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In Portugal, as in the rest of Europe, the incidence of cancer has been steadily increasing at a rate of about 3% per year.1,2 This increase is mainly related to the aging of the population and with changes in habits and lifestyles.3
According to the 2018 edition of Health at a Glance: Europe report (Organization for Economic Co-operation and Development – OECD), Portugal has one the lowest avoidable mortality rates in Europe, reflecting greater efficacy in the treatment of patients.4
However, cancer disease remains the second leading cause of death in Portugal after cardiovascular disease5,6, and the leading cause of premature death (defined as death before the age of 70).7
Colorectal cancer is currently one of the major forms of cancer in the world, with significant mortality and morbidity associated. In general, it is more common in older people (most patients are over 60 years at the time of diagnosis, being unusual in people with less than 40 years), in males and in urbanized regions.
According to the latest data from the International Agency for Research on Cancer (World Health Organization), colorectal cancer is currently the third most frequent type of cancer in the world and the second largest cause of death by cancer.
In Europe, it is the second most common type of cancer and the second deadliest. In Portugal, it is the second most frequent type of cancer in males (18,8% of the new cases, after prostate cancer) and females (16,2% of the new cases, after breast cancer) but ranks first in the most prevalent types of cancer for both genders.8
In 2018, Portugal has diagnosed 10 270 new cases of colorectal cancer (more than 20 cases per day), corresponding to 17,6% of the total number of new cases of cancer in the country.8 Despite the increasing therapeutic success in oncological disease, the number of deaths caused by this type of cancer has been increasing, especially in the most advanced ages.5,6 It is currently the second most deadly type of cancer (following lung cancer), accounting for approximately 4214 deaths (about 12 individuals per day)8 and about 12 years of potential life lost.9
The reduction of the mortality and morbidity associated with oncological disease depends mainly on preventive strategies and the early detection of the disease. However, the early stages of colorectal cancer are usually asymptomatic or produce little symptoms. The first manifestation of disease is often the asymptomatic loss of small amounts of blood in the stool, not visible to the naked eye, making the early detection difficult. For this reason, many countries now offer systematic population screening programs.
Most cancers of the colon and rectum develop from polyps or adenomas. These lesions are benign but have a significant risk of developing dysplasia, and therefore are considered pre-malignant. The screening programs aim to detect cancer in its initial phase but also to identify and remove these precursor lesions.
Due to the increasing number of cases, the screening for colorectal cancer is now considered a Public Health priority in Europe, and Portugal makes no exception.
Although the significance of the colorectal cancer screening program is unanimously proven (it has the potential do reduce mortality rates by at least 20%)3, there is no international consensus on the methodology that should be used. The strategies vary according to the human and financial resources available and the characteristics of each country. The most validated diagnostic exams currently in use are fecal occult blood tests (FOBT), rectosigmoidoscopy and complete colonoscopy. The fecal immunochemical test (FIT) is currently the most commonly used primary screening test worldwide and has been shown to contribute to increased participation rates, with appropriate sensitivity and cost-effectiveness10.
Portugal follows the European guidelines and has been developing the foundations for the implementation of a comprehensive population screening program. Thus, in Portugal, screening should be offered to the asymptomatic population aged between 50 and 74 years. As in most European countries, the primary screening test is the FIT, performed every 2 years. The convocation of patients for screening is ensured through their General Practitioners11.
In case of a positive result in the FIT (cut off of 100 ng/mL), the patient should be referred for colonoscopy, under informed consent and within the scope of the Portugal National Health Service, in an average period of no more than 30 days.
The referral algorithm after colonoscopy varies depending on the result of the exam and is performed according to the recommendations of the European Society of Gastrointestinal Endoscopy (ESGE)11.
Population-based screening programs for cancer have evolved significantly in Portugal during the last few years, with expansion of the geographic coverage, increased numbers of patients screened, and significant improvement in adherence rates. However, screening for colorectal cancer continues to present low countrywide coverage (about 19%)1, with significant regional asymmetry.
Portugal is currently making efforts to extend colorectal cancer screening throughout the country and to create the channels to adequately screen all the eligible individuals. As a result of the acknowledgement as a Public Health priority and the ongoing efforts, it is expected that in a few years, Portugal will be able to effectively reduce this problem.
Fábio Ricardo Elias Sousa Gomes
PH resident Aveiro, Portugal
References:
The Ministry of Health has recently established a National Immunisation Information System (IIS), through the Ministerial Decree of 17 September 2018 published in the Gazzetta Ufficiale n. 257/20181. The aim of the electronic registry is to facilitate estimation of vaccine coverage, monitor the nation-wide implementation of the National Immunisation Plan (NIP) throughout the national territory; and to provide information both to the international bodies and for administrative tasks.
The need to create a single IIS from 21 regional registers was agreed upon in the State-Regions Conference of 19 January 2017, and highlighted on the National Immunisation Plan 2017-20192. The Ministerial Decree of 17 September 2018 defines the information that all Italian regions and autonomous provinces must provide to the Ministry of Health, including:
1) vaccinated individuals;
2) individuals to be vaccinated;
3) subjects already immunised after natural infection;
4) subjects temporarily or permanently exempted for health reasons;
5) doses and timing of administrated vaccines.
The IIS should be linked to the national databases of communicable diseases and adverse events.
The national IIS will aggregate individual records from the regional registries and, through a more precise estimate of vaccination coverage, will improve the monitoring activities of the programs in place, and identify areas where extraordinary interventions are required. Furthermore, in order to maintain updated regional vaccine registries, the national IIS will make available to the Regions information related to citizens who will modify their residence. The Ministry of Health will have access only to anonymised information. The first upload of files from the regional authorities is expected by April 2019.
The last update of Italian regional IISs characteristics and functionalities are presented elsewhere3.
Vincenza Gianfredi
PH resident, University of Perugia, Italy
References:
1. Ministero della Salute [Ministry of Health]. Decreto del Ministero della Salute: Istituzione dell’Anagrafe nazionale vaccini [Decree of Ministry of Health: Establishment of a National Immunisation Information System] 17 September 2018 published in the Gazzetta Ufficiale n. 257/2018
2. Ministero della Salute [Ministry of Health]. Piano Nazionale di Prevenzione Vaccinale 2017-2019 [National Plan of Vaccination Prevention 2017-2019]. 3 Apr 2018. Rome: Ministry of Health; 2018. Available from: http://www.salute.gov.it/imgs/C_17_pubblicazioni_2571_allegato.pdf
3. D’Ancona F, Gianfredi V, Riccardo F, Iannazzo S. Immunisation Registries at regional level in Italy and the roadmap for a future Italian National Registry. Ann Ig. 2018 Mar-Apr;30(2):77-85. doi: 10.7416/ai.2018.2199.
Dear EuroNetters,
A new year has just begun and the new board is working hard to make 2019 another amazing one for EuroNet!
I want to start this first communication as new Internships Lead by thanking my predecessor Julio and all the people that have been working hard on the Internships projects during 2018, your work has been precious for the development of the 2019 plan, and any future collaboration on the new projects will always be truly appreciated.
The main goals for 2019 are resumable in the following points:
The main actions to achieve these goals will require a strong involvement of endeavoured residents, not only those who already are actively participating to EuroNet activities (members of National Commissions), but also of those who still are not fully engaged, but play a role inside their National Associations or simply are interested in working on mobility and helping their colleagues achieving internships periods.
Another important action, in order to try to raise the number of possible positions, is to engage in new partnerships that could provide internships and trainings or grants for summer schools and similar projects. At the same time, strengthening the already existent collaborations, in continuity with the previous board´s excellent work, might also lead to new opportunities of this kind.
The main actions to achieve these goals will require a strong involvement of endeavoured residents, not only those who already are actively participating to EuroNet activities (members of National Commissions), but also of those who still are not fully engaged, but play a role inside their National Associations or simply are interested in working on mobility and helping their colleagues achieving internships periods.
Another important action, in order to try to raise the number of possible positions, is to engage in new partnerships that could provide internships and trainings or grants for summer schools and similar projects. At the same time, strengthening the already existent collaborations, in continuity with the previous board´s excellent work, might also lead to new opportunities of this kind.
The results of this work can contribute to the formation of a working group, to the creation of workshops about this theme or can be used for whatever other useful scopes that will cross our path.
So, to be short, the plan is settled, now I need YOU!!!
If you are interested in joining the Internships Team, just send me an email (internships@EuroNetmrph.org), I will be extremely pleased to welcome you in the team and we can start working together.
There is of course a lot of room for plan improvement and for you to add new ideas, the work to do is not little but it´s going to be fun, interesting and never overwhelming!
And keep in mind that during the meeting in Torino we will have time to know each other and have the chance to organize the main part of the work.
This call for action is of course open to any PH resident, whether this is the first time you are reading the newsletter or not, just join if interested or simply curious!
Join the Internships, Stay for the Net!
Internships Lead
Robin Thomas
I suppose that this is the first article from Turkey in EURONET-MRPH Newsletter. So, I want to share our experience for communication as first. It is very exciting and important to communicate between European students for us. It is also very important to provide a good communication medium between Turkish residents.
However, it is very difficult to choose best social medium, especially if there are hundreds of residents. For example, it is estimated that there are about 500 public health residents in more than 50 medical schools in Turkey. We use google mail group and whatsapp application to get in contact. Well, most of the residents have hesitations to write or to ask to the mail group, and they find whatsapp more practical then the mail group.
They think that they could get answers to their questions rapidly in whatsapp. Although, whatsapp is preferable for notifications, all residents couldn’t participate to residents’ group due to participant limitation.
As a representative of residents in HASUDER (Turkish Society of Public Health Specialists), i had carried out an online survey to choose the best social medium / media which had continued for ten days in November 2018. Then, we discussed the results to decide communication media in Medical Residents Session of 20th National Public Health Congress, Antalya.
Figure 1. Social Media Use of Public Health Residents for Academic Purposes
Total 156 residents completed the online survey (about 1/3 of all residents). Mean age of participants was 29.3±3.2 years and mean duration of residency was 23.5±15.6 months. About three quarters of the residents (73.7%) was female. Please don’t worry; it is not an error, there is apparently female predominance in Turkish public health residents. Most of the participants (84.5%) specified that they used social media every day. More than 90.0% of residents could interest in social media several times in a week. However, only 76.3% of residents specified that they could interest in social media for academic purposes several times in a week.
Youtube, mail groups and whatsapp application were the most used media for academic purposes (Figure 1).
Residents preferred to communicate mostly with mail groups, whatsapp, telegram and instagram for academic communication (Figure 2).
Figure 2. Social Media Communication Preferences of Public Health Residents for Academic Purposes
Youtube, researchgate, linkedin and academia.edu were excluded for academic communication preferences. Because, they were not suitable for mutual and group communication. Few residents chose medscape and discord under the title of “others” for both in Figure 1 and 2.
It could be concluded that mail groups and whatsapp are trending media. In public health conference , we discussed that whatsapp was not enough, maybe it would be better to change it to telegram according to survey results. Instagram was a surprise in this survey. Perhaps, it might have a function in the future in terms of the public health.
Ferhat Yildiz
MD, Representative of Residents, HASUDER, Turkey
Aydin Adnan Menderes University, School of Medicine
Department of Public Health
Merhaba (Hello)!
References and Social Media resources used
Introduction
History of modern society is riddled with public health breakthroughs. Advances based on the notion of prevention of disease and promotion of good health allowed for better living conditions, safe transportation, diverse and nourishing diets, and numerous other standards of developed societies most of us take for granted.
In retrospect, we praise much of those advances as prototypal public health measures. Did ingenious minds behind those actions perceive themselves as public health pioneers? One might even argue that they needn’t identify as such (1). John Snow, Louis Pasteur and Robert Koch transformed the world through their work and for that they only had to subscribe to the ideal of public health – not to the profession. They were inventors that spawned a health revolution. But times have changed. We are faced with globalised world, global warming and regular political tantrums with possibly perilous consequences (2). Nations of the world are putting health high on the agenda with concerted actions such as Millennium Development Goals and Sustainable Development Goals (3). Further advancement of public health demands a different toolset and approaches from those of past eras. This holds true for public health practice on international as well as on an national or even local level (4). Modern challenges of public health require a workforce with capacities to address and overcome them (5,6). Public health practitioners of today and tomorrow need to be leaders as much as scientists and inventors (7). Development of such a workforce is the common theme of following reflections provided by a group of professionals with deep insight into education and training practices in public health.
The collection of reflections starts with an overview of current status and recent initiatives in public health workforce development in the European region written by Robert Otok, Katarzyna Czabanowska, and John Middleton who are all active in Association of Schools of Public Health in the European Region, a key independent European organisation dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research.
Alberto Mateo, president of the European Network of Medical Residents in Public Health, further reflects on the topic of international cooperation and on importance of internationally harmonised curricula in public health education. Afterwards authors focus on analysing and reflecting on public health workforce development in Slovenia. Tit Albreht from National Institute of Public Health addresses the challenge of diversification of public health workforce in Slovenia. In his commentary, he stresses the importance of standard education as well as continuous professional development. Recognising the importance of having a modern and comprehensive public health educational programme for medical residents, Lijana Zaletel Kragelj from Faculty of Medicine at University of Ljubljana provides us with a summary of the transformation of Slovenian public health specialty training programme from its conception and offers us with a glimpse of what we can expect in near future. Ivan Eržen from National Institute of Public Health completes the overview of graduate and postgraduate programmes which offer public health topics in their curriculums. Acknowledging the limitations of current landscape of educational opportunities in public health he points out the need for a school of public health which has yet to be established in Slovenia. In the following commentary, Marjan Premik, one of the main protagonists of establishment of school of public health in Slovenia, introduces arguments for school of public health as an integral part of health care system. Putting the emphasis on the wider public health workforce, Mitja Vrdelja from National Institute of Public Health, gives his view on working in public health in Slovenia from a communications expert perspective and complements reflections on workforce developments from previous authors with challenges that could be solved with appropriate education and training of public health workforce. Current Perspectives are rounded up with a playful note by a discussion I had with Damir Ivanković, a former public health resident from Croatia who is presently a researcher at the Academic Medical Center in Amsterdam. Since both of us are a young public health professionals from relatively small countries we take a look at benefits and drawbacks of starting a career in such an environment.
Matej Vinko
National Institute of Public Health of Slovenia, Ljubljana, Slovenia
Keep reading the article at:
http://www.nijz.si/sites/www.nijz.si/files/uploaded/vinko_jz_03-06.pdf
References
As published in Revija Javno zdravje
“Proudly by ourselves” – this was a Portuguese nationalist slogan advertised before April 25th 1974 revolution. However, globalization changed the paradigm of international relationships and communication technologies connected the whole world by a simple click. We no longer live in a place where our actions have no consequences, but rather influence people and the environment around us – both as individuals and through organizations.
As you know, Public Health was defined by Acheson as “the science and art of preventing disease, prolonging life and promoting health through organized community efforts” and Ottawa Charter for Health Promotion called for “community health partnerships, health alliances or socio-ecological approaches to prevention and health promotion”.
Therefore, non-governmental organizations (NGO) play an interesting role in promoting community development while remaining independent from governments. Currently, some of the most important European NGOs in Public Health area are ASPHER (Association of School of Public Health in Europe), EHMA (European Health Management Association) and EUPHA (European Public Health Association)1. The aim of most of these kind of organizations is to bring together experts to develop innovative health research and implement it through effective policy making.
Another perfect example of cooperation between European public health professionals is the European Network of Medical Residents in Public Health (EuroNet MRPH), which gathers 10 national based Public Health associations training programs.
Following its mission, EuroNet MRPH aims to promote the sharing of educational opportunities, facilitate exchange internships and develop international scientific research. Euronet-like networks are keen on knowledge transferring, research collaboration and they create a unique environment for ideas to develop, encouraging the rapid spread of information in Europe.
The lack of bureaucracy (but not organizational anarchy) among networks is one of its strengths when comparing to governments and institutions, which makes it so useful in creating knowledge, exchanging information and spreading good practice2. Individuals from different organizations and areas can collaborate free from the constraints that exist in more hierarchical models3. Also, collaborative papers tend to get cited more often, which is an important “bonus”4.
Summing up, networks should focus on five specific pillars:
Figure 1. The 5C Wheel, including core features of an effective network4
Right now, in my opinion, EuroNet MRPH follows the main essentials for a successful network. That is amazing in such a short period of time, while having room for development, especially regarding partnerships and cooperation. Networks are just the bottom level of a collaboration hierarchy, gathering a huge potential for development and expansion for the following years, until they achieve a full collaboration status5.
Partnerships can be defined as “contextually relevant peer-to-peer collaborations which offer a platform for sharing knowledge and growing expertise globally, working towards a common goal, across disciplines and perspectives”6. This allows organizations to explore their differences and find solutions beyond their limited visions7.
Similar to networks’ main pillars, partnerships also need6:
As discussed in 2018’s Winter Meeting, communication and partnerships are fields where Euronet MRPH needs to invest some workforce and time, in order to develop proper foundations for the future. As referred by Rahman, EUPHA added value to members association through contact to other European Public Health Associations and more ideas for research and collaboration, among others1. Therefore, members of both organizations in a partnership also expect to develop future collaborations through existing ones.
Addressing the big elephant in the room, there are hundreds of public health related institutes and NGOs in Europe. Many of them are already connected but it’s crucial to align most important NGOs agendas in Public Health, strengthening integration policies and influence8. While integrating activities in a single network is already a complicated task, integration of activities between different organizations it’s even more problematic – but when well coordinated, they have a bigger impact.
Challenges in Public Health collaboration will be hard to tackle, but young professionals willingness to act and innovate play a crucial role. Today, in my opinion, Euronet MPRH is a successful network with a clear direction, encouraging innovation and quality improvement. There is a potential in advocacy for Public Health residents and promoting community driven initiatives which still remains on hold, while a broader influence in European Public Health can also be addressed through more meaningful and structured partnerships.
In the Velika Planina winter meeting, Euronet MRPH members discussed the role of partnerships for the future of the network and there was a call for reviewing Euronet MRPH partnerships in an objective way, highlighting the need for meaningful and relevant benefits for enrolled public health residents, like scholarships, reduced fees and opportunities for research collaboration. But most of all, is crucial to gather feedback from residents and understand what they expect from partnerships.
In the Velika Planina winter meeting, Euronet MRPH members discussed the role of partnerships for the future of the network and there was a call for reviewing Euronet MRPH partnerships in an objective way, highlighting the need for meaningful and relevant benefits for enrolled public health residents, like scholarships, reduced fees and opportunities for research collaboration.
But most of all, is crucial to gather feedback from residents and understand what they expect from partnerships. There will be many challenges in the future and it’s up to us to prepare and embrace the opportunities that they will bring.
Public Health Resident
Public Health Unit Lisboa Central, Portugal
References
Nowadays many people die from weight related diseases, these can normally be prevented by improving eating habits and lifestyle choices. But, how easy is it for people to choose better?
As a dietitian and public health professional I find myself promoting healthy eating very often. However, I have realised that it is not just up to the people to try to get healthier. It is the government’s job to make it easier for everyone to make these changes.
A year ago, I found myself moving to Barcelona, a city full of life and full of bars and restaurants. Asking for tap water in Barcelona is impossible as waiters argue that tap water is not drinkable in Spain. In fact, Barcelona’s water is safe to drink as it follows EU regulations and the company in charge of water in Barcelona has many ISO certifications that secure the water’s innocuousness. In addition to this, a bottle of water in Barcelona is sometimes either the same price or more expensive than a beer or sugary drinks. In contrast, countries in the European Union like the UK and France make it mandatory for bars and restaurants to give free tap water to customers, making it easier for people to choose healthier.
By the same token, in consultation, I always suggest patients to choose whole meal bread and pastas over white ones. Many of them stick to refined grains given that wholemeal products are normally more expensive. It is a fact that eating refined carbs lead to increased risk of obesity and type 2 diabetes, such as it is a fact that it is cheaper to make wholemeal products than to make heavily processed ones, and still people need to pay more for getting the healthier option.
The idea that to eat better is necessary to spend lots of money is a problem I have encountered many times. The current trend of organic foods makes it seem like eating healthily is only for those who can actually afford it. People from a low socioeconomic status find it impossible to eat the so-called organic products. Showing people that healthier does not necessarily mean organic or more expensive should be a public health priority.
Given these points, it is evident that support from the government is essential in order to make it easier for people to choose the healthier option.
Masters in Public health student at the Universitat Pompeu Fabra in Barcelona
References:
Access to health services in the prison system is conditioned by legal barriers, social marginalization and stigma which can increase infectious diseases among the prison population1.
The prison population is different from other populations and it’s in a situation of increased vulnerability. There are several factors that contribute to this, mainly: more exposure to violence; transmission of infectious diseases; increased unprotected sexual, confinement and overpopulation; difficulties in the patients flow up1.
The number of prisoners in Portugal is about 14.000 on 2017, for a theoretical capacity of approximately 13.000, generating, thus, a panorama of indisputable overcrowding of the prison system. In addition there is also a high turn-over of inmates2. The most relevant characteristics of Portuguese prisoners are summarized in Table 1 and Figure 1.
Figure 1. Prisoners, by age. Portugal 20172
In order to achieve the goals to 2020 outlined on Onusida/Unaids and reduce the morbimortality of viral hepatitis, the General Directorate for Reinsertion and Prisional Services (Direção-Geral da Reinserção e dos Serviços Prisionais) and 28 hospitals of the National Health Service (SNS) will sign a protocol for the treatment of human immunodeficiency virus (HIV) and viral hepatitis infections in the prison population, extending to the whole country the pilot project that runs between the Hospital de São João in Porto and the prison of Custóias.
This pilot project started on january 2017, in order to promote appropriate diagnostic procedures and to provide medication to cure hepatitis C.
This initiative enabled the elimination of Hepatitis C in prisons in Custóias and Santa Cruz do Bispo and is now being expanded geographically and to include other viral hepatitis and HIV4.
Table 1. Characteristics of the Portuguese Prison Population, Portugal, 20172,3
Up until now, prisoners were subject to security procedures when traveling to healthcare facilities, which caused constraints to clinical observation. From now on they will be treated in the prison itself. This new model will allow physicians – infecciologists, gastroenterologists and internists – to move to prisons to care for the HIV-infected, hepatitis B and C prison population of 45 prison facilities across the continent. In addition, screening will be done at the entrance, during and at the end of the sentence.
Thus, it is expected that this protocol will shape a new approach to health care for infectious diseases in prisons.
Public Health Resident, Portugal
Public Health Resident, Portugal
References:
Sexual and reproductive health and rights (SRHR) are at the intersection of health care and the legal and moral system of a country. Issues related to SRHR are not only under the control of the woman herself, eventually her partner, and healthcare professionals, but also of lawmakers and often religious leaders. Matters as abortion, contraception, fertility and reproduction, the definition of consent, the choice of a partner, are hence both extremely intimate and public, influenced by power dynamics and contextual factors.
Of abortion, in 1992 H. David wrote: “Although universally practiced, no other elective surgical procedure has evoked as much divisive public debate, generated such emotional and moral passion, or received greater sustained attention from the media”1.
Abortion is indeed universally practiced, but an estimated 25% of the world’s population lives in the 66 countries where abortion is either prohibited or permitted only to save a woman’s life2. Of these, eight countries are in Europe: Northern Ireland in the United Kingdom, Ireland, Monaco, Liechtenstein, San Marino, Poland, Andorra and Malta. In the first six countries, abortion is forbidden outside extremely limited circonstances, for example, depending on the country, to avert a substantial risk to a woman’s life, in case of severe foetal impairment or if the pregnancy is a result of a sexual assault. Andorra and Malta do not allow it in any situation3.
A report published in December 2017 by the Council of Europe details the effects of restrictive laws on women in Europe3. In countries with restrictive laws, womens are forced to travel outside the country to receive care, or they have to access illegal abortion, for example by buying abortion pills online, with the fear to seek post-abortion care, because of the legal implications. Travelling outside the country in fact is not always an option, for administrative and financial barriers, especially for adolescents, undocumented migrants or women at risk for domestic violence.
Restrictive laws can have tragic effects on the health and lives of women, as we know from the most covered country with restrictive laws in Europe, which is Ireland. In Ireland, the 8th amendment of the Constitution, which was introduced in 1983 to recognise the right to life of the unborn as an equal to that of the mother, was repealed by referendum, on the 25th of May 2018. The repeal came after appalling events like the death by sepsis of Savita Halappavanar in 20124 and the stories of some of the around 3’000 women who every year travel to the UK to access abortion services and the efforts of grassroot activism. Activism that extends across the border to Northern Ireland, in support of the women who may theoretically face a life sentence if found guilty of having an abortion5.
However, the possibility to access safe, prompt abortion care can be limited even in the European countries with liberal laws, meaning where abortion is accessible on request, for reasons of distress or on broad socio-economic grounds. For example, a mandatory waiting period, with or without mandatory counseling, exists in many countries, such as Germany, Italy and The Netherlands, and was recently reintroduced in countries in Central and Eastern Europe,6 while it was suppressed by the health law of 2016 in France7. The mandatory waiting period does not fulfill any medical purpose8.
Lack of professionals who provide abortion services is another barrier to access. The lack of professionals can be due to a shortage of professionals who are trained in this practice or because of the refusal to provide abortion services on grounds of conscience or religion.
Some solutions to the shortage of trained professionals exist: for example, France faces a lack of gynecologists, especially in rural areas, so the health law of 2016 introduced the possibility for midwife to provide medical abortion.
When refusals of care on grounds of conscience or religion are not well regulated, or the mechanisms to oversight the respect of regulations are not functional, the access to legal services is not guaranteed. For example, in Italy, in some regions more than 80% of gynecologists are objectors, and only 60% of the health care structures of the country provide abortions9, 10.
These circumstances can induce European women to travel to other countries, a theme that is being studied by a research project called Europe Abortion Access Project. The first results about cross-country travel will be available in the winter of 2018, while the results on in-country travel will be available in 202011.
These elements invite public health professionals to remain vigilant on abortion. The situation is ever changing and, in some cases, it is developing for the best, as we saw in Ireland, where representations on abortion have finally been shifted after years of reflections and advocacy12. In others it is stagnating or there is even a real risk of retrogression, as in Poland, where since 2016 there have been different attempts at hardening what is already one of the most restrictive abortion laws in Europe13, 14.
Maria Francesca Manca
Public Health Resident, France
References