace a higher technology. As long the U.S. health care system serves as a model for developing countries, distrust of ORT by American doctors will hamper efforts to spread ORT in the developing world.
