'SWINE INFLUENZA VIRUS' ON PROWL

By Sarah Williams & M H Ahssan

A new strain of influenza is infecting people in Mexico and the United States and may have killed up to 60 people in Mexico, global health officials said today.

The authorities has analyzed samples of the H1N1 virus from some of the U.S. patients, all of whom have recovered, and said it is a never-before-seen mixture of viruses from swine, birds and humans.

Here are some facts from the U.S. Centers for Disease Control and Prevention about how swine flu spreads in humans:

• Swine flu viruses typically sicken pigs, not humans. Most cases occur when people come in contact with infected pigs or contaminated objects moving from people to pigs.

• Pigs can catch human and avian or bird flu. When flu viruses from different species infect pigs, they can mix inside the pig and new, mixed viruses can emerge.


• Pigs can pass mutated viruses back to humans and they can be passed from human to human. Transmission among humans is thought to occur in the same way as seasonal flu - by touching something with flu viruses and then touching their mouth or nose, and through coughing or sneezing.

• Symptoms of swine flu in people are similar to those of seasonal influenza - sudden fever, coughing, muscle aches and extreme fatigue. This new strain also appears to cause more diarrhea and vomiting than normal flu.

• Vaccines are available to be given to pigs to prevent swine influenza. There is no vaccine to protect humans from swine flu although the CDC is formulating one. The seasonal influenza vaccine may help provide partial protection against swine H3N2, but not swine H1N1 viruses, like the one circulating now.

• People cannot catch swine flu from eating pork or pork products. Cooking pork to an internal temperature of 160 degrees Fahrenheit kills the swine flu virus as it does other bacteria and viruses.

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza that regularly cause outbreaks of influenza among pigs. Swine flu viruses do not normally infect humans, however, human infections with swine flu do occur, and cases of human-to-human spread of swine flu viruses has been documented.

Swine influenza virus : (referred to as SIV) refers to influenza cases that are caused by Orthomyxoviruses endemic to pig populations. SIV strains isolated to date have been classified either as Influenzavirus C or one of the various subtypes of the genus Influenzavirus A.

Swine flu infects people every year and is found typically in people who have been in contact with pigs, although there have been cases of person-to-person transmission. Symptoms include fever, disorientation, stiffness of the joints, vomiting, and loss of consciousness ending in death. Swine influenza is known to be caused by influenza A subtypes H1N1, H1N2, H3N1, H3N2, and H2N3.

In swine, three influenza A virus subtypes (H1N1, H3N2, and H1N2) are circulating throughout the world. In the United States, the H1N1 subtype was exclusively prevalent among swine populations before 1998; however, since late August 1998, H3N2 subtypes have been isolated from pigs. As of 2004, H3N2 virus isolates in US swine and turkey stocks were triple reassortants, containing genes from human (HA, NA, and PB1), swine (NS, NP, and M), and avian (PB2 and PA) lineages.

Avian influenza virus H3N2 is endemic in pigs in China and has been detected in pigs in Vietnam, increasing fears of the emergence of new variant strains. Health experts[who?] say pigs can carry human influenza viruses, which can combine (i.e. exchange homologous genome sub-units by genetic reassortment) with H5N1, passing genes and mutating into a form which can pass easily among humans. H3N2 evolved from H2N2 by antigenic shift. In August 2004, researchers in China found H5N1 in pigs. Measured resistance to the standard antiviral drugs amantadine and rimantadine in H3N2 in humans has increased to 92% in 2005.

Chairul Nidom, a virologist at Airlangga University's tropical disease center in Surabaya, East Java, conducted an independent research; he tested the blood of 10 apparently healthy pigs housed near poultry farms in West Java where avian flu had broken out, Nature reported. Five of the pig samples contained the H5N1 virus. The Indonesian government has since found similar results in the same region. Additional tests of 150 pigs outside the area were negative.

Swine in Human
The Centers for Disease Control and Prevention (CDC) reports that the symptoms and transmission of the swine flu from human to human is much like seasonal flu, commonly fever, lethargy, lack of appetite and coughing. Some people with swine flu also have reported runny nose, sore throat, nausea, vomiting and diarrhea. It is believed to be spread between humans through coughing or sneezing of infected people and touching something with the virus on it and then touching their own nose or mouth. The swine flu in humans is most contagious during the first five days of the illness although some people, most commonly children, can remain contagious for up to ten days. Diagnosis can be made by sending a specimen, collected during the first five days, to the CDC for analysis.


The swine flu is susceptible to four drugs licensed in the United States, amantadine, rimantadine, oseltamivir and zanamivir, however, for the 2009 outbreak it is recommended it be treated with oseltamivir and zanamivir. The vaccine for the human seasonal H1N1 flu does not protect against the swine H1N1 flu, even if the virus strains are the same specific variety, as they are antigenically very different.

1976 U.S. outbreak
On February 5, 1976, an army recruit at Fort Dix said he felt tired and weak. He died the next day and four of his fellow soldiers were later hospitalized. Two weeks after his death, health officials announced that swine flu was the cause of death and that this strain of flu appeared to be closely related to the strain involved in the 1918 flu pandemic. Alarmed public-health officials decided that action must be taken to head off another major pandemic, and they urged President Gerald Ford that every person in the U.S. be vaccinated for the disease. The vaccination program was plagued by delays and public relations problems, but about 24% of the population had been vaccinated by the time the program was canceled.

About 500 cases of Guillain-Barré syndrome, resulting in death from severe pulmonary complications for 25 people, were probably caused by an immunopathological reaction to the 1976 vaccine. Other influenza vaccines have not been linked to Guillain-Barré syndrome, though caution is advised for certain individuals, particularly those with a history of GBS.

2007 Philippine outbreak
On August 20, 2007 Department of Agriculture officers investigated the outbreak of swine flu in Nueva Ecija and Central Luzon, Philippines. The mortality rate is less than 10% for swine flu, if there are no complications like hog cholera. On July 27, 2007, the Philippine National Meat Inspection Service (NMIS) raised a hog cholera "red alert" warning over Metro Manila and 5 regions of Luzon after the disease spread to backyard pig farms in Bulacan and Pampanga, even if these tested negative for the swine flu virus.

2009 swine flu outbreak
In March and April 2009, more than 1,000 cases of swine flu in humans were detected in Mexico, and more than 80 deaths are suspected to have a connection with the virus. The Mexican fatalities are said to be mainly young adults, a hallmark of pandemic flu. Following a series of reports of isolated cases of swine flu, the first announcement of the outbreak in Mexico was documented on April 23, 2009.

The origins of the new Swine Influenza Virus SIV-H1N1 strain remain unknown. One theory is that Asian and European strains traveled to Mexico in migratory birds or in people, then combined with North American strains in Mexican pig factory farms before jumping over to farm workers. The Mexican health agency acknowledged that the original disease vector of the virus may have been flies multiplying in manure lagoons of pig farms near Perote, Veracruz, owned by Granjas Carroll, a subsidiary of Smithfield Foods.

Some of the cases have been confirmed by the World Health Organization to be due to a new genetic strain of H1N1. The new H1N1 strain has been confirmed in 16 of the deaths and 44 others are being tested as of April 24, 2009.

As of April 25, 2009 19:30 EDT there are 11 laboratory confirmed cases in the southwestern United States and in Kansas, and several suspected cases in the New York City metropolitan area.

A variant of H1N1 was responsible for the Spanish flu pandemic that killed some 50 million to 100 million people worldwide from 1918 to 1919.

The seasonal flu tends to kill just a fraction of 1% of those infected. In Mexico, about 71 deaths out of roughly 1,000 cases represents a fatality rate of about 7.1%. The Spanish flu pandemic of 1918, had a fatality rate of about 2.5%.

Statistical projections for this virus pathology based upon the same infection rate as the Spanish flu pandemic and current fatality rate, indicates that as many as 284 million deaths could occur worldwide as a result of the genesis of this new Swine Influenza Virus SIV-H1N1 strain.

At 8 p.m. on Sunday, April 26, the New Zealand Minister of Health confirmed that 22 students returning from a school trip from Mexico had flu-like symptoms (most likely swine flu). 13 of the students with flu-like symptoms were tested and 10 tested positive for Influenza A, their cases strongly suspected to be the swine flu strain. However there is a possibility that the infected are not infected with the swine flu but other forms of the flu. The government has suggested that citizens of New Zealand with flu-like symptoms should see their physician immediately.

There have been five cases of possible swine flu in Canada, according to the Canadian Press. Two are in British Columbia, and three in Nova Scotia. According to the provincial government, four students in Windsor, Nova Scotia have confirmed cases of swine flu.

The new strain appears to be a recombinant between two older strains. Preliminary genetic characterization found that the hemagglutinin (HA) gene was similar to that of swine flu viruses present in U.S. pigs since 1999, but the neuraminidase (NA) and matrix protein (M) genes resembled versions present in European swine flu isolates. Viruses with this genetic makeup had not previously been found to be circulating in humans or pigs, but there is no formal national surveillance system to determine what viruses are circulating in pigs in the U.S.

On April 26, 2009, some schools in the United States announced closures and cancellations related to possibilities that students may have been exposed to swine flu.

According to University of Virginia virologist Frederick Hayden, the most recent flu season was dominated by H1N1 viruses, and people who had received flu shots in the U.S. may have some protection against swine flu.

According to the Centers for Disease Control and Prevention, the seasonal influenza strain H1N1 vaccine is thought to be unlikely to provide protection against the new Swine Influenza Virus SIV-H1N1 strain.

According to the Centers for Disease Control and Prevention, the virus has been detected in multiple areas, indicating that containment is unlikely. This is exacerbated by the incubation and infectious periods of influenza.

Veterinary swine flu vaccine
Swine influenza has become a greater problem in recent decades as the evolution of the virus has resulted in inconsistent responses to traditional vaccines. Standard commercial swine flu vaccines are effective in controlling the infection when the virus strains match enough to have significant cross-protection, and custom (autogenous) vaccines made from the specific viruses isolated are created and used in the more difficult cases.

Present vaccination strategies for SIV control and prevention in swine farms, typically include the use of one of several bivalent SIV vaccines commercially available in the United States. Of the 97 recent H3N2 isolates examined, only 41 isolates had strong serologic cross-reactions with antiserum to three commercial SIV vaccines. Since the protective ability of influenza vaccines depends primarily on the closeness of the match between the vaccine virus and the epidemic virus, the presence of nonreactive H3N2 SIV variants suggests that current commercial vaccines might not effectively protect pigs from infection with a majority of H3N2 viruses.

The current vaccine against the seasonal influenza strain H1N1 is thought unlikely to provide protection. The director of CDC's National Center for Immunization and Respiratory Diseases said that the United States' cases were found to be made up of genetic elements from four different flu viruses—North American swine influenza, North American avian influenza, human influenza A virus subtype H1N1, and swine influenza virus typically found in Asia and Europe. On two cases, a complete genome sequence had been obtained. She said that the virus is resistant to amantadine and rimantadine, but susceptible to oseltamivir (Tamiflu) and zanamivir (Relenza).

Want ot be 'Broadcast Journalist'?

By M H Ahssan

Broadcast Journalism is the collection, verification and analysis of information about events which affect people, and the publication of that information in a fair, accurate, impartial and balanced way to fulfil the public's right to know in a democratic society. This involves a variety of media including television, radio, the internet and wireless devices. Broadcast Journalists working in television work in a variety of genres including news, current affairs, or documentaries. They may be employed by broadcasting companies, or work on a freelance basis.

The role of a Broadcast Journalist is to turn information into pictures and sound, both reporting and producing live and/or recorded packages as well as researching, preparing and reading bulletins. You will be responsible for generating content from a wide range of subjects. You will be encouraging new contributors and developing their ideas as well as your own. You are likely to be working as part of a team, generating your own stories and bringing on board new ideas.

You will be initiating and producing a wide range of news and current affairs material and will be expected to carry out in-depth research to a broad brief, write material for programme scripts, bulletins etc and at all times exercise excellent editorial judgement and adhere to legal and good practice guidelines.

You may carry out interviews and reporting duties, in both recorded and live situations, in a studio or perhaps on location. You can expect to be involved in originating and developing programme ideas to support forward planning of material and future programmes and provide briefings for reporters, camera crews and other resources staff and contributors.

You will need to operate broadcast equipment: in radio, portable recording equipment, self-operating outside broadcasting vehicles and studio equipment in television, to direct camera crews on pre-recorded and live coverage, to oversee editing and operate gallery equipment.

You may be responsible for programme budgets, ensuring effective use of money and resources, supervise the work of Broadcast Assistants and most certainly, as a Broadcast Journalist you would need to develop and maintain local and perhaps national contacts and fulfil a public relations role.

Qualities: What you need to be able to do the job
You will need to be an experienced journalist with strong editorial judgement and organisational skills, with a first class news awareness and judgement. You must be able to work as part of a team and you will also be able to work with minimal supervision, be brimming with ideas, and a creative self-starter. Excellent verbal and written communication skills are a must, including skills and style when it comes to interviewing.

One of the key qualities is a voice for broadcasting, together with knowledge of radio production techniques and broadcast equipment.
Of course, a passion for radio, current affairs and a real grasp of the subjects that interest audiences are a must.

Key Skills include:
- excellent verbal and written communication;
- ability to work under pressure, to tight deadlines;
- excellent interviewing and listening techniques;
- excellent content editing skills with basic picture and sound editing abilities;
- precise attention to detail and advanced analytical skills;
- excellent organisational abilities, initiative and problem solving skills;
- ability to see the broader picture and focus in on any niche angle the programme requires;
- self management abilities combined with effective team working, and self-discipline skills;
- diplomacy and sensitivity when working with members of the public and colleagues;
- personality, and excellent interpersonal skills at all levels;
- ability to build a rapport with interviewees without losing objectivity;
- current knowledge of the relevant legislation, regulations, and associated procedures, including Libel and Contempt, Copyright, Data Protection, Public Liability, etc., and how to comply with regulatory requirements;
- knowledge of the requirements of the relevant Health and Safety legislation and procedures;

Career path: How you start and where you can go with it.
Broadcast Journalists should have successfully completed a BJTC accredited Undergraduate degree, a Postgraduate Diploma or MA in Broadcast, Bi-Media, Multi-Media, TV or Online Journalism. IT and word processing qualifications are also required.

Broadcast Journalists may begin their careers working as Researchers or Newsroom Assistants, progressing to become On Screen Reporters, Special Correspondents, News Presenters, and Bulletin or Programme Editors. They may also move into Programme Production or Management roles, or become Journalists, Newspaper Reporters or Writers. Some Broadcast Journalists may also start their careers working as Newspaper or other Print Press Journalists.

As a Broadcasting Journalist, jobs are available across a range of functions, requiring different skills, knowledge and experience. Initially, a recognised journalistic qualification or substantial practical experience in journalism (say 3 years plus) is a starting point. A special interest, for example in sport, entertainment, fashion, health, arts etc, with a good all round knowledge of current affairs would also support your career as a Broadcast Journalist.

Revealing the Real Risks: Obstetrical Interventions and Maternal Mortality

By Aeman Nishath

Recently, a woman in Iowa was referred to a university hospital during childbirth because of possible complications. At the university hospital it was decided that a cesarean section should be done. After the cesarean section was completed and the woman was resting in her hospital room, she went into shock and died. An autopsy showed that, during the cesarean section, the surgeon had accidentally nicked the woman's aorta, the biggest artery in the body, which led to internal hemorrhage, shock, and death.

A cesarean section can save the life of the mother or her baby, or both. A cesarean section can kill a mother or her baby, or both. Every procedure or technology used during pregnancy and birth carries risks for the mother and baby. Whether or not to use any procedure or technology will be a judgment based on balancing the chances that it will make things better against the chances that it will make things worse.

We live in the age of technology. Since long before human beings landed on the moon, we have believed that technology can solve all of our problems. It should come as no surprise that doctors and hospitals are using more and more technology and invasive interventions on pregnant and birthing women. Has all this technology solved the problems surrounding birth? Let's look at the record. Is the increasing use of technology saving the lives of more pregnant and birthing women? In fact, the risk of a woman in this country dying from maternal mortality (i.e., causes related to pregnancy) has not decreased in more than 25 years. Each year, nearly 1,000 women die during pregnancy, during birth, or in the first week after giving birth. Nearly half of these deaths could have been prevented with better access to higher-quality maternity care. Hundreds of thousands of other women experience medical complications from pregnancy.2

The data also suggest an increase in recent years in the number of women dying during pregnancy and birth in the US.3 We have known for some time that maternal mortality in the US is underreported--in one state in one year, a third of the maternal deaths had not been reported.4 But the latest evidence suggests that "The actual pregnancy-related death rate could be more than twice as high as that reported for 1990."5

WHY ARE MORE AMERICAN WOMEN DYING?
It is difficult to pinpoint why more American women are dying before, during, and after giving birth--the data give only the leading or immediate cause of death, not the underlying causes. But if we look at the six leading causes of pregnancy-related deaths in the US, three--hemorrhage, anesthesia, infection--are often the result of invasive obstetric interventions.6 For example: Although the immediate cause of death is frequently given as "hemorrhage," in many cases the hemorrhage is associated with cesarean section (as in the case cited in the first paragraph). There is good research, both in the US and the United Kingdom, showing that the maternal mortality rate for cesarean section is four times higher than for vaginal birth.7-9 The rate of maternal mortality is still twice as high as for vaginal birth even when the cesarean section is routine, or "elective"; i.e., it is not an emergency procedure. With nearly twice as many cesarean sections as are necessary being done today in the US, the procedure could be a significant part of the reason for the country's rising rate of maternal mortality.10

Another possible cause of rising pregnancy-related deaths in the US is the markedly increasing use of epidural blocks for normal labor pain. Administering an epidural block doubles the risk that the woman will die; "anesthesia complications" are documented as one of the leading causes of maternal mortality in the US.11

There is good reason to believe that other obstetric technologies also contribute to the rising number of women who die during childbirth in this country. Data from the Centers for Disease Control (CDC) show that in the past ten years the number of women given powerful and dangerous drugs to induce labor has gone from 10 percent of all births to 20 percent.12 In the same ten years, the drug Cytotec, not approved by the FDA for labor induction because of insufficient scientific evaluation of risk--a warning often ignored by doctors--has become the single most popular labor-inducing drug. New scientific data show that inducing labor with Cytotec causes a marked increase in uterine rupture, an obstetric catastrophe in which a quarter of all babies die, many women die as well, and, of the women who survive, almost none can ever have another baby.

Why has the rate of Cytotec-induced labor doubled when the ability of women's bodies to begin labor has not decreased? Further CDC data show that the answer is doctor convenience. In those same ten years, the number of births taking place Monday through Friday greatly increased.13 Like taking prenatal X-rays in the 1930s, prescribing the drug di-ethyl-stillbesterol (DES) to pregnant women in the 1950s, and thalidomide in the 1960s, inducing labor with Cytotec in the 1990s is another obstetric intervention that has gone into widespread use without adequate scientific evaluation, with tragic consequences for thousands of women and babies.

The scientific evidence strongly suggests that the increasing use of obstetric interventions and technologies--cesarean section, epidural anesthesia, and drugs to induce labor--is not saving more women's lives, but ending them. Medical care was responsible for some of the earlier decreasing mortality of pregnant and birthing women, not because of high-tech interventions but because of basic medical advances, such as the discovery of antibiotics and the ability to give safe blood transfusions. There has never been any scientific evidence that such high-tech interventions as the routine use of electronic fetal monitoring during labor decrease the mortality rate of women.14 There is also no scientific evidence to prove that the fall in maternal mortality was because birth was moved into the hospital.15 The evidence does show that, as long as a system is in place that can transport women in labor within 30 minutes to a facility where antibiotics, blood transfusions, and necessary cesarean sections are available, there should be very little maternal mortality. For example, in the Netherlands, a third of all births are planned homebirths attended by midwives that refer women to doctors when necessary. The rate of maternal mortality in the Netherlands is far lower than in the US.

THE IMPORTANCE OF QUALITY CARE
The US spends twice as much as any other country on maternity care, and yet 15 other countries have lower rates of maternal mortality. There are at least two reasons for this, both having to do with access to quality care. More than 40 million Americans have no health insurance; many of these are women needing maternity care. If a woman applies for Medicare support for her maternity care, she must have means testing, which necessitates that she jump through many bureaucratic hoops before she can receive care. This can be a disaster. Furthermore, women receiving publicly funded care go to overcrowded hospitals staffed by interns and residents who are overworked and insufficiently trained.16 In addition, when poor women qualify for their maternity care to be funded by Medicare, they may be referred to a private practitioner, and receive this care in the doctor's private offices and private hospitals. There they often receive less attention than the women whose care is being funded by private insurance instead of public funds, in part because of the cultural and socioeconomic gaps between the poor women and their doctors. The delays and crowding, and lack of understanding and skill of some doctors, can all lead to pregnancy-related deaths.

The second reason the US has a higher rate of maternal mortality than 15 other countries is the way birthing women are cared for here. American doctors insist that women need to be in the hospital when giving birth, yet these same doctors who need to provide maternity care for them are not in the hospital when the women actually give birth, but in their offices doing prenatal checkups on healthy women, or in another hospital doing gynecological surgery, or at home eating dinner.17 So when the birthing woman who is in the hospital (or transported to the hospital) needs urgent attention for developing complications, the obstetrician is often not there, must be called, and may come too late. Research shows that, in more than 70 percent of cases, the main factor in the death of babies at birth is the doctor's absence.18

The US and Canada are the only countries in the world in which obstetricians provide primary birth care for the majority of normal births. The American obstetrician tries to be all things to women: a primary provider of maternity care for healthy pregnant and birthing women; a provider of preventive care for women; a specialist in women's diseases; and a highly skilled surgeon. No other doctor anywhere in healthcare tries to maintain competence at all of these levels and in so many areas because it is unreasonable to expect this from one human being. It's unlikely that an obstetrician can perform a six-hour gynecological surgical procedure on a woman with extensive cancer, then rush to his or her office and do the best job of quietly, patiently counseling a pregnant woman about her sex life. If you are considering a hospital birth with an obstetrician as your primary birth attendant, ask the doctor how much time he or she will spend with you during your labor. One of the reasons a midwife, rather than an obstetrician, is generally a better choice to attend your hospital birth is that, assuming a normal pregnancy, midwives have been shown statistically to be safer birth attendants than doctors.19 This is, in part, because the midwife is there in the hospital with you throughout your labor, while the obstetrician is not.

For more than 50 years now the US has had a system of maternity care that often boils down to this: A woman goes into labor, goes to the hospital, and is admitted by the labor and delivery (L&D) nurse, who examines her. The L&D nurse then calls the obstetrician, who gives orders over the telephone to the nurse. The obstetrician may or may not come by the hospital during the labor to check the woman. It is the job of the L&D nurse to monitor the labor and call the obstetrician when the birth is imminent so that the doctor does not have to hang around the hospital waiting for the birth.

During my 15 years as Director of Women's and Children's Health for the World Health Organization, I frequently visited the industrialized countries of Europe. I observed that in the 15 countries that lose fewer pregnant and birthing women than the US does--including those countries with the world's lowest rates of maternal mortality--obstetricians remain in the hospitals, ready to jump in and treat serious complications. In those countries, it is the midwives who are out in the community, giving prenatal and postnatal checkups, and who are also in the hospitals as the only health professionals at the births of 80 to 90 percent of women who give birth without serious complications.

It cannot be overemphasized that American women's lack of access to quality, immediate obstetrical attention in the hospital is a major reason so many of them die unnecessarily during pregnancy and childbirth. Put differently, every one of the 15 countries that have lower rates of maternal mortality has universal healthcare coverage for all pregnant and birthing women (with no bureaucratic hoops to jump through), and all obstetricians are hospital-based, ready to care for these women should they develop complications. Furthermore, maternal mortality is not higher in those countries where there are large numbers of planned homebirths with midwives, because there is a system in place for transporting birthing mothers to the hospital, and for managing complications with mutual respect and collaboration between out-of-hospital midwives and hospital staff.

Data from many states in the US show maternal mortality to be four times higher for African-American women than for Caucasian women, and nearly twice as high for Hispanic women.20 The markedly greater risk that African-American and Hispanic women will die during pregnancy and childbirth is because this group includes a higher proportion of uninsured women, poor women, and women who go to hospitals with insufficient and/or poorly trained staff. In short, African-American and Hispanic women have less access to quality maternity care.

WHERE'S THE DATA?
Occasionally, a group of obstetricians tries to get a handle on maternal deaths in their locale. In a study of ten hospitals in the greater Chicago area, reported in 2000, the maternal mortality rate there was twice as high as reported by the CDC.21 Furthermore, on investigation of each case, these Chicago obstetricians found that 37 percent of the deaths were preventable. In the preventable cases, mistakes by doctors and nurses were determined to be the cause of death more than 80 percent of the time. Unfortunately, as is nearly always the case, the study made no attempt to determine how many of the deaths were related to obstetric interventions such as induction of labor, epidural block, and cesarean section. Lamenting that state maternal mortality committees, which carefully review all maternal deaths, are now largely defunct in the US, the study urged that these committees be revived to investigate causes and develop programs of intervention and education.

There is an urgent need for careful auditing of every single maternal death in the US, with a thorough analysis of causes--including underlying causes--and presentation of the results to the public. The Federal Aviation Authority could not set policies for safe flying if they were unaware of half of the planes falling from the skies, and couldn't retrieve the "black boxes" of most of those planes they knew had fallen. But this is analogous to the CDC trying to set policy for safe motherhood when they have limited data on maternal mortality. Federal policy prohibits the CDC from making surveys of what is happening in all states with maternal deaths.22 At the state level, there are enormous pressures from state and local medical societies to prevent adequate investigation of all maternal deaths.23 It's not easy to get information about the nearly 1,000 women who die each year in the US around the time of birth. To begin with, it's difficult to track maternal deaths, as death certificates in only 16 states include a question concerning whether the deceased had been pregnant within a year of her death. Although some states have regulations requiring that such deaths be reported, in no state can anyone, including scientists who want to study why these women die, gain access to information about individual cases of maternal death. If there is an investigation of a maternal death by a hospital, it is a longstanding policy that this happen behind closed doors, which protects the doctor and hospital involved. There is no public accountability. Public knowledge of pregnancy-related deaths does not fit well into any HMO or healthcare facility's marketing efforts. Employees of most hospitals know that their job security often depends on their willingness to keep silent, and the tribal loyalty of doctors is a powerful deterrent to accessing information. The CDC is doing everything it can to push states to improve their maternal death audits. It has had some successes, but today only a few states conduct thorough audits of all maternal deaths, and only one state, Massachusetts, has a law, passed after intense lobbying by consumer groups, mandating that newspapers report maternal deaths.

We know that at least half of these maternal deaths are not reported anywhere, that nearly all of these women die in the hospital, not at home, and that, with adequate medical attention, close to half of these women need not have died. The possibility of liability due to inadequate medical attention has doctors terrified of litigation, and reluctant to release information concerning maternal mortality. American women need to know that their chance of dying around the time of birth is increasing. They have a right to know why.

Women in medicine—whatever next?

By Reema Fatima Subia

The Changing Face of Medicine: Women Doctors and the Evolution of Health Care in America

One afternoon at the Royal College of Physicians, I expressed mild interest in the fact that in the election for my successor as Academic Vice President, there had been no female candidates. My (senior and male) colleague looked at me in astonishment and said “haven't there been enough women already?” An interesting perspective given that in around 500 years there have been only two female presidents and only three female vice presidents of the Royal College of Physicians of London. What is this all about?

Historically, caring for the sick was seen as women's work. The baton was taken back by the men when it secured professional status with the creation of the first medical royal colleges and societies. Since then, medicine has been dominated by men. But times are changing—just more than 500 years later—and women now make up the majority of medical school entrants, and are likely to become the dominant gender in the medical workforce in the next 10—15 years. Is this a triumph for those seeking gender equality, or is it a problem for the profession?

In the UK, this issue first hit the media spotlight in 2005, following which the Royal College of Physicians of London developed proposals for a research project to find the evidence base for a number of developing issues related to the increase in the number of women in the medical workforce. As the newest appointed female College Officer, I was asked to chair the research steering group. We appointed a researcher, and set off on an interesting journey to produce an unbiased and accurate evidence base. The research, done by Mary Ann Elston, will be published by the Royal College of Physicians next month. Perhaps I should have anticipated the potential controversy around the interpretation of those facts, given that each participant in the project was either a man or a woman, and came to it with their own values and experiences on the subject.

Ann Boulis and Jerry Jacobs' book about women doctors and their relation to the evolution of health care in the USA is timely and discusses these issues from a perspective that is pleasantly sympathetic to women. They have collated and analysed an impressive dossier of qualitative and quantitative data and put forward some suggestions as to why the “gender gap” still exists in the USA and how to address it. Not surprisingly, most of the challenges facing women doctors in the USA echo those being experienced in the UK, but interestingly, the UK seems to be doing better.

One explanation for why there has been this increase in women in medical schools is the depressing thought that it has come from the decline in status of the medical profession overall. Boulis and Jacobs have posed convincing arguments to show us how it is not a simple as that. The status of medicine was apparently declining before the rise in female applicants, and has been influenced by complex societal changes that reflect current general sociological trends in the USA. Moreover, American women are now better educated so provide a better pool of applicants and have access to impressive female role models.

There have also been government initiatives to reduce barriers and discrimination affecting women in the professional workforce. The authors describe a positive feedback loop of declining discrimination, expanding opportunities, women's early success, and continued women's interest in medicine over time. There was concern in the USA that the number of male applicants to medical school was declining, but the research in this book has shown that this is also not really the case. The percentage of male applicants has declined, but actual total numbers are still rising, although at a slower rate than the numbers of female applicants.

This is also the case in the UK. An interesting aside is the effect of the Vietnam War Draft in the USA, which encouraged men into the medical profession to avoid being called up, although this levelled off and then declined in the 1980s.
Another observation that also holds true for the UK is the so-called gender segregation within medicine: that women tend to aggregate in specialties with particular characteristics. These have been described as the more planable and less technical specialties, and those with a higher emphasis on the caring aspects of medicine. For example, there are more women in general practice and palliative care, and fewer in surgery or clinical research.

Why is this? The evidence presented in the book suggests that women and men have a similar approach to patient care, and practise in very similar ways, so segregation is not only caused by women's choice of career, there are other factors. What is interesting is that those in favour of better equality for women refer to these factors as “barriers”, whereas those who think there is no problem with gender equality attribute the career differences to choice. A choice becomes a barrier when it is influenced by external factors that make women decide not to choose that specialty. Examples include: gender stereotypes about appropriate roles for women; lack of flexibility in the structure of the working day; and out of hours work at times when child care is hard to find. All these become barriers that influence the choice about whether to enter that specialty.

Part-time working is a continuing source of controversy in medicine. With the increased number of women coming into the workforce, and their likelihood of working less than full time to complete their families, there will need to be alterations in the current pattern of the working day, and more opportunity for part-time work. It is essential to maintain the workforce, which means keeping women in the workplace. But this means that more people (jobs) will be required to fill the same number of working hours. An alternative approach would be to encourage women to work longer hours, but this would need to be supported by more flexible and accessible child care. Either way, an increase in part-time working will be more expensive.

Here in the UK, a 2006 report called for action in taking steps to increase the number of women in the most senior positions in medicine. A working party chaired by Baroness Deech has been set up and will report later this year. Although women will soon be the majority of medical school entrants, the numbers at the top do not reflect those going in at the lower levels. One of the arguments here is that it is not possible to become a part-time leader, and it is difficult to reach leadership status if you have not invested in the necessary extra activities along the way. The barriers to this—or the “choice” not to do these activities—is influenced by a number of issues. The working week has become longer, and societal expectations still presume that women will continue with the majority of the household chores and the child care. This makes it difficult for women with family responsibilities to participate in the “extras”, which involve going to meetings before or after the working day and participating in international travel.

The gender gap in medicine is narrowing. Gender equality is slowly filtering into the medical workplace, but there is still a way to go. The situation in the UK is better than the USA, with better pay equality, maternity leave provision, and opportunity for part-time working at consultant level, but organisational and cultural barriers continue to inhibit true equality in the medical workplace. Books like this, together with the research completed by the Royal College of Physicians, have presented the data in a usable form. It is now up to the profession to interpret it and act on it.

When I first became interested in women in medicine, I thought that I personally had not come across any discrimination in the workplace, but I now think that it was there, but subtle. It is only when you look carefully that you notice problems with the perceived normality around you.

Death in Birth

By Richard Lee

In a hospital ward in Freetown, the capital of Sierra Leone, Fatmata Conteh, 26, lay on a bed, having just given birth to her second child. She had started bleeding from a tear in her cervix, the blood forming a pool on the floor below. Two doctors ran in and stitched her up, relatives found blood supplies, and nurses struggled to connect a generator to the oxygen tank. One nurse jammed an intravenous needle into Conteh's arm, while another hooked a bag of blood to a rusted stand, and a third slapped an oxygen mask over her face. In the corner of the room, a tiny baby--3 hours old--lay on a bed, wailing, swaddled in bright-colored African fabric. "Listen! You must feel happy to hear your baby cry," said a nurse, pleading with Conteh to find strength. Three visiting members of a neighborhood church began chanting over Conteh: "Jesus, put blood into this woman! Thank you, Lord!" But as their chants grew louder, the nurses stepped back from the bed. Conteh was dead.

Some version of that scene is repeated around the world about once a minute. Death in childbirth is not just something you find in a Victorian novel. Every year, about 536,000 women die giving birth. In some poor nations, dying in childbirth is so common that almost everyone has known a victim. Take Sierra Leone, a West African nation with just 6.3 million people: women there have a 1 in 8 chance of dying in childbirth during their lifetime. The same miserable odds apply in Afghanistan. In the U.S., by contrast, the lifetime chance that a woman will die in childbirth is about 1 in 4,800; in Britain, 1 in 8,200; and in Sweden, 1 in 17,400. Deaths are heavily weighted to the poorest and most isolated in each country, which means that many politicians remain largely ignorant of the scale of the tragedy. "Often the people in the cities do not know what is happening in their own rural areas," says Sarah Brown, wife of British Prime Minister Gordon Brown and patron of the White Ribbon Alliance, a global advocacy organization that works with governments to lower maternal mortality rates. Brown--who lost a baby 10 days after giving birth in 2001--says that when she tells heads of state and their spouses how many women die in childbirth, "they are aghast."

The Gains Not Made
They have reason to be. For here is the truly ghastly reality of maternal mortality: in 20 years--two decades that have seen spectacular medical breakthroughs--the ratio of maternal deaths to babies born has barely budged in poor countries. To be sure, maternal health has seen advances, with new drugs to treat deadly postpartum bleeding and pregnancy-related anemia. But in many places, such gains are dwarfed by a multitude of problems: scattershot care, low pay for health workers and a scarcity of midwives and doctors. In Mozambique, where women have a 1 in 45 lifetime chance of dying in childbirth, there are just 3 doctors per 100,000 people; in all of Sierra Leone, there are 64 government doctors, only five of whom are gynecologists. Millions of families have never seen a doctor or nurse and give birth at home with traditional birthing helpers, while those who make it to a clinic--some being carried on bicycles or in hammocks--often find patchy electricity, dirty water and few drugs or nurses. Explaining the task of reducing maternal deaths, Sierra Leone's Minister of Health, Saccoh Alex Kabia, who returned home last year after decades of working as a surgeon in Atlanta, says, "The whole health sector is in a shambles."

Many hope that maternal death rates in poor nations will naturally fall over time, as they did in much of the world in the 20th century. They well might. But international officials say governments often lack the political will--as well as the money--to tackle the issue, perhaps because there are too few women politicians to push it. Monir Islam, director of the maternal-health program of the World Health Organization in Geneva, calls governments' low level of investment in reducing deaths in childbirth a "sinful neglect."

In an attempt to jolt officials into action, governments at the U.N. General Assembly in 2000 chose to make a drastic reduction in maternal mortality one of the eight Millennium Development Goals (MDGS)--a series of targets in a program that channels aid to key issues, including education and clean water--to be met by 2015. The MDGS hold people "to a golden standard for progress," says Jamie Drummond, executive director of the antipoverty organization DATA. When world leaders gather in New York City this month to take stock of the MDGS, their speeches are likely to tout the many achievements since 2000: millions more African children now attend school and sleep under mosquito nets; thousands of new water wells have been dug. Yet though maternal health care underpins many other development goals (healthy mothers are more likely to ensure that their children are well fed and educated), the total number of women dying in childbirth has remained virtually unchanged in eight years.

Why? Health officials are clear in their answers. Aside from lack of money and political will, they also face entrenched traditions and fatalistic attitudes to maternal mortality, especially in very poor communities. "People think that dying in childbirth is not preventable," says Nadira Hayat, Afghanistan's Deputy Minister of Health. "They say it is up to God."

So it seemed before dawn one Sunday in August in Kora Olia, a remote village in Afghanistan's northeastern province of Badakhshan, where maternal mortality is about four times the country's already high rate. Nine months pregnant, Harakatmo, 19, began bleeding heavily. Her husband and mother-in-law were concerned, but the local doctor was far away, and expensive, so they waited. When Harakatmo was still bleeding the next morning, they sent a horseman to fetch a village health worker, but Harakatmo's bleeding continued. Panicked, her husband strapped her to a makeshift stretcher and carried her down the steep track from their home until he found a police truck to take them to a clinic several miles away. The doctor there urged the family to rush Harakatmo to Badakhshan's only hospital, in Faizabad, the provincial capital. Harakatmo's husband hired a ramshackle minivan for the journey--a five-hour ride along rutted dirt roads. On the way, they stopped while Harakatmo's mother-in-law delivered the baby. It was already dead; the tiny corpse was wrapped in a cloth and placed next to Harakatmo. Lying in the hospital that evening, she said she considered herself lucky. "When I left my house this morning, I thought I would die."

More will die if health-care systems are not reformed. In the first half of this year, 889 babies were delivered in Freetown's crumbling Princess Christian Maternity Hospital. During that period, 70 women died giving birth, and about eight more women have died since--an astonishing death rate of about 9%. Yet far from being overstretched, the hospital most days feels desultory, with nurses lingering in near empty wards because people cannot afford to pay for care. Emergency maternity care is supposed to be free in Sierra Leone, but in reality, patients are asked to pay for every item, including cotton swabs, gauze and syringes--this in a country where the average income is about $200 a year. If transfusions are needed, relatives have to donate blood to replace what is used.

One morning I watched a fierce argument between nurses and the relatives of a woman whose unborn baby was already dead inside her. As she sat on a bed awaiting an emergency C-section, her relatives pleaded that they could not afford 400,000 leones (about $135) for the operation. Finally the woman's aunt handed some 250,000 leones (about $85) to a nurse, who counted the banknotes before jamming them into her pocket, explaining to me that the money was "for drugs and to pay the doctor." Since nurses and doctors earn about $150 a month, "the staff is struggling to survive," says Peter Sikana, technical adviser for the U.N. Population Fund in Sierra Leone.

The scribbled notes from nurses in patient records, many of them in school exercise books paid for by relatives, describe their battles to keep women alive. In one such note, a nurse describes a woman, 18, who arrived at the hospital in late July suffering convulsions days after a traditional birth attendant delivered her baby at home. Four days later, the nurse wrote, "All due nursing care rendered but in vain. May her soul rest in peace." Six weeks later, I find the woman's father sitting outside the tiny family home atop an escarpment that overlooks Freetown. Holding the newborn baby, he says his daughter gave birth at home because "the terrain is too rough to reach the hospital." By the time he carried her, half conscious, down the slope to the hospital, she was too sick to be saved. Even for women who give birth in a hospital, survival is no sure thing. Another woman, 20, was admitted in late July in early labor and began having seizures hours after giving birth. Through the night the nurses scrawled frantic notes, including this one at 1:30 a.m.: "Dr. was tried ... via mobile [phone] to no avail." The woman died two hours later. I find her husband grinding peanuts in a Freetown market. "She delivered a healthy baby," he says, showing me a photograph of his wife, a tall woman with a confident, beaming smile.

Hope, for Some
Though many die in hospitals, researchers say the riskiest births are those without any nurse, midwife or doctor in attendance--about 35% of all the world's births. In addition to age-old problems like unclean instruments and poor-quality water--in Sierra Leone, I visited a traditional birth attendant who said she had delivered hundreds of babies in a windowless room in a slum of cramped shanties, with no indoor plumbing--there are new hazards. Afghanistan, for example, has seen growing sales of over-the-counter oxytocin, an injectable hormone that is used to stanch postpartum bleeding and speed labor but that can kill if administered incorrectly. Shamisa, a midwife, says that recently a heavily pregnant woman was brought to her rural Badakhshan clinic in a coma after being given a range of drugs by a pharmacist; both she and the baby died.

After millions of deaths and years of muddled government policies, a groundswell of distress at maternal mortality rates is at last stirring action. At the July G-8 summit of industrialized nations in Hokkaido, Japan, leaders for the first time discussed maternal deaths as a crucial obstacle to development. And there has been progress. Some poor countries have shown rapid results from investments in maternal health: in Honduras, for example, maternal mortality rates dropped about 50% from 1990 to '97 after officials opened scores of rural clinics and trained thousands of midwives. Nepal and Sri Lanka have trained midwives in emergency obstetrics. In the Indian states of Assam, Madhya Pradesh and Orissa, pregnant women now get 1,400 rupees ($32) to spend on whatever maternity services they choose--even a taxi ride to a clinic to give birth. Afghanistan has built 1,465 clinics and trained about 19,000 community health workers since the Taliban was ousted in 2001. The incidence of this worldwide tragedy can be reduced.

Even in Sierra Leone there are glimmers of hope. Aid organizations recently began training traditional birth attendants; several towns now demand that they deliver babies in clinics, where nurses can monitor their work. An hour east of Freetown, I visited a village where local elders had just passed a law requiring all women to give birth at a clinic or face fines of about $8--more than the clinic fee. And the World Bank, UNICEF and the British government's Department for International Development have agreed to jointly invest $262 million over the next three years to overhaul Sierra Leone's shambolic health system. "We will lose two or three more generations," says Geert Cappelaere, UNICEF's representative in Freetown. "But the core message is one of hope."

For some, that hope has come too late. A week after Conteh's death, her relatives gathered to name her baby girl after the dead mother. Weeping, Conteh's parents and her boyfriend hugged and kissed the infant, a bittersweet reminder of their loss. They are not alone. In the time it has taken to read this story, about 20 more women have died in childbirth.

THE HEARTBRAKE

Women are dying in childbirth in the same numbers as they were decades ago. The slow progress is an outrage, argues HNN's Editorial Director Sarah Williams.

Habibu is lying on matting on the mud floor of her hut. The contractions are coming thick and fast now. The pain is intense, but she draws comfort from the memory that, the previous three times, this agony gave way to the peaceful, exhausted bliss of holding her baby in her arms.

Her husband’s mother is on hand to help – she has, after all, given birth many times herself and seen many more children born. Water has been brought from the pump and sits in two large bowls ready to be used – one to wash the baby and the other to wash everything and everyone else; pieces of old cloth have been gathered over the months before so as to soak up any blood and bodily fluid. A kerosene lamp has been borrowed from a neighbour to cast any light needed on this dark West African night.

The delivery itself seems to go well: a girl, Mama says, now to be heard crying. Habibu lies back and gives herself up to the pleasure of there no longer being any sharp pain, only exhaustion and discomfort, and to the satisfaction of having brought another life into the world.

It is a while before Mama realizes that blood is still pumping out of Habibu, forming a widening crimson pool on the mat and the floor. She uses the rags to try to staunch the flow; to no avail. There is no sign of the placenta being delivered, as would normally happen within minutes of birth. Mama waits in hope for further precious minutes before realizing that the blood flow is not going to stop and that there is serious danger. Alarmed now, she summons her son, who sets out on his bicycle to try to contact the nurse at the government clinic 12 kilometres away.

By the time the nurse arrives, two hours have passed and it is too late for Habibu, whose life has drained away with her blood. There is nothing the nurse can do for the woman. Instead she tends to the newborn baby, while cursing under her breath the fees she has to charge for attending a birth at the clinic – fees that mean so many women opt to go it alone. She knows she could easily have saved her – an injection of oxytocin, perhaps, or a manual delivery of the placenta – but knows just as clearly that this desperate experience will be repeated on many other nights and days over the months and years to come.

The specifics of this story are fictional, though I name its victim Habibu in honour of a woman I knew in a Burkina Faso village who died in childbirth. She had just remarried after years of hardship raising children as a widow and had been looking forward to cementing her new marriage with a baby. She could and should have attended the nearest health centre for antenatal checks and for her delivery – the last time I visited it, the maternity unit at that health centre had yet to lose a mother during childbirth. But she opted not to do so – in part because her previous children had been safely delivered at home, but also because such supervision costs money, and even the smallest sums are hard to find in a subsistence farming family.

Just one story – but one that is repeated an average of 1,500 times every day around the world, and with particular terrible regularity in Africa and South Asia. In other cases, the complication might be not postpartum haemorrhage but an obstructed labour that demands, but does not receive, a caesarean section. In many such instances the baby will die along with the mother; in others, the mother will survive but will have lost her child. And for every one woman that dies, another 20 suffer injury, infection or disability that can even leave them shunned by their family and community.

In the vast majority of these cases, the deaths are eminently preventable. While the number of child deaths worldwide has consistently fallen – from around 13 million in 1990 to 9.7 million in 2006 – the maternal mortality toll has remained stubbornly similar. For decades, the international estimate of the number of maternal deaths each year has hovered just over the half-million mark.

You might assume from this that maternal deaths are somehow mysterious, untouchable by medical science or development interventions. Yet nothing could be farther from the truth. Not only could the number of maternal deaths be radically reduced, but it could also be done within a few years if only there were sufficient will.

This was one reason why, when the Millennium Development Goals were set in 2000, arguably the most ambitious of all the targets set was in relation to maternal mortality. Whereas the target was to cut poverty in half and to cut child mortality by two-thirds, the aspiration was to slash the maternal mortality ratio by three-quarters. The chart overleaf shows just how far the world is falling short.

This is where the gulf between rich and poor worlds is at its widest and most obscene. The lifetime risk of maternal death is just 1 in 8,000 in the Global North compared with 1 in 76 in the Global South. At the national extremes, an Irish woman has a 1 in 47,600 chance of dying from a pregnancy-related cause compared with a staggering 1 in 7 chance of death for a woman in Niger.



No matter how good the supervision or the medical facilities, some deaths in childbirth will always occur. But the statistics indicate clearly how much less hazardous it is for a woman in the West now to have a baby than it was for previous generations. There is no point in pretending that Ireland’s remarkable safety record could be replicated overnight all over the world. But the Millennium Development Goal could certainly still be achieved – even now, with only 6 years of the 25 left to run, when such pathetic progress has been made to date. And, were we to do so, 400,000 women every year would be saved from unnecessary death – and their husbands, children and families from unimaginable grief.

Given this, there are just two big questions to ask. How might these lives be saved? And, if we know how to save them, why isn’t it happening?

The ‘how’ is surprisingly straightforward. The best way to reduce maternal mortality (as well as the deaths of newborn babies) is to ensure that all births are attended by skilled health workers – trained midwives, nurses or doctors. At the moment only 59 per cent of births in the developing world are attended. The lowest rates of skilled attendance are in South Asia (41 per cent) and sub-Saharan Africa (43 per cent) and it is no coincidence that these are also the regions with the highest incidence of both maternal and neonatal mortality. If you live in the countryside in one of those regions, moreover, you’re about half as likely to have your birth attended as if you live in a city.

Ensuring that skilled workers are there during the delivery will cut out many of the unnecessary deaths. To save even more lives, a suitably equipped maternity centre needs to be within reasonable striking distance (less than two hours’ journey away) if some major obstetric complication arises.

Of course there are all kinds of other factors involved that would further reduce maternal mortality – among them better nutrition for pregnant women, better access to contraception, antenatal and postnatal visits, teaching each pregnant woman and her family about the danger signs. But, in the simplest terms, if every birth were attended by a skilled health worker the numbers of maternal deaths would tumble.

If it is that simple, that attainable, why is it not happening? Is this not something the whole world could agree on as an uncontentious objective? Isn’t motherhood, like apple pie, supposed to be an unchallengeable good?

Actually, the stubborn lack of progress on maternal mortality suggests that the root cause lies in women’s disadvantaged position in most countries and cultures. In countries with similar levels of economic development, maternal mortality tends to be inversely proportional to women’s status – in other words, the worse women are treated in society in general, the more likely they are to die in childbirth.1

Against this background of discrimination, often handed down from generation to generation by cultural tradition, initiatives to enhance maternal health need to go hand in hand with measures to promote women’s rights and to protect girls and women from violence, exploitation and abuse. Getting girls into school is a fast track to improving maternal health (and the health of their children) later; it also helps to protect them from child marriage, with its inevitable consequences of premature pregnancy and motherhood. The evidence is clear that educated adolescents are more likely to wait until they are out of their teenage years, when pregnancy risks are highest, to begin a family, and are more likely to have healthy babies. Pregnancy and childbirth-related deaths are the leading cause of mortality for girls aged 15-19 worldwide, killing 70,000 every year. Girls who give birth at even younger ages than 15 are even more at risk due to their physical immaturity, being five times more likely to die in childbirth than women in their twenties.2

Because there is such a close link between women’s oppression and maternal mortality, we need to treat maternal health as a fundamental human right – especially if we are to reach the poorest and most socially excluded women. The Convention to Eliminate Discrimination Against Women (CEDAW), which has been ratified by 185 countries, requires that governments ‘ensure to women appropriate services in connection with pregnancy, confinement and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation’. Very few developing countries are currently delivering on this commitment.

So women’s oppression is part of the background. But don’t go away thinking that this means there’s little that can be done about maternal mortality. The scandal is that mothers are dying unnecessarily because the world is unprepared to stump up the relatively meagre resources required to protect them.

That maternal deaths could be reduced by making sure all deliveries were attended has been known for decades – certainly ever since the international conference at Alma Ata in 1978 that propounded the notion of Primary Healthcare. The Alma Ata vision was of relatively low-cost outreach workers in communities, building on the model of ‘barefoot doctors’ pioneered in Maoist China. But those health workers and midwives at work out in the community were always supposed to be backed up by clinics – and beyond them hospitals to which they could refer patients.

This eminently sensible model of an integrated healthcare system that could have transformed the lives of people right across the Majority World was abandoned almost entirely because those pulling the purse-strings of ‘development’ considered this to be too expensive.

It was replaced in the 1980s by the disastrous idea that the funding gap in health should be met by getting the ‘consumers’ themselves to pay user fees. The legacy of that approach is still killing women all over Africa and South Asia, where the poor inevitably take their chances rather than pay for care, just as Habibu did.

A great deal of time and many millions of lives have been lost in the intervening decades since the vision of the Alma Ata Declaration was articulated, but we have returned to the same point. An integrated health system that would allow the MDGs to be met, and would transform maternal, neonatal and child health worldwide, is still achievable – provided the necessary resources are invested.

We could not get overnight to the point where all births are attended and have access to emergency obstetric care when needed – especially given the drain of doctors and nurses away from the countryside and even from Majority to Minority Worlds. There is at present a shortage of 2.3 million doctors, nurses and midwives spread across 57 countries.3 But ultimately it is still a question of resources: if we spent the money required to create health systems that functioned properly, we could still solve this problem in time to meet the MDG target.4

Back in 2003, global development assistance to maternal and neonatal health stood at $663 million a year. It was estimated then that an extra $6.1 billion would be required each year by 2015 to increase coverage to desired levels.5 To put this in perspective, the economic impact of maternal and newborn deaths has been estimated at $15 billion per year in lost productivity, while global military spending passes the $6-billion mark every one-and-a-half days.6

As global recession takes hold and the economic meltdown continues, it will be argued that such resources cannot easily be found. Yet with what ease are hundreds of billions of dollars found to bail out banks, to insure the financial system against its bad debts! Why could we not, over the last two decades, have found the much smaller sums necessary to bail out poor countries by investing in the kind of health services they so badly needed? Why could we not, long ago, have spent the sums necessary to insure young women and their families the world over against death and disability?

This article began by telling the story of Habibu, before sweeping off into the realms of statistics and health policies to make its case. But it is all too easy in discussing the global situation to forget that every single one of the 536,000 mothers who die in childbirth each year has her own story just like Habibu’s. Like her, they approached their labour full of expectation and hope for the new life that they were about to bring into the world, only to die for want of the care that should have been their right – and that mothers in the rich world routinely expect. We should hold stories like theirs in the forefront of our minds as we consider in the months and years ahead exactly what kind of world economy we are now to remake.

Votes cast as a 'weapon of the weak'

By M H Ahssan

India's rich and middle class urban voters have failed to show up in large numbers to exercise their franchise in the country's 15th month-long general election. Despite a massive campaign to get the educated to vote, the software hubs of Bangalore and Pune, the two main metros which went to the polls in the second phase of voting on April 23, registered poor turnout.

In contrast to rural areas, which had a turnout of 60%, constituencies in Bangalore city registered a mere 46% turnout, a figure that is below the national average in two phases of voting so far but also lower than turnout in the 2004 general election. As in previous elections, in the two rounds of voting that have been completed in India's multi-phase general election, urban middle-class voters have indicated that they are laggards in comparison to the rural or urban poor.

Media reports on the Indian elections often draw attention to the magnitude of the electoral exercise. Indeed, it is hard not to be impressed by the sheer scale of the election. A 714-million-strong electorate will vote in 828,804 polling booths in 543 constituencies in a five-phase election spread over a month. Four million electoral officials and 2.1 million security personnel are overseeing the process to ensure that it is free, fair and peaceful. Animals, too, are on hand to assist in the process. In the states of Assam and Meghalaya in India's northeast, elephants carry officials and polling material to voting booths.

The Election Commission (EC), which conducts the polls, goes the extra mile to ensure that voters can exercise their franchise. In some parts of the country, which are inaccessible by roads, officials trek for three to four days or ride on the backs of elephants to set up polling booths.

In the western state of Gujarat, the EC has set up a polling booth for one voter - a priest in a temple in the heart of the Gir forest, which is home to the Asiatic lion. He will vote in the third phase of the election.

Officials brave wild animals, scorching heat, long treks, militants and impatient voters to ensure that people can exercise their fundamental right to vote.

As remarkable as these statistics or the logistics involved in conducting the election is the mass participation in Indian elections. Unlike the global trend of a steady decline in voting levels, in India voter turnout over the years has either increased or remained stable.

And what makes this rise in voter turnout significant is that it is spurred by the rise in participation in elections by the poor, women, lower castes and Dalits and tribals. The most vulnerable sections of Indian society are increasingly enthusiastic about voting.

Unlike Western democracies, which granted the right to vote first to propertied men, later educated men, then all men and only after much debate and agitation to women, independent India granted all adult men and women regardless of their religion, caste, language, wealth or education the right to vote in one fell swoop, points out Ramachandra Guha, author of India after Gandhi: The History of the World's Largest Democracy.

The Indian constitution granted all its citizens the right to vote. Right from the first general election in 1952, India's poorest and most marginalized sections have possessed the right to vote. And they have been the most keen to exercise this right.

Voter turnout in India has been higher in rural areas than in cities since 1977. The poor vote more than the rich, especially in urban areas and in the past four general elections, Dalits (or Untouchables as they used to be called) have voted more than upper-caste Hindus, says Yogendra Yadav, a political analyst with the Center for the Study of Developing Societies. "This 'participatory upsurge' from below has defined the character of Indian democracy in the past two decades or so," he says.

This is quite unlike the experience in Western democracies where it is the rich, the well-educated and those belonging to the majority community who are more likely to vote and participate in political activity.

Analysts have pointed out that if those at the lower end of the socio-economic hierarchy take the trouble to vote, defying threats and violence, it is because democracy is bringing change in their lives, however small these might be. Polling day is that one big day on which their decision matters, when their choice counts.

Voters defy militants' calls for a boycott of the poll to exercise their franchise. Maoists have called for a poll boycott and sought to impose it with intimidation and violence. Still, people in the states of Jharkhand and Chhattisgarh have come out to vote. In assembly elections in Jammu and Kashmir in November and December last year, 62% of the electorate voted in spite of a boycott call by separatists.

The media have often underestimated the rural/poor voter, looking on him or her as someone who votes along caste or other parochial lines, who votes as told to rather than on the basis of an informed choice.

This might be true, but only to a limited extent. In 2004, the ruling National Democratic Alliance (NDA) campaigned on an "India Shining" slogan. But India was not shining for rural Indians and those at the bottom of the heap. Unlike the educated/urban voter who swallowed the NDA's propaganda campaign, the rural voters registered their protest through the ballot box. They voted out the NDA. The vote is the "weapon of the weak", points out Yadav.

This time around, whether the rural voter who is reeling under a severe agrarian crisis is impressed by the 8% average economic growth rate achieved under the Congress-led United Progressive Alliance (UPA) government is debatable. To its credit, the UPA has put in place a rural employment guarantee scheme that provides one member of every rural household with work for 100 days every year.

Both the Congress and the main opposition Bharatiya Janata Party (BJP) have made provision of heavily subsidized wheat and rice a central plank in their election campaigns. The Congress has promised every poor family 25 kilograms of wheat or rice at 3 rupees (US$0.06) a kilogram and the BJP 35 kilograms at 2 rupees per kg.

One of the districts that voted in the first phase was Kandhamal in the eastern state of Orissa, which was ravaged by anti-Christian violence last year. Voter turnout in the district was 65.7%. About 90% of those still living in relief camps - people who are too terrified to return to their homes for fear of communal violence - turned up at polling booths despite a Maoist call for a poll boycott and fear of communal violence. Clearly, these victims of communal violence are looking on the ballot box with some hope.

How do Muslims - India's largest religious minority - view the democratic process? Contrary to the perception worldwide that Muslims do not believe in democracy, Muslims in India are as enthusiastic as Hindus in their stated support of democracy. Voter turnout among Muslims, which dipped in the early 1990s and again in 2004, has generally been rising or stable and is as robust as that among Hindus. "Clearly, Indian Muslims are not opting out of democratic politics," says Yadav.

It is not religion but class that appears to influence voter turnout. The rich and middle class Indian doesn't seem to share the faith the poor have in the elections and the power of the vote. Over the years, urban apathy has grown. All the parties are the same, urban voters grumble, pointing to the fielding of criminal and corrupt candidates in some areas.

Voter turnout in successive elections over the past two decades indicate that for all their whining about the quality of politicians who represent them in parliament and state assemblies, India's educated and more privileged sections don't do anything about it on polling day. They simply stay away.

South Mumbai, where many of India's millionaires and billionaires live and work is notorious for poor turnout on polling day, as is Bangalore, India's software hub. State assembly elections in Bangalore in May last year saw an abysmal 44% exercise their franchise, the lowest in the past five elections.

Will Mumbai, Delhi and other Indian cities go Bangalore's way in the coming phases of voting? The terror attacks in Mumbai in November last year shook up the country's politically apathetic youth and brought them out into the streets demanding greater accountability and better performance from the political elite. Thousands participated in candlelight vigils and online campaigns.

Whether they will leave the comfort of their air-conditioned homes to wait in long lines outside polling booths to vote in scorching heat is another matter.

Big money seeks common man's blessing

It was once hoped that curbing election expenses would keep the process fairer. Today, the opposite is true, and neither the UPA nor the NDA wants to disturb this comfortable arrangement. HNN reports.

Fighting elections in India has become extremely expensive. According to an Election Commission (EC) representative, while an estimated Rs.4500 crores was spent for the 2004 Lok Sabha elections, this time around, the expenditure will cross Rs.10,000 crores. Though a huge sum, even this is in all probability a conservative estimate. About 20 per cent of this constitutes government expense; the remaining will be spent by political parties and their candidates.

The high election expenditure is not a reflection of the basic cost of the campaign but rather an indication of the permissive environment that has evolved over time where there is no limit for the amount of money that political parties can collect and spend on elections. Political parties are neither accountable nor transparent about their finances. The state machinery is unwilling or unable to curb illegal expenditure by political parties, allowing the elections to become an outlet for huge quantities of black money. Such an environment encourages political parties to outdo each other in spending in the quest for political advantage. Politicians across the country have chartered as many as 60 helicopters costing between Rs.75,000 and 2 lakhs per hour for use over a month (Hindustan Times, 21 April 2009). Profligate spending is no longer frowned upon. But this was not always so.

The law on election expenses

The election-related laws framed in 1950s had the objective that money should not be allowed to influence the outcome of elections. The Representation of People Act, 1951 required every candidate to keep an account of all election expenditure incurred or authorized by him. The expenditure was to be kept within prescribed limits and subject to inspection by EC representatives. Violating the limit was deemed a corrupt practice, punishable by disqualification from contesting elections for a period up to 6 years.

While limits of the candidates' spending were established, the law did not set limits on the expense of political parties themselves, and there was a reason for this. The Constitution of India did not recognise the 'Political Party' as a formal entity at that time; political parties had no defined role to play, either in the elections or in the formation of government. The law to limit expenses therefore only dealt with the expenditure by the candidate; this was considered sufficient to curb overall expenses on the elections. In time, political parties started exploiting this loophole.

Did expense incurred by the sponsoring political party or by the friends and supporters of a candidate towards his election in excess of prescribed limits constitute a corrupt practice? This issue came up before the Supreme Court in the case of Kanwarlal Gupta vs. Amar Nath Chawla (1974). Using the occasion to expound on the objectives of the ceiling on spending by candidates, the Supreme Court observed:

"It should be open to any individual or to any political party, however small, to be able to contest an election on a footing of equality with any other individual or political party, however rich and well financed it may be, and no individual or political party should be able to secure an advantage over others by reason of its superior financial strength."

"The other objective of limiting expenditure" the Supreme Court added, "is to eliminate, as far as possible, the influence of big money in electoral process. If there were no limit on expenditure, political parties would go all out for collecting contributions and obviously the largest contributions would be from the rich and the affluent who constitute but a fraction of the electorate ... The small man's chance is the essence of Indian democracy and that would be stultified if large contributions from rich and affluent individuals or groups are not divorced from the electoral process."

After outlining these objectives, the Supreme Court argued that "if a candidate were to be subject to the limitation of the ceiling, but the political party sponsoring him or his friends and supporters were to be free to spend as much as they like in connection with his election, the object of imposing the ceiling would be completely frustrated and the beneficial provision enacted in the interest of purity and genuineness of the democratic process would be wholly emasculated." The Supreme Court thus answered the original question in the affirmative.

This judgment met with the negative reaction of the government of the day. The Representation of People Act, 1951 was amended by the Congress government in 1975 and an infamous "explanation" added to the election expense provision. The explanation ran thus:

"Notwithstanding any judgment, order or decision of any Court to the contrary, any expenditure incurred or authorized in connection with the election of a candidate by a political party or by any other association or body of persons or by any individual (other than the candidate or his election agent) shall not be deemed to be, and shall not ever be deemed to have been, expenditure in connection with the election incurred or authorized by the candidate or by his election agent."

Not only the sponsoring political party but also friends, relatives and supporters of a candidate were freed from any limits on spending for their candidate. The objectives of the original provisions in law limiting election expenses of candidates had been completely frustrated!

Financial transparency of political parties

The Income Tax Act was amended in 1979 requiring political parties to file income tax returns every year. The tax law allowed a political party to claim full exemption from income tax for a variety of sources of income including voluntary contributions received from any person provided the party maintained books of accounts, recorded details of all voluntary contributions above Rs.10,000 and got their books audited. However, most parties including the Congress and the BJP did not comply with the law and file returns. This fact only came to public notice after a Public Interest Litigation filed by Common Cause came up before the Supreme Court in 1995. The Supreme Court ordered the Government to investigate and prosecute the erring political parties, but it is not clear if anything came of this. The Law Commission of India in its 170th report, Reform of the Election Laws in 1999, made this scathing comment on the issue:

"While a small income-tax payer who fails to file his return is prosecuted and penalized, the political parties which are in receipt of huge funds which they spend on elections and other occasions are not being touched. The parties too do not appear to have realized that if they themselves do not follow the law, not only it sets a bad example to others, they will not have the face to tell others to abide by law."

The Commission followed a comprehensive analysis of the problem of election expenses with the recommendation that political parties must be required by law to keep accounts, have them audited and publish them for the general public and strong penalties should follow including de-recognition of the party by the EC for non compliance. The National Commission to Review the Working of the Constitution also expressed similar views in 2002.

The election expense laws were finally amended in 2003, but not on the lines suggested by the Law Commission. The Election and Other Related Laws (Amendment) Act, 2003 was passed by the NDA Government with the support of almost all parties including the Congress. While the infamous 1975 "explanation" to the election expense clause was finally deleted, this change made no difference any longer. The election laws and rules were amended to allow political parties to "accept any amount of contribution voluntarily offered to it by any person or company". Only contributions to parties over Rs 20,000 (earlier Rs 10,000) were to be recorded and reported. The punishment for not submitting returns was that income tax exemptions could not be claimed! The income tax laws were also amended to give 100 per cent tax exemptions to companies and individuals for contributions to political parties.

The NDA government claimed that these changes would bring about more political accountability. But many questions remained unanswered. Would companies, for example - solely in business for profit - contribute a part of their profit to party funds without any expectation of return favors when/if the party came to power?

The idea of limiting election expenses had been buried once and for all by codifying in the Representation of People Act, 1951 the right of political parties to accept (and consequently spend) any amount. Enacting strict penalties to ensure transparency and accountability in finances of political parties had been given the go by, even though it was clear that the laws would not be respected otherwise.

The Election Commission suggested to the UPA government in 2004 that "political parties must be required to publish their accounts (at least abridged version) annually for information and scrutiny of the general public and all concerned, for which purpose the maintenance of such accounts and their auditing to ensure their accuracy is a pre-requisite" Their plea fell on deaf ears. The UPA was as comfortable with the status quo as the NDA.

Who will fund the parties?

The escalating cost of elections puts pressure on parties to mobilize funds whichever way they can. Most political parties do not collect money for party activities and elections by building a broad membership and collecting regular dues. The funds collected using legal channels from companies and individuals are only a fraction of what they 'need', given the possibilities of unlimited expenditure. During the 2004 elections, for example, all the political parties put together showed expenditure less than Rs.230 crores, according to figures made public by the EC. Sources of unaccounted wealth need to be tapped; this is probably what makes parties shy of making their 'real' books open to the public.

Seen against this context, the recent action of the Bahujan Samaj Party (BSP) in Delhi in nominating extremely wealthy businessmen is understandable. The BSP candidates for four of the seven Delhi constituencies have declared assets of Rs.622, 155, 14.5 and 19 crore rupees respectively! The President of its Delhi unit admits that as the party does not fund its candidate's election expenses, it expects them to have deep pockets if they should have a fair chance to win. And the original argument against huge money in political campaigns has come full circle - wealth, once seen as distorting the playing field, is now seen as necessary to keep it level.