Author: Tom Geraghty

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

This discussion focuses on strengthening health system service delivery and accessibility in Mexico, via the “Oportunidades” programme. The Oportunidades programme is a useful one to explore, firstly because its horizontal approach “has led to increased health service utilization” (Blas et al p.155, 2011) and improved school attendance and nutrition of children across Mexico. Secondly, it has wider applications, as over 50 countries have since replicated the Oportunidades model (Lamanna, 2014). 

 

Oportunidades has also been known as “Progresa” and “Prospera”, but for the purpose of this discussion, “Oportunidades” will be used throughout.

 

Context

 

Mexico is a Lower and Middle-Income Country (LAMIC) with high degrees of social inequality. It encapsulates many of the challenges experienced by countries of all income levels (Frenk, 2006). Poor children in Mexico are more exposed to health risks and hazards than their wealthier counterparts and have less resistance to disease due to undernutrition; reduced access to healthcare further compounds this inequity (Victora et al, 2003). A commitment to Universal Healthcare (UHC) is embedded within the constitution of Mexico, and was achieved in 2012 via a national health insurance programme called Seguro Popular (Knaul et al, 2012), alongside universal education, shelter and social security (Lárraga, 2016). 

 

As such, Mexico is an excellent candidate for research into strengthening health systems, particularly through a Social Determinants of Health (SDH) lens. Under the direction of Julio Frenk, Health Minister 2000-2006, SDH and evidence-based approaches were used to develop policies which focused on equity and quality (Lancet, 2004). 

 

The health system in Mexico is a hybrid model of publicly and privately financed and delivered healthcare and is segmented via three categories: salaried and retired citizens, self-employed or unemployed workers, and those with the ability to pay (Frenk and Gomez-Dantes, 2016). 

 

Health System Service Delivery Improvement

 

Founded in 1997, Oportunidades is a conditional cash transfer (CCT) programme, funded through general taxation. Unlike vertical, selective interventions, Oportunidades takes a horizontal approach. This reflects the Alma-Ata statement that realising ‘Health For All’, “requires the action of many other social and economic sectors in addition to the health sector” (WHO, 1978, I). It is intended to lift families out of cycles of poverty through combined healthcare, nutrition and education approaches, which aligns with the first five Sustainable Development Goals (SDGs) set in 2015 by the United Nations General Assembly, of No Poverty, Zero Hunger, Good Health and Well-being, Quality Education and Gender Equality.

 

The programme is centrally administered and initially covered 300,000 families across 12 states with a budget of 58.8 million USD (Levy, 2006). By 2006, the programme covered 5 million families across 32 states (Bautista Arredondo et al, 2008). The programme now covers over 6.4 million families, alongside training programmes to boost employment, and programmes to support the elderly (Sedesol, 2012). 

 

Conditional payments are made directly from the government to the primary caregiver (usually the mother) of eligible children if they meet requirements, such as school attendance, registering with health clinics, accepting preventative healthcare, attending prenatal and postnatal clinics, and visiting nutrition clinics (Gertler, 2000). The money goes into beneficiaries’ banks accounts or onto prepaid debit cards and consists of contributions for nutrition, health and education, alongside food supplements. This incentivises the uptake of health system services while giving families autonomy over how they spend payments.

 

Crucially, education is integrated into Oportunidades – the strong universal correlation between education and health outcomes is well-established (Holmes and Zajacova, 2014). The programme further demonstrates its SDH credentials and alignment with the goal of Gender Equality, by providing larger incentives for girls to remain in school (Darney et al, 2014). Girls’ education is closely linked to health outcomes; women with higher levels of education have fewer children (Darney et al, 2014), experience fewer childbirth complications because they are more likely to seek medical assistance (Mainuddin et al, 2015), and have greater employment opportunities which help break the intergenerational cycle for families in poverty. Over medium and longer terms, this reduces the burden on health system service delivery. 

 

Operational and strategic strengths

 

One of the programme’s strengths is that two of its key functions facilitate a robust evaluation and improvement feedback loop. Firstly, the well-defined target populations and sequential rollout aids in assessing effectiveness and provides researchers with a Randomised Control Trial (RCT) model (Ambroz and Shotland, 2013) which can compare treatment group families with control group families in locations not yet covered by Oportunidades. Secondly, information collected before payments begin is compared with later results, to establish longitudinal data about the intervention effectiveness (Skoufias, 2005). This has allowed service delivery improvements to be evidence-informed and targeted. 

 

For example, continuous evaluation and improvement has enabled controlled scaling of the programme. Initially, only families that fell below an “extreme poverty” line in rural areas with schools and healthcare facilities within five kilometres were targeted (Ordóñez-Barba, 2019). Using evidence-based decisions, the criteria have since been revised to include urban families above the extreme poverty line (Lárraga, 2016).

 

Another strength is that the programme’s Operational Monitoring Model (MSO) combines national oversight with empowered, autonomous local delivery, which enables rapid response to feedback and systemic changes to service delivery. In 2010, mobile devices were introduced to carry out the ENCASEH (Socio-Economic and Demographic Characteristics of Households) eligibility survey. This increased the pace of eligibility interviews, and allowed staff to inform beneficiaries of their eligibility immediately. However, after staff reported negative reactions to delivering news of ineligibility, including having mobile devices destroyed or stolen and individuals refusing to let them leave, this was quickly changed to ensure that families were not informed until staff had left (Lárraga, 2016).

 

Through the MSO, an Operational Monitoring Report is produced every two months, and references 41 key performance indicators organised around themes of “i) enrollment of families; ii) continuity of beneficiaries in the roster; iii) education; iv) health; v) nutrition; vi) certification of co-responsibilities; and vii) payment of cash benefits” (Lárraga, 2016). The short reporting cycle with accurate indicators of performance has allowed for rapid evaluation of programme changes and early identification of issues or trends. 

 

Although the programme strategy is defined nationally, it is coordinated through 32 state offices. Within each state, local organisations are coordinated within zones, and component “microzones” serve local families who are visited regularly by staff. This presence on the ground has facilitated communication with beneficiaries even in remote areas, aiding early problem detection and improving engagement (WHO, 2014).

 

By making direct payments to families, Oportunidades reduces the potential for corruption and improves financial efficiency. For every $100 allocated to the program, $8.20 is absorbed by administrative costs, compared with equivalent programs such as LICONSA and TORTIVALES where $40 and $14 are absorbed respectively (Coady, 2000). Building on that strength, payments are made to the mother “to guarantee that the spending of these resources would be directed toward buying food for the most vulnerable members” (Skoufias, 2005, p88), thus maximising the return on investment in service delivery.

 

Another strength of the programme, and one reason it has survived changes of government, is its transparency and lack of political alignment. In election years, there has been little or no mass enrollment, to avoid any suggestion that the incumbent government is “buying” votes of beneficiaries. In 2003, workshops and marketing campaigns adopted the slogan “In Oportunidades we all do our share”, to embed a sense of collective ownership and responsibility for the programme. There is therefore little political profit to be gained from a new government changing the scope of Oportunidades, or halting it altogether.

 

Success of UHC requires health-care service delivery to be managed efficiently (Sumriddetchkajorn et al, 2019). Financially, Oportunidades has proven to be efficient and stable at scale. Whilst the coverage and the budget of the programme has increased from 0.3million to 6.4million families from 1997 to 2017, the share of the federal expenditure never exceeded 2.3 percent (Ordóñez-Barba and Silva-Hernández, 2019). 

 

Impact on service delivery and access

 

In respect to service delivery, the impact of Oportunidades is striking. Access to healthcare services has increased: more than 93 percent of beneficiaries in the programme have access to regular medical care, including preventative medicine and treatment (ASF, 2016, in Ordóñez-Barba & Silva-Hernández, 2019), compared to the average of 51.5% across the population (Gutiérrez et al, 2014). 

 

Access to prenatal and postnatal healthcare increased by 12.2% over a ten-year period (Barber & Gertler, 2009). In the programme’s first year, healthcare clinic visit rates grew faster than in control areas, as did immunisation rates and prenatal and postnatal care. The increase in prenatal care also significantly reduced the number of first visits in the second and third trimesters of pregnant women (Gertler, 2000). Maternal and child mortality has improved significantly (Gertler, 2000) and the number of children suffering from malnutrition dropped from 25% to 8.2% between 2000 and 2015, “alongside a greater efficiency in relation to the cost of medical attention” (Ordóñez-Barba & Silva-Hernández, p.97, 2019). A 2004 study on Oportunidades’ impact on growth and anaemia in children, showed that haemoglobin levels were higher in children in treatment groups, and the programme was associated with better growth among the poorest and youngest infants (Rivera et al, 2004). 

 

Participation in Oportunidades also correlates with increased diabetes mellitus detection and treatment (Behrman and Parker, 2011) through improved healthcare access.

 

Weaknesses in relation to health system service delivery 

 

Oportunidades is not without weaknesses. Errors are prevalent in targeting, to the exclusion of eligible, and inclusion of ineligible, families (Ordóñez-Barba and Silva-Hernández, 2019). Some have critiqued the programme’s RCT methodology, suggesting that a quantitative approach that drives towards binary options of success or failure leaves little room for qualitative debate and nuance (Faulkner, 2014). Another criticism is that “contamination” of the treatment groups could occur through members of control groups immigrating to treatment group locations in an attempt to become eligible (Behrman & Todd, 1999). 

 

The programme has been criticised for perpetuating “family-ism”, and the gender inequality inherent in assuming “the role of mothers in guaranteeing the effectiveness of public investments,” (Barba and Valencia, 2016, in Ordóñez-Barba and Silva-Hernández, 2019, p.86), though the same authors also recognise the programme’s commitment to addressing gender inequality through its potential to transform the traditional roles of women.

 

Some critics doubt how much impact CCT has on the trajectory of families in areas of low job availability. (Ordonez-Barba & Silva-Hernández, 2019) Likewise, it is of little use sending women to health clinics and children to school if the health clinics and schools are poor (Marmot, 2015; García-Guerra et al, 2019). To realise genuine improvements to health systems, the programme must be closely linked to economic strategy to ensure that it can improve “the productivity of families so that they are able to generate income through their own efforts and diminish their dependency on monetary transfers” (Presidencia de la República, 2014, para. 20). 

 

Finally, some consider CCT programmes authoritarian. Whilst Oportunidades is intended to empower beneficiaries: “development can be seen as a process of expanding the freedoms that people enjoy” (Sen, 1985, p.3), imposing conditions upon payments can be seen as infringing on “freedom and dignity, creating disempowerment and power imbalances between programme providers and beneficiaries” (Scheel et al, 2020, p.718). Therefore, whilst Oportunidades aligns with the Alma Ata principles of “comprehensive healthcare for all” (WHO, 1978, VII, 6), it could be argued that its use of CCT conflicts with its spirit of self-determination.

 

Conclusions

 

Through their themes of “dignity, people, planet, partnership, justice, and prosperity for majority” the SDGs align with the WHO definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Oleribe et al, 2015, Commentary). They therefore provide an appropriate ‘North Star’ for improving health system service delivery.

 

The Oportunidades programme supports the SDGs, particularly as they reflect the interrelationships and dependencies of escaping poverty through education, equality, economic development, partnerships and strong institutions (UN, 2015). Despite its critics, it has proven highly effective in strengthening health system service delivery and access, through its SDH approach.

 

Word count: 1999

 

References:

 

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Behrman, J. R., & Todd, P. E. (1999). Randomness in the Experimental Samples of PROGRESA (Education, Health and Nutrition Program); IFPRI Discussion Paper.

 

Behrman, J. and Parker, S. (2011) “The Impact of the Progresa/Oportunidades Conditional Cash Transfer Program on Health and Related Outcomes for the Aging in Mexico”, SSRN Electronic Journal. doi: 10.2139/ssrn.1941850.

 

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(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

Social science approaches to research differ from epidemiological approaches in a number of ways. Whilst epidemiological approaches are deductive (that is, typically starting with a hypothesis to be proven or disproven) quantitative, social science methodologies may typically be inductive (beginning with an observation that may result in a hypothesis being created), and qualitative. The two approaches are still regarded by many researchers as incompatible means for knowledge construction (Teddlie & Tashakkori, 2003).

 

Both approaches align with the scientific method: methodologies are explained so that studies may be understood and replicated by others, results are presented clearly, and conclusions are stated. The two approaches could be considered complementary to each other, each providing the foundation for further research and generation or confirmation of hypotheses as in figure 1 below.

Figure 1: The complementary nature of Social Science and Epidemiological Methodologies.

 

The 2013-2015 ebola outbreak in Sierra Leone presented urgent clinical and epidemiological challenges, whilst cultural, sociological and political aspects complicated and compounded the situation. 

 

Park et al (2015) analysed sequences from 232 patients in Sierra Leone, along with 86 previously released genomes from earlier in the epidemic, in order to establish whether the virus was being transmitted inter or intra-country. The study took 7 months to complete and provided strong evidence showing that ebola transmission was primarily within-country, not between-country. This provided decision makers with actionable rationale for controlling the movement of people; however it did so only after a full 7 months, by which time over 9,430 cases had been reported (CDC 2017 data).

 

Ebola is transmitted via bodily fluids including blood, faeces and vomit. The cause of death includes hemorrhaging from orifices and the skin, and as a result, the corpses of ebola victims are highly infectious. In Sierra Leone, washing a corpse prior to burial and touching a corpse during a funeral are common and important elements of local funeral traditions (Richards et al, 2015). Therefore, it was important to quickly understand how to reduce the ebola infection rates related to funerals and burials, and how safe medical burials may be encouraged through understanding local beliefs and practices.

 

Lee-Kwan et al (2017) carried out a rapid qualitative assessment using focus group discussions that explored community knowledge, attitudes, and practices towards safe and dignified burials in seven chiefdoms in Bo District, Sierra Leone. The study took place over the week of October 20th, 2014, and identified perceived barriers to accepting safe burials that were then used to inform emergency response teams with the goal of reducing transmission of the disease. In less than a month, this data was accessible by aid workers and humanitarian agencies who were able to improve the way they worked with affected communities and slow the spread of the disease.

 

These examples show that whilst an epidemiological approach provided valuable, precise, and reliable confirmatory data regarding the spread of ebola, a social science approach provided rapid, actionable information that could be used to slow the spread. 

 

Social science methodologies that use qualitative assessments, despite a potential for lower reliability and validity, can generate rapid and actionable insights. This is where the RAR (Rapid Assessment and Response) emerges. RAR is not a single method but a collection of largely qualitative tools, such as interview guidelines and surveys, designed for a particular public health issue. RARs utilise the strengths of social science methodologies such as highly contextual, informal and rapid data gathering to identify existing resources and opportunities for intervention, and help plan, develop and implement interventions and programmes. (Boyce et al, 2004). The goal of a RAR is “to accumulate just enough information to be able to assess whether a particular problem is occurring and how this may be resolved.” (McKeganey, 2000). RARs, and other social science approaches, possess strengths in being able to utilise local expertise, tools and resources which improves cost-effectiveness and provides training for the local community to mitigate health risks. Additional RAR guides are available specifically for use in other health issues, such as working with vulnerable young people (Malcolm & Aggleton, 2004). 

 

Some practitioners and policymakers may see qualitative research, RARs in particular, as weaker in validity than quantitative methods, though it should be seen as an indicator reliable enough to start effective health promotion interventions. (Trautmann & Burrows, 1999)

 

Not only can social science methodologies provide more rapid data and actionable outcomes, but these types of research methods have an unrivalled capacity to constitute compelling arguments about how things work in particular contexts. (Mason, 2002) Social science methodologies can “explore the perspectives, experiences, relationships and decision-making processes of human actors within health systems, and in so doing, help uncover and explain the impact of vital but difficult-to-measure issues such as power, culture and norms” (Topp et al, 2018). 

 

However, in the power of highly specific context resides a weakness: quantitative evidence possesses less validity in different contexts to the original study, thus it is more difficult to transpose findings into different contexts. It is also more difficult to control for a variety of biases such as recallability or framing, with such methodologies.

 

Combining social science and epidemiological methods can be powerful. A mixed-method approach can provide the means to more accurately target qualitative research studies. For example, Wilson et al (2016), used an epidemiological approach to analyse cell phone data to rapidly identify population displacement from affected areas in Nepal after the 2015 earthquake. This quantitative data was used to direct, triangulate and strengthen the findings of immediate aid and further qualitative studies. 

 

The essential rationale of the mixed methods approach is that through a multidisciplinary approach that combines qualitative and quantitative methods, one can utilise their respective strengths and escape their respective weaknesses (Tashakkori & Teddlie, 1998) (From Lund, 2012). 

 

When studying health risks, social science approaches can provide rapid, actionable data, deep context, and additional benefits to the communities in question. Quantitative epidemiological approaches provide greater validity and reliability, and may facilitate more robust decision making. Ultimately, a mixed-methodology approach provides actionable, context-rich data in the shortest possible timescale.

 

Word Count: 988

 

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Lee-Kwan, S.H., DeLuca, N., Bunnell, R., Clayton, H.B., Turay, A.S. and Mansaray, Y., (2017). Facilitators and barriers to community acceptance of safe, dignified medical burials in the context of an Ebola epidemic, Sierra Leone, 2014. Journal of health communication, 22(sup1), pp.24-30.

 

Lund, T., (2012). Combining qualitative and quantitative approaches: Some arguments for mixed methods research. Scandinavian journal of educational research, 56(2), pp.155-165.

 

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McKeganey, N., (2000). Rapid assessment: really useful knowledge or an argument for bad science?. International Journal of Drug Policy, 1(11), pp.13-18.

 

Park, D.J., Dudas, G., Wohl, S., Goba, A., Whitmer, S.L., Andersen, K.G., Sealfon, R.S., Ladner, J.T., Kugelman, J.R., Matranga, C.B. and Winnicki, S.M., (2015). Ebola virus epidemiology, transmission, and evolution during seven months in Sierra Leone. Cell, 161(7), pp.1516-1526.

 

Richards, P., Amara, J., Ferme, M.C., Kamara, P., Mokuwa, E., Sheriff, A.I., Suluku, R. and Voors, M., (2015). Social pathways for Ebola virus disease in rural Sierra Leone, and some implications for containment. PLoS Negl Trop Dis, 9(4), p.e0003567.

 

Tashakkori, A. and Teddlie, C. (1998). Mixed methodology: Combining qualitative and quantitative approaches, Thousand Oaks, CA: Sage.

 

Topp, S.M., Scott, K., Ruano, A.L. and Daniels, K., (2018). Showcasing the contribution of social sciences to health policy and systems research. Int J Equity Health 17, 145

 

Trautmann, F. & Burrows, D., (1999). Conditions for the effective use of rapid assessment and response methods, Marrickville: International Journal of Drug Policy.

 

Wilson, R., zu Erbach-Schoenberg, E., Albert, M., Power, D., Tudge, S., Gonzalez, M., Guthrie, S., Chamberlain, H., Brooks, C., Hughes, C. and Pitonakova, L., (2016). Rapid and near real-time assessments of population displacement using mobile phone data following disasters: the 2015 Nepal Earthquake. PLoS currents, 8.

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

 

Charles Rosenberg’s 1992 essay “What Is An Epidemic” characterises an epidemic into four Acts, and utilises Albert Camus’s 1948 novel “The Plague” to describe these Acts of “Progressive Revelation”, “Managing Randomness”, “Negotiating Public Response”, and “Subsidence and Retrospection” (Rosenberg, 1992). Whilst this “Four Acts” model cannot fit all mass disease events, it is a useful lens which will be used here to explore the cultural impacts of population-scale diseases. This essay focuses on one historic epidemic: Spanish Flu during 1918-1919, drawing on parallels with other historic pandemics such as HIV/AIDS in the 1980s, and Ebola in West Africa during 2014, and critically addresses how those lessons were later applied to the Covid-19 pandemic of 2020. 

 

Culture is the manifestation of the history, knowledge, values, and beliefs of people, and plays a significant role in the spread of disease by influencing how often and the manner in which people interact, and the scale of interactions, alongside rituals, ceremonies and traditions. These include everything from purchasing groceries to attending large concerts. Culture is fundamental to epidemiology: it is a contributing factor in how rapidly a disease spreads, to whom, and to how people who are diagnosed are treated, or if they are treated at all (Bristow, 2010). 

 

Spanish Flu constitutes a prime example of a post-germ theory, pre-influenza vaccine, epidemic in developed urban centres. Pharmaceuticals to effectively treat influenza were not widely available, and as such non-pharmaceutical interventions, including behavioural changes, were the primary response. The US rather than European context of Spanish Flu is more pertinent to cultural change, as World War I and its impacts obscures much of the impact of the disease and its effect on culture in Europe. The virus did not originate in Spain, and was termed Spanish Flu because Spain did not censor its press during the war, unlike many other countries, so those first Spanish cases, including the King of Spain, made for a highly visible disease that became known as Spanish Flu (Whiting, 2020). The epidemic lasted for two years from the first recorded case in March 1918 to the last in March 1920, killing an estimated 50million people, though the true death toll may be up to twice that number (Johnson and Mueller, 2002). The Covid-19 death toll at time of writing is 4.1million people (Dong et al, 2021). 

 

Act I, Progressive Revelation.

 

“Progressive Revelation” is the slow acceptance and acknowledgement of the problem, a slowness which may be explained by the suggestion that acknowledging it can threaten existing economic and institutional interests and power structures (Sajtos et al, 2021). At the time of the Spanish Flu epidemic, people and information travelled more slowly than they do today. There were no commercial aeroplanes, and cars and telephones were the preserve of the rich: although the 1918 influenza virus spread slower than Covid-19 (Terry, 2020), the spread of information about the dangers, precautions and treatments was equally slow. 

 

The history of medicine is incomplete without the stories of the patients, their experiences, beliefs and behaviours (Porter, 1985), and it is this narrative backdrop that provides us with the greatest understanding of the epidemic itself. In post-germ theory USA at the time, life expectancy was on the rise and it was perceived by some at least that infectious diseases may be a thing of the past (Karlen, 1996). Influenza, however, was a familiar visitor, bringing sickness every year, which made the public complacent, a fact which even prior to 1918 caused concern for public health officials who recognised the need for public vigilance (Anderson, 1894). Public complacency was similarly a worry early in the Covid-19 pandemic as the previous SARS-CoV epidemic of 2002, and the H1N1 epidemic of 2009 were remembered as diseases that were significantly less transmissible or deadly than initially feared (Rogers, 2020). Health authorities in 2020, conscious that public complacency could hamper measures to control the pandemic if they were not adhered to, ensured that messaging was as clear and commanding as possible, whilst trying to avoid hysteria or spectacle (Krpan and Dolan, 2021).

 

Early behaviour change is an essential strategy in the management of an epidemic. For example, the rapid spread of the 2014 Ebola epidemic in West Africa was partly related to cultural practices of washing the dead to help them transition to the afterlife (Manguvo and Mafuvadze, 2015). Even once it was recognised that Ebola spreads through physical contact with an infected person’s bodily fluids, the value placed on these rituals, as with many cultural practices, meant that behaviour change was difficult to engender. Some families were so motivated to continue their funeral rites that they bribed corpse collectors to provide false cause of death reports (Dixon, 2014). Like Ebola, Spanish Flu also delayed or prevented funerals, and meant many were buried in mass graves, all of which deprived families of their traditional mourning process. This experience, along with a fear of infecting loved ones with an invisible disease, is believed to have inspired many of the zombie-like figures in the works of H. P. Lovecraft and the 1919 silent film “J’accuse” by Abel Gance, through a desire to visualise an invisible monster (Outka, 2019). Learning this lesson, visually engaging the public as early as possible particularly in order to convey the human impact of the disease, has proven powerful in encouraging behaviour change during the Covid-19 pandemic (Wilson and Frey, 2020).

 

During the early phases of the 1918 pandemic, many governments attempted to impose “maritime quarantine” in order to prevent the spread of the disease from elsewhere, but it was often imposed too late or was breached by people not yet symptomatic (Crosby, 1976). Australia was the notable exception, successfully delaying the second wave of the pandemic (Crosby, 2003), and indirectly protecting many Pacific islands from the worst of the disease (Shanks et al, 2018). This cultural lesson was only learned by a handful of governments responding to Covid-19. Some governments such as New Zealand, which suffered 5 deaths per million people, implemented full border controls very early on, in contrast to the UK, which kept borders open and suffered 1,900 deaths per million (Our World In Data, 2021). Most Western governments attempted to implement a modern-day equivalent of maritime quarantine using border testing and quarantine. However, the 2009 H1N1 epidemic experience showed that only 6.67% of cases were accurately detected through border testing (Gunaratnam et al, 2014), and education programmes to encourage people to only make essential travel, and get tested prior to travelling, were proven to be more effective (Grépin et al, 2021). 

 

Act II, Managing Randomness.

 

In Rosenberg’s second Act, “Managing Randomness”, a recurring epidemic theme is the scapegoating of groups already seen as undesirable or undeserving. Rosenberg suggests this is an effort to create order and meaning out of chaos, and has been recorded in many epidemics, including impoverished Jews who were blamed for the cholera pandemic of 1892 (Markel, 1999), Chinese immigrants for the bubonic plague outbreak in San Franscico in 1900 (Kraut, 1994), and the stigmatisation of gay men and Haitians in the HIV/AIDS epidemic in the 1980’s (Grmek, 1990). Even amongst some medical professionals in 1982, HIV became known as “GRID”: Gay-Related Immune Deficiency (Epstein, 1996). In general, immigrants were not blamed for Spanish Flu, possibly because it struck individuals of all groups and classes (Kraut, 2010). In 2020 however, President Trump’s “Chinese virus” statements led to a rise in Asian hate crime (Kurtzman, 2021), and naming Covid-19 variants as originating from a particular country, align with this leitmotiv of pandemics (Markel, 2007). Scapegoating and stigmatising certain groups makes it more difficult for those people to get treatment, and distracts from the true causes of the disease. This is clearly a lesson yet to be learned.

 

Just as “big pharma” conspiracy theories grew during the Covid-19 pandemic, during 1919, rumours emerged that Spanish Flu was linked to the German pharmaceutical firm Bayer intentionally spreading disease, and was compounded by the start of the epidemic coinciding with the end of WW1 (Cohut and Guildford, 2020). Physicians of the time were unaware of the side effects of high doses of aspirin, which can result in hyperventilation and pulmonary oedema – symptoms often seen in early deaths from Spanish Flu. Many victims were treated with high dose aspirin, and as a result, a significant proportion of Spanish Flu deaths may in fact be attributable to aspirin toxicity (Starko, 2009), a correlation which emboldened the conspiracy theorists. In the face of uncertainty, governments and healthcare organisations during Covid-19 attempted to provide as much clear and accessible information as early as possible, to enable people to spot conspiracy theories before they fell for them (Douglas, 2021).  

 

The economic impact of the 1918 epidemic was greater for developing countries than developed countries (Murray et al, 2006). Learning from this lesson, the Indian government prioritised healthcare, supply chains and employment opportunities during the Covid-19 crisis in order to avoid deeper economic harm (Sharma et al, 2021). However, not all economic lessons have been so clearly learned. The impact of Spanish Flu exacerbated the increasingly protectionist approaches of governments after World War I, restricting the free movement of people and goods (Boberg-Fazlic, et al, 2021). Similar nationalistic and protectionist approaches are already being seen as a result of Covid-19, highlighting “the downsides of extensive international integration while fanning fears of foreigners and providing legitimacy for national restrictions on global trade and flows of people” (Legrain, 2020). 

 

Economically and sociologically, Spanish Flu provided a stimulus to socialised healthcare through a realisation that treating disease at an individual level was insufficient for managing pandemics that affected entire populations. Prior to 1918, there persisted a eugenics-based belief that disease was a particular problem of the lower classes due to their inherent inferiority (Lombardo and Dorr, 2006). After the 1918 pandemic, it was clear that treating individuals in isolation or blaming people for becoming infected was an ineffective strategy, and subsequently many governments embraced socialised medicine; Russia first, via a state-run health insurance programme, followed by other European countries. The USA followed suit in their own way by consolidating healthcare into employer-based insurance schemes (Spinney, 2017). 

 

Act III, Negotiating Public Response.

 

Public response must be negotiated in order to build collective, sustained, and consistent action against epidemics. Rosenberg’s third Act, “Negotiating Public Response”, describes how prophylactic measures were strictly enforced in slums and poor areas of the city, but less so in affluent areas, despite affluent areas generating many cases (Rosenberg, 1992). Although public adoption of facemasks was relatively high in the US during the Spanish Flu epidemic, due to a consensus that influenza was airborne (Crosby, 1976), the surgical masks adopted by the public at the time were made of gauze, which was insufficient to prevent the spread of virus particles (Nakayama, 2020). Cities where masks were compulsory suffered as much as cities where masks were optional (MacDougall, 2007) and there was significant opposition on some fronts to the wearing of masks (The Seattle Star, 1918). During the Covid-19 pandemic, effective mask materials such as N95 have been widely available and largely adopted in countries where wearing masks in public was previously rare, but has been accompanied by vocal opposition from some (Barceló & Sheen, 2020). The same tension between individual liberty and collective responsibility arose in the HIV/AIDS epidemic in the 1980s, where there was initially strong resistance to the percieved oppression of gay people and their rights, including wearing of condoms. This is understandable response, given the wider context of gay freedom that had been so hard-won (Berridge, 1996; Shilts, 1987), and illustrates a key cultural barrier to proactive public engagement.

 

Schools have an ability to engage with and influence the public response. In 1918, American schooling was in the process of transformation; by 1920, almost 65% of the eligible population had attended school, with attendance rates consistently over 90%, a significant increase in uptake (Ross, 1924). Children in public schools were subject to regular health inspections and believed to be better protected from the threat of infectious disease than those out of school (Doty, 1911). Many schools had full-time nurses, smallpox vaccination programs, and contingency plans for serious disease outbreaks (Stern et al, 2010). Most schools in the USA closed during Spanish Flu, but some schools such as those in New York, Chicago and New Haven, opted for a successful strategy of remaining open during the epidemic under a rationale which recognised the role that schools could play in monitoring the spread of disease, communicating health and hygiene information to parents, and providing more hygienic school environments than many children had at home (Robertson, 1919). The lessons from this success were perhaps overlooked during the Covid-19 pandemic, when many schools in the USA were closed in efforts to hinder the spread of the virus, which has resulted in an increased attainment gap between higher- and lower-income families, exacerbated food insecurity, and increased the risk of childhood abuse or trauma (Van Lancker and Parolin, 2020, UNICEF, 2021). 

 

Act IV, subsidence and retrospection

 

“The most vexing phase of an epidemic” (Markel, 2007, p. 47): the eventual decline in cases and the opportunity to reflect, learn and adapt. After 1919, enthusiasm for the scientific method in the USA waned, in part due to the significant blow to the prevailing consensus at the time that all diseases were caused by bacteria (Tognotti, 2003); if science was wrong about this, what else was science wrong about? Conversely, Chinese culture, which has typically embraced Traditional Medicine and suffered less from the impact of Spanish Flu (Cheng and Leung, 2007), learned valuable lessons and became more scientific after 1919, including improved public health surveillance and better data collection (Whiting, 2020).

 

Economically, Spanish Flu had a devastating impact and reduced the average GDP by 6% (Maas, 2020). The largest adverse macroeconomic events of modern times were World War II, the Great Depression of the 1930s, and WW1, followed by Spanish Flu (Barro and Ursúa, 2008). Such a devastating economic impact would surely leave significant scars on society, yet the cultural memory of Spanish Flu feels faint (Onion, 2020) and American culture in particular failed in some respects to acknowledge the impact of the epidemic (Bristow, 2010). It can be difficult for people to contextualise disease, particularly population-scale diseases (Outka, 2019). After a war, it may be possible to reconcile death with a sacrifice that was necessary for the war to end, and people who died in wars may be memorialised as heroic, but rarely are those who died in epidemics memorialised: instead, they are seen as only tragic (Bristow, 2010). Learning lessons from pandemics is much more difficult because the acute visual reminder of the scale of the deaths is not present, unlike deaths caused by conflict, which may leave scars on the land as well as the memory. As a result of this faint epidemic memory, many of the lessons that could have been learned from such a devastating pandemic have been lost, or painfully learned again during the Covid-19 pandemic.

 

References:

 

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Barceló, J. and Sheen, G.C.H., 2020. Voluntary adoption of social welfare-enhancing behavior: Mask-wearing in Spain during the COVID-19 outbreak. PloS one, 15(12), p.e0242764.

 

Barro, Robert J. and Jose F. Ursúa (2008). “Macroeconomic Crises since 1870.” Brookings

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Berridge V. 1996. AIDS in the UK: The Making of Policy,1981–1994. Oxford, UK: Oxford University Press.

 

Boberg-Fazlic, N., Lampe, M., Pedersen, M.U. and Sharp, P., 2021. Pandemics and Protectionism: Evidence from the “Spanish” flu. Humanities and Social Sciences Communications, 8(1), pp.1-9.

 

Bristow, N.K., 2010. “It’s as Bad as Anything Can Be”: Patients, Identity, and the Influenza Pandemic. Public Health Reports, 125(3_suppl), pp.134-144.

 

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Cheng, K.F. and Leung, P.C., 2007. What happened in China during the 1918 influenza pandemic?. International Journal of Infectious Diseases, 11(4), pp.360-364.

 

Cohut, M and Guildford, A. 2020.The flu pandemic of 1918 and early conspiracy theories. Medical News Today. Available at: https://www.medicalnewstoday.com/articles/the-flu-pandemic-of-1918-and-early-conspiracy-theories (Accessed: 12 July 2021).

 

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Douglas, K.M., 2021. COVID-19 conspiracy theories. Group Processes & Intergroup Relations, 24(2), pp.270-275.

 

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Kurtzman, L. 2021. Trump’s ‘Chinese Virus’ Tweet Linked to Rise of Anti-Asian Hashtags on Twitter. Available at: https://www.ucsf.edu/news/2021/03/420081/trumps-chinese-virus-tweet-linked-rise-anti-asian-hashtags-twitter (Accessed: 14 July 2021).

 

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Outka, E., 2019. Viral Modernism. The Influenza Pandemic and Interwar Literature. Columbia University Press.

 

Onion, R. (2020) The 1918 Flu Pandemic Killed Millions. So Why Does Its Cultural Memory Feel So Faint?, Slate Magazine. Available at: https://slate.com/human-interest/2020/05/1918-pandemic-cultural-memory-literature-outka.html (Accessed: 12 July 2021).

 

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Ross, F.A., 1924. School attendance in 1920: An analysis of school attendance in the United States and in the several states, with a discussion of the factors involved (Vol. 5). US Government Printing Office.

 

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Sharma, A., Ghosh, D., Divekar, N., Gore, M., Gochhait, S. and Shireshi, S.S., 2021. Comparing the socio‐economic implications of the 1918 Spanish Flu and the COVID‐19 pandemic in India: A systematic review of literature. International Social Science Journal.

 

Shilts, R. 1987. And the Band Played On: Politics, People, and the AIDS Epidemic. St. Martin’s Press, New York.

 

Spinney, L. 2017. How the 1918 Flu Pandemic Revolutionized Public Health. Smithsonian Magazine. Available at: https://www.smithsonianmag.com/history/how-1918-flu-pandemic-revolutionized-public-health-180965025/ (Accessed: 13 July 2021).

 

Starko, K.M., 2009. Salicylates and pandemic influenza mortality, 1918–1919 pharmacology, pathology, and historic evidence. Clinical Infectious Diseases, 49(9), pp.1405-1410. 

 

Stern, A.M., Reilly, M.B., Cetron, M.S. and Markel, H., 2010. “Better Off in School”: School Medical Inspection as a Public Health Strategy During the 1918–1919 Influenza Pandemic in the United States. Public Health Reports, 125(3_suppl), pp.63-70.

 

Terry, M. 2020. Compare: 1918 Spanish Influenza Pandemic Versus COVID-19 | BioSpace (2021). Available at: https://www.biospace.com/article/compare-1918-spanish-influenza-pandemic-versus-covid-19/ (Accessed: 20 July 2021).

 

The Seattle star., October 30, 1918, Page 7, Image 7. (Seattle, Wash.) 1899-1947, October 30, 1918, Image 7 (1918). Available at: https://chroniclingamerica.loc.gov/lccn/sn87093407/1918-10-30/ed-1/seq-7/ (Accessed: 14 July 2021).

 

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Van Lancker, W. and Parolin, Z., 2020. COVID-19, school closures, and child poverty: a social crisis in the making. The Lancet Public Health, 5(5), pp.e243-e244.

 

Whiting, K., 2020, April. A science journalist explains how the Spanish Flu changed the world. In World Economic Forum. https://www. weforum. org/agenda/2020/04/covid-19-how-spanish-flu-changed-world.

 

Wilson, N, Frey, T. 2020. COVID-19: Visualizing the impact of an invisible threat. McKinsey. Available at https://www.mckinsey.com/featured-insights/coronavirus-leading-through-the-crisis/covid-19-visualizing-the-impact-of-an-invisible-threat (Accessed: 14 July, 2021)

 

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

Introduction

This study aims to understand the sexual behaviours, attitudes to risk, and levels of health literacy of men who have sex with men (MSM) in a small rural community in sub-saharan Africa, in relation to the spread of HIV/AIDS. Research objectives include:

 

• To gather data to improve the understanding of the links between behaviour and the spread of HIV/AIDS in MSM in this location. 
• To improve health literacy and awareness of HIV/AIDS transmission.
• To identify existing resources and community structures that could be utilised in health interventions.

 

Contextual considerations for the study will be explored, then study design itself, analysis and interpretations, followed by limitations and conclusions.

Design considerations

MSM, and individuals with HIV/AIDS have always been stigmatised: “What society judged was not the severity of the disease but the social acceptability of the individuals affected with it…” (Shilts, 1987). Studies show that while unprotected sex between MSM is commonplace in Africa, knowledge of the risk of HIV/AIDS is poor. Stigma, violence, and a lack of safe social and health resources is widely reported (Smith, 2009). 

 

As with any public health issue, it is critical to recognise “the importance of taking into account the characteristics of the relationships and interactions in which risk takes place” (Van Campenhoudt et al., 1997, from Dulor and Hubert, 2000). In this case, the stigmatised and illicit nature of sex between men is one in a complex array of factors which influence attitudes to risk and decision making.

 

MSM are particularly vulnerable to HIV/AIDS due to transmission via unprotected sex (Jaffe, 2007, Smith, 2009). Although this has prompted effective interventions to reduce transmission, it is still difficult to access and identify MSN for the purpose of needs assessment and other health-focused research. Reasons include that homosexuality in some regions is illegal or stigmatised, sex may occur under coercion and force, or MSM may not identify as gay (McKenna, 1996, from Boyce et al, 2004). 

 

This stigmatisation and marginalisation means that these groups are hard to reach, or hidden, and may be under-served by health research and interventions. Sydor (2013) describes this type of group as:

 

• Hard to reach: a population that is difficult to access.
• Hidden: a population with no defined limits, such that its exact size cannot be known.
• Sensitive subject: a subject that some people prefer not to discuss publicly.

 

Not only are these groups difficult to identify and access, but people who engage in illicit or stigmatised behaviour may be reluctant to provide personal information to researchers or health practitioners. MSM may perceive threats to their livelihoods, social status or lives, should their sexual behaviour be revealed. 

 

A lack of understanding of research, mistrust in western medicine and a distrust of authority increases friction. Prevention and control programs for HIV/AIDS in sub-saharan Africa have seen patients refuse surgery or other medical treatment unless their traditional healer sanctions it. (Liverpool et al, 2004)

 

Another contextual factor to consider is that communities such as this may present low educational attainment (Williams, 2005); in one study, rural students in sub-saharan countries scored significantly lower in reading tests than their urban counterparts (Zhang, 2006). This low literacy alongside poor understanding of health risks can result in reduced condom use, low rates of HIV testing and higher incidence of HIV/AIDS, but crucially it also presents challenges in study design and obtaining informed consent.

 

Finally, exploring heuristics is important to this study in order to understand how people who may not possess the knowledge or information to make fully-informed, rational decisions make “short-cut” decisions instead: “Individuals use heuristics to rationalize uncertainty” (Bailey and Hutter, 2006). For instance, the perceived risk of HIV/AIDS may be lowered by knowing the sexual partner (Skidmore and Hayter, 2000), believing their partner is faithful, or sex occurring between consenting adults rather than being paid for (Vanlandingham and Trujillo, 2002). There may even be a belief that sex between men (opposed to women) does not pose a risk for HIV. (Zulu and Zulu, 2006)

Study Design

The study design chosen for this research is based upon the Rapid Assessment and Response (RAR) model of cross-sectional community-based qualitative research. Through this, the study will focus on the settings and contexts of the sexual behaviours, health literacy and attitudes to risk of MSM in this location. 

 

The study will adopt a Social Determinants of Health (SDH) approach, recognising that individual behaviours are not always an individual choice; health and choices are influenced by life circumstances and a complex web of social, political and economic conditions (Lins et al. 2010). As well as targeting individuals, interventions to control HIV should aim to change aspects of cultural and socio-economic context that increase the vulnerability of people and communities to HIV (Buve et al, 2001, from Marmot and Wilkinson, 2005). An SDH approach allows examination of systemic “causes of the causes” to better facilitate effective health interventions.

 

The study population is men aged 16+, living within this community who have engaged, or engage, in sex with men, even if they do not identify as being MSM. 

 

Participants will be identified and accessed by working with existing community groups, aid and outreach workers, and medical professionals. Recruitment posters will be placed in suitable locations. Screening questions will be used to ensure participants meet the criteria for the research. Whilst social media may provide an avenue for promotion, the small geographic study size in this case makes this approach unlikely to prove worthwhile.

 

Snowball sampling will be employed to increase the size of the survey group in this study, as it is an effective method for sampling hidden populations (Atkinson, 2001). Participants will be asked to recruit friends and acquaintances who also meet the criteria. It is recognised that selection bias, gatekeeper bias and the risk of only recruiting participants from a sub-group (Becker 1963) may limit the validity of the samples. However, as qualitative research, this study does not require significant representativeness for generalisability, and as such these potential issues are not of great concern (Bonevski et al, 2014).

 

Small payments for time and expenses will be provided to participants. The size of this payment will ensure that participants are not put at a financial disadvantage through their involvement, whilst avoiding the potential for acquiescence bias.

 

Focus groups of six to ten individuals will be used to build the exploratory information base, while providing a platform for improving the health literacy of participants. Then private semi-structured, questionnaire-driven interviews will be conducted to dive deeper into beliefs and contexts.

 

Questionnaires will be pre-tested for time taken, ease of use and any emotionally overly-burdensome questions, using volunteers from the same region with similar socio-economic and literacy status to the participants. 

 

Contextual questions include socio-demographic characteristics such as estimated birthdate, education and work status and multivariate poverty assessment. Sexual behaviour, spousal status, and sexual history will be discussed and recorded, alongside health literacy, including understanding of the transmission and effects of HIV/AIDS and other STIs. 

 

The use of substances including drugs and alcohol will be investigated as although findings are inconsistent, studies have shown that substance use can be correlated with high risk behaviours such as unprotected sex. (Myers et al, 2004)

 

The interviews will be written and tested to reduce bias related to question framing, anchoring and recency/recallability. Self-completion or electronic questionnaires could be used, and have shown to be useful when surveying sensitive topics (Gnambs and Kaspar, 2015, Johnson et al, 2001), but due to the variable literacy level of the target population, this is not considered viable in this case. 

 

As in research by Maher et al (2009), text messaging will be offered as an effective way to keep in touch with participants and remind them of interview sessions and focus group meetings. 

 

Building rapport with the participants is essential to generate deep insights given the sensitive nature of the issues, and to obtain interactive informed consent, particularly when participants may have low levels of literacy (Cortes et al, 2010). Researchers will be encouraged to initiate conversations with participants about the study itself, and about unrelated topics if they arise. Participants will also be encouraged to initiate contact with the researchers themselves: this provides participants with a degree of autonomy and control over the process that may aid communication. To further build rapport and trust, interviews will be carried out in the participants’ native language, by men of the same ethnicity as participants. 

 

The venue will be easily accessible and unrelated to the diagnosis and treatment of HIV/AIDS: the study is focussed on context, understanding and behaviours, and perceived “medicalisation” of the study could be detrimental. Similarly, although participants will be offered voluntary HIV tests, it will be made clear that testing is not compulsory or part of the research, as concerns about compulsory testing could reduce the sample size.

 

It is important to measure the MSM population size in this region in order to determine representativity of the study sample, and establish effective health interventions. A capture-recapture method as in Mastro et al (1994) would take too long, and other methods require data that is not available for this region. As the size of the general population is known, the network scale-up method as described by Bernard et al (2010) is a suitable approach. Each participant will be asked to estimate how many people they know, and how many of those are MSM. This method is subject to inaccuracies and will tend towards an underestimate as MSM may be hidden from other MSM in the same population, but accuracy is improved by increasing the number of respondents.

 

Reassuring participants that their data will be safeguarded is paramount in order to minimise loss to follow up. Researchers will demonstrate measures to safeguard data by visibly entering paper records and recordings at the conclusion of an interview into a lock box for transport. Data will be anonymised and participants will be offered the opportunity to provide pseudonyms.

 

The establishment of a longitudinal cohort as a by-product of this study is tempting, but requiring participants to agree to long term involvement is likely to reduce participation, and as such has been discarded.

Analysis and Interpretation

Questionnaire data will be analysed using SPSS and R. Regression analysis will be conducted to examine the association between variables such as health literacy and condom use. Level of significance will be set at a probability of less than or equal to 0.05. Metrics such as health literacy will be quantified by converting to a scale of 1-5 upon normalisation of recorded responses.

 

Study data and findings in the form of a comprehensive report will facilitate health interventions intended to reduce the incidence of HIV/AIDS, including education programs, public health communication, social and medical provision alongside influencing local and regional policy.

 

The insights gained from this study will steer proactive testing programs and improved services for those who are living with HIV/AIDS.

Limitations

A limitation of this study includes being unable to establish any causal links between associations: only correlation, not causation, can be demonstrated due to a lack of any temporal aspect to the study. Multiple confounding factors may be present; a further longitudinal cohort study may be able to demonstrate causal relationships between the factors examined in this research and eliminate confounding variables. This study is carried out in a specific temporal, spatial and cultural context, and as such, the findings will not be representative of other contexts. 

Conclusion

This study will generate rapid, actionable insight into health literacy and sexual behaviours of MSM in this region, while improving awareness and helping men make more informed decisions. Existing resources available for utilisation in further research and investigations will be identified.

 

Whilst policy makers and agencies may prefer quantitative research that is seen as more repeatable, rigorous and robust for decision making (Tierney and Clemens, 2011), the results of this study can be used to quickly inform potential health interventions and local decision making, along with directing future research.

 

 

 

 

Word count: 1999

 

References:

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Bernard, H.R., Hallett, T., Iovita, A., Johnsen, E.C., Lyerla, R., McCarty, C., Mahy, M., Salganik, M.J., Saliuk, T., Scutelniciuc, O. and Shelley, G.A., (2010). Counting hard-to-count populations: the network scale-up method for public health. Sexually transmitted infections, 86(Suppl 2), pp.ii11-ii15.

 

Bonevski, B., Randell, M., Paul, C., Chapman, K., Twyman, L., Bryant, J., Brozek, I. and Hughes, C., (2014). Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC medical research methodology, 14(1), p.42.

 

Boyce, Paul, Aggleton, Peter and Malcolm, Anne (2004) Rapid assessment and response adaptation guide on HIV and men who have sex with men. Technical Report. World Health Organization, Geneva.

 

Buvé, A., Lagarde, E., Caraël, M., Rutenberg, N., Ferry, B., Glynn, J.R., Laourou, M., Akam, E., Chege, J., Sukwa, T. and Study Group on Heterogeneity of HIV Epidemics in African Cities, (2001). Interpreting sexual behaviour data: validity issues in the multicentre study on factors determining the differential spread of HIV in four African cities. Aids, 15, pp.S117-S126. 

 

Cortés, D.E., Drainoni, M.L., Henault, L.E. and Paasche-Orlow, M.K., (2010). How to achieve informed consent for research from Spanish-speaking individuals with low literacy: a qualitative report. Journal of Health Communication, 15(S2), pp.172-182.

 

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Gnambs, T. and Kaspar, K., (2015). Disclosure of sensitive behaviors across self-administered survey modes: a meta-analysis. Behavior research methods, 47(4), pp.1237-1259.

 

Jaffe, H.W., Valdiserri, R.O. and De Cock, K.M., (2007). The reemerging HIV/AIDS epidemic in men who have sex with men. Jama, 298(20), pp.2412-2414.

 

Johnson, A.M., Copas, A.J., Erens, B., Mandalia, S., Fenton, K., Korovessis, C., Wellings, K. and Field, J. (2001) ‘Effect of computer‐assisted self‐interviews on reporting of sexual HIV risk behaviours in a general population sample: a methodological experiment’, AIDS 15, 111‐115.

 

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Liverpool, J., Alexander, R., Johnson, M., Ebba, E.K., Francis, S. and Liverpool, C., (2004). Western medicine and traditional healers: partners in the fight against HIV/AIDS. Journal of the National Medical Association, 96(6), p.822.

 

Maher, J.E., Pranian, K., Drach, L., Rumptz, M., Casciato, C. and Guernsey, J., (2010). Using text messaging to contact difficult-to-reach study participants. American Journal of Public Health, 100(6), pp.969-970.

 

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(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

Access to safe abortion services is a neglected issue in sexual and reproductive health worldwide. In 2008, more than 70,000 women died from complications related to unsafe abortions globally, whilst unsafe abortions account for 13% of all maternal mortality (WHO, 2012, A). In some regions such as sub-Saharan Africa, this figure can be as high as 520 deaths per 100,000 (Say et al, 2014). One third of all abortions worldwide between 2010 and 2014 were carried out in unsafe contexts, and 97% of unsafe abortions occurred in Lower and Middle Income countries (LAMICs). 

Chart 1. Maternal mortality vs fertility rate by country, 2015. (Our World In Data, 2015)

 

Whilst total abortion rates are similar between countries with highly restrictive abortion regulations and those where abortion is permitted (Vogelstein and Turkington, 2019), the proportion of unsafe abortions is significantly higher in states that impose more restrictive abortion laws than in states with less restrictive abortion laws (UN Department of Economic and Social Affairs, 2014, Ganatra et al, 2017). Additionally, as chart 1 shows, women suffer significantly higher maternal mortality as fertility rate increases, whilst removing restrictions to accessing abortion services reduces maternal mortality (WHO, 2012, B)

 

In Sierra Leone, where abortion is still illegal, around 1 in 75 pregnancies result in the death of the mother (Our World in Data, 2015). Laws legalising abortion were blocked by the President, Bai Koroma, in 2016 after protests by religious leaders, despite the bill being passed by MPs (BBC, 2016) and there remains a significant cultural pressure to restrict access to abortion in Sierra Leone and many other countries around the world.

 

Where abortion is restricted, survey data shows that the wanted fertility rate is on average 1 child lower than the actual fertility rate (Our World In Data, 2016), demonstrating a clear need and desire for improved access to reproductive and sexual health services to avoid unwanted pregnancies.

 

Evidence also shows a correlation between the number of children a woman has and a reduction in earning potential, through an inability to work whilst children are young, and a subsequent lowering in earnings upon returning to work (Lundborg et al, 2017). Permissive abortion laws are also shown to increase female labor force participation via a decrease in fertility rate (Bloom et al, 2009). The ability to choose whether to carry a pregnancy to term therefore impacts a woman’s right to work and to equal pay under Article 23 of the Universal Declaration of Human Rights (UDHR) (United Nations, 1948). Further rights, such as the right to an education, are impacted where young mothers are prevented from attending school as a result of childcare responsibilities. 

 

Whilst access to abortion improves access to education, education itself also influences the rates of abortion. In countries where abortion is legal and safe, a higher level of education is generally correlated with a lower frequency of abortion (Eskildet al, 2007) and a lower fertility rate (Leon, 2004), alongside an increased support for relaxed (“pro-choice”) abortion laws (Jelen and Wilcox, 2003). 

 

Human Rights and Abortion

 

A lack of access to family planning, contraception, and safe abortion services can be shown to impact womens’ rights in many ways, including the essential right to bodily autonomy and integrity and the ability to take paid employment and participate in cultural activities (Tzvetkova and Ortiz-Espina, 2017).

 

Article 27 of the UDHR states that everyone has the right to share in scientific advancement and its benefits. Safe pharmaceutical abortion practices have been available since 1988 (Baulieu & Rosenblum, 1991) and yet many abortions are carried out in unsafe contexts not because safe abortions are illegal, but because they are unavailable (Chemlal and Russo, 2019). 

 

The right to life and the right to health are enshrined in the UDHR and the 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR) alongside more specific treaties such as the 1979 Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). CEDAW affirms the right of all women “to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights” (UN General Assembly, 1979). “There can be no right to health without the right to access safe abortion” (Priyanka, 2019, pp. 2359). 

 

However, despite this apparent consensus that access to safe abortion services should be an essential human right, in practice, access is still restricted.

 

Restricted Access to Abortion

 

The reasons for restricting access to abortion are often cultural or religious. Followers of many religions believe that abortion is morally wrong, often due to an assertion that a foetus is “alive” from the point of conception. Most abortion legislation recognises the difficult ethical compromise between the rights of women and the rights of an unborn child, usually differentiating between early and late-term abortions, with the cut-off around 12 weeks of pregnancy, beyond which abortion is only permitted if the mother’s life is at risk (Center for Reproductive Rights, 2021). 

 

Strict abortion laws aim to reduce the number of abortions by restricting access to cases only where the mother’s life is at risk or banning the procedure entirely. However, this often has the unintended consequence that women will travel to seek abortions elsewhere or access illegal and unsafe abortion services (Barr-Walker et al, 2019; Jerman et al, 2017).

 

Example: Northern Ireland

 

In the UK, abortion was decriminalised by the Abortion Act of 1967. However, due to conservative and religious pressure, an exemption to the 1967 Act was made for Northern Ireland (Jelen et al, 1993), and abortion remained illegal there until 2019. Women who wanted an abortion were forced to travel to England or self-manage a medical abortion at home, which was both stigmatised and criminalised (Aiken et al, 2018).

 

This situation was widely considered unacceptable on a human-rights basis, and a UN expert committee declared that the UK was in violation of women’s human rights through restricting access to safe abortion: “The situation in Northern Ireland constitutes violence against women that may amount to torture or cruel, inhuman or degrading treatment,” stated CEDAW Vice-Chair Ruth Halperin-Kaddari (OHCHR, 2018). 

 

In June 2018, in a case brought by Sarah Ewart against the Northern Ireland Executive, the UK Supreme Court concluded that “the current law in Northern Ireland breaches human rights, in particular women and girls’ right to private and family life under Article 8 of the European Convention of Human Rights” (NIHRC, 2019). The UK government subsequently clarified that the Northern Ireland Executive must make CEDAW-compliant changes to regulations to ensure that women seeking an abortion do not have to travel to England (House of Commons, 2019). 

 

Despite the UN declaration, the Supreme Court ruling, and clarification by Westminster, there is considered to be a cultural reluctance in Northern Ireland to fulfil the obligations placed upon the Department of Health (Gallen, 2020). Abortion services, despite being legal, remain sparse and many women seeking abortions must still travel to England. 

 

Example: The USA

 

During the 1960s, a number of US states began to decriminalise abortion under certain circumstances, such as cases of rape, incest, or if pregnancy could lead to permanent physical impairment of the mother (Kliff, 2013). Other states followed suit, and Washington and Hawaii passed laws allowing elective abortions. In 1973, the Supreme Court in Roe v. Wade declared all laws in the USA prohibiting abortion to be invalidated, and set guidelines for the availability of safe abortion services up to 12 weeks gestation. The court made this decision based upon the rights implied in the 14th Amendment of the Constitution of the United States of America: “No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property…” (US Const. amend. XIV, sec. 1). The human rights in the US constitution were sufficent to change the laws of 30 states where abortion was previously illigal, and normalise laws in 20 further states.

 

Despite this, an anti-abortion stance persists in parts of the US and has shaped abortion policy. Just three years after Roe v. Wade, The United States Congress passed the “Hyde Amendment”. This amendment, introduced by conservative Congressman Henry J. Hyde, bars the use of federal funds (not state funds) to pay for abortion services except when the life of the mother would be endangered by carrying the pregnancy to term (ACLU, 2021). Implementation of the Hyde Amendment was blocked for some time by pro-choice organisations but was eventually passed in 1977. 

 

The Hyde Amendment violates CEDAW by restricting access to essential reproductive and sexual health services (RHS), and availability of abortion services in the US remains limited by a reluctance to recognise the fundamental rights of women to “decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights,” (CEDAW, Art. 16, e). The implementation of CEDAW in the U.S. “would radically change the basic equality rights of American women, including the right to an abortion.” (Benshoof, 2011. pp.105). However, the USA has to date refused to ratify CEDAW at federal level, though several US cities, counties and states have adopted the principles of CEDAW in local laws (Pierson, 2018). 

 

This anti-abortion stance spreads beyond the US via mechanisms such as the “Global Gag Rule” or the “Protecting Life in Global Health Assistance” policy. This policy bans foreign NGOs that receive US Government funds from using funds from any source to provide abortion services, counselling or advocate for progressive abortion laws. President Trump expanded this in 2017 to include funds through the “President’s Emergency Plan For AIDS Relief” (PEPFAR). PEPFAR constitutes nearly $9billion in funding and meant NGOs had to choose between complying with the rules and denying access to safe abortion, or losing funding (Priyanka, 2019). 

 

The impact of such policies increases unwanted pregnancies and unsafe abortions in LAMICs via two mechanisms: it makes it harder to access safe abortion services provided by NGOs, and it impacts the funding of NGOs providing reproductive and sexual health services, reducing access to contraception (Mavodza et al, 2019). 

 

However, under President Biden, there appear to be moves towards a rights-based approach. On January 28, 2021, he rescinded the Mexico City Policy, as part of “the administration’s plan to protect the rights of women both domestically and abroad” (Brennan, 2021). Foreign NGOs can now obtain PEPFAR and family planning funding whilst offering safe abortion services and counselling.

 

Example: Organisation of African Unity

 

In 1995, the OAU (Organisation of African Unity) Assembly, consisting of the heads of state of all 54 African member states, mandated the creation of a protocol to recognise and enshrine womens’ rights. The process took many years, but after lobbying by NGOs, the finished Protocol To The African Charter On Human And Peoples’ Rights On The Rights Of Women In Africa, better known as the Maputo Protocol, was adopted by the African Union in 2003. 

 

Article 14 of The Maputo Protocol explicitly defines access to safe abortion as a human right in cases of “sexual assault, rape, incest, and where the continued pregnancy endangers the mental and physical health of the mother or the life of the mother or the foetus” (African Union Maputo Protocol, 2003. Art. 14, 2, c) and additionally states that women’s reproductive rights are “inalienable, interdependent and indivisible” human rights.

 

Many African countries expressed reservations about Article 14 which specifically relates to womens’ health and reproductive rights, including Burundi, Senegal, Sudan, Rwanda and Libya (Viljoen, 2009), and the US-based anti-abortion organisation “Human Life International, described it as “a Trojan horse for a radical agenda.” (Vatican Radio, 2008)

 

Despite the Maputo Protocol, in many areas in Africa, abortion is still highly stigmatised. In many clinical settings, either through personal belief or fear of reprisals for conducting abortions, that despite abortion facilities being present, there are not the clinicians available to perform them (Favier et al, 2018). Thus, whilst the Maputo protocol advanced the rights of women in principle, in practice, governments have not ensured equitable availability of safe abortion services, and there is still a gap between governments recognising and fulfilling their obligations (Albertyn, 2015). 

 

Example: Israel

 

Abortion was made legal in Israel in 1977 and in 2014, the law was updated to allow for on-demand abortions at no cost to women between 20 and 33 years of age (Kamin, 2014). 

 

However, Israel implemented abortion laws as a result of many years of compromise. Chaika Grossman, one of very few female members of the Israeli Parliament in 1977, avoided any mention of human rights in relation to abortions in order to appease the highly conservative parliament. Instead, legislation was drafted based on “the assumption that such a reform would increase the birthrate among middle-class Jewish women on the one hand, and control the fertility of the less privileged sectors of the community on the other hand.” (Rimalt, 2017, pp. 329).

 

Thus, despite Israel’s abortion laws being some of the most permissive in the world (Kamin, 2014), this approach leaves them vulnerable to political influence and change. Without a grounding in “inalienable, interdependent and indivisible” human rights, laws drafted by legislators may be changed according to the whim of the government of the time, which leaves the women of Israel vulnerable to abortion services being restricted once again.

 

Conclusion

 

It is clear that human rights frameworks and rights-based approaches to access to abortion services:

 

• Offer a framework for governments to shape policies, programmes, statutes and Protocols, as seen in the Maputo Protocol and by President Biden’s rescinding of the Global Gag Rule.
• Provide clarity for courts to make decisions and turn rights into law, as seen in the USA in Roe v Wade. 
• Empower individuals to know, understand, demand and exercise their rights, as exemplified by Sarah Ewart’s actions in Northern Ireland.
• Enable governments to be held accountable when they do not protect those rights, as is ongoing in Africa and Northern Ireland, where women have the right to access abortion but accessibility remains limited.

 

The increasingly progressive standards codified by human rights frameworks serve to improve access to safe abortion services, through transforming abortion laws, advancing law and policy reforms, and putting in place frameworks that persist despite political change (Fine et al, 2017). Governments that recognise abortion as a human right must do more than make it legal; they are obligated to ensure that safe abortions are available, accessible, acceptable and of appropriate quality. 

 

The cases of the USA, Northern Ireland and Africa demonstrate the power of absolute, and inalienable human rights. Whilst governments change and cultures shift, human rights are immutable. Courts, in their power to define law, can utilise human rights frameworks, such as the UDHR, CEDAW, the Maputo Protocol or the US Constitution to make clear and lasting  decisions, including the decision to respect, protect and fulfil the right of every woman to access safe abortion services.

 

 

 

References:

 

ACLU, 2021. Access Denied: Origins of the Hyde Amendment and Other Restrictions on Public Funding for Abortion. Available at: https://www.aclu.org/other/access-denied-origins-hyde-amendment-and-other-restrictions-public-funding-abortion (Accessed: 21 April 2021).

 

Aiken, A. et al. 2018. “The impact of Northern Ireland’s abortion laws on women’s abortion decision-making and experiences”, BMJ Sexual & Reproductive Health, 45(1), pp. 3-9. doi: 10.1136/bmjsrh-2018-200198.

 

Albertyn, C., 2015. Claiming and defending abortion rights in South Africa. Revista Direito GV, 11(2), pp.429-454.

 

Barr-Walker, J., Jayaweera, R.T., Ramirez, A.M. and Gerdts, C., 2019. Experiences of women who travel for abortion: A mixed methods systematic review. PloS one, 14(4), p.e0209991.

 

Benshoof, J., 2011. US Ratification of CEDAW: An Opportunity to Radically Reframe the Right to Equality Accorded Women Under the US Constitution. NYU Rev. L. & Soc. Change, 35, p.103.

 

Baulieu, Etienne-Emile; Rosenblum, Mort, 1991. The “abortion pill” : RU-486, a woman’s choice.

New York: Simon & Schuster. 

 

Brennan, T. 2021. Biden’s decision to rescind the Global Gag Rule could have implications for the US approach to sexual health and reproductive rights at the UN | Universal Rights Group. Available at: https://www.universal-rights.org/universal-rights-group-nyc-2/bidens-decision-to-rescind-the-global-gag-rule-could-have-implications-for-the-us-approach-to-sexual-health-and-reproductive-rights-at-the-un/ (Accessed: 27 April 2021).

 

BBC News, 12 March 2016. Sierra Leone abortion bill blocked by President Bai Koroma again. Available at: https://www.bbc.co.uk/news/world-africa-35793186 (Accessed: 20 April 2021).

 

Bloom, D.E., Canning, D., Fink, G. and Finlay, J.E., 2009. Fertility, female labor force participation, and the demographic dividend. Journal of Economic growth, 14(2), pp.79-101.

 

Center for Reproductive Rights. 2021. The World’s Abortion Laws Available at: https://maps.reproductiverights.org/worldabortionlaws (Accessed: 27 April 2021).

 

Chemlal, S. and Russo, G., 2019. Why do they take the risk? A systematic review of the qualitative literature on informal sector abortions in settings where abortion is legal. BMC women’s health, 19(1), pp.1-11.

 

Eskild, A., Nesheim, B.I., Busund, B., Vatten, L. and Vangen, S., 2007. Childbearing or induced abortion: the impact of education and ethnic background. Population study of Norwegian and Pakistani women in Oslo, Norway. Acta obstetricia et gynecologica Scandinavica, 86(3), pp.298-303.

 

Favier, M., Greenberg, J.M. and Stevens, M., 2018. Safe abortion in South Africa:“We have wonderful laws but we don’t have people to implement those laws”. International Journal of Gynecology & Obstetrics, 143, pp.38-44.

 

Fine, J.B., Mayall, K. and Sepúlveda, L., 2017. The role of international human rights norms in the liberalization of abortion laws globally. Health and human rights, 19(1), p.69.

 

Gallen, E. et al. 2020. “Abortion is now legal in Northern Ireland – but why aren’t procedures actually being carried out?”, The Telegraph. Available at: https://www.telegraph.co.uk/women/life/abortion-now-legal-northern-ireland-arent-procedures-actually/ (Accessed: 9 March 2021).

 

Ganatra, B. et al. 2017 “Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model”, The Lancet, 390(10110), pp. 2372-2381. doi: 10.1016/s0140-6736(17)31794-4.

 

Guttmacher Institute, 2017. Appendix Table 1: Status of the world’s 193 countries and six territories/nonstates, by six abortion-legality categories and three additional legal grounds under which abortion is allowed.

https://www.guttmacher.org/sites/default/files/report_downloads/aww_appendix_table_1.pdf (Accessed: 20 April 2021).

 

House of Commons Women and Equalities Committee. 2019. “Abortion law in Northern Ireland”. Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmwomeq/1584/158408.htm (Accessed: 9 March 2021).

 

Jelen, T., O’Donnell, J. and Wilcox, C. 1993. “A Contextual Analysis of Catholicism and Abortion Attitudes in Western Europe”, Sociology of Religion, 54(4), p. 375. doi: 10.2307/3711780.

 

Jelen, T.G. and Wilcox, C., 2003. Causes and consequences of public attitudes toward abortion: A review and research agenda. Political Research Quarterly, 56(4), pp.489-500.

 

Jerman, J., Frohwirth, L., Kavanaugh, M.L. and Blades, N., 2017. Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states. Perspectives on sexual and reproductive health, 49(2), pp.95-102.

 

Kamin, D., 2014. Israel’s abortion law now among world’s most liberal. The Times of Israel, 6.

 

Kavaler, T., 2021. Israel’s abortion rate continues 32-year decline. Jerusalem Post. Available at: https://www.jpost.com/israel-news/israels-abortion-rate-continues-32-year-decline-654367 (Accessed: 27 April 2021).

 

Kliff, S., 2013. Charts: How Roe v. Wade changed abortion rights. The Washington Post, 22.

 

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