Early-Phase Perceptions of COVID-19's Impact on Ophthalmology Practice Patterns: A Survey from the Pan-American Association of Ophthalmology.

Purpose: The COVID-19 pandemic affected medical practice worldwide due to interventions to prevent spreading. Its effect on ophthalmology practices in Latin America has not yet been explored. We aimed to assess the perceptions about the pandemic from countries' ophthalmological national and subspecialty retina societies affiliated to the Pan-American Association of Ophthalmology (PAAO). Patients and Methods: A survey-based study of leaders of national ophthalmological and retinal societies was conducted. The survey was sent by email to 30 societies, from which 20 responded (12 countries, 66.6% response rate). It included closed- and open-ended questions about (1) operational capacity and precautions, (2) telemedicine and virtual care, (3) procedures, and (4) post-pandemic considerations. Results: There was a marked decline in ophthalmology patient visits (80-95%) and elective surgeries (90%) during 2020 compared to before the pandemic. Precautions like temperature checks, mask usage, and social distancing were widely implemented while personal protective equipment (PPE) availability varied. Telemedicine use was limited due to lack of experience with it. Reopening plans focused on maintaining precautions and gradually resuming activities. Economic and security concerns were raised, and adherence to guidelines was emphasized. Respondents acknowledged the need to adapt to a "new normal". Long duration drugs, fewer imaging studies, and shorter wait times were preferred; however, availability of long duration drugs was limited. Conclusion: The pandemic impacted ophthalmology in Latin America, with reduced patient visits, procedures, and surgeries. Delayed treatment and complications were likely the result of the pandemic.

Importancia de la acreditación internacional de facultades de medicina

A partir de 2024, egresados de facultades de medicina que deseen hacer estudios de postgrado en los EE.UU o el Canadá, deberán graduarse en escuelas de medicina con programas educativos de calidad avalados por agencias reconocidas capaces de otorgar una acreditación internacional. La World Federation for Medical Education (WFME) es una de estas agencias. La WFME aceptó la nueva política de acreditación del Educational Committee for Foreign Medical Education (ECFMG) por la que médicos que postulen para la certificación del ECFMG del 2024 en adelante, tendrán que haberse graduado en un centro universitario de medicina acreditado por una agencia de aseguramiento de calidad que se encuentre reconocida por la WFME. El COMAEM (Consejo Mexicano para la Acreditación de la Educación Médica) está avalado por la WFME y otros organismos internacionales que aseguran la calidad de la educación superior. La acreditación que concede el COMAEM es un reconocimiento que el programa de medicina cumple con los criterios, indicadores y parámetros de calidad establecidos por este organismo. A partir de 2024, los egresados de un programa acreditado podrán postular para la certificación del ECFMG a través del examen de licencia médica de los Estados Unidos o USMLE (United States Medical Licensing Examination) y así poder hacer una residencia de especialización o trabajar en EE. UU. En el Perú, solo la Facultad de Medicina Alberto Hurtado de la Universidad Peruana Cayetano Heredia ha completado el proceso de acreditación internacional a través de COMAEM y ha recibido dicha acreditación.

As of 2024, medical school graduates who wish to pursue graduate studies in the U.S. or in Canada, they must have graduated from medical schools with quality educational programs endorsed by recognized agencies, capable of granting international accreditation. The World Federation for Medical Education (WFME) is one of these agencies. The WFME accepted the new accreditation policy of the Educational Committee for Foreign Medical Education (ECFMG) whereby physicians applying for ECFMG certification from 2024 onwards, must have graduated from a university medical center accredited by a quality assurance agency that is recognized by the WFME. The COMAEM (Mexican Council for the Accreditation of Medical Education) is endorsed by the WFME and other international organizations that ensure the quality of higher education. The accreditation granted by COMAEM is a recognition that the medical program meets the criteria, indicators and quality parameters established by this organization. Starting in 2024, graduates of an accredited program will be able to apply for ECFMG certification through the United States Medical Licensing Examination (USMLE) and thus be able to do a specialty residency or work in the U.S. In Peru, only the Alberto Hurtado School of Medicine of the Cayetano Heredia Peruvian University has completed the international accreditation process through COMAEM and has received such accreditation.

Mejor nutrición no significa necesariamente más comida": educación alimentaria y fomento agrícola en Argentina (1960-1970) / Better nutrition does not necessarily mean more food": food education and agricultural promotion in Argentina (1960­1970) / Melhor nutrição não significa necessariamente mais comida": educação alimentar e promoção agrícola na Argentina (1960-1970)

Introducción: el artículo analiza los lineamientos en educación alimentaria y de fomento agrícola que circularon en la Revista Educador Sanitario, publicación oficial de la repartición nacional de educación sanitaria de Argentina durante la década de 1960. Desarrollo: el trabajo explora las adaptaciones discursivas de los sanitaristas argentinos a las directrices internacionales de desarrollo para promover la campaña mundial contra el "hambre oculta", definida como aquellos patrones culturales alimentarios de baja calidad nutricional. Luego, examina las prescripciones dietéticas para las familias populares que pretendían estimular como hábitos, calidad, variedad y austeridad. Por último, revisa las tensiones y las contradicciones inmanentes a las referencias eruditas en torno al fomento agrícola y a las reglas del libre comercio, al evidenciar las inequidades alimentarias y la falta de infraestructura federal para lograr la ansiada modernización agroalimentaria. Conclusiones: el discurso de los desarrollistas sobre alimentación nutritiva apropiadas por la revista fueron funcionales al clima de proscripción peronista. Los consejos dietéticos y en economía doméstica apuntaron a sustituir el consumo cárnico por otras fuentes proteicas, como legumbres y lácteos, y los hidratos de carbono simples, por complejos, como las hortalizas. No obstante, sus vinculaciones con el fomento a las agroeconomías de subsistencia refutaron la pre- valencia del "hambre oculta" como problema alimentario en Argentina, pues, en sintonía con los parámetros internacionales, de esta manera se propiciaría una dinámica de redistribución alimenticia, capaz de reponer las vacancias del mercado interno y de estimular las exportaciones netas al prevenir la erosión de los saldos exportables

Introduction: This article analyzes the guidelines on food education and agricultural promotion that circulated in the Revista Educador Sanitario, the official publication of the national health education department of Argentina during the 1960s. Development: The study explores the discursive adaptations by Argentinean sanitarians to the international development guidelines toward promoting the global campaign against "hidden hunger," which referred to the cultural eating patterns of low nutritional quality food. Then, the study examines the dietary prescriptions for popular families that were intended to stimulate quality, variety, and austerity as healthy habits. Finally, it reviews the tensions and contradictions immanent in the scholarly references to agricultural promotion and free trade rules, highlighting food inequities and the lack of infrastructure at the federal level to successfully achieve the desired agri-food modern- ization. Conclusions: The developmentalist disourse on nutritious food appropriated by the Revista were found to be functional to the climate of peronist prescription. Dietary and home economics suggestions attempted to substitute meat consumption for other protein sources such as legumes and dairy products and that of simple carbohydrates for complex ones such as vegetables. However, their links with the promotion of subsistence agro-economies refuted the prevalence of "hidden hunger" as a food problem in Argentina. In line with the international parameters, this approach would promote a dynamic of food redistribution to replenish the gaps in the domestic market and stimulate net exports by preventing the erosion of exportable balances.

Introdução: o artigo analisa as orientações sobre educação alimentar e promoção agrícola que circularam na Revista Educador Sanitário, publicação oficial do departamento nacional de educação sanitária da Argentina durante a década de 1960. Desenvolvimento: o trabalho explora as adaptações discursivas que foram feitas por sanitaristas argentinos às diretrizes de desenvolvimento internacional para promover a campanha global contra a "fome oculta", definida como aqueles padrões alimentares culturais de baixa qualidade nutricional. Em seguida, examina as prescrições alimentares para famílias populares que visavam estimular a qualidade, a variedade e a austeridade como hábitos. Por fim, revisa as tensões e contradições inerentes aos referenciais acadêmicos sobre desenvolvimento agrícola e regras de livre comércio, evidenciando as iniquidades alimentares e a falta de infraestrutura no nível federal para alcançar a tão esperada modernização agroalimentar. Conclusões: os discursos desenvolvimentistas sobre alimentação nutritiva apropriados pela Revista foram funcionais ao clima de proscrição pero- nista. Aconselhamento dietético e de economia doméstica visando a substituição do consumo de carne por outras fontes de proteína, como leguminosas e laticínios; e carboidratos simples para os complexos, como vegetais. No entanto, seus vínculos com a promoção de agroeconomias de subsistência refutaram a prevalência da "fome oculta" como problema alimentar na Argentina. Pois bem, em sintonia com os parâmetros internacionais, isso promoveria uma dinâmica de redistribuição de alimentos, capaz de repor as vagas no mercado interno e estimular as exportações líquidas ao evitar a erosão dos saldos exportáveis

O auto do [consenso] de Viena: Estratégias de legitimação no Sistema Internacional de Controle de Drogas / The Tale of the Vienna [Concensus]: legitimation Strategies in the International Drug Control System

As drogas foram construídas como um problema mundial por organismos internacionais, responsáveis pela elaboração de normativas com a finalidade de combater seu consumo, cultivo e comércio, enquanto interpreto esse fenômeno como um problema público, criado a partir da universalização de algo tão específico quanto a compreensão segundo a qual elas devem ser usadas para fins médicos e científicos. Esta visão de mundo mobiliza grandes estruturas burocráticas e moralizantes onde agentes engendram esforços para disputar a hegemonia no Sistema Internacional de Controle de Drogas que, por sua vez, é organizado pela Organização das Nações Unidas. Seus Estados-Membros disputam a hegemonia de um campo que viu seu balizador se quebrar recentemente, qual seja, o Consenso de Viena, o entendimento de que a demanda por drogas deve ser extinta. Mas, na Década da Gestão do Dissenso (2009-2019), o principal argumento, tanto dos agentes hegemônicos, quanto daqueles contra-hegemônicos, persistiu: deve-se proteger a saúde. Com o objetivo de identificar e compreender as estratégias de legitimação adotadas durante a 62ª Sessão da Comissão de Drogas Narcóticas (2019), empregamos uma metodologia que conjugou etnografia de eventos e de documentos, observação participante e realização de entrevistas semiestruturadas. Foram delineadas 15 estratégias, acionadas num contexto de árdua batalha entre delegações de todos os continentes por categorias referentes à Redução de Danos e aos Direitos Humanos, como "atitudes não estigmatizantes" e "mulheres que usam drogas". Esperamos colaborar para debates institucionais em escala global e local mais permeáveis às contribuições das Ciências Sociais e Humanas em Saúde, fortalecendo uma ciência capaz de reformular radicalmente a política de drogas

Drugs were constructed as a global problem by international bodies, responsible for drafting regulations in order to combat their consumption, cultivation and trade, while I interpret this phenomenon as a public problem, created from the universalization of something as specific as understanding that they should be used for medical and scientific purposes. This worldview mobilizes large bureaucratic and moralizing structures where agents engender efforts to dispute hegemony in the International Drug Control System, which, in turn, is organized by the United Nations. Its Member States are vying for the hegemony of a field that has recently seen its beacon broken, namely the Vienna Consensus, the understanding that the demand for drugs should be extinguished. But, in the Decade of Dissent Management (2009-2019), the main argument, from both hegemonic agents and those against hegemonic ones, persisted: health must be protected. In order to identify and understand the legitimation strategies adopted during the 62nd Session of the Commission on Narcotic Drugs (2019), we used a methodology that combined ethnography of events and documents, participant observation and semi-structured interviews. Fifteen strategies were outlined, triggered in a context of an uphill battle between delegations from all continents for categories related to Harm Reduction and Human Rights, such as "non-stigmatizing attitudes" and "women who use drugs". We hope to contribute to institutional debates on a global and local scale that are more permeable to the contributions of the Social and Human Sciences in Health, strengthening a science capable of radically reshaping drug policy.

Las Agencias internacionales, su papel en la creación y expansión del modelo Escuela Nueva / The International Agencies: Their Role in the Creation and Expansion of the New School Model

Pensar la educación básica primaria en la ruralidad colombiana implica pensar en el modelo de la Escuela Nueva, el cual desde finales de los 70's y principios de los 80's se configuró como la propuesta educativa más importante para atender esta población. ¿Cómo nace? Y ¿qué la hizo tan llamativa y exitosa para convertirse en el Programa bandera de la educación básica primaria en el campo colombiano? Son los interrogantes principales que buscan ser discutidos en el presente artículo. La principal conclusión visibiliza el motor que le dieron las Agencias Internacionales, al reconocer en la Escuela Nueva una propuesta para el campo bajo las lógicas del progreso y desarrollo, que buscaban instaurar los principios y estrategias del mercado en la educación.

Thinking about the primary basic education in the Colombian rurality implies thinking about the New School model. Such a model, since the end of 1970's and the beginning of 1980's, was shaped as the most important educational proposal in serving such a population. How did it originate? What made it so remarkable and successful in order for it to become a flagship program of the primary basic education in the Colombian countryside? These are the main concerns, which are to be addressed in this article. The main conclusion shows the engine, which the International Agencies, gave the New School, by recognizing in it, a proposal to the countryside, under the rationale for progress and development, which attempted to establish the principles and the strategies of the market in education.

Las instituciones y sus críticos o la costumbre de polarizar la realidad: el caso de la influenza A (H1N1) / Institutions and their critics, or the habit of polarizing reality: the case of influenza A (H1N1)

Declarada a fines de abril de 2009 la epidemia de influenza A (H1N1) en México, se realizaron toda una serie de críticas y en menor grado de apoyos respecto de las medidas aplicadas y de la forma de operar del sector salud mexicano. En este texto trato de explicitar, a través de materiales publicados en revistas médicas y en la prensa mexicana, cuáles son los presupuestos técnicos e ideológicos con que trabajó el sector salud y cuáles son los manejados por los críticos. Esto se realiza con dos objetivos complementarios: primero, tratar de entender por qué actuó como actuó el sector salud mexicano y, segundo, para observar la legitimidad técnica de las acciones que desarrolló dicho sector y de las críticas que se hicieron a dichas acciones.(AU)

The declaration of the influenza A (H1N1) epidemic in late April 2009 in Mexico was followed by a series of criticisms and to a lesser degree shows of support of the measures applied and of the manner of operation of the Mexican health system. In this text, I attempt to explain, using materials published in medical journals and in the Mexican press, the technical and ideological assumptions behind the work undertaken by the health sector as well as the assumptions behind the criticisms received. This exploration has two complementary objectives: first, to understand why the Mexican health sector acted the way it did; and second, to consider the technical legitimacy of the actions developed by the health sector and of the criticisms made regarding those actions.(AU)

Las instituciones y sus críticos o la costumbre de polarizar la realidad: el caso de la influenza A (H1N1) / Institutions and their critics, or the habit of polarizing reality: the case of influenza A (H1N1)

Declarada a fines de abril de 2009 la epidemia de influenza A (H1N1) en México, se realizaron toda una serie de críticas y en menor grado de apoyos respecto de las medidas aplicadas y de la forma de operar del sector salud mexicano. En este texto trato de explicitar, a través de materiales publicados en revistas médicas y en la prensa mexicana, cuáles son los presupuestos técnicos e ideológicos con que trabajó el sector salud y cuáles son los manejados por los críticos. Esto se realiza con dos objetivos complementarios: primero, tratar de entender por qué actuó como actuó el sector salud mexicano y, segundo, para observar la legitimidad técnica de las acciones que desarrolló dicho sector y de las críticas que se hicieron a dichas acciones.

The declaration of the influenza A (H1N1) epidemic in late April 2009 in Mexico was followed by a series of criticisms and to a lesser degree shows of support of the measures applied and of the manner of operation of the Mexican health system. In this text, I attempt to explain, using materials published in medical journals and in the Mexican press, the technical and ideological assumptions behind the work undertaken by the health sector as well as the assumptions behind the criticisms received. This exploration has two complementary objectives: first, to understand why the Mexican health sector acted the way it did; and second, to consider the technical legitimacy of the actions developed by the health sector and of the criticisms made regarding those actions.

Cooperações técnicas bilaterais de saúde entre Brasil e organismos internacionais / Bilateral technical cooperations for health between Brazil and international organizations

A cooperação internacional é a expressão de solidariedade entre as nações, segundo o Ministério da Saúde brasileiro; baseada no respeito mútuo, onde as nações e instituições compartilham de experiências e conhecimentos acumulados a fim de resolver problemas de um ou mais envolvidos, a cooperação se dá de diversas formas: judiciária, econômica, técnica, entre países em desenvolvimento, bilateralmente, multilateralmente, entre países e organizações etc. Verificando a necessidade de produção científica em língua portuguesa sobre os organismos internacionais que atuam na área de saúde no Brasil e a importância do conhecimento sobre esses organismos para o planejamento das ações nas áreas da saúde, o presente texto apresenta um panorama das cooperações técnicas de saúde entre Brasil e seis organismos internacionais: Movimento de Saúde dos Povos,Fundação Bill e Melinda Gates, Fundo Monetário Internacional, Banco Interamericano de Desenvolvimento, Fundação Rockfeller e Organização Pan-americana de Saúde. Aborda-se brevemente a história do organismo, o momento de chegada no Brasil e os principais projetos de cooperação realizados entre essas entidades e o país. Também é analisado, quando significativo, o impacto de tais cooperações no cenário sociopolítico brasileiro. Apesar de ainda ser, muito comumente, praticada de forma vertical e sobreposta à cultura local, a cooperação técnica em saúde é importante no tocante à superação das fragilidades dos sistemas nacionais de saúde e,especificamente no Brasil, no fortalecimento de um sistema verdadeiramente único de saúde (SvUS) – único em suas políticas e no respeito à diversidade.

Revisitando as influências das agências internacionais na origem dos conselhos de políticas públicas / Reexamining the international agencies influences in the origin of the public-policy councils

Este artigo tem como objetivo aprofundar o debate acerca da influência exercida pelas agências internacionais nos processos que deram origem aos conselhos de políticas públicas no Brasil como canais institucionais de participação. Situa a intensa atividade internacional do final da Segunda Guerra Mundial e a criação dos organismos multilaterais. Detém-se na reflexão sobre o papel das agências internacionais na área da saúde no Brasil, buscando reconstruir as orientações que incidiram no estímulo a estratégias participativas nas políticas públicas, que culminaram com a criação dos conselhos de saúde, referência inaugural para outras áreas implantarem seus sistemas descentralizados e participativos.

This article aims at deepening the debate on the influence of international agencies in the processes that gave rise to the councils of public policies as institutional channels of participation in Brazil. It focuses on the intense international activity at the end of World War II and the creation of multilateral institutions. It contemplates the international agencies'role in the field of health policies in Brazil, and it seeks to reconstruct the guidelines that focused on the stimulation of participatory strategies that led to the creation of health councils, which were the first reference for other areas to implement their decentralized and participatory systems.

Cooperacao internacional e politicas de acao afirmativa: o papel da Organizacao Pan-Americana da Saude (OPAS) / International cooperation and affirmative action policies: the role of the Pan American Health Organization (PAHO)

O artigo analisa o processo de formulacao, legitimacao e implementacao de uma politica de recorte racial no ambito da Organizacao Pan-Americana da Saude (OPAS). O trabalho compreende a emergencia do tema no interior da organizacao internacional, a dinamica institucional em torno da questao e as propostas centradas na populacao negra na America Latina. Essas sao abordadas com base nas interacoes estabelecidas entre a OPAS e um conjunto de agencias intergovernamentais e organizacoes privadas com atuacao relevante no dominio da saude internacional. O envolvimento da OPAS com a tematica etnico-racial fornece elementos para entendimento do duplo papel desempenhado por organizacoes intergovernamentais no novo cenario global: como atores sociais e arenas. Como ator social importante no campo da saude internacional, a OPAS produziu e disseminou valores e enunciados prescritivos relacionados com a tematica etnico-racial. Como arena, a organizacao mostrou-se permeavel a interesses de origens variadas, com sua burocracia interna procurando movimentar-se em sintonia com os mesmos.

The article analyzes the formulation, legitimation, and implementation of a policy with an ethnic/race approach by the Pan American Health Organization (PAHO). The study includes the emergence of the theme within this international organization, the institutional dynamics related to it, and the proposals focused on the Black population in Latin America. These issues are discussed on the basis of interaction between PAHO and a range of intergovernmental agencies and private organizations working in the international health domain. Participation by PAHO in the ethnic/racial theme provides elements for understanding the dual role played by intergovernmental organizations in the new global scenario, as both social actors and arenas. As an important social actor in the international health field, PAHO has produced and disseminated values and guidelines related to the ethnic/racial theme. As an arena, the organization has proven open to various interests, seeking to work harmoniously with them through its internal administration.

Brazil's response to the polio outbreak in Angola.

PIP: The Brazilian government responded to the poliomyelitis outbreak in Angola by organizing a team tasked at implementing measures that would avoid the risk of importation of wild poliovirus to their country. This team is comprised of representatives from the National Health Foundation of the Ministry of Health and a staff from the Pan American Health Organization. The team enhanced the surveillance of acute flaccid paralysis (AFP) in hospitals of cities that were most likely to have visitors from Angola. In Rio de Janeiro, children under 5 years who were living in areas with the most number of Angolans were administered with oral poliomyelitis vaccine (OPV). Furthermore, the National Immunization Advisory Committee recommended that all people traveling from Brazil to Angola and to other endemic areas should be immunized with at least one dose of OPV prior to traveling. Physicians were also advised to follow certain recommendations that include immediate notification of any AFP case, full investigation, and immunization guidelines for travelers. In addition, all 27 states agreed to review coverage data by municipality so that risk areas or groups can be identified.^ieng

The immunisation programme in the Caribbean.

PIP: The Directing Council of Pan American Health Organization approved a resolution concerning the formal inauguration of the Expanded Programme on Immunization (EPI) in the Americas in October 1977. Subsequently, the EPI entered full implementation in those countries that were members of the Caribbean Epidemiology Center (CAREC) during 1978-80. All 19 CAREC Member Countries (CMC) were conducting routine immunization with diphtheria, pertussis, tetanus, poliomyelitis, measles and BCG vaccines by 1980. The establishment of the program in these countries resulted in focused activities, including training and the development of operational guidelines. Health education has been primarily used to encourage mothers to have their children vaccinated at optimum age, and to advise parents and guardians about adverse reaction to vaccines. Great efforts have been made in immunization coverage in all the CMCs for the six vaccine preventable diseases. The eradication of poliomyelitis, the interruption of measles transmission (8 years measles-free), and the implementation of strategies for the elimination of rubella and CRS have presented many challenges to public health practitioners in the region. The success of all these initiatives is a reflection of the deep commitment and strong partnerships, which have been developed between the governments, health practitioners, and people of the region. Moreover, technical and financial support from both international agencies and service clubs played a major role in the success of the program.^ieng

Sylvatic yellow fever outbreak in Bolivia.

PIP: In the past 10 years, Bolivia has reported more than 400 cases of yellow fever, representing 30% of all cases reported in the region in the same period. In January 1999, Bolivia notified a sylvatic yellow fever outbreak. A provisional total of 29 cases have been reported nationally since the beginning of the year, all occurring in rural settings of the Department of Santa Cruz. The area reporting the most cases is localized 120-200 km south of the city of Santa Cruz de la Sierra between the provinces of Cordillera and Vallegrande. 23 cases were male and 6 female. 82% of cases were over age 15 years, 11% were aged 10-15 years, and 7% were under age 10 years. 27 cases were not vaccinated against yellow fever and 2 had an unverified history of vaccination. There were 10 deaths as of mid-February. A mass immunization campaign of all age groups living in outbreak areas was implemented immediately after the first cases were confirmed. In the Department of Santa Cruz, 30,000 vaccinations have thus far been given in municipalities surrounding the outbreak, increasing the vaccination coverage to higher than 90% in those counties. Recent cases present a similar epidemiologic profile to those in previous yellow fever outbreaks. PAHO recommendations to prevent and control yellow fever are presented.^ieng

Mindful of the various constraints. Trinidad and Tobago. The Hague Forum.

PIP: Recognizing the linkages between population and development, and the need for an integrated approach to development, the government of Trinidad and Tobago in 1989 reformulated the Population Council of Trinidad and Tobago with the mandate to design and implement an explicit population-influencing policy for the country. The draft population policy, developed before the 1994 International Conference on Population and Development (ICPD), was revised following the ICPD to accommodate the recommendations of the Cairo Plan of Action. Efforts were made to sensitize government planners from sector ministries to the need to incorporate population into the planning process. Procedures are now being adopted which will enable the Population Council to review the government's medium-term plan before it is finalized to ensure that the programs of sector ministries pay enough attention to population. Population growth, teen pregnancy, HIV/AIDS, return migration, and population aging are among the issues discussed.^ieng

Chile shadow report to the United Nations sheds light on women's rights.

PIP: Three Chilean women's rights organizations and CRLP presented a Shadow Report to the UN Committee on the Elimination of All Forms of Discrimination Against Women (CEDAW). The 25-page Shadow Report indicates in summary the disappointment of the Chilean women in their government. Although Chile has emerged from its history of military dictatorship and is taking its first steps toward returning to a democratic-style of government, the military and the Catholic Church still exert a very strong influence, especially when it comes to policy making. Chilean people especially women, continue to be tyrannized by repressive attitudes, laws, and policies. This tyrannization is exemplified by the rampant discrimination against women in the prisons and the punishment of those undergoing illegal abortions. In short, women have no rights in Chile, and the government has not done enough to eliminate discrimination against them.^ieng

Bolivia benefits from PAHO / World Bank partnership.

PIP: As part of a 10-year health sector reform effort, the government of Bolivia is collaborating with the Pan American Health Organization and the World Bank to increase coverage of vaccines included in the national immunization program and to introduce other important vaccines (such as yellow fever vaccine in affected areas and vaccination against hepatitis B in endemic areas) into the program. Financing will be covered by a World Bank loan of US $6.5 million, grants from international agencies ($4.5 million), and $9 million from the government. A 5-year plan offers specific strategies to 1) strengthen the national immunization program to improve adoption and implementation of immunization policies, 2) strengthen health services to improve coverage and introduce other vaccines, and 3) strengthen the information and surveillance systems. Indicators to monitor implementation of the project will include 1) coverage of DPT3 dose in 1999 and coverage with pentavalent 3 vaccine by the year 2000; 2) the number of municipalities with DPT3 coverage less than 80% and the number with pentavalent 3 coverage less than 80% by 2000; and 3) national financing of immunization programs.^ieng

Child health and the international monetary fund: the Nicaraguan experience.

PIP: In 1979, when the Frente Sandinista de Liberacion Nacional (FSLN), a popular revolutionary front, deposed Nicaragua's ruling Somoza family, the Nicaraguan population's health status ranked with that of Bolivia and Honduras as the worst in Latin America. The Sandinista government committed itself to improving health services and health status such that in 1982, the World Health Organization commended the major advances in health care made in the government's first few years. That progress, however, has not been maintained as Sandinista health, nutrition, literacy, and agrarian programs have been abandoned by the government under pressure from the International Monetary Fund (IMF) and the US government to privatize and cut public spending. The progress made over the past decade is now being undone by an imposed structural adjustment policy and the burden of international debt. The IMF has disregarded social equity as a criterion for its programs. Under current conditions, the health and well-being of the Nicaraguan people will continue to deteriorate. Until the Nicaraguan debt situation is resolved, there is no hope for sustainable growth and development.^ieng

The WHO antenatal care randomised controlled trial: rationale and study design.

The World Health Organisation and collaborating institutions in developing countries are conducting a multicentre randomised controlled trial to evaluate a new antenatal care (ANC) programme, consisting of tests, clinical procedures and follow-up actions scientifically demonstrated to be effective in improving maternal and newborn outcomes. These activities are distributed, for practical reasons, over four visits during the course of pregnancy and are aimed at achieving predetermined goals. The study is taking place in four countries, Argentina, Cuba, Saudi Arabia and Thailand. Recruitment of study subjects started on 1 May 1996. All 53 ANC clinical units had been enrolled by December 1996. Clinics in each country were randomly allocated (cluster randomisation) to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for ANC at these clinics over an average period of 18 months will have been recruited. As women attending the control clinics receive the 'best standard treatment' as currently offered in these clinics, individual informed consent is requested only from women attending the intervention clinics. Authorities of the corresponding health districts and all participating clinics have provided written institutional informed consent before randomisation. The primary outcome of the trial in relation to maternal conditions is the rate of a morbidity indicator index, defined as the presence of at least one of the following conditions for which ANC is relevant: (a) pre-eclampsia or eclampsia during pregnancy or within 24 h of delivery; (b) postpartum anaemia (haemoglobin < 90 g/L); or (c) severe urinary tract infection/pyelonephritis, defined as an episode requiring antibiotic treatment and/or hospitalisation. The primary fetal outcome is the rate of low birthweight (< 2500 g). Adverse maternal and fetal outcomes are expected for approximately 10% of the control group. Several maternal and perinatal secondary outcomes are also considered. A comprehensive cost-effectiveness analysis and women's and providers' satisfaction evaluation are performed concurrently with the trial. Health-care programmes should be rigorously evaluated by randomised controlled trials, which are feasible in developing countries and should be conducted before introducing new treatments or health interventions.

PIP: The procedures and examinations included in currently practiced prenatal care have not been subjected to systematic, scientifically rigorous evaluation. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating a new prenatal care regimen with demonstrated efficacy in improving maternal and newborn outcomes. Program activities include screening for health conditions that increase the risk of specific adverse pregnancy outcomes, therapeutic interventions known to affect these outcomes beneficially, and education of pregnant women regarding potential health emergencies and appropriate responses. The study's hypothesis is that the tests, clinical procedures, and follow-up actions associated with this approach, delivered over the course of four visits during pregnancy, are more effective than the traditional prenatal care package in terms of specific maternal and perinatal results without being more expensive. This paper addresses the rationale, design, and methodology of this trial. 53 prenatal care clinics in four well-defined geographic areas (Khon Kaen Province, Thailand; Havana, Cuba; Rosario, Argentina; and Jeddah, Saudi Arabia) have been randomized to the two arms of the study. By the end of 1997, 24,000 women presenting for prenatal care at these sites had been enrolled. The primary maternal outcome is the morbidity indicator index, defined as the presence of at least one of the following conditions: pre-eclampsia or eclampsia during pregnancy or within 24 hours of delivery, postpartum anemia, or severe urinary tract infection/pyelonephritis. The primary fetal outcome is the rate of low birth weight. A comprehensive cost-effectiveness analysis and provider satisfaction evaluation will be performed concurrently with the trial. Data collection will be completed in 1998.

Methodological considerations in the design of the WHO Antenatal Care Randomised Controlled Trial.

We discuss methodological issues arising in a recent evaluation trial of a new antenatal care programme, as sponsored by the Special Programme of Research, Development and Research Training in Human Reproduction, and WHO's Division of Reproductive Health (Technical Support). The randomisation unit for the trial is the antenatal care clinic, with 53 clinics located in four countries randomly allocated to provide either the new programme or the traditional programme currently in use. Approximately 24,000 women presenting for antenatal care over an average period of 18 months will have been recruited.

PIP: The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial is evaluating the impact of a new program of prenatal care on the health of mothers and newborns. Study subjects will receive either the standard prenatal care program currently offered at participating sites or a new regimen comprised of scientifically evaluated, objective-oriented prenatal care services. A total of 24,000 pregnant women from 53 prenatal care clinics in Argentina, Cuba, Thailand, and Saudi Arabia have been enrolled and stratified on the basis of the number of pregnant women enrolled in each clinic during the year preceding the study, the type of clinic (free-standing or hospital), and the administrative health system to which they belong. This article discusses methodological issues related to the study's design, with emphasis on sample size considerations, planned approaches to the statistical analysis, and data quality control. The rationales for selecting clinics as the unit of randomization are to reduce the risk of treatment contamination, encourage participation, and facilitate administrative and logistic convenience in the implementation of the intervention. Randomization of intact clinics to different intervention groups with predefined strata reflects the fact that the aim of the trial is to show the equivalence, not necessarily the superiority, of the new prenatal care program with the existing program of standard care. The two major adverse outcomes, a high maternal morbidity index and low birth weight, are expected to be in the range of 10%. To ensure that a statistically nonsignificant effect can be interpreted meaningfully, the trial has been designed to have a 90% power for ruling out an absolute difference of at least 0.02 in the expected incidence of the primary end points. A confidence interval approach was selected for sample size estimation, as recommended for equivalence trials, to provide additional assurance that the sample size is adequate.

Methods for economic evaluation alongside a multicentre trial in developing countries: a case study from the WHO Antenatal Care Randomised Controlled Trial.

The WHO is testing a new rationalised programme of antenatal care in a multicentre randomised trial. The motivation for this trial arose from the current uncertainty about the effectiveness of different approaches to provision of routine antenatal care. Decision makers also lack information about the costs of providing routine antenatal care and the cost-effectiveness of one programme over another. Such information will be needed before the final choice of programme can be made. The WHO trial provides an ideal opportunity to estimate and compare the incremental costs and cost-effectiveness of the new programme in four countries (Argentina, Cuba, Saudi Arabia, Thailand). A separate economic component has been organised to measure the costs of antenatal care. Methods for cost identification and measurement, and methods for economic analysis in the context of an international study are based on current recommendations for the conduct of economic evaluations alongside trials. However, several aspects require further development. In particular, this includes defining standard methods for costing in different countries; measuring women's costs of access to care; and making comparisons across international settings. The economic evaluation will also inform similar multicentre international trials and investigate issues of generalisability beyond trial settings.

PIP: Economic estimations at the technology assessment stage of health interventions permit early recognition of the relative efficiencies of health care interventions and allow those that are expensive and have limited health effects to be discouraged from widespread adoption. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial includes a component aimed at estimating the incremental costs and cost-effectiveness of a new rationalized program of prenatal care relative to those associated with the standard prenatal care package. 2400 pregnant women attending 53 clinics in Argentina, Cuba, Thailand, and Saudi Arabia have been enrolled. The central concern is that the new program of prenatal care does not result in higher overall costs to either the health care system or women receiving care than the currently practiced model. Resources included in the unit cost estimation are staff, drugs and medications, materials, equipment, vehicles, utilities, and buildings and land. Monthly costing data are being collected at all study sites in Cuba and Thailand over a 12-month period and a questionnaire has been developed to assess the costs borne by women. Data from these two sources will be collated to produce tables of costs at the health facility, country, and international levels. The reliability of the results should be enhanced by the association of the economic analysis with a carefully designed randomized trial intended to minimize bias in terms of differences in the quantities of services used.