Molly M. Ginty

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The Health Risks of Racism

Black women are twice as likely as white women to give birth prematurely and five times more likely to do so in Southern states such as Mississippi.

A black woman is 3.7 times more likely to die during pregnancy than a white woman and six times more likely to do so in some urban areas such as New York City.

Researchers at the Atlanta-based Centers for Disease Control and Prevention found college-educated black women twice as likely as other women to deliver premature or underweight babies. Scientists found subjects' birth outcomes resembled those of unemployed, uninsured white women with low education levels.

These are among the findings of five landmark reports released today by the Washington-based Joint Center for Political and Economic Studies that draw together existing data in a comprehensive review that calls for an end to the inequities.

The center concludes that African American babies -- who are twice as likely as white infants to die before their first birthday -- will have a better shot at life if the health inequities plaguing black mothers, such as less prenatal care and adequate nutrition, are corrected.

"The health disparities affecting African American women are nothing less than shocking, and we need to address the social causes behind them," says Alexine Jackson, board president of the Black Women's Agenda.

Stress, Racism, Poverty Implicated

The center's 19-member Courage to Love: Infant Mortality Commission -- funded by the W.K. Kellogg Foundation and partnering with the UCLA School of Public Affairs and the University of Michigan's NIH Roadmap Disparities Center -- says the health problems of black women and black infants stem not just from inadequate medical care but from stress, racism, poverty and other social pressures.

Released during the Congressional Black Caucus Foundation Annual Legislative Conference from Sept. 26 to 29, the reports also coincide with a meeting organized by the Joint Center and the Washington-based Black Women's Agenda for 250 representatives of black women's organizations in Washington, D.C. Attendees will discuss the reports and preview "Unnatural Causes: Is Inequality Making Us Sick?" an upcoming PBS television series that explores race and health.

In the five reports -- one on breastfeeding, one on nutrition, two on infant mortality and one summarizing the others -- commission members address the possible reasons for black women's negative birth outcomes.

Only 75 percent of African American women have prenatal care compared to 89 percent of white women.

Black women are more likely than their peers to have hypertension and diabetes, which can leave the fetus undernourished.

Although the American Academy of Pediatrics, in Elk Grove Village, Ill., says breastfeeding protects against ear infections, diarrhea and other health problems among infants -- and though it recommends exclusive breastfeeding for the first six months of life -- black women are 50 percent less likely to breastfeed than white or Hispanic women.

"Black women's eating habits also play a role," notes commission member Dr. Michael C. Lu, an associate professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA. "Only 1 in 4 African American women meets the recommended daily allowance for calcium, magnesium, zinc and vitamin E and 1 in 3 does not meet the RDA for iron and folate. Among low-income women, approximately 1 in 3 is anemic in the third trimester of pregnancy. And among low-income African American women, only 40 percent enter pregnancy with normal weight, and less than 30 percent achieve ideal weight gain during pregnancy."

Economic, Social Factors

Joint Center authors stress not only health factors, but economic and social conditions.

Black women are more likely to work part time and to go without health benefits. They are 20 percent more likely to be uninsured, and three times more likely to live below the federal poverty line.

Research shows black women are under more stress than their peers, and that stress can compromise the immune system, disrupt the hormonal balance and threaten vascular function.

The reports also implicate racism.

For instance, authors note recent studies at Chicago's Feinberg School of Medicine at Northwestern University find African American women who deliver pre-term, very low weight infants have a twofold greater lifelong exposure to racial discrimination than African American women who deliver full-term, normal weight babies. They cite a 2007 study from Atlanta's Spelman College in which black women agree racism is a source of the stress they cite as their "major" health risk.

"For black women, the effects of racism, sexism and class are multiplicative rather than additive," says Vijaya Hogan, director of the Health Disparities Curriculum at the University of North Carolina at Chapel Hill, who was not involved in the Joint Center reports. "Each increases the individual effect of the other and together they add up to more than the sum of their parts."

Contributions to Overall Crisis

Experts say the same problems causing poor birth outcomes for black women are likely contributing to an overall crisis in their health.

Black women are twice as likely as white women to be overweight, have heart attacks, develop diabetes or fail to get the recommended 30 minutes of exercise daily, reports the CDC.

They account for 72 percent of new AIDS cases even though they represent just 6 percent of the population, reports the Los Angeles-based Black AIDS Institute.

Their life expectancy is 69 years, eight years less than for white women, reports the Census.

Black-white health disparities explain why 40,000 African American women die of treatable causes each year, notes the office of the U.S. Surgeon General.

Authors of the center's reports call for better health care access and education to improve birth outcomes. They also call for sweeping social change such as legislation that will work to end economic and educational disparities.

On Sept. 29, the Chicago-based advocacy group African American Women Evolving is holding its own 100-member symposium on black women's health at Malcolm X College in Chicago.

"We need to pay attention to -- and address -- high infant mortality and other health problems affecting black women," says Gina E. Wood, deputy director of the Joint Center's Health Policy Institute. "This is broader than a medical issue. It's about the total environment -- and the total life -- of African American women."

Silicone Breast Implants Face Hearings in Congress

Cheryl Henley loves her second set of breasts.

After developing breast cancer in 1988, she had a bilateral mastectomy and had her surgeon insert two silicone implants before the devices were banned amid health concerns in 1992.

"Now that silicone is available again, I'll likely get it a second time if I need my implants replaced," says Henley, a 62-year-old health administrator in Albany, Ga. "I know there are risks, but I think they're worth it because this type of implant looks and feels so natural."

Since the Food and Drug Administration approved silicone breast implants in November, the questions Henley is considering also face the 365,000 U.S. women who have breast augmentation and the 46,000 who have reconstruction each year.

"When they talk to their doctors about breast surgery, the first thing women want to know is if it's true that silicone is more realistic," says Dr. Walter Erhardt, a spokesperson for the Arlington Heights, Ill.-based American Society of Plastic Surgeons. "Second, they ask, 'Is it safe?'"

The FDA, based in Rockville, Md., has approved silicone implants for reconstruction in women of all ages and for augmentation in those over 22, basing its decision on large-scale studies (including one from the Washington-based Institute of Medicine) that found the implants safe.

Due to the possibility of leakage, the agency recommends checking for ruptures with magnetic resonance imaging, or MRI, three years following surgery and every two years after that. Due to concerns about silicone's connection to autoimmune diseases and other health problems, it is also requiring implant manufacturers to track safety and efficacy in 80,000 patients for 10 years.

After the FDA gave silicone a green light in November, the two current U.S. makers -- Allergan, based in Irvine, Calif., and the Mentor Corporation, based in Santa Barbara, Calif. -- saw their stock prices soar, and surgeons were barraged with calls about the new option.

Implant Boom Expected

In the wake of the FDA announcement, Wall Street analysts predicted breast implant sales in the United States would skyrocket, hitting $2 billion by 2012.

"Though many patients are now taking a wait-and-see approach, the number of women having implant surgery could grow," says Erhardt.

So, too, could the controversy. Rep. Rosa L. DeLauro, D-Conn., plans to hold congressional hearings on silicone implants later this year. "The FDA's decision is very disturbing given the unproven safety record of these devices," she says, contending the studies used to justify lifting the ban are not convincing.

Some grassroots health groups -- including the Washington-based National Women's Health Network, the Boston-based Our Bodies, Ourselves and the San Francisco-based Breast Cancer Action -- also object.

Health advocates say the FDA is not taking into account silicone implants' high price and possible health problems: joint pain, mental confusion, headaches, rupture (reported in 69 percent of patients in one study) and leakage of silicone outside the breast area (reported in 21 percent of patients in another study).

On top of these concerns come the potential problems of implants in general: scarring, loss of sensation, blurring of breast cancer detection images and difficulty breastfeeding.

Critics point to women like Karen Guerriero, a 39-year-old Houston mother who had breast augmentation at age 21 and learned five years ago that both her silicone implants were leaking, causing dizziness, nausea and blurred vision. "I don't have the money to have them removed," says Guerriero. "I want this poison out of me, and can't sleep at night worrying about it."

Cost a Concern

Cost is another concern. Unless implants are deemed medically necessary, usually only the case with reconstruction after mastectomy, they are not covered by health insurance. Surgery can run $5,000 to $10,000, which covers the $1,800 to $2,000 price of a pair of silicone implants.

"Even if women can afford the initial surgery, they may not be able to pay for potential problems that arise or for the replacement implants that are eventually necessary," says Diana Zuckerman, director of the Washington-based National Research Center for Women and Families.

For women with silicone implants, biannual MRIs recommended by the FDA, which cost about $2,000 each, would not be covered by insurance and would over time likely cost a woman far more than her initial surgery.

Women cite various reasons for wanting breast implants: lopsidedness, droopiness, loss of tissue after cancer, self-consciousness about small size or a simple desire to change their appearance.

Available in the United States since the 1960s, silicone implants -- which are made of a silicone shell filled with silicone gel -- were for decades a popular way to address these concerns. Allowed but not heavily regulated, they were in a statutory limbo called "pre-market approval." They did not undergo rigorous studies until 1991, when the FDA, responding to complaints by women who reported leakage and health problems, demanded further research.

Limited Use After 1992

For lack of proof that silicone devices were safe and effective, the FDA pulled them from the mainstream market in 1992, allowing them only for patients having reconstructive surgery or pre-existing implants replaced, and then only in FDA-approved clinical trials.

Two years later, women claiming they were injured by silicone implants won $3.75 billion in compensation from manufacturers. The largest legal settlement in U.S. history at the time, it helped plunge Dow Corning -- a major implant manufacturer in Midland, Mich. -- into bankruptcy the next year.

After the silicone ban, the only type of breast implant widely available in the United States was the saline implant (made of a silicone shell and filled with saline or salt water). Half the price of its silicone counterpart, it proved in studies to be half as likely to leak.

But many patients didn't think saline made for believable breasts. "Silicone is softer, more pliable and feels more like human breast tissue," says Dr. Brent R.W. Moelleken, a Beverly Hills, Calif., plastic surgeon. "It is also less detectible because it ripples less."

From 1992 to 2006, while surgeons honed techniques that gave saline implants a better result, the FDA continued gathering evidence on silicone devices. They reviewed studies by manufacturers, university researchers and independent scientific bodies.

In 1999, an Institute of Medicine report found silicone implants did not boost the risk of connective tissue disease, cancer or immune disorders. And in 2000, a study published in the New England Journal of Medicine found the implants did not cause systemic disease. Along with other evidence, these studies influenced the FDA's decision to lift the ban.

"The extensive body of scientific evidence provides reasonable assurance of the benefits and risks of these devices," says Dr. Daniel Schultz, director of the FDA's Center for Devices and Radiological Health.

While debate over this assertion heats up, a new generation of silicone breast implants is winding its way through the FDA approval process. Available in Europe and described as having the consistency of "gummy candy" (which makes them less likely to leak), these implants could be available in the United States within the next two years.

How Environmental Pollutants Are Causing Reproductive Problems

This below story includes both parts of a two-part series.

In California, female sea lions are spontaneously aborting their fetuses.

In the Great Lakes area, mother gulls are sharing nests and raising eggs together because their male partners have forgotten how to parent.

In upstate New York, female frogs have as much testosterone in their bodies as males.

Scientists say these aberrations all share a common link: exposure to toxic chemicals called "endocrine disruptors," which pollute the air, soil and water.

"At the rate this pollution is going, we will likely have population decreases in many wildlife species, especially amphibians and fish that are more susceptible to toxins because their skin is constantly exposed to these chemicals in an aquatic environment," says Sarah Janssen, a science fellow at the New York-based Natural Resources Defense Council. "These animals serve as canaries in the coal mine for human females, teaching us how synthetic chemicals might affect our nervous system development, immune function, fertility and other health outcomes."

In the past six decades, U.S. manufacturers have unleashed an estimated 100,000 synthetic compounds into the environment.

When animals come into contact with these pollutants, which have been detected in rainwater and in the rivers and soil of even the most remote areas, they absorb synthetic chemicals into their bloodstreams and their bodies. Researchers are finding that the female halves of many species are displaying biological reactions.

Earthworms Dosed With Prozac

Synthetic compounds have been detected in even the simplest life forms. According to a 2006 study by the U.S. Geological Survey (USGS), earthworms now have an average 31 pollutants in their bodies, including perfumes, household disinfectants and the antidepressant Prozac.

"As you go up the food chain, the numbers or relative amounts of synthetic chemicals can be even higher," says Diana Papoulias, a USGS biologist in Columbia, Mo. "Mammals, in particular females, have more fat in their bodies than other animals and therefore can have more toxins in their fat."

Years after they were created and put into common use, many synthetic chemicals were found to be endocrine disruptors, which means they interfere with the action of hormones that regulate animals' growth, development and fertility. These chemicals are of particular concern to female animals, since their hormones, like those of human females, fluctuate more than those of males.

Common endocrine disruptors include pesticides, phthalates (which make plastic flexible and make cosmetics adhere to the skin) and polychlorinated biphenyls (PCBs, industrial cooling agents banned in the United States in 1979 but still present in the environment.) Individual chemicals such as these -- or groups of them working together -- are making animals' hormones go haywire.

In Washington state, endocrine disruptors have been tied to the deaths of mother orcas, whose orphans have been adopted by other female whales. Some waterfowl and fish are experiencing 'feminization' from chemicals.

In Alaska, they have caused female polar bears' ovaries to shrink.

In Massachusetts, they have lowered the over-winter survival rates of female tree swallows.

In Florida, they have accumulated in the milk of mother dolphins, poisoning and killing their calves.

In addition to harming female animals, endocrine disruptors can cause the "feminization" of males. In Arizona, these chemicals have shrunken the gonads of largemouth bass and common carp. In the Midwest, they have spurred male waterfowl to grow female organs. In Washington, D.C., they have caused male fish to produce eggs.

Small Amounts, Big Impact

Just as alarming as these problems is the low level of exposure at which they are occurring. When Tyrone Hayes, an assistant professor of biology at the University of California, Berkeley, studied the endocrine-disrupting properties of atrazine, a common weed killer, he discovered reproductive abnormalities in affected leopard frogs at 0.1 parts per billion parts water, 30 times less than the Environmental Protection Agency's limit for atrazine in drinking water.

Though proof that endocrine disruptors can harm female wildlife is mounting, scientists say it is difficult to assess the total damage.

"In the wild, subtle outcomes such as length of gestation, litter size and the age of onset of puberty are difficult to ascertain," says Janssen. "You would have to know exactly when these females became pregnant and gave birth. You would have to anesthetize them to take blood samples. You would have to carefully observe and measure life events that are difficult to track in the field. Measuring these effects would ideally involve more controlled studies."

In laboratory settings, studies have repeatedly shown the adverse effects of some of the most prevalent endocrine disruptors.

Consider phthalates, those chemicals that help prevent makeup from smudging. In 2003, an Environmental Protection Agency study found these substances could reduce fertility in rodents, causing female rats to bear 50 to 90 percent fewer offspring.

Take bisphenol-A, a compound used to make everything from computer keyboards to dental sealants to food-can lining. A 2005 study by the National Institute of Environmental Health Sciences in Research Triangle Park, N.C., found that exposure to this chemical can spur obesity in female rats. In August 2006, researchers at Tufts University in Boston found it can also cause breast cancer in female rodents.

There's also dioxin, a byproduct of paper manufacture and waste incineration. In 1998, researchers at the Washington-based Environmental Protection Agency found this chemical could trigger spontaneous abortions in rhesus monkeys. In 2003, a University of Ottawa study found it could also cause female primates to develop endometriosis, a disease that causes endometrial tissue normally found in the uterus to grow outside the womb.

More Questions Than Answers

As lab studies on endocrine disruptors continue, questions about what's happening in the wild persist. Why are mother sea ducks in Alaska producing fewer offspring? What's causing female dolphins in the Southeast to develop tumors in their reproductive tracts? Why are loon hatchlings in Wisconsin emerging deformed from their eggs?

Since only 10 percent of the synthetic chemicals in our environment have been tested on animals, scientists have yet to offer answers to these questions.

While research continues, some environmental advocates recommend that women avoid consuming fish and meat from the wild (such as carp caught in rivers or deer or pheasant shot by hunters) to avoid ingesting endocrine disruptors found in these animals' bodies.

Others recommend political action: calling for reduced emissions of synthetic chemicals, and calling on the Environmental Protection Agency to beef up its study of endocrine disruptors, a step Congress mandated in 1996 but one that the EPA has yet to take because it says setting up the research is proving more difficult than expected.

Because these chemicals also surround people, concern is building about their effect on humans.

"Animals don't use computers, apply makeup or use chemical solvents in their homes every day," says Theo Colborn, former director of the Wildlife and Contaminants Program at the Washington-based World Wildlife Fund. "In the end, female humans may be at even greater risk than female animals."

PART TWO
The Hereditary Consequences of Environmental Pollutants

It starts in the first weeks of life.

As the umbilical cord sends nutrients to the fetus, pumping 300 quarts of blood per day, it also delivers what nature never intended: synthetic chemicals that may wreak havoc with development and cause health problems later in life.

The Atlanta-based Centers for Disease Control and Prevention, which tests the "body burden" of chemicals every two years, finds the average American now has 116 synthetic compounds in her body, including dioxin (produced by burning plastic), polycyclic aromatic hydrocarbons (found in auto exhaust) and organochlorine pesticides (found in farming areas).

Recent studies have detected these pesticides, plastics and polymers not only in umbilical cord blood, but in the placenta, in human milk and in the bloodstreams and body fat of infants.

Though some of these chemicals pass through body systems in a matter of days, they maintain a long-term presence because exposure is constant.

Scientists say women are especially sensitive to synthetic chemicals because these substances can interfere with female hormone cycles and because they adhere to body fat that is more prevalent in women than in men.

In 2007, California will launch the nation's first statewide, voluntary biomonitoring program to measure chemical contaminants in people and find out which pollutants are most common in the state's residents.

The National Institute of Child Health and Human Development next year will also begin a $2.5 billion study to track children's exposures from birth to age 21, examining which chemicals are building up in the bodies of U.S. children and how they relate to individuals' susceptibility to different diseases.

Precautions Recommended

While waiting for the results of these and other studies, health advocates are encouraging consumers to shun pesticides, remove outdoor shoes in the house, choose fragrance- and toxin-free products, use baby bottles that are free of a carcinogenic chemical called bisphenol-A and press authorities for stricter laws and more studies.

"Manufacturers are producing new chemicals all the time with little government oversight," says Julia Brody, director of the Silent Spring Institute, based in Newton, Mass. "We need tighter restrictions, like those in Europe, if we hope to protect the next generation."

One toxin threatening mothers and children is mercury, which can spur breast cancer, autism and attention deficit disorder. In 2002, a study found that 1 in 6 U.S. women of reproductive age has enough of this contaminant in her blood to endanger a developing fetus.

Researchers say infants and children are also at high risk, because at the time of early and rapid growth, susceptibility to pollutants can be greatest.

How these pollutants wound up in babies' bodies -- and what impact they may have on the next generation -- are the subjects of inquiry by a growing number of concerned scientists.

According to federal records, U.S. companies produce an estimated 75,000 chemicals; of those, 3,000 are produced in amounts of more than a million pounds per year.

All told, more than 100,000 chemicals -- some of them toxins that were banned decades ago -- persist in the soil, air and water. Whenever people come into contact with these substances, they can pass through the skin, nostrils or mucus membranes and into bloodstreams and body fat.

Some compounds can linger for decades after a single exposure. Take DDT, a pesticide that can damage the nervous system. In May 2006, the Seattle-based Toxic-Free Legacy Coalition tested Washington residents and found 80 percent had detectible levels of the chemical in their bloodstreams 34 years after it was banned in the United States.

'Increased Susceptibility' to Illness

"Our increased susceptibility to a variety of illnesses may be related not just to our exposure to these chemicals, but to exposures our mothers and grandmothers experienced during pregnancy," says Theo Colborn, president of the Endocrine Disruption Exchange, an environmental advocacy group based in Paonia, Colo.

The Washington-based Environmental Working Group in May tested mother-and-daughter pairs and found that each daughter had more chemicals in common with her mother than with other women. Because the mothers had decades more exposure, they had levels of lead, mercury and flame retardants in their bodies up to 5.2 times higher than their daughters.

To date, most studies on mother-to-child transmission -- and on these chemicals' long-term effects -- have been done on laboratory animals.

"It's unethical to experiment with these chemicals on people," says Shanna Swan, director of the Center for Reproductive Epidemiology at New York's University of Rochester. "And that's just one reason we don't have clear answers. There are hundreds of chemicals involved here, and studying just one of them costs upwards of $1 million."

Representatives of the petro-chemical industry say that until studies prove otherwise, there is little reason to worry about these compounds' negative effects.

"Finding a chemical in the body doesn't tell you anything about the source of the exposure, what caused the exposure or what risk it might pose at that level," says Sarah Brozena, a senior director at the American Chemistry Council, an industry trade association in Arlington, Va.

Some scientists are more cautious.

"There is extensive evidence of harm in animals and growing evidence of harm in humans," says Frederick vom Saal, a professor of biology at the University of Missouri-Columbia.

Four-Generation Legacy

He points to an October 2006 study from Washington State University that showed damage caused by some pollutants could last for four generations.

Though scattered, studies on humans who were accidentally exposed to high levels of synthetic chemicals give a glimpse of their possible effects.

In 2000, a University of Michigan study found breast-fed girls exposed in utero to polybrominated biphenyls (PBBs, a type of flame retardant) started menstruating at an earlier-than-average age.

In 2002, a Taiwanese study examined men born to mothers who were exposed to polychlorinated biphenyls (PCBs, coolants banned in the U.S. in 1979). Researchers discovered the men's sperm were misshapen and could not swim as quickly or strongly as those of other men.

In 2005, Swan lead a University of Rochester study that examined phthalates, chemicals that soften plastic and help cosmetics adhere without smudging. She discovered that exposure to these compounds in utero resulted in the "feminization" of baby boys, who had smaller penises, shorter distances between the anus and genitals, and a higher risk for undescended testicles.

Health advocates suspect synthetic chemicals such as these may be linked to a whole flurry of health problems that have grown more common since industrialization surged in the past century.

They say pollutants may be partly responsible for the rising incidence of breast cancer, up 90 percent in 50 years and triggered in lab studies by organochlorine pesticides, mercury, PAH (found in auto emissions) and polyvinyl chloride (PVC, found in plastics).

Other health problems that researchers say may be linked to environmental toxins include male infertility, which has increased twelvefold in the past 80 years; prostate cancer, up 75 percent in 30 years; diabetes, which has doubled in the past 25 years; and obesity, which has doubled in the past 15 years.

Through the Back Door

Her rapist could have impregnated her. But a new state protocol saved her from that fate.

In 1998, when Washington state started allowing pharmacists to dispense emergency contraception without a doctor's prescription, one of the first women to ask for this medication was a Tacoma-area teen who had been raped by her boyfriend.

"She was 15 years old and scared spitless," says Don Downing, a clinical associate professor of pharmacy at the University of Washington in Seattle. "She was too afraid to tell her parents about the rape and too afraid to go to the police or her regular doctor. But when her pharmacist gave her this medication, it prevented her from getting pregnant. And if more states pass these laws, thousands of other women will benefit in the same way."

In September, Massachusetts became the eighth state to legalize "collaborative practice agreements" for Preven and Plan B, hormonal drugs known as "emergency contraception" because they are 89 percent effective at preventing pregnancy if taken within 72 hours of unprotected sex.

Alaska, California, Hawaii, Maine, New Mexico, New Hampshire and Washington already have these agreements on their books.

In a collaborative practice agreement, a doctor agrees to oversee or sanction a pharmacist who dispenses emergency contraception without a prescription.

The doctor is off-site and anonymous. His or her name does not appear on any receipt or other sales record, so the woman buying emergency contraception may never know that a doctor is part of the process. To her, it's like buying any other medication that does not require a prescription.

A single doctor can work with several pharmacists under this type of agreement, which usually requires several days of training for the pharmacist so he or she can properly instruct the buyer.

"Since the Food and Drug Administration has spent two years stalling the approval of over-the-counter emergency contraception, collaborative agreements are vital," says Karen Pearl, interim president of the Washington-based Planned Parenthood Federation of America, Inc. "These laws allow women to get medication they need without scurrying to find a doctor, get a prescription and find a pharmacist to fill the prescription."

Renewed Pressure on FDA

This week, after a 60-day public comment period expired on a drug maker's most recent application for over-the-counter sale, four dozen medical and public health groups renewed pressure on the FDA. The groups urged the FDA to "heed the scientific consensus" about the safety of emergency contraception.

Signatories, which included the Washington-based American College of Obstetricians and Gynecologists, said that requiring a prescription creates a medically unjustified barrier to women who need these drugs.

Yesterday, a bipartisan group of congressional legislators turned up the heat by announcing new legislation to require the FDA to make a decision on emergency contraception. Within 30 days of this legislation's enactment, the FDA would have to approve or disapprove over-the-counter sale or publish a determination to do so.

Emergency contraception caused a 43 percent drop in abortion rates from 1994 to 2000 and could prevent 800,000 abortions annually if it were more widely available, according to the Washington-based Alan Guttmacher Institute.

In the past decade, collaborative practice agreements have become popular in the treatment of diabetes, a disease that causes blood sugar levels to spike and that a growing number of patients are now managing with direct help from their pharmacists.

In the case of emergency contraception, collaborative practice agreements can spare users from potentially harmful delays.

"Emergency contraception works best within the first 24 hours of unprotected sex," says Dr. Carole Ben-Maimon of Barr Pharmaceuticals, Inc., the Woodcliff Lake, N.J.-based maker of Plan B. "Its efficacy decreases by 50 percent with every 12 hours of delay. So it's helpful if women can bypass their doctors and get it directly from their pharmacists."

In six states, collaborative practice agreements allow pharmacists to distribute emergency contraception when acting under the guidance of a physician. In two other states, pharmacists can distribute the drugs in accordance with separate state-approved protocols.

"We are working with advocacy groups and lobbying state legislatures in the hope of passing more laws," says Ben-Maimon.

Barriers Abound

In August, the FDA said it was considering the over-the-counter sale of Plan B to women over 17. Then, in what critics say is a response to pressure from the Bush administration, the agency said it would launch a period of "public comment" on the drug that could delay its approval indefinitely.

The announcement infuriated activists such as Cynthia Pearson, executive director of the Washington-based National Women's Health Network, who called it "denial couched in the bureaucratic language of delay."

Before making the announcement, FDA officials alleged that girls under 16 would engage in riskier sex if they could obtain get the drug. Studies, however, show no increase in pregnancy or sexually transmitted diseases when women have access to emergency contraception.

A similar struggle surrounds a newly-developed vaccine for cervical cancer. Pharmaceutical company Merck, based in Whitehouse Station, N.J., plans to ask the FDA to approve the vaccine for sale before the end of the year, according to the Washington Post.

But some conservative groups argue its release will condone premarital sex. In a retort to them, Congresswoman Lois Capps, D-Calif., circulated a letter to her colleagues this week urging them to overlook "ideological agendas" while reviewing public input about the vaccine.

The battle for access to Plan B goes beyond state laws and the FDA and extends to policymaking by pharmacies and hospitals.

Wal-Mart, the largest retailer in the U.S., does not carry emergency contraception in any state, even those with collaborative practice agreements. Chains including Rite-Aid and Winn-Dixie allow their pharmacists to refuse to fill prescriptions for emergency contraception.

Arkansas, Georgia, Mississippi and South Dakota recently enacted "conscience clause" laws that allow pharmacists to refuse to dispense emergency contraception to women who have prescriptions.

In the past year, 14 other states have considered similar legislation.

Hospital Practices Can Vary

Hospitals can also raise barriers to emergency contraception.

Eight states--California, Illinois, Massachusetts, New Mexico, New York, New Jersey, South Carolina and Washington--require hospital emergency rooms to offer emergency contraception to women who have been sexually assaulted.

But due to a recent spate of Catholic hospital mergers, a growing number of private hospitals are now following Catholic doctrine and refusing to dispense this medication to rape survivors as well as other patients.

For women in the 42 states without collaborative practice agreements, such obstacles can mean emergency contraception isn't available when contraception fails or when they are sexually assaulted.

As a result measure, the American Medical Women's Association, based in Alexandria, Va., and the American College of Obstetricians and Gynecologists are encouraging women to get advanced prescriptions for Plan B or Preven.

Health advocates also encourage women to lobby their state representatives to pass collaborative practice agreements. Sixty-six percent of U.S. women support pharmacy access to emergency contraception, according to the Pharmacy Access Partnership in Oakland, Calif.

But the main target of activists remains the FDA.

"Collaborative practice agreements are an important step," says Kirsten Moore, president of the Washington-based Reproductive Health Technologies Project. "But ultimately, this drug should be available over the counter and nationwide."

Women on the Front Lines

It struck Lori Piestewa of Tuba City, Ariz. when her Humvee crashed and she was captured in Nasiriyah, Iraq.

It hit Pamela Osbourne of Fort Hood, Texas, when a bomb targeted her camp in southern Baghdad.

It struck Kimberly Voelz of Carlisle, Pa., when she was defusing explosives in the town of al-Iskandariyah.

Death has claimed a record number of female soldiers serving in the U.S. military in the current conflicts in Afghanistan and Iraq.

Despite rules that have prohibited women from fighting on the front lines, female soldiers in these conflicts are facing virtually the same risks as men because of the nature of these missions and because of overall troop shortages in Iraq, some military analysts say. In light of this – and in response to charges that the military has failed to adequately protect its female soldiers – the House Armed Services Committee is preparing a report on the feasibility of assigning women to combat-related positions.

The forthcoming report – due this spring – has stirred debate on how female soldiers should serve alongside men and whether the military can and should uphold rules meant to minimize women's risks.

"These rules no longer make sense because no place is safe in Iraq," said former Congressional Rep. Pat Schroeder, D-Colo., who served on the House Armed Services Committee from 1973 to 1996. "The whole place is literally a front line."

Record Number of Injuries, Fatalities

According to U.S. military records, 33 female soldiers – three in Afghanistan and 30 in Iraq – have been killed since operations started in Afghanistan in 2001 and Iraq in 2003.

In addition, 240 women have sustained combat-related wounds in Iraq and Afghanistan. Left with permanent injuries that have sometimes required amputation, most of these women – like those killed – were struck by bombs that hit transport units or camps with no warning.

"We don't track the number of women soldiers wounded by U.S. forces in friendly fire," said Army spokesperson Lt. Col. Bryan Hilferty. "But these accidents don't happen often."

The death and injury toll for female soldiers in the current conflicts shatters previous records for women serving in positions that are also shared by men. In the Gulf War – the first major conflict where women soldiers served alongside male soldiers – 216,000 women were enlisted and 16 were killed. In Iraq and Afghanistan, only 17,000 female soldiers are enlisted. But their deaths account for 33 of the 1,000 estimated fatalities among servicewomen in U.S. history. To date, nearly all of these fatalities have been among female nurses and support staff.

"Having this many female casualties in uniform is certainly new," said Michael O'Hanlon, a military analyst for The Brookings Institution in Washington. "It has made this policy debate more visible and more visceral."

Women More Active in Military

Historians estimate that only 20,000 American women have fought in battle since Margaret Corbin hoisted her petticoats and took charge of a canon after her husband fell in the Revolutionary War.

Since the creation of the Army Nurse Corps in 1901, women have been employed directly by the military. But until recent decades, most have served as nurses and support staff. That started to change in the Korean War during the early 1950s, when the military began accepting women for active duty.

In 1992 the Air Force began allowing female pilots to fly in some combat missions. In 1993 the Navy started allowing women to serve on combat ships. In 1994 the Army dropped a rule prohibiting women from filling positions with a "substantial risk of capture." These changes opened up 90 percent of military jobs to women for the first time.

"From this point onward, women were not only trained to use arms, but could also fire them on the job," said retired Air Force Capt. Barbara Wilson, founder of Military Women Veterans in St. Augustine, Fla.

Today, female soldiers take infantry training alongside their male companions, learning how to fire assault weapons and move under direct and indirect fire. Accounting for 15 percent of all service people and 10 percent of soldiers in Iraq and Afghanistan, women work as engineers, truck drivers, pilots and weapons experts.

Two prohibitions hold female troops back from full parity. They are barred from positions that involve direct combat (such as serving on submarines, in the Special Forces and in infantry, armor and artillery positions). They are also barred from "collocated units" that support combat troops. A woman can serve as a medic, for instance, but not as a medic in a unit that "collocates" or supports a unit on the front line.

Allegations Against Army

The Army is covertly violating its collocation rule and assigning women to units that support front-line troops, says Elaine Donnelley, president of the Center for Military Readiness, a public policy organization in Livonia, Mich. Donnelley contends this is because commanders are failing to follow established regulations and because an overall male troop shortage means there is a lack of adequate male troops in Iraq.

Last year, in response to a petition Donnelly sent to President Bush and the Pentagon, Army Secretary Francis Harvey ordered a systematic review of Army regulations and asserted that current policies keeping women out of combat and collocated units will stand.

But last month, under continued pressure from Donnelley and other critics, the chair of the House Armed Services Committee ordered an investigation into whether collocated units in Iraq violate Pentagon regulations against same-sex service.

"This is a serious question and we hope to have an answer soon," said Committee Chair Rep. Duncan Hunter, R-Calif.

While waiting for the release of this report, expected this spring, the Army maintains that is upholding established policy. "We're not violating the collocation rule," Hilferty told Women's eNews. "We are conforming with 1994 regulations, and any changes to that policy will be coordinated with Congress as required by law."

Are Women Fit for Combat?

According to a 2001 Gallup poll, the U.S. public is split on whether women should fight on the battlefield, with a slim majority supporting the assignment of women to ground combat.

As the debate on women in combat continues, the Bush administration has not set a firm date for withdrawing from Iraq. Retired Lt. Gen. Claudia J. Kennedy, the highest-ranking woman to ever serve in the Army, predicts that as the conflict continues, more female soldiers will be called up for active duty. She notes that military recruiting is down by 27 percent, and estimates that 30,000 to 50,000 more soldiers may be needed in Iraq.

"Regardless of whether the military changes its policy on women in combat, we need to honor the women who are serving in this conflict," says Kennedy. "Willing to step outside traditional roles and answer their country's call, they are vital to this mission and should not be segregated. Women soldiers deserve to be treated just as all soldiers should be treated – properly trained, properly equipped and given the proper respect."

A Day Without Roe

Abortion could go underground.

Now that President George W. Bush has been elected to a second term, he may appoint new Supreme Court justices who fundamentally disagree with the premises of Roe v. Wade, the 1973 Supreme Court decision that provides U.S. women the right to legal abortion.

In response to this threat, the Washington, D.C.-based Planned Parenthood Federation of America is stepping up the work of its Post-Roe Service Delivery Task Force – a group dedicated to exploring the legal and practical aspects of providing abortion despite a federal ban.

"Bush's election has prompted us to forge ahead with greater urgency," says Linda Williams, co-chair of the task force. "Reproductive freedom – a fundamental freedom that many of us have taken for granted – is now seriously at risk."

For the past four years, Williams and her group's 13 other members have explored the post-Roe challenge on many fronts.

Among other options, they've looked at maintaining services by strengthening state laws and the possibility of providing abortions in places where federal laws don't apply.

To prepare for what would likely be a health epidemic, they've urged physicians to get special training so they know how to treat infections, uncontrolled bleeding and other life-threatening complications caused by botched abortions.

Bush Record on Reproductive Rights

During his first term, Bush slashed family planning programs and promoted "abstinence-only" sex education. He signed legislation that criminalizes some abortion procedures that are common after 12 weeks or injure a fetus. He has appointed more than 200 anti-choice federal judges. His appointed attorney general and secretary of the Health and Human Services department oppose keeping abortion legal.

"Immediately after Bush took office four years ago, we realized he would try to revoke Roe vs. Wade," says Williams. "Since three Supreme Court justices are nearing retirement and since Bush is likely to appoint anti-choice justices, we knew we had to be prepared."

Abortion services have already been curtailed, with only 13 percent of U.S. counties offering an abortion provider, according to Medical Students for Choice, based in Oakland, Calif. State legislatures have enacted more than 380 measures to restrict abortion since 1994, according to the New York-based Center for Reproductive Rights.

Now before Congress: The "Unborn Child Pain Awareness Act," that requires doctors to inform women before they have abortions at 20 weeks or later that the fetus may feel pain.

"We are absolutely delighted to have four more years with pro-life President Bush," says Carol Tobias, political director of the Washington, D.C.-based National Right to Life Committee.

Pro-Choice Advocates Explore Legal Loopholes

Twenty states are likely to protect abortion rights in the face of a federal ban, with 10 states guaranteeing access to abortion in their state constitutions, according to a recent report from the Center for Reproductive Rights.

To maintain reproductive choice in the 20 "safe" states and to bolster it in the remaining ones, Planned Parenthood says reproductive-rights activism is needed on the local level.

"Women should lobby state legislators to eradicate laws that date from the 1800s and early 1900s and that call abortion murder," says Chris Charbonneau, second co-chair of the task force. "They should push state legislators to adopt modern-day laws like those in Washington, Maryland, and California, the three states that have air-tight laws because these laws echo the wording of Roe vs. Wade."

Even if all 50 states outlaw abortion, task force members are looking at other ways to legally offer safe abortions.

They consider the possibility of operating abortion clinics on Native American reservations, which have laws independent of federal ones. They consider launching programs like Women on Waves, a Netherlands-based nonprofit that offers abortion in countries where it is illegal by performing procedures on a ship offshore. They consider lining the border of Canada – where abortion is legal and likely to remain so – with clinics that cater to U.S. women.

Botched Abortions Biggest Concern

If Roe v. Wade is revoked, task force members say their biggest concern will be treating women harmed by botched abortions. "Just as they did before Roe v. Wade, women with unwanted pregnancies will take desperate measures," says Wilson. "They will have back-alley abortions. They will insert sharp objects like coat hangers into their uteruses. And they will douche with toxic chemicals like lye or Clorox."

To prevent such a potential health crisis, task force members are urging doctors to get special training so they know how to treat the complications of botched abortions, which include infection, cervical tearing, uterine perforation and blood in the uterus.

Task force members admit, however, that their strategies offer no real substitute for Roe vs. Wade. They expect that abortion providers – fearing prosecution and violence at the hands of anti-choice extremists – would likely stop providing procedures. They expect that a sizable number of the 3 million women with unplanned pregnancies each year will take matters into their own hands.

Abortion rates were higher in the United States before the procedure was legal, Gloria Feldt, president of the Planned Parenthood Federation of America, has said.

More than 200 U.S. women died each year from the complications of illegal abortions in the decade before Roe v. Wade, Stanley Henshaw, a senior fellow at The Alan Guttmacher Institute in New York, has said.

Task force members say that if Roe v. Wade is overturned, poor and low-income women – who seek 57 percent of the 1 million abortions performed in the United States each year – will be the ones hardest hit. "Women with enough money will be able to find a way to terminate their pregnancies," says Williams. "They will go abroad or find qualified doctors to treat them behind closed doors. But poor women will be exploited. And they will die."

Stem Cells May Swing Voters

They're the stuff of medical miracles, offering the promise of cures for multiple sclerosis, spinal cord injuries, heart disease, lymphoma, diabetes, and even cancer.

Animal studies indicate embryonic stem cells may be able to cure diseases ranging from Alzheimer's to Parkinson's. Health advocates say that whether these cures come in 10 or 20 years depends on the speed of research – and on who wins the November election.

Embryonic stem cells are primordial cells with the ability to morph into any type of cell in the body. They can fight disease by replacing dying cells with healthy ones. And now they've become weapons in another battle: the fight to win November's Presidential election.

At the Democratic National Convention in July, vice presidential candidate John Edwards pledged that, if elected, presidential contender John Kerry would reverse President George W. Bush's August 2001 ban on federal funding for new embryonic stem cells. Since that date, researchers have not been permitted to fertilize human eggs with human sperm and use the resulting "stem cells" in government-supported studies. Edwards also promised to spend at least $100 million per year on stem cell research, which is three times what the Bush administration devoted to the cause in 2003.

At the Republican National Convention in August, GOP leaders were on the counter-attack. Republican Senate Majority leader Bill Frist stood before the nation and said, "The federal government is funding stem cell research at record levels. And the private sector remains free to fund and pursue any type of stem cell research. But this president will not use your taxpayer dollars to destroy human life or create human embryos solely for the purpose of experimentation."

Any Type of Cell

Embryonic stem cells form when a sperm and egg meet and the resulting cell begins to divide into a ball of cells called a blastocyst. Cells at this early stage of development are "undifferentiated" in that DNA has yet to give them specific marching orders. When transplanted to any part of the body, they can become any type of cell: muscle, skin, organ, tissue, bone or brain.

In addition to embryonic stem cells, there are two other types of stem cells: undifferentiated cells harvested from the tissues of adults and undifferentiated cells harvested from the tissues of fetuses. Though adult stem cells are used in bone marrow transplants and though fetal stem cells may be able to repair stroke damage to the brain, both types have their limitations.

They don't grow in lab dishes as readily as embryonic stem cells. They are more likely to be rejected when they are introduced into the body. And they don't migrate as readily to an injured area and form appropriate cell types.

Though adult stem cells and fetal stem cells have no restrictions on their funding, embryonic stem cells – in which scientists place the greatest hope – are subject to the Bush ban. Hoping to reverse this ban and garner more funding, health care advocates and lobbyists are putting pressure on both presidential candidates.

Supported By Most Voters

A July poll conducted by NBC news indicated that 71 percent of Americans support more embryonic stem cell research. Most Americans know someone who suffers from a disease that might be cured by these studies and many Americans will develop one of these diseases at some point in their own lives.

In another survey conducted in August by the Pew Research Center for the People and the Press, 52 percent of Americans believe it is more important to study stem cells than to avoid destroying potential human life. The Pew poll found that most swing voters hold this view.

"This election is so close that stem cell research could become an important wedge issue," says Carroll Doherty, the associate director of the Pew Center. "Though Kerry isn't going to lose his supporters because of his position, Bush is more at risk. His views could alienate the 22 percent of Americans who are swing voters in this election."

Women – who represent the majority of swing voters – are more likely to support Kerry's position. An August survey by the Annenberg Public Policy Center at the University of Pennsylvania in Philadelphia, found that 60 percent of women support more federal funding for stem cell research, while 31 percent of women oppose it. (The comparative numbers for men are 67 and 25 percent.)

Already, Bush's hard-line stance has estranged some within his own party. In July, 14 Republicans were among the 58 U.S. Senators who sent the president a letter urging him to lift the ban. And when former President Ronald Reagan died in May, it was after a 10-year battle with Alzheimer's disease. Reagan's widow Nancy, a leading figure in the Republican party, has publicly criticized Bush for failing to support stem cell research that might have prolonged her husband's active life. At the Democratic National Convention in July, her son Ron made a speech calling for more stem cell funding.

Research Inches Forward

While holding out hope for more federal funding, scientists are working to make the most of the 19 viable embryonic stem cells lines that they can study under the Bush ban. Each line was created in a lab using donated sperm and eggs at some point before August 2001.

"Getting access to these lines is difficult," says Dr. Ronald G. Crystal, chair of the Department of Genetic Medicine at Weill Cornell Medical College. "There are paperwork hurdles. There are cost hurdles. These cells are very finicky and can die easily without experienced handling. Having a limited number of lines also means you don't know if the results of your research hold true for all embryonic stem cells or just for that particular line."

Dr. Susan Fisher, co-director of the human stem cell biology program at the University of California at San Francisco, says that scientists in her lab have lost at least two years' of progress because of the ban.

"We're just dead in the water here," says Fisher. "But when we can start working with the usual amount and sources of funding, American scientists will hopefully be able to catch up."

Meanwhile, research marches forward in Britain, which last month started allowing scientists to create new human blastocysts and harvest them for stem cells. The British government recently spent $4.7 million to create a national stem cell bank. Spain and Japan are also creating stem cell banks of their own.

Since the U.S. federal government won't fully fund stem cell research, some individual states have decided to take action. This November, California residents will vote on a measure to devote $3 billion in state financing to stem cell research each year – 12 times more than what is now being spent by the federal government.

As they jockey to win swing voters in a closely contested race, Kerry and Bush must hail stem cells' promise while defusing the ethics involved.

"Embryonic stem cells have enormous disease-curing potential," says Dr. Crystal. "But this potential will only be realized when politicians and the public find a way to comfortably support this research."

Prevention and Cure

This spring, researchers will launch the final round of clinical trials for Herpevac, a vaccine that has proved to be 74 percent effective at preventing symptoms of herpes in young women. Herpes is the most common sexually transmitted disease.

Over the next six months, scientists from the Bethesda-based National Institute of Allergy and Infectious Diseases, the Philadelphia-based GlaxoSmithKline Biologicals, and 20 other medical facilities nationwide plan to test Herpevac on 7,550 healthy female volunteers ages 18 to 30. If all goes well with these clinical trials, the vaccine could win approval from the Food and Drug Administration and be on the market within five years.

Already health advocates such as Yesenia Polanco, a junior at the University of North Carolina and a peer educator for Mujeres, also known as the organization Women United Together Understanding Responsibility Education and Health, are talking up news of the vaccine among their clients.

"I’m very excited about Herpevac," says Yesenia Polanco. "But a vaccine alone is not enough to solve this problem. We still need more conversation among young people, parents and community members. We still need more dialogue if we’re going to stop this national health epidemic."

Researchers, meanwhile, are expressing optimism. "We hope this vaccine will prevent many herpes cases in women and thereby prevent many cases in men," says Dr. Robert B. Belshe, a professor at the Saint Louis University School of Medicine and chair of the Herpevac study. "We also hope it will reduce the number of babies born with neonatal herpes, a potentially fatal disease."

National Health Threat

Herpes infects an estimated 60 million Americans. Though it can be effectively treated with prescription medications such as valacyclovir (Valtrex) and famciclovir (Famvir), it has no known cure. The disease is transmitted when an uninfected person touches skin or mucus membranes where the virus is active. After infection, symptoms vary widely from person to person, ranging from a tear in the skin to a rash of burning, red blisters. Lesions appear when the virus is active or "shedding," and can disappear for weeks or even years between outbreaks.

Since many herpes cases have no visible symptoms, an estimated 90 percent of carriers don't even realize they are infected. Because carriers are unwittingly infecting their sexual partners, herpes has become a national health epidemic.

The U.S. Centers for Disease Control and Prevention reports that, since the 1970s, the number of clinically diagnosed herpes cases has increased 11-fold. Each year, the disease racks up 1.6 million new cases and an estimated $1 billion in health care costs.

Though widespread, herpes is not an equal-opportunity disease. Herpes afflicts 30 percent more women than men, striking an estimated 1 in 4 women. If an infected mother transmits the virus to her baby when the child passes through the birth canal, the baby can suffer severe brain damage. Without aggressive treatment from anti-viral drugs, half the babies who contract neonatal herpes will die of the disease.

According to the latest research, herpes is of particular threat to women under 25 -- the population most likely to engage in unprotected sex. The American Journal of Epidemiology reported in 2001 that 40 percent of infections occur among people between the ages of 15 and 24. A report released last month by the Centers for Disease Control and Prevention, based in Atlanta, and the American Social Health Association, based in Research Triangle Park, N.C., found that 640,000 Americans ages 15 to 24 acquire herpes each year.

"One in two Americans will contract an STD by the time they're 25," says Joan Cates, a principal investigator for the study. "The human and financial costs of herpes and other STDs should serve as wake-up call for our nation." STD is the acronym used for Sexually Transmitted Disease.

Promising but Problematic Vaccine

Researchers have tried to develop other herpes vaccines, but Herpevac is the first to show real promise. It prevents the spread of herpes simplex virus type 2 (HSV-2), the strain of the herpes virus that usually affects the genitals. But the vaccine does have serious limitations. When it was tested in men, it failed to reduce their symptoms and rates of infection.

The vaccine only works in women -- and only in those women who have never been infected with herpes simplex virus type 1 (HSV-1), the strain of the virus that typically causes cold sores on the mouth. "By age 12, most kids will already be exposed to HSV-1," says Charles Ebel, co-author of the 1999 book Herpes Controlled: New Drugs, New Strategies, New Solutions. "For this reason, adolescent administration may be the only effective delivery route."

In tests so far, Herpevac has prevented outbreaks in 74 percent of infected women. But it has only prevented herpes infection in 48 percent of uninfected women. This means the vaccine is far more effective at preventing a vaccinated person from developing symptoms than it is at preventing them from contracting herpes.

Despite these limits, Geoff Garnett, a health researcher at the Imperial College of London, predicts, based on his mathematical models, that the vaccine could achieve a 40 percent reduction in herpes prevalence in both sexes after 25 years.

Though Herpevac shows promise, health advocates worry about the practical implications of administering the vaccine to adolescent teens. Belshe says Herpevac will most likely be delivered by private doctors.

But how do you convince parents to vaccinate their 10- to 12-year-old daughters against a sexually transmitted disease? How do you get pediatricians -- who usually don't deal with reproductive health -- to broach the topic with their patients? How do you convince insurance companies to cover an STD vaccine for patients who aren't even sexually active yet? Some health advocates have suggested a novel solution: vaccinations at public schools.

"Across the U.S., high schools have recently started offering vaccinations for hepatitis B, another sexually transmitted disease," says Tamara Kreinin, president of the New York City-based Sexuality Information and Education Council of the U.S. "But the shame and stigma that surround herpes could make this scenario problematic. Girls lining up to get their shots could be fearful about being seen. Or they may never line up, mistakenly thinking, 'This disease is for sluts who run around a lot -- not for someone like me.'"

Regardless of who administers Herpevac, health advocates agree that delivering the vaccine will require cooperation from everyone involved with female adolescents: parents, youth-service providers, teachers, clergy and policy makers. It will also require clear communication about Herpevac's limitations.

"Teens need to know that this vaccine isn't 100 percent effective at preventing infection," says JoAnn Purkey, an STD educator who runs a herpes support group in Rochester, Mich. "Will this disease make kids feel like they have free rein? Will they think, 'Now I can go out and have sex without a condom?' We need to continue educating them so they know how to protect themselves."

Molly M. Ginty is a freelance writer based in New York City.

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