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Resumen: 15. En este trabajo se revisita el concepto de confidencialidad, a la luz de nuevos desafíos que surgen de los avances tecnológicos y de comunicaciones, y sus aplicaciones en la práctica profesional clínica y la investigación científica. Se fundamenta el análisis en la presentación de antecedentes filosóficos, así como también la distinción y precisión respecto de conceptos relacionados: intimidad, privacidad, anonimato, secreto profesional. Se hace un contrapunto entre privacidad, como derecho de los pacientes y participantes de la investigación científica, y confidencialidad y secreto profesional, como deber profesional. Se examinan nuevos retos a la confidencialidad en la práctica profesional y en la investigación científica en salud mental, como por ejemplo la protección de la información en la ficha clínica electrónica. Se concluye enfatizando la incorporación del tema en la reflexión ético-legal en la investigación y formación profesional.

Abstract: 19. In this paper the concept of confidentiality is revisited in the light of the challenges arising from technological and communications advances and their applications in clinical practice and scientific research. The analysis is based on the presentation of philosophical background as well as the distinction and precision regarding related concepts: intimacy, privacy, anonymity, and professional secret. A counterpoint between privacy rights of patients and participants of scientific research and professional secrecy and confidentiality as professional duty is done. Also new challenges to privacy are developed in professional practice and scientific research in mental health, like the protection of confidentiality of the electronic clinical file. The authors conclude emphasizing the need to include the subject in the ethical and legal reflection in research and professional education.

Resumo: 23. Neste trabalho foi revisitado o conceito de confidencialidade, à luz dos novos desafios decorrentes de avanços tecnológicos na comunicação e suas aplicações na prática profissional clínica e na investigação científica. A análise foi fundamentada na apresentação dos antecedentes filosóficos, bem como também, na distinção e na precisão a respeito de conceitos relacionados: intimidade, privacidade, anonimato e sigilo profissional. Faz-se um contraponto entre a privacidade como um direito dos pacientes e de participantes de pesquisa científica e a confidencialidade e sigilo profissional, como um dever profissional. Desenvolve-se novos desafios à confidencialidade na prática profissional e na pesquisa científica em saúde mental, por exemplo, a proteção das informações em fichas clínicas electrônicas. Conclui-se enfatizando a importância da incorporação do tema na reflexão ética-legal na pesquisa e na formação profissional.

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PIP: The return of migrants to Jamaica is closely associated with the persistence of the transnational household, which is established between the family members abroad and those who remain in Jamaica. The strength of transnational linkages is strongly determined by the manner and purpose of migration, by whether the migration involves an individual or a family, and the extent of the migrant's obligations in compensation for the neglect of responsibilities during his or her absence. Remittances precede, accompany, and follow the return of migrants. There was a consistent increase in remittances during the 1990s; they increased in revenue from US$183.3 million in 1991 to US$668.7 million in 1997. Quantitative statistics on return migration to Jamaica have only been gathered officially since 1992. Data showed a steady increase in the volume of return migration from 1992 to 1997. The largest numbers of returning residents were recorded in 1993 (2493) and in 1994 (2417). The majority of the migrants came from the US followed by the UK. A smaller percentage of return migrants came from Canada and other locations, chiefly Caribbean countries. Seeing potential in the Jamaican overseas community, the Government of Jamaica has established programs, such as the Return of Talent program, to encourage the return of its nationals. Two factors have had an impact on return migration to Jamaica: 1) the characteristics of the migrants in terms of skill level, experience, and attitudes and 2) the social and economic condition of the country itself.^ieng

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PIP: The Cardinal of Milan and the linguist and writer Umberto Eco maintained a correspondence in the mid-1990s in connection with the Italian magazine ¿Liberal¿. One of the issues discussed was the conflict between belief in the value of human life and existing abortion legislation. Umberto Eco stated that he would do all in his power to dissuade a woman pregnant with his child from having an abortion, regardless of the personal cost to the parents, because the birth of a child is a miracle. He would not, however, feel capable of imposing his ethical position on anyone else. Terrible moments occur in which women have a right to make autonomous decisions concerning their bodies, their feelings, their futures. Those who disagree cite the right to life, a rather vague concept about which even atheists can be enthusiastic. The moment at which a new human being is formed has been brought to the center of Catholic theology, despite its uncertainty; the beginning of a new life may always need to be understood as a process whose end result is the newborn. Only the mother should decide at what moment the process may be interrupted. The cardinal¿s response distinguished between psychic and physical life, on the one hand, and life participating in the life of God on the other. The threshold is the moment of conception, reflecting a continuity of identity. The new being is worthy of respect. Any violation of the affection and care owed to the being can only be experienced as a profound suffering and painful laceration that may never heal. The response of Eco is unknown.^ieng

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PIP: The relationship between urban projects and planning has received increased attention in the past decade or so, simultaneously with changes in modes of construction and increasingly limited availability of new urban spaces. The discussion has reaffirmed the importance of the interaction between a project and the plan; the plan is valuable as an important element of the project, and the project becomes concrete proof of the value of the plan. This view of project and plan is part of the process underway since the 1970s, in which context emerged as a preeminent part of an architectural project along with the conception of the project itself as a critical dialogue with existing structures and their modification. Greater attention has thus been given to the constructed city and its history. This work traces the debate over aesthetic and practical aspects of the relationship, including commentary on the social implications of reactions to the renewed debate among architects and others.^ieng

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PIP: Equality between men and women is one of the basic human rights. Investments in health, education, and family planning are the fundamental measures for promoting sexual equality. Promoting equality in turn is an investment in improving the health of women and children and the quality of human resources. By reducing pressure for large families, sexual equality creates conditions for faster economic growth. Women control most of the nonmonetary economy including subsistence agriculture, care of children, and domestic work, and they also play an important role in the monetary economy, although much of their work is unrecognized. The unfavorable condition of women limits their access to productive goods and social services. A strong inverse relationship exists between fertility and female education. More educated women have a greater probability of receiving prenatal care and of providing adequate care for their children. In many countries of Latin America, more than 20% of births are to adolescents. Adolescent pregnancies are often problematic, resulting in interrupted education, perpetuation of poverty, health complications, abortion, or even suicide. The problems of adolescent maternity are closely related to the inferior position of women. Education and family planning services are essential in breaking the vicious cycle. Access to employment for women contributes to reducing fertility, improves the position of women in the family, directly aids children, and reduces the woman's need to have many children for old age security. To establish conditions of equality between men and women, political actions must be taken to assure women equal social conditions and economic opportunities. Men must become more involved in family planning and in child care. The society as a whole must understand the social function of maternity.^ieng

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PIP: The professional achievements of Halfdan Mahler, for which he was awarded the 1995 UN World Population Prize, are summarized, and Dr. Mahler's acceptance speech is presented. Dr. Mahler worked for reproductive health and sustainable development during his six years as secretary general of the IPPF. Under his leadership, the IPPF established world standards for family planning and reproductive health. Dr. Mahler also guided creation and implementation of the long-term IPPF strategic plan, Vision 2000. During his tenure as director general of the World Health Organization from 1973 to 1988, he established the special program of education, development, and training for research in human reproduction. Dr. Mahler's acceptance speech sketched a world of the future in which women control their reproductive lives and enjoy equality with men in work and at home, where adolescents understand and control their sexuality, where all children are desired and cared for, and where hard work brings success even in the poorest population sectors. The challenges of achieving this vision are enormous. The world's population will have doubled to 10 billion, and tensions and inequities will persist. But if the vision is not fulfilled, the present population will triple to 15 billion and competition for every kind of resource will be intolerable. In order to succeed, the rights to free and informed reproductive decision making must be guaranteed for every couple. Harmful practices that violate the right to autonomous reproductive decision making, such as early marriage or female genital mutilation, must be eliminated. Governments must commit themselves to educating and providing resources to women so that they can exercise their rights. Family planning services must be extended to the poor and marginal population sectors that still are denied access, and to adolescents who are at risk of unwanted pregnancy and disease.^ieng

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PIP: This work constitutes a plea for the widest possible acceptance and encouragement of family planning throughout the world in order to avoid the irreversible environmental damage that will inevitably come with excessive numbers. Limitation of reproduction, preferably voluntarily, is possible by means of the effective and generally safe contraceptive methods now available. Preservation of the environment will require effective antipollution policies and an unwelcome control of the rampant consumerism of contemporary culture. Alarm among demographers in developed countries concerning exponential population increase developed about a half-century ago, only shortly after the feminist-led struggle for reproductive freedom provided a moral and juridical foundation for family planning. The demographic focus was not used to promote family planning among Third World countries, as that would have been viewed as heavy handed intrusion into the most intimate realm of domestic life. Instead, the nondemographic benefits such as improved maternal and child health and family well-being were stressed. It may be time to modify the focus. Ecologists must strive for a radical transformation of consumerist culture but must not ignore the pressure of numbers. Satisfying the needs of the world's most impoverished will greatly increase pressure on resources. Family planning has been accepted by the majority of the world's couples, but the unsatisfied demand has been estimated to amount to 100 million couples throughout the world. Providing information and services for such couples is the greatest challenge facing family planning programs. Many enemies of family planning have lost influence, but some critics from within family planning programs have deflected attention from the tasks of service delivery and may have postponed progress in some areas. Feminists who object to the concentration on female methods, developmentalists who believe that contraception will be accepted eventually as living standards improve, and integrationists who emphasize maternal-child health services to the detriment of family planning are examples. In view of the environmental threat as the twenty-first century dawns, the time may have come to view family planning not only as a right, but as a duty.^ieng

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PIP: This work identifies human rights conflicts that may result from the confrontation of the reproductive patterns of a population with family planning policies. It seeks to identify the parties involved in specific conflicts in order to document them and propose resources for their management. The fertility decline that began in Mexico in the 1970s and the significance of family planning policy as a means of facilitating the preexisting desire of couples to control fertility are examined. Possible sources of conflict are then explored in the relations between the population and health care providers. Class differences between service providers and clients, possible failure of providers to provide full information on reproductive and contraceptive options to their clients, imposition of one-sided decision making and power relations, and gender discrimination should all be examined from this perspective. Failure to allow a sufficient delay between birth of the last child and sterilization is a concrete example in which questions may be asked concerning safeguarding of the reproductive rights of individuals. The relationship of service providers to population and health policy is a potential source of conflict if, as has occurred in Mexico, the goals for fertility reduction are not met and the decision is made to redouble institutional efforts rather than modify the goal. A first step in confronting possible conflicts is to demonstrate systematically that inequalities exist in access to rights. Conflicts should be documented and interpreted in terms of underlying power relations. The concepts of reproduction, human rights, and family planning should be analyzed for their exact semiotic significance to indicate possible sources of conflict at the level of conceptualization. An awareness of reproductive rights and a willingness to defend them should be promoted in the population.^ieng

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The author "explains that the Greek philosophy and scientific thought developed elements of what is known today as population policies. These include roles and gender relationships, the population volume, the family, sexuality, birth control, eugenics, abortion and [quality of life]....The first part of the article reviews issues on family and women's roles. The second part is related to aspects associated with sexuality and...population policy." (SUMMARY IN ENG)

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PIP: A professor of bioethics discusses the ethics of abortion. Three absolute principles from the tradition of Western moral philosophy constitute the ethical basis for treatment of unwanted pregnancy. The principle of individual freedom guarantees the right to freedom of decision and action. The principle of the common good defines as morally correct the policy or action that most benefits the majority, and the principle of justice establishes that all individuals should have equal access to needed goods and services. Each of these principles is discussed as it relates to abortion, and potential conflicts and controversies are assessed in accordance with the principles. The three principles require application of the moral mandate of tolerance for the beliefs and practices of others, a necessity for coexistence in a pluralistic world. A series of natural and social rights may also be invoked, notably the right to decide freely and responsibly the number and timing of children and the right of access to the information and materials making this possible, which were affirmed in the 1974 World Population Conference at Bucharest in a statement signed by representatives of 136 governments. Universal agreement on ethical matters is unlikely to occur in a plural world. Different persons may recognize different priorities when ethical principles are in competition. The most difficult conflict is probably that between the rights of the woman and those of the fetus. This conflict differs from most others in that the legitimacy of the fetus as a bearer of rights may be questioned. Extremist positions whether motivated by religious or political factors are based on dogmas or doctrines that resist rational analysis. Applying the three principles to the problem of unwanted pregnancy, it is concluded that women have a natural right to reproductive freedom and a social right to family planning and abortion services.^ieng

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PIP: Although Colombia is one of the few countries that have not legalized abortion under any circumstances, abortion is very common. No totally reliable statistics are available because of its illegality. It is estimated however that some 300,000 abortions occur each year. 20% of women aged 13-45 are believed to have undergone at least one abortion, and 30% of those have had more than one. Hospital statistics show abortion to be the third most frequent cause of maternal mortality and morbidity. 75% of maternal deaths from infection were due to abortions. 200,000 women are estimated to die each year worldwide from complications of illegal abortion, and 15 women suffer serious medical complications for each one who dies. The deaths, complications, and suffering from illegal abortion are preventable. A recent Profamilia study showed that two-thirds of Colombian women of fertile age wanted no more children. Of the 900,000 births each year, 540,000 are desired at the time, 135,000 occur before the parents would have wished, and 171,000 are frankly unwanted. It is easy to imagine the atmosphere of emotional and affective disadvantage that surround unwanted children, as well as the possible social consequences. The one undeniable fact about abortion is that, despite the sermons of the church and the terrorizing tactics of antiabortion groups, women will continue to seek abortions. Legal and safe abortion must be defended if women are to be able to opt freely for motherhood.^ieng

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PIP: According to the 1990 Demographic and Health Survey, 21% of fertile-aged women in Colombia are adolescents aged 15-19. Research throughout the world has revealed that young people are initiating their sexual lives at ever earlier ages, due to earlier sexual maturation, constant erotic stimuli, and a mistaken understanding of sexuality. A Colombian survey showed that 49% of males and 11% of females had sex by age 18. Earlier sexual activity is leading to increased incidence of unwanted pregnancy. 78 of each 1000 adolescents become mothers each year. Among adolescents aged 16-18 with positive pregnancy tests at the Profamilia Adolescent Clinic in Bogota, 80% did not use contraception and 85% did not with to be pregnant. Unwanted adolescent pregnancy is usually traumatic, with implications for all areas of life. None of the options open to an adolescent with an undesired pregnancy is desirable. Keeping the baby exposes the mother to ostracism and rejection by the family, expulsion from school, and societal rejection. Forced marriages almost always end in separation. Adoption leads to frustration and feelings of guilt in the future. Abortion in Colombia is illegal and exposes the women to emotional and physical trauma and to risk of death or injury. The unwanted child is at risk of mistreatment, abandonment, or rejection. A demographic survey by Profamilia showed that 25% of Colombian women are mothers by age 19. 62% of uneducated adolescents are mothers by this age. Low educational level is associated with early pregnancy and limited economic opportunity. Adolescents are at higher risk of pregnancy complications due to physiological immaturity, stress, poor adaptability to pregnancy, and inadequate prenatal care. Adolescent pregnancy should be prevented. The prevention should be achieved through integrated sex education beginning at the first contact of the child with the world outside the family. The child should learn basic concepts of self-esteem, values, and responsibility because it is important to be able to say no. Sexuality should be a positive and responsible experience in which the love, sharing, and understanding of the couple permit coitus to be postponed. Society incites adolescents to coital activity but criticizes and abandons them when problems arise. Only with adequate education, sufficient maturation, and knowledge and access to contraception can adolescent pregnancy be avoided.^ieng

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Tropical medicine's fundamental task is to improve health in the tropics. By adopting primary health care strategies, it satisfies the real needs of the population while doing research, improving its effectiveness and social impact. We illustrate this with some examples drawn from our experience, where this potentiation is evident. A sanitary dermatology study, based on health auxiliaries and promoters, encompassed a whole jungle province, with 68,977 km2 and 103,681 inhabitants. It resulted in an excellent relationship with the populations, and findings of significance for early diagnosis and control of hanseniasis and other diseases. It also facilitated an extension of activities to include the entire Amazonian Region, with specific concentration on training of the health personnel. Clinico-epidemiological studies on leishmaniasis in Andean valleys incorporated activities of sanitary education, health care, aspects of community development, etc., and extended into other geographic areas. Migrant workers from high-altitude communities in Cusco who have been to the jungle and acquired cutaneous or mucocutaneous leishmaniasis formed Patient Associations. The latter now receive support for their health and development needs from health authorities and many institutions; our Institute contributes with improved therapeutic procedures and further epidemiologic studies to orient preventive and control measures.

PIP: Tropical medicine is characterized by its focus on targeted research, which has improved biomedical knowledge for application to diagnosis, treatment, and prevention of illness. The UN Development Program/World Bank/World Health Organization Special Program for Research and Training in Tropical Diseases is promoting research to improve application of the results of targeted research. Combining a primary health care strategy with tropical medicine can help ensure that the real needs of the population will be met while research continues, maximizing effectiveness and social impact. Three examples from Peru illustrate the efficacy of this combined approach. A sanitary dermatology study was conducted in Alto Amazonas, a province of the Department of Loreto with a 1980 population estimated at 103,681 living in 68.977 sq. km of jungle. An intensive training program was held for physicians, nurses, auxiliaries, and other health personnel as well as the prospective health promoters who would participate in the pilot program to diagnose and control Hansen's disease (leprosy). The training included preparation of specimens for serological and other studies and other diagnostic procedures. Two 4-member field teams covered the entire province in 18 months, during which they censused 57,927 persons and clinically examined 47,160. After diagnosis of Hansen's disease was confirmed, a project physician or nurse initiated treatment with the multidrug regimen recommended by the World Health Organization and instructed the patient in the procedures to be followed to avoid incapacity. The auxiliary in the nearest health post supervised treatment and referred the patient to a higher level if adverse reactions occurred. 45 patients with Hansen's disease were detected during the study, along with 784 with leishmaniasis, 290 with malaria, and 164 with tuberculosis. All patients diagnosed with these conditions received treatment. A clinical and epidemiological study of leishmaniasis in Andean valleys combined health education, treatment, community development, and other interventions. The incidence of leishmaniasis has been increasing in Peru, and 15,000 new cases are projected for 1992. Active collaboration with the populations involved was sought through the primary health care system. A number of different organizations participated in the work. Field studies conducted primarily in the Purisima Valley included a census, recruiting of promoters and other health workers to diagnose cases, surveillance of new cases, systematic study of leishmaniasis vectors in houses and outside, and observation of the activity patterns of the population that might increase risk of disease. Positive correlations were found with the concentration of vectors inside houses and with seasons of increased agricultural activity. The third example concerned migrant workers from the highlands who contracted leishmaniasis in the jungle. They formed associations to seek assistance from the health system.

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PIP: This work questions the assumption that population policies in Latin America and the Caribbean are closely related to population growth, identifies common obstacles to population policies, and recommends actions to increase the efficacy of population policies. The demographic transition has occurred in Latin American countries with widely varying levels of economic development, cultural traditions, and family planning programs. The governments of the region that regard their rates of population growth and fertility as satisfactory seldom intervene to modify them. The demographic transition is well underway in all these countries except Guatemala and Paraguay. A diverse array of strategies has been used by the countries that have achieved significant fertility reductions, ranging from family planning services provided through the national health system in Mexico to key roles by the private and commercial sectors and intensive use of the mass media in Brazil. Governments adopting population policies defined various institutional forms for them, ranging from small technical units at a high level to interministerial councils. Institutionalization of population policies created high hopes for integration of population concerns into development strategies, but performance has largely failed to meet expectations, both because of the fragility and inferior status in the government bureaucracy of policy structures, and because of their inability to develop effective programs integrating population and development. The economic crisis of the 1980s lowered the priority of population themes. Political instability, lack of adequate human resources and financing, limited decision making capacity, and failure to establish strong interinstitutional ties have all been factors in the disappointing results of population policies. The difficulty of pinpointing exactly what constitutes the population policy and the tendency to equate population policy and family planning have been other factors hindering their full implementation. The effectiveness of population policies appears to have been compromised by their lack of specificity among government policies. To increase their efficacy it will be necessary to define their uniqueness with respect to other social policies. Population policies, their institutional framework, and the actors called upon to support then must be redefined. A national population policy should orient interventions in three areas: establishment of consensus regarding population goals, channeling funds to the implementing agencies, and providing follow-up and evaluation of demographic effects. Implementation of population policies and programs should be decentralized and should be achieved through insertion of population parameters in the activities of the health, education, and other social sectors.^ieng

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PIP: This work examines reproductive health within the framework of human rights assured by various international conventions, and analyzes the high maternal mortality rates of developing countries as a violation of several guaranteed rights. The 1st of 3 main sections of the report discusses the failure of governments to make protection of women's reproductive health a priority. Historically, women's principal role has been to bear children, and no recognition was given to the cost in health of accomplishing this duty. Women's reproductive health has created controversies in many traditional juridical systems because of its relation to human sexuality and morals. WHO has estimated that some 500,000 maternal deaths occur each year, with 25-50% resulting from unsafe abortions. The causes of maternal mortality often have their roots in the poor nutrition or inadequate health care provided to the woman long before the 1st pregnancy. Early and frequent pregnancies and heavy physical labor are among the many factors that contribute to maternal death. Laws to protect women's health may be lacking or may not be applied. For example, many countries have no legal minimum age for marriage. To combat the traditional negligence, a new viewpoint is emerging which views women's reproductive health as a condition in which childbearing occurs in a state of physical, mental, and social wellbeing. It implies that women have the capacity to reproduce, regulate their fertility, and enjoy sexual relations. Laws that deny access to reproductive health services or place obstacles or conditions in the way are coming under question as violations of basic human rights of women protected by international conventions. The main such convention discussed in this article is the Convention on the Elimination of All Forms of Discrimination Against Women, although several other conventions are relevant to protecting women's reproductive health. If international law on human rights is to become truly universal, it is necessary to require that nations take preventive and curative measures to protect women's reproductive health and provide women with the capacity for reproductive self-determination. International human rights treaties require that national and international laws guarantee the rights of women to be free from discrimination; enjoy the rights to marriage and formation of a family; rights to private and family life; rights to information and education; and access to medical attention and to the benefits of scientific progress. The 2nd major section of this work discusses interpretations of these treaties using empirical evidence and feminist juridical principles. The 3rd section discusses international protection of women's reproductive rights, including the reporting system and specific categories of clearly differentiable rights.^ieng

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PIP: The use of RU-486 to induce abortion represents a new era in reproductive technology and merits ethical attention. The feminists principles of concern for women's well-being, paying attention to the specific needs of women in specific circumstances, and balancing risks and benefits can be applied to an examination of RU-486. RU-486 has invoked the image of women's medical empowerment and has been deemed "the moral property of women." Support for RU-486 has come from major international health and feminist organizations, while the opposition of the anti-choice forces has been matched by that of the Feminist International Network of Resistance to Reproductive and Genetic Engineering. Issues critical to the introduction of RU-486 include 1) access and suitability, 2) whether RU-486 increases women's control over reproduction in a safe manner, and 3) the political problems involved when feminist leaders press for testing and attempt to explain varied and even opposing feminist positions in productive ways.^ieng

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PIP: Poverty alleviation has not been achieved through rural development efforts in the Andean region of South America. The social and environmental crisis can be addressed by engaging the rural poor with their considerable skills in resource management in the development effort. Efforts need to be coordinated both within and outside the immediate peasant situation. For example, the origins of the biased spatial organization of resource use, (the best lands are dominated by large farmers and more fragile lands are in the hands of small farmers) need to be addressed in any viable strategy of sustainable development. Obstacles need to be overcome at the field, farm, community, region, and national level in technological, institutional, political, and economic ways. This article focuses on the regional and institutional level and technology as instrumental to change at the local level. The structure of the discussion centered on the main ideas of "sustainable thinking," the application of this thinking within a case study in Chimborazo conducted from 1988 to the present in the Ecuadoran Andes, and a description of how resource use has changed over time within the context of regional economic, social, and demographic change. There is an analysis of how peasants have struggled to sustain their social systems through changes in resource and labor use systems. Future efforts might be better coordinated based on the unsuccessful experiences exposed in the case study. The article further develops the ideas proposed by Gow on sustainable use of the land and the need for political commitment, institutional strengthening, improved local organization, environmental education, and economic development. Peasants constructed their own ideas about desirable livelihoods. This thinking led to the attacks on the hacienda as a way of coping with integration into the national economy. The peasant federations were not changing the basic structures underlying this incorporation. The local level could only do so much toward changing regional and national political strategies. These federations need support, because they are part of a weak and limited process of dealing with underdevelopment.^ieng

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PIP: It is probably not possible to implant a family planning program that will have a reasonable demographic impact in areas lacking awareness of the disadvantages of overly high fertility. Rural-urban migration, increasing educational levels, women's labor force participation, and declining infant mortality are all factors that have been found to correlate with demand for family planning services. It has been recognized since the Bucharest World Population Conference in 1974 that development and family planning are both required for the fertility transition to begin. Where these conditions exist, a family planning program appropriate to the needs, limitations, preferences, and expectations of the target population has an excellent chance of success. Expanded and improved coverage results from tailoring programs to the specific groups served. Most programs are directed toward women. It has been found most effective to provide services for men in separate sessions. It is also useful to distinguish between services for adolescents, who require more information and fewer services, for mature women who require more services than information, and for premenopausal women whose needs for information and services are both declining. Contraceptive preferences vary with social class, but family planning programs in developing countries should concentrate on the lower middle and lower classes which comprise 80% of the population. Rural areas and marginal urban areas require special attention. In order to provide services that will attract all potential users, the maximum possible variety of methods should be available. A family planning program offering a variety of methods throughout the country and financially accessible to the population should be successful. Family planning programs, whether public or private, require adequate financial resources and the support or at least tolerance of the government. Knowledge of contraception is now almost universal. A major challenge of family planning programs is to prompt women who say they want to limit their reproduction but who do not practice family planning to adopt a method. Program leadership and interpersonal relations with clients should be competent. The experience of PROFAMILIA in Colombia suggests that charging fees for all services offered by the family planning program is a positive feature allowing the client to avoid feeling like a charity recipient and the program to account for materials and services more easily. Goals and objective indicators stimulate performance and allow progress to be assessed. It is recommended that client education focus on a synthesis of information concerning available methods and provision of somewhat greater detail on the method chosen. Integration of services is usually an enemy of family planning because, despite theoretical advantages, it usually means neglect of family planning in favor of curative care.^ieng

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PIP: Studies by WHO and the US National Research Council have concluded that early pregnancy is associated with elevated health risks for both the mother and infant. Adolescent pregnancy is a problem that should be confronted before the end of the century in the southern hemisphere, where the large majority of the population is comprised of young people. The International Medical Advisory Group of the IPPF has identified specific functions for programs directed to adolescents. Which should contribute to social development and prepare young people to understand and cope with the physical and emotional changes of adolescence and to make responsible decisions about sexuality and reproduction. A strategy for adolescent pregnancy prevention should include specific objectives. The adolescent should acquire adequate knowledge of human sexuality as part of integrated personality development. A more effective sex education program in the formal educational system could contribute to this goal. Efforts should be made to promote postponement of intercourse until a later age. A study in Atlanta, Georgia, indicated that such programs can succeed. Contraception should be easily accessible in adolescent clinics and elsewhere. Postcoital contraception should be available for occasional use. Venezuelan laws should be reviewed and legal barriers to contraception should be eliminated. At present, Ministry of Health facilities are prohibited from offering family planning (FP) services to minors unless they have previously been pregnant. Actions to meet these objectives include reinforcing the sex education curricula of primary and secondary schools, creating adolescent centers to channel the activities of young people and provide accessible health and FP services, and creating FP centers for young people where information and reliable and low cost contraception would be available. In 1991 PLAFAM, the Association for Family Planning, reached 4662 adolescents and their parents and teachers through its Services for Adolescents program. It contracted 39 institutions, gave 64 talks in educational centers, and held 3 workshops for students. An FP center exclusively for adolescents is planned for Caracas. A survey of fertility and contraceptive usage is badly needed. PLAFAM has initiated planning and the search for funding but as yet little interest has been shown by the Ministry of Health.^ieng

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PIP: A complete analysis of the problem and extent of adolescent pregnancy must be based on data, but relevant statistics are scarce in Venezuela. There are about 5000 births annually to mothers aged 11-15, 65,000 to those aged 16-18, and 100,000 to women under 20 each year in Venezuela. But these figures refer only to pregnancy terminating in birth. An unknown number of pregnancies are never reported and their outcomes are not known. New strategies to combat adolescent pregnancy must take into account such variables as the age at initiation of sexual activity, which is apparently about 16 in Venezuela. The problem of adolescent pregnancy is aggravated by the failure to promote contraception among adolescents. An erroneous association has been established between promiscuity and contraception, and between contraception and family planning. Most adolescents who visit Family Planning Association of Venezuela facilities are sexually active or have children already. No true preventive or educational programs exist. A well designed program for adolescents should provide services including counseling and emotional support for pregnant adolescents, programs to help adolescent males control their sexuality, and programs to inform parents and educators about the potential contributions of sex education.^ieng

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