[e-med] (2) Santé de la reproduction

["remed" <remed@remed.org>]

Nous reprenon un message diffusé sur e-drug au sujet de rumeurs relatives à l'opposition des Etats-Unis à l'inscription de deux pilules abortives sur la liste des médicaments essentiels. La réunion du comité d'expert s'est tenue du 7 au 11 mars 2005 et généralement la nouvelle liste est publiée dans les jours qui suivent, ce qui n'est pas le cas cette année. Il semblerait que la méthadone fasse l'objet d'un blocage similaire. L'adresse de la page internet sur les médicaments essentiels est la suivante :
www.who.int/medicines/organization/par/edl/expcom14/expcom05agenda.shtml
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E-drug a diffusé un article du Guardian mentionnant ce blocage. 
Le BMJ daté du 30 avril a publié un article sur les réticences des pharmaciens américains à délivrer les pilules abortives.  
Pour ces deux articles, vous trouverez une traduction résumée suivie des versions originales et complètes. 
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Les Etats-Unis accusés de tenter de bloquer les pillules abortives.
The Guardian, Sarah Boseley, 21 avril 2005
Le gouvernement des Etats-Unis tente d'empêcher l'OMS de donner son aval à deux pilules abortives qui peuvent sauver chaque année la vie de 68 000 femmes qui décèdent des suites de mauvaises pratiques dans les PED.
L'OMS veut inscrire ces pilules sur la liste des médicaments essentiels [...]
Le mois dernier, un comité d'expert s'est réuni pour évaluer de nouveaux médicaments à inclure dans la liste. Pour la première fois, ils ont approuvé deux médicaments utilisés en association (mifepristone et misoprostol). Dans les pays pauvres où l'avortement est légal, les médecins n'ont d'autre solution que la chirurgie. 
Le Guardian comprend que le département de la santé des Etats-Unis a fait pression sur le directeur général pour bloquer l'approbation de ces pilules, dans la ligne de la position néoconservatrice de Georges Bush sur l'avortement.
[...]
Le comité de l'OMS [...] a unanimement recommandé l'inscription de ces médicaments sur la liste des médicaments essentiels. Mais alors que l'approbation du directeur général est habituellement une simple formalité et que les modifications sont publiées dans les jours qui suivent, plus d'un mois s'est écoulé.
Le 23 mars, le bureau du directeur général a écrit au comité lui demandant s'il a pris en compte les risques, rares, d'infections bactériennes et d'hémorragies, associés au mifepristone. Les membres du comité ont répondu que les effets indésirables ont été pris en compte et que les hémorragies et les infections dans les pays en développement sont plus important en chirurgie.
[...]
Un porte-parole du directeur général a déclaré que les délais étaient motivés par le besoin d'éclaircissement.
[...].

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BMJ 2005;330:983 (30 April), doi:10.1136/bmj.330.7498.983-a 
La contraception d'urgence remise en cause par les pharmaciens américains.
Emergency contraception is under attack by US pharmacists, Janice Hopkins Tanne 
Un nombre croissant de pharmaciens aux Etats-Unis refusent de délivrer les médicaments precrits pour la contraception d'urgence, y compris en cas de viol. Certains pharmaciens ne délivrent pas les contraceptifs oraux pour des raisons morales et religieuses.
Karen Pearl, la président par interim du Planned Parenthood Federation of America a déclaré " nous recevons de plus en plus de déclarations [de refus de délivrance] en provenance de plus en plus  d'Etats. C'est clairement un mouvement concerté pour répondre à la manière dont les femmes maitrisent les naissances. "
[...]
Le News & Record, un journal de Caroline du nord, a rapporté que certains pharmaciens détruisent les ordonnances, tiennent des discours moraux aux patients et se dérobent pour indiquer au patient où la dévivrance de la contraception d'urgence est faite.
[...]
Alors que le Canada est devenu le 34e Etat a approuver la contraception d'urgence " plan B " sans prescription médicale le 19 avril, la Food ans Drug administration (FDA, USA) continue à retarder l'approbation, attendue en janvier. 
Pour protester contre ce délai, deux sénateurs américains - Hillary Rodham Clinton de New York et Patty Murray de l'Etat de Washington state - ont bloqué la nomination du Dr Lester Crawford à la tête de la FDA.
[...]
Les défenseurs de la contraception d'urgence disent qu'elle peut réduire le nombre d'avortements. 
Les opposant déclarent que l'être humain est créé qaund le sperme et l'oeuf s'unissent  [a human being is created when sperm and egg unite] et puisque la contraception eempêhce l'implatation cela revient à la même chose qu'un avortement. D'autre opposant disent que la contraception d'urgence promouvoit la promiscuité. 
[...]

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Version originales des articles
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US accused of trying to block abortion pills, 
Sarah Boseley, health editor, Thursday April 21, 2005, The Guardian 
The US government is trying to block the World Health Organisation from endorsing two abortion pills which could save the lives of some of the 68,000 women who die from unsafe practices in poor countries every year. 
The WHO wants to put the pills on its essential medicines list, which constitutes official advice to all governments on the basic drugs their doctors should have available. 
Last month, an expert committee met to consider a number of new drugs for inclusion on the list. They approved for the first time two pills, to be used in combination for the termination of early pregnancy, called mifepristone and misoprostol. In poor countries where abortion is legal, doctors currently have no alternative to surgery. 
The Guardian understands that the US department of health and human services has been lobbying the director general's office at the WHO to block approval of the pills, in line with President George Bush's neoconservative stance on abortion. 
While the availability of pills might make abortion easier and could increase the number choosing it, the experts want them listed to reduce the deaths and damage caused by surgery. Every year, 19 million women have unsafe abortions - 18.5 million of those take place in developing countries. An estimated 68,000 women die as a result of botched or unhygienic surgery, while many others suffer long-term damage, including sterility. 
The WHO's own department of reproductive health proposed the addition of the abortion pills to the list. 
In a review of the drugs for the committee, a Brazilian professor of pharmacology, Lenita Wannmacher, wrote: "There is great concern about the effectiveness and safety of surgical methods that may be less effective and may increase the risk of infection, uterine perforation, cervical laceration, incomplete evacuation, haemorrhage, miscarriage, future sterility and even death." 
The risk of death from abortion in developing countries is 100 times higher than in countries such as the UK, where mifepristone has been licensed since 1991. The pills were licensed in the US in 2000. 
The WHO committee, which included two British and two US experts, recommended unanimously that the pills go on the essential medicines list. But although the director general's approval is usually a formality and the changes are published within days, more than a month has now passed. 
On March 23, the director general's office wrote to committee members asking if they had considered a warning that mifepristone can, in rare cases, carry a risk of serious bacterial infections, sepsis and bleeding. The committee members replied that all side-effects had been considered, adding that the risks of infection and bleeding from surgery in poor countries were far greater. 
One committee member told the Guardian that all the evidence on the risks and benefits of the pills had been on the WHO website for months. 
A spokeswoman for the WHO director general's office said there had been delays because "we had some questions and sought clarification." 
Asked whether there had been any contact between the US department of health and human services and the director general's office, she said: "I can't answer that. I just don't know." She said a decision would be made within days.

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Emergency contraception is under attack by US pharmacists 
http://bmj.bmjjournals.com/cgi/content/full/330/7498/983-a?etoc
Janice Hopkins Tanne 
A growing number of pharmacists across the United States are refusing to fill prescriptions for emergency contraception, even in cases of rape. Some pharmacists won't fill prescriptions for oral contraceptives for moral and religious reasons. 
Karen Pearl, interim president of the Planned Parenthood Federation of America, said, "We're getting more and more reports [of denials to fill prescriptions] from more and more states. This is a clearly orchestrated movement to stand in the way of women getting the birth control they need. Pharmacists are standing in the middle of the doctor-patient relationship." 
The "conscience clause" trend began several years ago when doctors and healthcare workers were allowed to refuse to take part in abortions ( BMJ 2004;329: 476[Free Full Text]). Some states allow pharmacists to refuse to fill prescriptions, while other states require them to. 
The News & Record, a North Carolina newspaper, reported that some pharmacists were destroying prescriptions, giving patients speeches on morality, and stalling the patient beyond the point where emergency contraception would be effective. 
In Illinois the governor issued an emergency order requiring pharmacists to stock emergency contraceptives and to fill prescriptions quickly. He was challenged by a conservative group. Legislatures in several states are fighting over whether hospitals, including Catholic hospitals, must tell women who have been raped about emergency contraception. 
While Canada became the 34th country to approve the emergency contraceptive "Plan B" without a doctor's prescription on 19 April, the US Food and Drug Administration continued delaying approval, which was expected in January ( BMJ 2004;328: 1219[Free Full Text]). The manufacturer of Plan B, Barr Pharmaceuticals, first sought approval in 2003. 
To protest about the FDA's delay two US senators-Hillary Rodham Clinton of New York and Patty Murray of Washington state-have blocked the approval of Dr Lester Crawford as the new head of the FDA. 
The Democrats introduced federal legislation requiring pharmacies that serve people on the federal Medicare healthcare programme (for elderly people) or Medicaid (for poor people)-which would probably be most US pharmacies-to fill all prescriptions or refer the customer to a pharmacy that would. 
Supporters of emergency contraception say that the emergency contraceptive, a high dose of ordinary oral contraceptives, could reduce the number of abortions. About 1.3 million abortions are performed each year in the United States. 
Opponents of contraception, such as Pharmacists for Life International, say that a human being is created when sperm and egg unite and that because contraceptives may prevent implantation using them is the same as abortion. Other opponents say that emergency contraception promotes promiscuity. 
The American Pharmaceutical Association, which represents more than 50 000 pharmacists, reacted angrily to a New York Times editorial (2005 April 3; sect 4, 12) that said that pharmacists should fill doctors' prescriptions or find another line of work. 
The association recommends "appropriate staffing within a pharmacy, proactively directing patients to designated practices, and working with physicians and other prescribers to establish alternative dispensing methods." 
Such proposals won't work, said Ms Pearl. Health insurance plans required many women to get prescriptions filled at a particular chain of pharmacies, so their choice was restricted.