Prevention programmes f i for haemoglobinopathies appropriate appropriate ...
Asia
South & Southeast AsiaSouth & Southeast Asia
Asia• Widely varying economies• Religions/ social customs• Education standards Education standards • Health systems /stat...
POPULATION COUNTRY GDP per capita (US$) (Millions) Bangladesh 1...
COUNTRY POPULATION (Millions) GDP per capita (US$) Brunei 0.42 31,238.6 ...
COUNTRY POPULATION GDP per capita ($) Afghanistan 33,609,937 ...
Burden of disease Burden of disease• The South & Southeast Asia Region accounts  for about 50% of the w...
Burden of Disease NUMBER OF SEVERE  COUNTRY Source ...
NO. OF NEW BIRTHS OF β COUNTRY THALASSAEMICS  PER YEARBangladesh ...
NO. OF NEW BIRTHS OF βCOUNTRY Source THALASSAEMI...
% CARRIERS COUNTRY α Β Hb E Hb CS Bangladesh ...
Cost of Treatment Cost of TreatmentCountry Cost of treatment annually Source ...
Cost to do es a ea t ca e Cost to Indonesian Healthcare Cost per patient per year to the system Registered In...
Prevention Vs Treatment Prevention Vs TreatmentThe estimated costs of treatment and prevention of thalassa...
Comparison of the cost of treatment and prevention of  1000 severe thalassaemia cases in Thailand ...
Cost of prevention Cost of prevention• Cost of one year’s prevention = 8 week’s f ’ i ...
Prevention programmes
Main strategies Main strategies• Prenatal diagnosis & termination of pregnancy• Dissuasion of marriages betwee...
The three pillars The three pillars• Health Education• Screening• Genetic counseling Genetic counseling
Every country should• assess the extent of the problem assess the extent of the problem• Identify the populations at ris...
Strategies  Strategies• P Prevalence figures for thalassaemia ( l fi f h l i (t...
Prevalence figures Prevalence figures• Micro mapping geographically• Helps understand the extent of problems, an...
• Convincing the regional  or National  g governments  of the importance p• Need data on prevale...
Thalassaemia competes with other  diseases• Thalassaemia is not any nations health  priority! i i !
Top 10 causes of deaths, all ages in Thailand 2002  (estimated) CASUSE ...
Leading Causes of Hospital Death in Sri Lanka,2007 Source: Annual Health  Bulletin of S...
Top 10 causes of deaths, all ages in Iran 2002 (estimated) CAUSE DEATHS ...
Screening• Should be National ( regional) policy• Taking into account local ethnic/ local  g sensitivi...
Screening methodology Screening methodology• What tests to use? ( something is better than  gp y ) nothing ...
Is screening school children effective?Is screening school children effective?• Yes ( Haemoglobinopathies & Tay Sachs) Ye...
Who to screen Who to screenPre marital screening :• how to access them? how to access  them?• discrimination...
Cascade screening Cascade screening• Very effective in Sardinia ( detection of 90% of  p y ...
Screening• Screening programme should be supported by p public education and regulatory structures ...
Should screening be made mandatoryShould screening be made mandatory• Yes in Iran (Government legislature)• Done by religi...
Would people take up voluntary  screening?• 30 years after starting the screening  f i h...
Public education Public education• Screening technology should be in place and  i h l h ld b i...
Manpower development Manpower development• Medical /para‐medical• Health educationist Health educationist• ...
Learn from others! Learn from others!• Iranian experience• Maldivian experience• Saudi Arabian experience Saudi...
Iran
Iran• Population 70 million (2007)• Per Capita GDP 4459 Per Capita GDP 4459• IMR 2009  26• Literacy rate 82%• N...
Thalassaemia distribution in IranThalassaemia distribution in Iran o Hassa...
Iranian experience Iranian experience• N ti National prevention programme started in 1996 l ti ...
Iranian experience Iranian experience• Public education for target groups ( young  y) males mainl...
Iranian Experience Iranian Experience• Between 1996 to 1999  to identify carrier  p g ...
Iranian Experience Iranian Experience• Conclusion……. prevention programme only  p g ...
Iranian experience Iranian experience• This has resulted in a 70% reduction in the  expected  annual birth rate...
Maldives
Maldives• 1192 i l d 1192 islands• The population of 309 000 in 200 islands The population of 309 000  in  200 islands• ...
Maldivian experience Maldivian experience• In 1992, SHE (Society for Health Education) a  pp NGO stepp...
Maldivian experience Maldivian experience• E t i Extensive public education, especially school  bli ...
Maldivian experience: impact of the  programme• thalassaemia has become a household word in the  Maldives• un...
Maldivian experience : counter claimsMaldivian experience : counter claims• It has managed to reduce new births of  ...
New cases registered at NTCNew cases registered at NTC
Maldives• The current preventive program focuses on• The approach has not helped in reducing the The approach has not hel...
Maldives• More emphasis on PND and TOP?
Saudi Arabia Saudi Arabia• Population 25 million• Per capita GDP 17700 $ Per capita GDP 17700 $• ...
Saudi Premarital screening and  Genetic counseling programme• Main objective: reduce prevalence of sickle  ...
Saudi programme Saudi programme• Safe marriages and at risk marriages declared  g after lab t...
Saudi programme Saudi programme• 8925 incompatibility certificates issued  between 2004 and 2009.• Data availa...
Saudi programme Saudi programme• 1425 (26%) 1425 (26%) marraiges proposals were cancelled i...
Saudi Programme: Counter claims Saudi Programme: Counter claims• Other studies quote figures of 2% cancelation• (Al Sulaim...
Saudi programme Saudi programme• “ The six years of pre marital screening and  g genetic counselling markedly...
FAILED PROGRAMMES
US sickle screening programme US sickle screening programme• In early 1970• Afro Carribean communities initially accepte...
Why did it fail? Why did it fail?• The differences between carrier status and the  yg homozygous con...
Why did it fail? Why did it fail?• Suggestion that the existence of sickle cell  g p ...
Why  did it fail? Why did it fail?• However through poor planning it was finally  p perceived as “ racist” a...
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Prevention programmes for haemoglobinopathies appropriate for Asia – A policy perspective

Prevention programmes for haemoglobinopathies appropriate for Asia – A policy perspective - by Anuja Premawardhena of the University of Kelaniya, Sri Lanka
Published on: Mar 4, 2016
Published in: Health & Medicine      Travel      
Source: www.slideshare.net


Transcripts - Prevention programmes for haemoglobinopathies appropriate for Asia – A policy perspective

  • 1. Prevention programmes f i for haemoglobinopathies appropriate appropriate  for Asia – A policy perspective Anuja Premawardhena j dh y y University of Kelaniya Ragama Sri Lanka Sri Lanka
  • 2. Asia
  • 3. South & Southeast AsiaSouth & Southeast Asia
  • 4. Asia• Widely varying economies• Religions/ social customs• Education standards Education standards • Health systems /statistics
  • 5. POPULATION COUNTRY GDP per capita (US$) (Millions) Bangladesh 164.47 637.9 Bhutan 0.71 1,978.3 India 1,215.94 1,264.8 Maldives 0.32 5,841.3 Nepal 28.19 561.9 Pakistan 166.58 1,049.7 Sri Lanka 20.40 2,435.1
  • 6. COUNTRY POPULATION (Millions) GDP per capita (US$) Brunei 0.42 31,238.6 Burma 61.19 702.0 Cambodia 14.29 813.8 East Timor East Timor 1.07 1 07 588.4 588 4 Indonesia 234.38 3,015.4 Laos 6.44 984.2 Malaysia 28.25 28 25 8,423.2 8 423 2 Philippines 94.01 2,007.4 Singapore 5.17 43,116.7 Thailand 63.88 4,991.5 , Vietnam 88.26 1,173.5
  • 7. COUNTRY POPULATION GDP per capita ($) Afghanistan 33,609,937 486 Iran (2006 Census)   70,495,782 4,459
  • 8. Burden of disease Burden of disease• The South & Southeast Asia Region accounts  for about 50% of the worlds carriers ‐ around  f b 50% f h ld i d 40 million people – and almost half of homozygote births. d l h lf f h b h …………Prevention of Thalassaemia and other haemoglobin disorders  by thalassaemia international federation (2003))• (
  • 9. Burden of Disease NUMBER OF SEVERE  COUNTRY Source THALASSAEMICS Prevention of Thalassaemia and other  i f h l i d hIndia 65,000 haemoglobin disorders by thalassaemia  international federation (2003)Maldives 600Sri Lanka 3000 De Silva et al (1999) An economic review of the national screening  An economic review of the national screeningIran 25,000 policy to prevent thalassaemia major in  Iran by  Dhotgi N, Tsukatani T, 2002. NUMBER OF SEVERE  COUNTRY Source THALASSAEMICS The Inherited Diseases of Hemoglobin are an Indonesia 30,000 (estimated for 2000) Emerging Gobal Health Burden by Suthat FucharoenThailand 450000
  • 10. NO. OF NEW BIRTHS OF β COUNTRY THALASSAEMICS  PER YEARBangladesh 2,400Bhutan 31India 9000  to 12,000Maldives 60Nepal 327Pakistan 5000Sri LankaSri Lanka 62Afghanistan 465Iran 2000
  • 11. NO. OF NEW BIRTHS OF βCOUNTRY Source THALASSAEMICS  PER YEARBurma 1,400 7,000 1 400‐7 000 The Inherited Diseases of Hemoglobin  are an Emerging Gobal Health Burden  207(Homozy), 3212(b‐thal/Hb E,  833 (Hb by Suthat FucharoenThailand Bart’s) 5600 B t’ ), 5600 (Hb H)Cambodia 12,250Indonesia 12,514 Prevention of Thalassaemia and other Malaysia ?   4 ? 4 haemoglobin disorders by  thalassaemia international federation  (2003)Philippines ?    2Singapore 19Vietnam 4,125
  • 12. % CARRIERS COUNTRY α Β Hb E Hb CS Bangladesh ND 3 4 ‐ Cambodia (+) (+) (+) ‐ China : Guang China : Guang xi 15 5 (+) ‐ China : Hong Kong 2.2 3 ‐ 6 ‐ ‐ China : Taiwan 4 1 ‐ 3 ( ) (+) ‐ India  5 ‐ 97 3 ‐ 4 (+) (+) Indonesia 6 ‐ 16 3 ‐ 10 1 ‐ 25 ‐ Laos (+) (+) (+) Malaysia (+) 4.5 (+) (+) Maldives 28 18 0.69 0 69 0.4 04 Myanmar 10 0.5 ‐ 1.5 2 ‐ 28 ‐ Singapore g p 2.92 0.93 0.64 ‐ Sri Lanka 14 2.2 0.5 ‐ Thailand 10 ‐ 30 3 ‐ 9 10 ‐ 53 ‐ Vietnam 2.5 1.5 (+) ‐• (+ means the present of abnormal gene but the exact frequency is not known)
  • 13. Cost of Treatment Cost of TreatmentCountry Cost of treatment annually Source Management of f Haemoglobin Disorders, India Rs. 100,000 – 150,000 Report of WHO‐TIF Meeting, 2007. M ti 2007Sri Lanka 5% of annual health budget De Silva et al 1999 150,000 Euro  for 30 year Thailand Leelahavarong P et al 2010  life span  life span
  • 14. Cost to do es a ea t ca e Cost to Indonesian Healthcare Cost per patient per year to the system Registered In No of Patients $ 1 30,000 2010 1500 45,000,000 1 222,222 222 222 2020 22500 5,000,000,000One month’s treatment based on 25Kg with Ferriprox and blood is$600 of which the government allocates $25 per patient permonth for the blood and medicines leaving an approx shortfal of$575. Source:‐ Advanced Annual Sickle Cell and Thalassaemia  course, 4‐8 October, 2010. U.K.Thalassaemia Society.
  • 15. Prevention Vs Treatment Prevention Vs TreatmentThe estimated costs of treatment and prevention of thalassaemia in Iran (Thousands of US dollars; from WHO documents)of US dollars; from WHO documents) The  The Ratio of  Annual cost of number  optimal treatment  A b Annual cost of  l t f annual cost of  l t f of   prevention  treatment to (no prevention) annual  annual preventionbirths of thalassa Year 1 (1  Year 10  emiai birth  (10 birth  Year 1 Year 10 birth (10 birth Year 1 Year 10 Year 1 Year 1 Year 10 Year 10 major cohort) cohorts) 1251 12,387 123,874 7,730 7,730 1.6 16.0
  • 16. Comparison of the cost of treatment and prevention of  1000 severe thalassaemia cases in Thailand Prevention Expected No.  Treatment  Birth (av.life = 30yrs)Hb Bart’s  48,280  B 2 42,500 Bhydrops fetus (US$ 1379) (US$ 1,214)Beta  48,280  B 4# **26,400,000 Bthalassaemic (US$ 1379) (US$ 1379) (US$ 754,285) (US$ 754 285)Disease*( * include both homozygous beta thalassaemia and beta thal/HbE,(*i l d b hh b h l i db h l/HbE# 1 homozygos beta thalassaemia and 3 beta thal/HbE,** cost per case = 6,660,000 B ) By Suthat Fucharoen, B S th t F h Thalassaemia Reasearch Center, Thailand.
  • 17. Cost of prevention Cost of prevention• Cost of one year’s prevention = 8 week’s f ’ i k’treatment  (Angastiniotis M et al 1986)• Lifetime healthcare cost of caring forone patient versus the cost of a nationalprevention program  4.22:1prevention program = 4.22:1 (Ginsberg G et al 1998)
  • 18. Prevention programmes
  • 19. Main strategies Main strategies• Prenatal diagnosis & termination of pregnancy• Dissuasion of marriages between carriers
  • 20. The three pillars The three pillars• Health Education• Screening• Genetic counseling Genetic counseling
  • 21. Every country should• assess the extent of the problem assess the extent of the problem• Identify the populations at risk• Identify the contribution of the disease to  p problems in society and health y• Should know how thalassaemia compares to  other diseases in importance th di i i t
  • 22. Strategies  Strategies• P Prevalence figures for thalassaemia ( l fi f h l i (type/incidence) /i id )• Development of a national policy (need for prevention)• Screening methodology• Education of medical staff/ and the masses• Data management
  • 23. Prevalence figures Prevalence figures• Micro mapping geographically• Helps understand the extent of problems, and  how resources should be distributed in a  h h ld b di ib d i country
  • 24. • Convincing the regional  or National  g governments  of the importance p• Need data on prevalence/ patient figures/  new births new births• Cost for treatment• Cost for prevention• St Stressing the importance of prevention i th i t f ti
  • 25. Thalassaemia competes with other  diseases• Thalassaemia is not any nations health  priority! i i !
  • 26. Top 10 causes of deaths, all ages in Thailand 2002  (estimated) CASUSE DEATHS Thousands (%)HIV/AIDS / 56 14Ischaemic heart disease 28 7Cerebrovascuar disease 24 6Diabetes mellitus 19 5Road Traffic Accidents Traffic Accidents 18 5CPOD 17 4Liver cancer 13 3Lower respiratory infections 12 3Nephritis and Nephrosis 11 3Trachea, bronchus, lung cancers 9 2Total 419 100 Source: Mortality Country Fact Sheet 2006 by WHO.
  • 27. Leading Causes of Hospital Death in Sri Lanka,2007 Source: Annual Health  Bulletin of Sri Lanka 2007 CAUSE DEATHS Number (%)Ischaemic heart disease 4,536 13.1Neoplasms 3,498 10.1Pulmonary heart disease & diseases of 3,490 10.1pulmonary  Circulation.Cerebrovascular disease 3,193 9.2Disease of GI tract 2,431 7.0Respiratory tract disease 2,258 6.5Zoonotic and other bacterial diseases 1,923 5.6Symptoms, signs and abnormal clinical  1,829 5.3and  laboratory findings y gDisease of urinary system 1,803 5.2Traumatic injuries 1,389 4.0Pneumonia 1,380 4.0All cases 34,593 100.0
  • 28. Top 10 causes of deaths, all ages in Iran 2002 (estimated) CAUSE DEATHS Thousands (%)Ischaemic hI h i heart disease di 81 21Road traffic accidents 40 11Cerebrovascuar disease 31 8Perinatal conditions 18 5Hypertensive heart disease yp 11 3Stomach cancer 9 3COPD 8 2Diarrhoeal diseases 8 2Inflammatory heart disease 7 2Lower respiratory infections 6 2Total 384 100 Source: Mortality Country Fact Sheet 2006 by WHO.
  • 29. Screening• Should be National ( regional) policy• Taking into account local ethnic/ local  g sensitivities and ground realities
  • 30. Screening methodology Screening methodology• What tests to use? ( something is better than  gp y ) nothing policy??)• Wh Whom to screen ( school children/ pre  ( h l hild / marital/ ante natal/ cascade screening)
  • 31. Is screening school children effective?Is screening school children effective?• Yes ( Haemoglobinopathies & Tay Sachs) Yes ( Haemoglobinopathies & Tay Mitchelle JJ et al 1999  (Montreal Canada)• Yes Even 15 years after Yes. Even 15 years after  screening(Haemoglobinopathies) Lena‐Russo D et al 2002 ( Marseille  France) l ( ll )• Best not done Frumkin & Ziatogora 2008 (Israel)
  • 32. Who to screen Who to screenPre marital screening :• how to access them? how to access  them?• discrimination against carrier females Ante natal screening: Ante natal screening:• must have PND to offer• Should present early in pregnancy
  • 33. Cascade screening Cascade screening• Very effective in Sardinia ( detection of 90% of  p y g y at risk couples by screening only 15% of the  adult population)• Effective in extended families• U Unsuccessful in Sri lanka? f li S il k ?
  • 34. Screening• Screening programme should be supported by p public education and regulatory structures g y• should empower individuals to make informed  h ld i di id l t k i f d decisions• should ensure that people are protected against should  ensure that people are protected against  discrimination as a result of their test results
  • 35. Should screening be made mandatoryShould screening be made mandatory• Yes in Iran (Government legislature)• Done by religious authorities in Cyrus• Voluntary programmes? Voluntary programmes?
  • 36. Would people take up voluntary  screening?• 30 years after starting the screening  f i h i programme• showed that 75% of the people were aware of  the seriousness of thalassemia, ,• However only 42% came voluntarily to be  screened. screened• The remaining 58% came as it was  compulsory. l ( Experience in Cyprus)
  • 37. Public education Public education• Screening technology should be in place and  i h l h ld b i l d available widely• Programme to target the groups designated• Sustainable programme• Incorporate into school curriculum p ( Australia/Canada/Maldives)
  • 38. Manpower development Manpower development• Medical /para‐medical• Health educationist Health educationist• School teachers• Relegieous leaders• Marriage registrars Marriage registrars• Every body in the health delivery system  should be familiar with the disease
  • 39. Learn from others! Learn from others!• Iranian experience• Maldivian experience• Saudi Arabian experience Saudi Arabian experience
  • 40. Iran
  • 41. Iran• Population 70 million (2007)• Per Capita GDP 4459 Per Capita GDP 4459• IMR 2009  26• Literacy rate 82%• Number of thalassaemics registerd 13879  (2007)
  • 42. Thalassaemia distribution in IranThalassaemia distribution in Iran o Hassan Abolghasemi et al 2007, Hassan Abolghasemi et al 2007
  • 43. Iranian experience Iranian experience• N ti National prevention programme started in 1996 l ti t t d i 1996• Thalassaemia prevention intergrated to primary health prevention intergrated to primary health  care• Strategy: pre marital screening• Screening made mandatory by law• Screening was included as part of existing mandatory premarital blood tests
  • 44. Iranian experience Iranian experience• Public education for target groups ( young  y) males mainly)• If b h If both partners are carriers non directive  i di i counselling ( separate or marry))
  • 45. Iranian Experience Iranian Experience• Between 1996 to 1999  to identify carrier  p g g couples before marriage  to offer counseling,   providing them with the opportunity to  separate  separate• Audited in 1999 >>>>> couples were still Audited in 1999 >>>>>  couples were still  opting to marry rather than separate
  • 46. Iranian Experience Iranian Experience• Conclusion……. prevention programme only  p g g on the basis of the premarriage counseling  ineffective and extremely expensive• law  amended in 2001 ……..option of selective  abortion up to 15 weeks gestation for  thalassaemia  thalassaemia
  • 47. Iranian experience Iranian experience• This has resulted in a 70% reduction in the  expected  annual birth rate of affected infants d l bi h f ff di f ( Samavat &  Modell)
  • 48. Maldives
  • 49. Maldives• 1192 i l d 1192 islands• The population of 309 000 in 200 islands The population of 309 000  in  200 islands• average of 1000 people per community g p p p y• IMR   14 per 1000  (2003)• 95% coverage in child immunization• Adult literacy rate 98%
  • 50. Maldivian experience Maldivian experience• In 1992, SHE (Society for Health Education) a  pp NGO stepped in• Data suggesets thalassaemia prevalence rate  was 18.1% (1 in 5) was 18 1% (1 in 5)• population screening programme launched,  visiting each island in the Maldives every 5  years  years• targeting 12–35‐year‐olds.
  • 51. Maldivian experience Maldivian experience• E t i Extensive public education, especially school  bli d ti i ll h l education• 1996  inclusion of thalassaemia in the formal  curricula of secondary schools l f d h l• Main strategy: discouraging the marriage of  carriers to one another• 1999 by legalization of PND and MTP (PND 1999 by legalization of PND and MTP (PND  facilities slow to develop)
  • 52. Maldivian experience: impact of the  programme• thalassaemia has become a household word in the  Maldives• unstigmatized condition in the Maldives • 50% d ti i th l 50% reduction in thalassaemia majors births within a  i j bi th ithi decade,  (even prior to the commencement of PND  services) NAILA FIRDOUS Annals of Human Biology, 2005
  • 53. Maldivian experience : counter claimsMaldivian experience : counter claims• It has managed to reduce new births of  y thalasseamia early on• B But unsuccessful in achieving its target of  f li hi i i f prevention of new births
  • 54. New cases registered at NTCNew cases registered at NTC
  • 55. Maldives• The current preventive program focuses on• The approach has not helped in reducing the The approach has not helped in reducing the  number of new cases• most of the children with thalassemia are still  f h hild ih h l i ill being born , to those who know their career  status at the time of marriage
  • 56. Maldives• More emphasis on PND and TOP?
  • 57. Saudi Arabia Saudi Arabia• Population 25 million• Per capita GDP 17700 $ Per capita GDP 17700 $• IMR 18 per 1000 (2009)• adult literacy rate 86%
  • 58. Saudi Premarital screening and  Genetic counseling programme• Main objective: reduce prevalence of sickle  y cell anaemia and thalassaemia by reducing  g the number of at risk marriages• Stipulated by law in December 2003 and Stipulated by law in December 2003 and  implemented in 2004 February• Couples with marriage proposals should  report to the nearest clinic to apply for pre  report to the nearest clinic to apply for pre marital certificate
  • 59. Saudi programme Saudi programme• Safe marriages and at risk marriages declared  g after lab testing• “incompatibility certificates” issuesd after  counseling• Choice of marriage was left to the couple• D t f t Data of out come followed up f ll d
  • 60. Saudi programme Saudi programme• 8925 incompatibility certificates issued  between 2004 and 2009.• Data available of 5370 (60%)at risk couples ( ) p
  • 61. Saudi programme Saudi programme• 1425 (26%) 1425 (26%) marraiges proposals were cancelled i l ll d• Marriage cancellations increased with time Marriage cancellations increased with time• But even at best 48% of marriages went ahead But even at best 48% of marriages went ahead (  Memish &  Saeed.  Ann Saudi Med 2011) ( Memish & Saeed Ann Saudi Med 2011)
  • 62. Saudi Programme: Counter claims Saudi Programme: Counter claims• Other studies quote figures of 2% cancelation• (Al Sulaiman et al PreNat Diagn 2010 (Al Sulaiman et al PreNat Diagn 2010
  • 63. Saudi programme Saudi programme• “ The six years of pre marital screening and  g genetic counselling markedly reduced the at  g y risk marriages in Saudi Arabia” ??• No data on actual births of thalssaemic  children
  • 64. FAILED PROGRAMMES
  • 65. US sickle screening programme US sickle screening programme• In early 1970• Afro Carribean communities initially accepted Afro Carribean communities initially accepted  the programme  • Af A Afro‐Americans were refused permission to  i f d i i marry unless they could demonstrate their  sickle cell status (Kipple and King, 1981).
  • 66. Why did it fail? Why did it fail?• The differences between carrier status and the  yg homozygous condition were misunderstood,  resulting in carriers being stigmatised and  screening being rejected by the populations  screening being rejected by the populations targeted
  • 67. Why did it fail? Why did it fail?• Suggestion that the existence of sickle cell  g p g among Afro‐Americans proved their genetic  inferiority.• mass screening of one disadvantaged ethnic mass screening of one disadvantaged ethnic  minority group was seen as  state surveillance  of black families (Bradby, 1996).  f bl k f l ( b )
  • 68. Why  did it fail? Why did it fail?• However through poor planning it was finally  p perceived as “ racist” and bordering on  g “Eugenics”• American screening programmes now have a  greater emphasis on voluntary participation  and informed decision making and informed decision making

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