Hannah Brown

Trends in abortionsOf the 210 million conceptions annually worldwide, almost half do not result in a live birth.2 Eighty million pregnancies end early, 42 million of these are terminated through abortions (20 million done illegally), and another 3 million babies are stillborn. Most of the abortions are carried out in the developing worldThe previous analysis of worldwide numbers of abortions in 1995 recorded 46 million procedures. The drop to 42 million by 2003, the latest year for which figures are available, has occurred mainly in developed countries, where abortion is legal, albeit contingent on various conditions being met. “We calculate that one in five pregnancies ends in abortion worldwide,” says Sharon Camp, president of the US based Guttmacher Institute, a sexual and reproductive health think tank that collaborated with the World Health Organization to compile the data. “Sixteen per cent of pregnancies end in unwanted or mistimed birth, and overall over one third of pregnancies are unintended,” she adds.In what seems to be a plateauing of a long term decline, the smallest drop since 1995 was observed in the US, which still has the highest abortion rate of any Western country, with half of pregnancies being unintended. The biggest drop occurred in Europe, which traditionally had high rates. “If we deconstruct the European drop, then it is clear that this is due to a steep decline in eastern Europe,” explains Dr Camp. “There was in fact a small rise in western Europe due to immigration of people with low levels of contraceptive awareness. One general truth is that abortion rates decline as contraceptive use increases,” she says.Dr Camp notes that the reason most abortions now occur in less developed countries is simply that this is where most of the world's women live, with China alone accounting for 9 million abortions a year. “The new data make it clear that prevention works; prohibition does not,” says Dr Camp. “Abortion is lowest where contraception and safe, legal, abortions are universally available. What is more, major abortion declines have occurred in countries where abortion is legal but not in countries where abortion is restricted.”

Wider problemThis situation, in which organisations set their own priorities in project areas and shout for their own causes, is symptomatic of a problem that affects many efforts to improve child and maternal health, says Flavia Bustreo, deputy director of the Partnership for Maternal, Newborn, and Child Health—a WHO hosted alliance of over 180 organisations, governments, and universities. The partnership aims to put an end to longstanding divisions that have held back progress in reducing mortality for these groups. Her organisation's first policy document, Opportunities for Africa's Newborns, published in November last year, emphasised the 4 million newborn deaths that occur every year—more deaths than caused by AIDS and malaria combined. But reducing this figure requires an integration of child and maternal health efforts, a process that means confronting a decades old divide.Although it is counterintuitive for outsiders, health programmes have treated maternal mortality and health of newborn babies separately, thanks to distinct funding streams and convenience based administrative divisions in international organisations. The maternal and child health sectors are strong, but newborns fall into a void between the two. The result is that although mortality of children under 5 years has fallen in several African countries, deaths during the first month of life are virtually unchanged. “One of the key problems is that some people are calling just for the mother and other people are calling just for the child. Combine that with other voices calling for malaria, HIV, and immunisation and you have the cacophony of calls,” explains Joy Lawn, a South African based senior policy and research adviser for Saving Newborn Lives/Save the Children USA. “In a lot of African countries people have been trying to move forward for maternal and child health, but the way donors organise money can ruin that united front,” she says.Although the main thrust of the conflict is about competition for advocacy and resources, there are ideological aspects too. Some champions on the child side perceive the maternal side as a competition, and some on the maternal side have overly focused on obstetric care when their community approaches could include newborns and children too. It is less about individuals than about ideologies that have become entrenched.

Five years ago, the world9s biggest publishing houses committed themselves to letting researchers in developing countries have free access to the content of their journals. Beset by technical problems and language difficulties, is HINARI succeeding in what it set out to do? Hannah Brown reports

Technology versus deliveryWhereas the Gates Foundation contests claims that it is neglecting the strengthening of health systems, co-chairs Bill and Melinda Gates have made no secret of the fact that they see breakthrough technologies as key instruments in global health. The foundation described its policy to the BMJ: “Effective and affordable health tools aren't available for many diseases. For this reason, we have focused a significant portion of our grant-making on discovering and developing new vaccines, drugs, and other tools that could save millions of lives.” However, according to Anne Mills, of the London School of Hygiene and Tropical Medicine, London, unless the foundation starts bridging the existing knowledge gap between proved technologies and how best to deliver them to communities, the problem is just going to get worse. “When money goes into new technologies you are just going to see more need for evidence on delivery systems to get them into practice,” she explains.Professor Sanders also believes the Gates Foundation's penchant for technological solutions limits the public health impact of its programmes because it ignores the realities of life in developing countries. “It is pretty clear that in the countries that I am acquainted with in southern and eastern Africa, the biggest problem is not lack of technology but systems to implement it; health systems have been seriously weakened by years of underfunding as a result of economic crises and structural adjustment,” he says.One of the starkest examples of the technology-delivery divide is the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunisation), a partnership established with a grant from the Gates Foundation in 2001. The alliance was set up at a time when worldwide immunisation rates were poor after steep rises in the 1980s—led mainly by Unicef —had waned. “Vaccination coverage had stagnated and in Africa it was at a miserable 50%,” explains Professor Sanders. GAVI had the primary aim of enticing the drug industry to produce more and new vaccines. But, says Professor Sanders, “We can't even administer the old vaccines to children in Africa.”GAVI has since begun investing directly into health system support for vaccine delivery but, according to Lincoln Chen, president of the New York based China Medical Board and an associate at Harvard University's Global Equity Initiative, the foundation has not yet achieved an ultimately effective balance. “I don't think Gates' investments are yet adequately balanced in closing the gap between what we know and what we can deliver,” he says. “I can understand Gates saying ‘That's not what a foundation can solve; it is too messy' but I look at the Rockefeller 100 years ago. It worked the whole system: the human resources in medical education and research, the necessary technologies, and the requisite social institutions for global health. Arguably, Rockefeller's huge investments in modern scientific medical education4 and establishing the field of public health5 were even more important than [its funding of] the discovery of penicillin and yellow fever vaccine. Gates has the opportunity to better balance its catalytic investments for the 21st century,” he says.

CompetitivenessYears of bitter wrangling between health campaigners, drug companies, and their respective supporters in both the commission and parliament, have led up to this point. The discussions began in earnest in 2001 when, concerned that the EU's drug industry had dropped behind its US and Japanese counterparts in innovation and profits, the commission set out to find ways to boost the industry's competitiveness. From the start, balancing economic and health priorities was a key objective. However, the first attempt to provide a forum for negotiating these diverse interests seemed to pay only lip service to the notion of balance.The commission set up a discussion forum called G10 Medicines in March 2001, comprising the health and enterprise commissioners, industry ministers from five member states, representatives from different sectors of the industry and mutual health funds, and a specialist in patient issues. Membership was kept intentionally small to make a consensus easier to achieve. The group came up with a set of proposals on which they all agreed in just 12 months. And, as expected, the recommendations for enhancing industry competitiveness included a relaxation of restrictions on drug companies communicating directly with the public, as well as suggestions for modifying the way drug prices are set and methods for assessing the cost effectiveness of medications. Around the same time, the European parliament was debating a set of amendments to existing patient information laws, introduced as part of a wide ranging revision of EU drug legislation. The commission, which came up with the changes after participating in the G10 discussions, had proposed that industry produced information for patients should be allowed for three diseases—HIV and AIDS, asthma, and diabetes—with the proviso that any material must conform to an industry authored code. Parliament's reaction was unequivocal: 70% of members of the European parliament (MEPs) voted against the proposed change.Despite this vociferous reaction from MEPs, the commission made no attempt to disguise its disappointment with the outcome. Erkki Liikanen, the enterprise commissioner at the time, went so far as to suggest that parliament had endangered health by rejecting the amendments because, he said, patients would be forced to seek information about drugs from US websites that might not be applicable to medicines sold in the EU.Even after the unpopular G10 group formally came to an end in June 2004, the commission did not lessen its resolve to advance the discussion over patient information. It set up a larger and more inclusive successor to the G10, called the pharmaceutical forum, to come up with practical ways to take liberalisation of patient information forward and increase the competitiveness of the industry. Earlier this month, the patient information working group of the pharmaceutical forum finally published a consultation on its tentative conclusions, including a pilot information package on diabetes and a set of “quality principles” to govern production of future information material for patients.

Hannah Brown investigates the use and abuse of journal rankings