Music session interventions were found to reduce anxiety among patients admitted to the intensive care unit (ICU), according to a systematic review and meta-analysis in the Journal of Clinical Nursing.
Reviewing 25 studies, music was found to significantly reduce anxiety scores overall, regardless of the system of measurement, reported Öznur Erbay Dalli, RN, MSc, PhD, of Bursa Uludag University in Turkey, and colleagues.
Music also significantly reduced anxiety scores versus standard care, including prescribed drugs or care protocol as part of usual treatment. This was comparable to noise-reducing methods. In the ICU, noise is an important driver of stress, the authors explained.
Throughout history, music has been used as one of the “proven non-pharmacological tools” to reduce anxiety, depression, and pain and to increase patient comfort, they added.
Dr Dalli told MedPage Todaythat ICU nurses and other healthcare workers may complement their daily routine care with music to reduce the anxiety of ICU patients and to avoid the side effects of medications, which are commonly used for treating anxiety.
No effect on diastolic blood pressure, respiration rate, or heart rate due to the music was seen. Subgroup analysis showed that multiple sessions produced better outcomes.
The researchers searched for studies published up to January 2022. All of the 25 included studies were randomised controlled trials or controlled clinical trials in 9 different countries with 1751 participants in total. Average age was 59 and 57% were male.
Of the anxiety assessment tools, the State-Trait Anxiety Inventory was the most commonly used tool (9 studies), followed by the Fear, Anxiety, and Stress Scale (4 studies) and the Visual Analogue Scale for Anxiety (2 studies).
Music interventions were mostly recorded music, although one study included a harp being played live. Music was used during rest times in most studies, though in four studies, music was used during specific procedures, like catheterisation or endotracheal suctioning.
No side effects were reported in the studies examined, but some patients objected to the choice of music, something which could be addressed by consultation with family members.
Limitations to the study included the fact that it was “difficult or impossible” to blind participants and other healthcare personnel involved in the study due to the nature of the intervention, which could lead to a “high risk of performance bias,” the authors noted. Additionally, the range of protocols and evaluation techniques used among the studies resulted in high heterogeneity.
Publication bias was possible due certain studies having small sample sizes, and a lack of available data.
In a study published in the Journal of the American Geriatrics Society with 159 255 female participants from a variety of racial and ethnic backgrounds, higher levels of optimism were associated with longer lifespans and a greater likelihood of living past 90 years of age.
Investigators found that the link between optimism and longevity was evident across racial and ethnic groups, and that lifestyle factors accounted for nearly one-quarter of the optimism-lifespan association.
“Although optimism itself may be patterned by social structural factors, our findings suggest that the benefits of optimism for longevity may hold across racial and ethnic groups,” said lead author Hayami K. Koga, of the Harvard T.H. Chan School of Public Health. “Optimism may be an important target of intervention for longevity across diverse groups.”
The whistle-blowing paediatrician Dr Tim de Maayer who spoke out about appalling conditions at Rahima Moosa Mother and Child Hospital (RMMCH) was suspended yesterday, apparently in a retaliatory move.
In the widely-read open letter appearing on the Daily Maverick, he spoke of the preventable tragedy of babies dying due to lack of resources. This came shortly after a viral video showed pregnant mothers sleeping on the floor.
Presciently, the Daily Maverick, which broke the story, stated that there were two options: act to change the situation for the better, or “shoot the messenger”. As the newspaper wryly noted as it broke the news on Friday, 10 June, the option of shooting the messenger has been taken.
Although there appeared to be an initial positive response, Dr Maayer gave notice on Thursday evening that he was not able to come into work on Friday as he was being placed on suspension. RMMCH doctors then contacted the Daily Maverick.
His suspension leaves the hospital without its only paediatric gastroenterologist, according to an anxious doctor who got in touch with the Daily Maverick late Thursday night. The news has spread like wildfire across social media, with other doctors quick to come to Dr de Maayer’s defence.
A petition on Change.org to reinstate the paediatrician is being circulated by ordinary citizens and clinicians including Professor Shabir Madhi, who has been vocal in his support of Dr de Maayer.
The Progressive Health Forum (PHF) called for the suspension of Dr de Maayer to be overturned.
“Dr de Maayer has been suspended on the grounds that he has a voice, a conscience and a professional ethic and being a committed public health clinician. This pattern of victimisation has been repeatedly applied to clinicians who dare call out inadequacies of the administration and negative impact on clinicians and on the lives of patients,” the PHF said in a statement.
Pregnant mothers have the ability to confer greater immunity to the vulnerable developing foetus with ‘super antibodies’. Now, a far-reaching study published in Nature provides a surprising explanation of how this actually works, and what it could mean for preventing death and disability from a wide range of infectious diseases.
The findings suggest the amped-up antibodies that expecting mothers produce could be mimicked to create new drugs to treat diseases as well as improved vaccines to prevent them.
“For many years, scientists believed that antibodies cannot get inside cells. They don’t have the necessary machinery. And so, infections caused by pathogens that live exclusively inside cells were thought to be invisible to antibody-based therapies,” said Sing Sing Way, MD. “Our findings show that pregnancy changes the structure of certain sugars attached to the antibodies, which allows them to protect babies from infection by a much wider range of pathogens.”
“The maternal-infant dyad is so special. It’s the intimate connection between a mother and her baby,” says John Erickson, MD, PhD, first-author of the study.
Drs Way and Erickson are both part of Cincinnati Children’s Center for Inflammation and Tolerance and the Perinatal Institute, which strives to improve outcomes for all pregnant women and their newborns.
Erickson continues, “This special connection starts when babies are in the womb and continues after birth. I love seeing the closeness between mothers and their babies in our newborn care units. This discovery paves the way for pioneering new therapies that can specifically target infections in pregnant mothers and newborns babies. I believe these findings also will have far-reaching implications for antibody-based therapies in other fields.”
How mothers make super antibodies The new study identifies the specific change in the sugar. During pregnancy, the “acetylated” form of sialic acid (one of the sugars attached to antibodies) shifts to the “deacetylated” form. This subtle molecular shift lets immunoglobulin G (IgG) take on an expanded protective role by stimulating immunity through receptors that respond specifically to deacetylated sugars.
“This change is the light switch that allows maternal antibodies to protect babies against infection inside cells,” Dr Way said.
“Mothers always seem to know best,” Dr Erickson added.
Revved-up antibodies can be produced in the lab The research team pinned down the key biochemical differences between antibodies in virgin mice compared to pregnant ones. They also identified the enzyme naturally expressed during pregnancy responsible for driving this transformation.
Further, the team successfully restored lost immune protection by supplying lab-grown supplies of the antibodies from healthy pregnant mice to pups born to mothers that were gene-edited to lack the ability to remove acetylation from antibodies to enhance protection.
Hundreds of monoclonal antibodies have been produced as potential treatments for various disorders, including COVID, with a variety of results.
Dr Way said this molecular alteration can be replicated to change how antibodies stimulate the immune system to fine-tune their effects. This potentially could lead to improved treatments for infections caused by other intracellular pathogens including HIV and respiratory syncytial virus (RSV), a common virus that poses serious risks to infants.
Another reason to accelerate vaccine development “We’ve known for years the many far-reaching benefits of breastfeeding,” Dr Erickson said. “One major factor is the transfer of antibodies in breastmilk.”
The study shows that nursing mothers retain the molecular switch, passing through the antibodies to their newborns.
Additionally, Dr Way says the findings underscore the importance of receiving all available vaccines for women of reproductive age – as well as the need for researchers to develop even more vaccines against infections that which are especially prominent in women during pregnancy or in newborn babies.
“The immunity needs to exist within the mother for it to be transferred to her child,” Dr Way said. “Without natural exposures or immunity primed by vaccination, when that light switch flips during pregnancy, there’s no electricity behind it.”
Scanning Electron Micrograph image of a human T cell. Credit: NIH/NIAID
In a groundbreaking new study, scientists report training T cells to protect against SARS-CoV-2 even without an antibody response. This could open the way to more broadly effective vaccines.
Current vaccines prompt the creation of antibodies and immune cells that recognise the spike protein. However, these vaccines were developed using the spike protein from an older variant of SARS-CoV-2, reducing their effectiveness against newer variants. Researchers have found that immune cells called T cells tend to recognise parts of SARS-CoV-2 that don’t mutate rapidly. T cells coordinate the immune system’s response and kill cells that have been infected by the SARS-CoV-2 virus.
A vaccine that prompted the body to create more T cells against SARS-CoV-2 could help prevent disease caused by a wide range of variants. To explore this approach, a research team led by Dr Marulasiddappa Suresh from the University of Wisconsin studied two experimental vaccines that included compounds to specifically provoke a strong T-cell response in mice.
The team tested the vaccines’ ability to control infection and prevent severe disease caused by an earlier strain of SARS-CoV-2 as well as by the Beta variant, which is relatively resistant to antibodies raised against earlier strains.
When the researchers vaccinated the mice either either nasally or by injection, the animals developed T cells that could recognise the early SARS-CoV-2 strain and the Beta variant. The vaccines also caused the mice to develop antibodies that could neutralise the early strain. However, they failed to create antibodies that neutralised the Beta variant.
The mice were exposed to SARS-CoV-2 around 3 to 5 months after vaccination. Compared to the controls, vaccinated mice had very low levels of virus in their lungs and were protected against severe illness, which was true of infection with the Beta variant too. This showed that the vaccine provided protection against the Beta variant despite failing to produce effective antibodies against it.
To understand which T cells were providing this protection, the researchers selectively removed different types of T cells in vaccinated mice prior to infection. When they removed CD8 (killer) T cells, vaccinated mice remained well protected against the early strain, although not against the Beta variant. When they blocked CD4 T (helper) cells, levels of both the early strain and Beta variant in the lungs and severity of disease were substantially higher than in vaccinated mice that didn’t have their T cells removed.
These results suggest important roles for CD8 and CD4 T cells in controlling SARS-CoV-2 infection. Current mRNA vaccines do produce some T cells that recognize multiple variants. This may help account for part of the observed protection against severe disease from the Omicron variant. Future vaccines might be designed to specifically enhance this T cell response.
“I see the next generation of vaccines being able to provide immunity to current and future COVID variants by stimulating both broadly-neutralising antibodies and T cell immunity,” Dr Suresh predicted.
Tobacco companies waged a massive disinformation campaign to keep people consuming their products. There are parallels with today’s antivaxx movement. Even before the 1964 US Surgeon General’s report on tobacco, the tobacco industry was deflecting health concerns by featuring doctors in their advertising and actively courting the medical industry. This advert is from 1930.
In a perspective piece published in the New England Journal of Medicine, authors find a parallel between the tactics used in the ‘tobacco wars’ and vaccination efforts. In a seeming repeat of history, anti-vaccination groups are using the same tactics the tobacco industry used to defend their products and undermine trust in science, but the successful anti-tobacco campaign holds important lessons for turning the tide against misinformation and normalising vaccination.
In late 2020 when the first COVID vaccines became available, the authors note that surveys indicated that about a third of US adults were keen to be vaccinated, 15% expressed strong resistance to vaccination (a proportion that has stayed fairly constant), and the remainder didn’t harbour strong ideological resistance. Now, about 27% of US adults now remain unvaccinated – and reaching this remainder is an important public health challenge.
The authors believe that the ‘tobacco wars’ can provide perspective. The tobacco industry fuelled preventable deaths by glamourising smoking, with almost 50% of US adults smoking cigarettes in the 1960s.
The current rate of about 12.5% is the result of decades of public health efforts to make tobacco use less socially acceptable. The first US Surgeon General’s report on smoking and health in 1964 was attacked by the tobacco industry. It was only until C. Everett Koop’s overwhelming report in 1986 that cemented tobacco use as a major preventable cause of cancer and death and highlighted the dangers of second-hand smoking.
Koop and others were vilified by the tobacco industry, which mounted a sustained campaign that cast doubts on the science, publicised misinformation, emphasised tobacco’s economic importance, and warned against restricting individual freedom. Industry leaders directly lied about knowing that nicotine was addictive and the lethal dangers of tobacco use. Indeed, from the 1920s to 1950s, in response to growing health concerns, the tobacco industry had actively courted doctors and influenced medical journals, widely reporting positive findings of studies that were deeply flawed. This may have only played into the hands of antivaxxers, creating a historical example of distrust in the medical system.
A 1940s advert showing how ‘doctors’ (probably actors) enjoyed Camel brand cigarettes. With the 1950 publication of studies showing the connection between cancer and tobacco, the public began to be suspicious and such campaigns featuring doctors ended by 1954.
While the focus of the debate was initially on smoking as an individual choice, two 1981 studies on nonsmoking wives of smokers vs nonsmokers revealed the dangers of secondhand smoke and shifted the discourse.
The US Congress has never enacted a federal smoking ban, but did grant the FDA limited authority to regulate tobacco in 2009, enabling restrictions on youth sales.
However, the broad-based effort from all levels of society that were important, discouraging smoking in public settings. This was supplemented by messaging from celebrities, taxation, and even a 1998 legal battle against the tobacco industry.
Efforts undertaken by the antivaccination movement, which is hardly new but is thriving during the COVID pandemic, bear many similarities to strategies used during the tobacco wars. Although not driven by a single industry but a collection of celebrities and social media groups, it sows mistrust in science and promotes conspiracy theories. Misinformation tactics are used that are strikingly similar to the tobacco industry’s, and this time Dr Antony Fauci is vilified instead of Koop.
There are big differences between tobacco control and vaccination; such as taking a long time for smoking interventions to reduce chronic diseases, whereas vaccinations usually reduce hospitalisations and severe illness within days or weeks.
The authors believe that success against antivaccination movement can draw on the tobacco wars’ lessons, illustrating COVID’s harm and the power of vaccines. Getting vaccinated and boosted should be the accepted social norm during a pandemic, they stress.
Drawing on similar efforts for anti-tobacco campaigns, vaccination campaigns using real patients in ICU who express regret over not being vaccinated. Unvaccinated people often assume they can be cared for if they get sick, so messages could also be included from healthcare works talking about the strain of the pandemic.
“There is an opportunity to mount a serious effort to provide accurate vaccination information using the same media channels on which people currently consume misinformation,” they wrote.
They also consider vaccine mandates which make being vaccinated a social norm such as wearing a seatbelt, and other regulations at the community and business level may be more effective.
They note that personal physicians play a key role, being the best way to transmit health information. But many people at risk of remaining unvaccinated have had negative experiences with health care, compounded by doctors spreading misinformation.
The authors note that the dangers of tobacco use were known to public health practitioners for years, but it took a well-funded concerted effort that emphasised the impact on others to achieve a change in behaviour. This is something that needs to be repeated for vaccinations.
“Freedom of choice remains; people can still smoke cigarettes and decline vaccinations. But the roadmap drawn by tobacco-control efforts shows that the public mindset can be tilted toward public health and social good. With vaccination, this work shouldn’t take decades; it needs to begin immediately.”
An increase in measles cases in January and February 2022 is a worrying sign of a heightened risk for the spread of vaccine-preventable diseases and could trigger larger outbreaks, particularly of measles affecting millions of children in 2022, warn WHO and UNICEF.
The agencies warn that pandemic-related disruptions, widening vaccine access inequality, and the under-resourcing of routine immunisation are leaving too many children open to measles and other vaccine-preventable diseases.
The risk for large outbreaks has increased as communities relax social distancing practices and other anti-COVID measures. Additionally, the displacement of millions of people due to conflicts and crises including in Ukraine, Ethiopia, Somalia and Afghanistan, is causing disruptions in immunisation services, a lack of clean water and sanitation, and overcrowding, all of which increase the risk of vaccine-preventable disease outbreaks.
Almost 17 338 measles cases were reported worldwide in January and February 2022, compared to 9665 during the first two months of 2021. Measles is highly contagious, so cases tend to show up quickly when vaccinations decline. The agencies are concerned that outbreaks of measles could also forewarn outbreaks of other diseases that do not spread as rapidly.
Apart from its direct, sometimes lethal, effect on the body, the measles virus also weakens the immune system rendering a child more vulnerable for months after to other infectious diseases like pneumonia and diarrhoea. Most cases occur in settings that have faced social and economic hardships due to COVID, conflict or other crises, and have chronically weak health system infrastructure and insecurity.
“Measles is more than a dangerous and potentially deadly disease. It is also an early indication that there are gaps in our global immunization coverage, gaps vulnerable children cannot afford,” said Catherine Russell, UNICEF Executive Director. “It is encouraging that people in many communities are beginning to feel protected enough from COVID to return to more social activities. But doing so in places where children are not receiving routine vaccination creates the perfect storm for the spread of a disease like measles.”
In 2020, 23 million children missed out on basic childhood vaccines through routine health services, the highest number since 2009 and 3.7 million more than in 2019.
Top 5 countries with reported measles cases in the last 12 months, until April 2022 1
Country
Reported Measles cases
Rate per million cases
First dose measles coverage (%), 20192
First dose measles coverage (%), 20203
Somalia
9068
554
46
46
Yemen
3629
119
67
68
Afghanistan
3628
91
64
66
Nigeria
12 341
58
54
54
Ethiopia
3039
26
60
58
As of April 2022, the agencies report 21 large and disruptive measles outbreaks around the world in the last 12 months. Most of the measles cases were reported in Africa and the East Mediterranean region. The figures are likely higher as the pandemic has disrupted surveillance systems globally, with potential underreporting.
Countries with the largest measles outbreaks since the past year include Somalia, Yemen, Nigeria, Afghanistan and Ethiopia. Insufficient measles vaccine coverage is the major reason for outbreaks, wherever they occur.
“The COVID pandemic has interrupted immunisation services, health systems have been overwhelmed, and we are now seeing a resurgence of deadly diseases including measles. For many other diseases, the impact of these disruptions to immunisation services will be felt for decades to come,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “Now is the moment to get essential immunisation back on track and launch catch-up campaigns so that everybody can have access to these life-saving vaccines.”
As of 1 April 2022, 57 vaccine-preventable disease campaigns in 43 countries that were scheduled to take place since the start of the pandemic are still postponed, impacting 203 million people, most of whom are children. Of these, 19 are measles campaigns, which put 73 million children at risk of measles due to missed vaccinations. In Ukraine, the measles catch-up campaign of 2019 was interrupted due to the COVID pandemic and thereafter due to the war. Routine and catch-up campaigns are needed wherever access is possible to help make sure there are not repeated outbreaks as in 2017–2019, when there were over 115 000 cases of measles and 41 deaths in the country – this was the highest incidence in Europe.
Coverage at or above 95% with 2 doses of the safe and effective measles vaccine can protect children against measles. However, COVID pandemic related disruptions have delayed the introduction of the second dose of the measles vaccine in many countries.
A major study published in the journal Biological Psychiatry has revealed key differences in brain structure between people with and without anorexia nervosa.
Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image and are unable to recognise the seriousness of their significantly low body weight.
Little is known about why some people develop anorexia whilst others do not, although biological factors are widely recognised. The findings from the study, which was coordinated by neuroscientists at the University of Bath with international partners, draws on extensive analyses of brain scans taken from patients around the world and goes some way to answering the question.
They reveal that people with anorexia demonstrate ‘sizeable reductions’ in three critical measures of the brain: cortical thickness, subcortical volumes and cortical surface area. Brain size reductions are significant due the implied loss of brain cells or the connections between them.
The results are some of the clearest yet to show links between structural changes in the brain and eating disorders. The team says that the effect sizes in their study for anorexia are in fact the largest of any psychiatric disorder investigated to date.
This means that people with anorexia showed reductions in brain size and shape two to four times greater than people with conditions such as depression, ADHD, or OCD. The changes observed in brain size for anorexia may be attributable to reductions in body mass index (BMI).
The team emphasised the importance of early treatment to help people with anorexia avoid long-term, structural brain changes. Existing treatment typically involves forms of cognitive behavioural therapy and, critically, weight gain. Many people with anorexia are successfully treated and these results show the positive impact such treatment has on brain structure.
Their study pooled nearly 2000 pre-existing brain scans for people with anorexia, including people in recovery and ‘healthy controls’ (people neither with anorexia nor in recovery). For people in recovery from anorexia, the study found that reductions in brain structure were less severe, suggesting that, with appropriate early treatment and support, brain self-repair is possible.
Lead researcher, Dr Esther Walton of the Department of Psychology at the University of Bath explained: “For this study, we worked intensively over several years with research teams across the world. Being able to combine thousands of brain scans from people with anorexia allowed us to study the brain changes that might characterise this disorder in much greater detail.
“We found that the large reductions in brain structure, which we observed in patients, were less noticeable in patients already on the path to recovery. This is a good sign, because it indicates that these changes might not be permanent. With the right treatment, the brain might be able to bounce back.”
“The international scale of this work is extraordinary,” said Paul Thompson, a professor of neurology and lead scientist for the ENIGMA Consortium, an international effort to understand the link between brain structure, function and mental health. “Scientists from 22 centres worldwide pooled their brain scans to create the most detailed picture to date of how anorexia affects the brain. The brain changes in anorexia were more severe than in other any psychiatric condition we have studied. Effects of treatments and interventions can now be evaluated, using these new brain maps as a reference.”
He added: “This study is novel in term of the thousands of brain scans analysed, revealing that anorexia affects the brain more profoundly than any other psychiatric condition. This really is a wake-up call, showing the need for early interventions for people with eating disorders.”
While the pandemic era has seen global supply chains strained and medicines running short even in the developed world, it was not the case with prescription opioids, namely oxycodone and hydrocodone in the early 2000s. In fact, the opposite was true, argues a study published in the Journal of Supply Chain Management: supply chains became so efficient that they produced a glut of opioids that helped spark the opioid crisis in the US that has since spread to other parts of the world.
This supply glut is partly due to the influence of supplier pool pressure on pharmacy participation in oversupply, according to research conducted by Ednilson Bernardes, professor at the West Virginia University John Chambers College of Business and Economics.
Simply put, pressure exerted by manufacturers and suppliers of opioids, particularly national corporations, influenced how pharmacies bought and distributed those prescriptions.
“We argued that when the pool of suppliers has cohesive expectations for how buyers should behave and sufficient power to dominate the supply relationship, then buyers are under pressure to act in line with those expectations,” Prof Bernardes said.
Prof Bernardes and co-author, Paul Skilton of Washington State University, analysed transactions involving oxycodone and hydrocodone between 2006 and 2012. They chose those two drugs, Prof Bernardes said, because they’re the most commonly abused, legally prescribed products and central to the American opioid epidemic.
The researchers tested a model using a dataset combining geographic, market and public health data. The model revealed that more than 90% of supply originated with three generics manufacturers that aggressively competed for shelf space in distributors and pharmacies.
Bernardes explained how several factors led to opioid oversupply, which occurs when ordinary production and distribution processes deliver products in excess of the safe needs of a market.
“First, even though pharmacists, suppliers and manufacturers knew the products were toxic, physicians were prescribing the products,” Bernardes said. “Second, although the DEA (US Drug Enforcement Agency) expected the companies selling opioids to report unusually large purchases, it put no controls to ensure that they did. Third, even if they had, individual transactions were typically small but made up very large totals.
“Under these conditions, the whole supply chain could produce far more of these products than were good for patients or society. While it is a system-level phenomenon, we theorize that it emerges from individual behaviours and that the actions of suppliers and competitors influence those behaviours in addition to demand from patients.”
In addition, Bernardes said market characteristics, such as demand, regulation and market population size, influenced pharmacy participation.
“Supplier pools can impose their expectations only if they have greater bargaining power than buyers or if buyers critically depend on them,” Bernardes said. “Pharmacies are critically dependent on the opioid supplier pool, which is regulated at the federal and state level, because opioids are an important contributor to supplier and pharmacy profitability.”
Bernardes and his colleague believe this study blazes a trail for further supply chain research as it develops a novel notion of oversupply, distinct from the traditional idea of excess inventory, and normal misconduct that explain how pressures within supply chains shape misconduct beyond the opioid context.
The research is also unique, Bernardes said, because previous studies focused primarily on firm-level consequences of behavior such as supplier sustainability risk and corrupt opportunism. The focus on firm-level outcomes leaves a gap in understanding systemic factors that normalize misconduct in supply chains.
“The phenomenon exposes supply chain behaviour that is widespread and persistent despite its negative consequences for society,” Bernardes said. “Examples include products that harm consumers and business models that degrade the environment, exploit labour or perpetuate social injustice.”
Writing for GroundUp, Rebecca Gore lays out the challenges of access to abortion for women in South Africa’s prisons.
As the legal researcher to Justice Edwin Cameron, head of the Judicial Inspectorate for Correctional Services (JICS), I’ve visited several women’s prisons. A recent encounter with a nurse in a big overcrowded prison was a poignant reminder of the challenges women in prisons experience, especially when it comes to exercising their sexual and reproductive rights.
Cramped in her consulting rooms, the nurse shut the door to talk to me. Outside, weary inmates sighed and waited in line. We discussed how JICS might try to resolve various issues, from mental health to how regularly doctors visit.
On abortions, the nurse’s eyes sparked with alarm. She told me of a perplexing problem she is faced with when an inmate requests an abortion. Is it enough to notify the head of the prison (or area commissioner) – or must she seek their prior approval?
For her, the healthcare policy is unclear. With pressure from her superiors and rumours about another nurse being reprimanded for not obtaining prior approval, she opts for the more constrictive process.
When I raised the issue with the head of the prison, she pointed out a gap in the Correctional Services Act 111 of 1998.
As a result, the prison has developed its own policy. If the inmate is above 18 years
they put their request for an abortion in writing;
the nurse facilitates the arrangements; and
the head of the prison and area commissioner are merely informed (so that they are aware of the inmates’ movements).
The head of the prison assured me that the Department of Correctional Services does not intervene. She said it is important to ensure the woman is not a minor and to have the request in writing as it shields the department from potential litigation.
Distressed by this interaction, I had to dig deeper.
There are no easily accessible statistics on abortions in South African prisons. But we do know that women comprise less than 3% of the entire prison population. Lillian Artz and Britta Rotmann have found that women prisoners are “among the most socially and economically vulnerable members” of our society. Their imprisonment has “obvious deleterious effects on both children and the remaining family members charged with childcare responsibilities.”
The Choice on Termination of Pregnancy Act
The lodestar for all women seeking abortions in South Africa is the Choice on Termination of Pregnancy Act 92 of 1996. The Preamble recognises “the decision to have children is fundamental to a woman’s physical, psychological and social health” and that the state shoulders the duty to provide reproductive healthcare.
The Act provides that a woman can request an abortion during the first 12 weeks of the gestation period without any constraints. A medical practitioner must be consulted from 13 to 20 weeks to identify risks such as an ongoing pregnancy that may “significantly affect the social or economic circumstances of the woman”, and after 20 weeks, when life and injury-threatening risks are present. While a minor must be advised to consult with her loved ones, she cannot be denied an abortion if she chooses not to.
The policies pertaining to women in prisons are markedly different.
The Correctional Services Act is silent on abortions. But the Department’s Regulations (last amended in 2012) provide that the “National Commissioner may approve an abortion at state expense” – though only in particular circumstances. Strikingly, these do not include when a woman requests an abortion during the first 12 weeks. And they do not extend to women seeking abortions on purely socio-economic grounds.
Unsettling questions
Unsettling questions spring to mind: Why can women prisoners not request an abortion during the first 12 weeks? Why are socio-economic grounds for abortion neglected when socio-economic issues are generally more acute behind bars? Most pressing, how can the deeply personal choice of whether to have an abortion be at the discretion of the National Commissioner?
To complicate matters further, the latest B-Orders – detailed rules the department issues – do not mention abortions. Yet, the older set states under “Women’s reproductive health” that the services rendered include “termination of pregnancy”. No further details. However, the department’s “Health Care Policy and Procedures” provide for termination of pregnancy to be “performed at state costs for medical reasons only”. What about the other legitimate reasons that warrant abortions? This is rights-throttling.
To be clear: Women imprisoned in South Africa do not have the same standard of care when it comes to accessing abortions. They have extra obstacles to overcome. And without clearly outlined and implemented policies, there is room for misuse and, worse, abuse.
More concerns crop up: Does the “equivalence of care” principle not extend to the sexual and reproductive healthcare of women prisoners? Have female inmates been overlooked in the fight for reproductive justice?
Laws and reality
The right to a woman’s bodily autonomy is a burning issue across the world. The recent exposure of a draft majority opinion from the US Supreme Court revealed a sharp repudiation of the right to abortion.
Fortunately for us, in democratic South Africa, the right to abortion is not a lightning rod for the political elite.
The Bill of Rights gives everyone the right of access to healthcare services. Critically, this includes reproductive healthcare. And is further buttressed by the right to bodily and psychological integrity, which expressly includes the right to “make decisions concerning reproduction”.
South Africa has ratified international and regional treaties, including the Maputo Protocol, that explicitly entrench the right to abortion.
Yet, there is a disturbing disparity between laws and reality.
Despite these progressive laws, many women still struggle to access safe abortions at state expense. Instead, some find themselves obliged to turn to illegal, informal and often dangerous means. This has awful consequences, in a country with high levels of sexual and gender-based violence coupled with avoidable maternal deaths.
Hurdles to safe and legal abortions, such as lack of information, stigma, judgmental attitudes and mistreatment by healthcare workers, have been identified by Amnesty International.
These barriers lead to the proliferation of illegal and informal abortion providers and have a brutal and often life-imperilling impact on women from marginalised communities. For instance, a sex worker explained that she would opt for a “backdoor” provider. Why? Because for her, privacy has to trump safety. A recent article in GroundUp revealed how poor treatment and stigma have led to more (sometimes botched) illegal abortions among sex workers.
Equivalence of care
When it comes to prisons, we must remember that by and large prisons are designed with men in mind. It is for this reason that the United Nations Bangkok Rules acknowledges that women prisoners “are one of the vulnerable groups that have specific needs and requirements”, including female-centric healthcare needs. The Rules reaffirm the “equivalence of care” principle – those in prison have a right to the same standard of healthcare as the general public.
When it comes to women prisoners’ access to abortions, the reproductive justice framework is crucial. Researchers from the Black Women’s Health Imperative state that reproductive justice encompasses the “social, political and economic inequalities that affect a woman’s ability to access reproductive health care services”.
According to Rachel Roth, abortions are “deeply personal” and “shaped by the larger political, economic and social context of women’s lives.” In the carceral setting, “[e]very dimension of reproductive justice is negatively affected.” In addition, the Prison Policy Initiative observes that in the US context there are “insurmountable barriers” to accessing abortions behind bars and “people behind bars often have very few – if any – choices and autonomy when it comes to their reproductive health and decisions”.
Political will
With political will, prison policies can be changed so that the law extends abortion rights to these women and guards the exercise of these rights.
JICS is committed to working on this.
But, we need to go further.
We need to ensure that women behind bars know their rights through education and awareness campaigns – and that healthcare workers are well-trained and do not deter or stigmatise abortion seekers.
We must establish independent healthcare in prisons, a point recently raised by Justice Cameron. Without independent healthcare, women prisoners’ access to abortions will be limited by the closed-off and security-focused nature of our prisons. My encounter with the nurse would not have been as frank and candid if a correctional official had been present.
South Africa has a long way to go to guarantee all women and girls access to safe, free and legal abortions with respect for their dignity, privacy, health and bodily integrity. In this fierce battle for reproductive justice, we must break the silence and not perpetuate the invisibility of women and girls behind bars.
