Women and Health

Rebecca J. Cook

ADVANCING SAFE MOTHERHOOD THROUGH HUMAN RIGHTS

BY REBECCA J. COOK, J.D., J.S.D., BERNARD M. DICKENS, Ph.D., LL.D. DEPARTMENT OF REPRODUCTIVE HEALTH AND RESEARCH, WORLD HEALTH ORGANIZATION 1211 Geneva 27, SWITZERLAND; e-mail: rhrpublications@who.int

CONTENTS: "Foreword // Executive Summary // I. Introduction: Purpose // The Significance of Human Rights // Human Rights Approaches to Safe Motherhood // Challenges and Opportunities // Overview // II. Understanding Unsafe Motherhood // III. Human Rights Affecting Safe Motherhood // IV. Strategies for Implementation // References // Appendices.

FROM THE FOREWORD:

It is well over a decade since the World Health Organization (WHO) and its partners launched the Safe Motherhood Initiative to help reduce the severe burden of pregnancy-related illness and death affecting so many women around the world.

One of the key lessons learned during this time has been that whereas safe motherhood is critically dependent on the provision and use of good quality reproductive health care, it must also involve strategies to empower women so that they have access to education and information, to employment and to other resources. In brief, achieving safe motherhood means fulfilling the human rights of women.

Health system interventions such as the provision of essential and emergency obstetric care are crucial to the reduction of maternal mortality and morbidity. Such interventions fall squarely in the domain of an international health agency such as WHO. These interventions cannot, however, be implemented without taking account of the host of social factors affecting pregnancy-related illness and death. Health services may be very far away with no transport available, or they may simply not exist. If they are reachable, a pregnant woman may not be able to decide to go there without her husband's permission, or she may not be allowed to travel on her own. She may not know that swollen ankles, vaginal bleeding or feeling giddy are signs for which she should seek professional advice. Or she may simply not be able to pay for professional health care. These factors often result from women's poor status in society, and from laws, policies and practices that hinder rather than promote their rights.

We believe that the essential health sector interventions can be strengthened by using the principles and tools of human rights. This may involve reviewing and modifying laws and policies so that they protect women's health interests; but it will also mean ensuring that health services and information are provided in a way that respects human rights.

This is a complex field - one which requires a joining of the disciplines of medicine and public health with that of law. In this paper, the authors lay out a framework for bringing together human rights and reproductive health so that the one may serve the aims of the other. 'The ideal that women should exercise free choice in maternity and survive pregnancy and childbirth is modest,' they state, but fundamental to the human dignity of women and to the building of families and societies on principles of justice.' For all of us who are working towards this ideal, Advancing Safe Motherhood through Human Rights is offered as an important contribution for debate and action.

EXECUTIVE SUMMARY

This report considers how human rights laws can be applied to relieve the estimated 1,400 deaths worldwide that occur every day, an annual mortality rate of 515,000, that women suffer because they are pregnant. Human rights principles have long been established in national constitutional and other laws and in regional and international human rights treaties to which nations voluntarily commit themselves. The intention of the report is to facilitate, initiatives by governmental agencies, nongovernmental groups and, for instance, international organizations to foster compliance with human rights in order to protect, respect and fulfill women's rights to safe motherhood.

The report outlines how the dimensions of unsafe motherhood can be measured and comprehended, and how causes can be identified by reference to medical, health system and socio-legal factors. It introduces human rights laws by identifying their sources and governmental obligations to implement them, and explains a range of specific human rights that can be applied to advance safe motherhood. The rights are shown to interact with each other, and are clustered in the following ways:

* rights to life, survival and security,

* rights relating to maternity and health,

* rights to nondiscrimination and due respect for difference, and

* rights to information/ education for women's health protection during pregnancy and childbirth.

ADVANCING SAFE MOTHERHOOD THROUGH HUMAN RIGHTS

The setting of performance standards for monitoring compliance with rights relevant to reproductive health, and availability and use of obstetric services are addressed. In conclusion, the report considers several strategies to encourage professional, institutional and governmental implementation of the various human rights in national and international laws relevant to reduction of unsafe motherhood, and to enable women to go through pregnancy and childbirth safely."

FROM THE INTRODUCTION:

Every year worldwide, an estimated 515,000 women die of complications of pregnancy and childbirth, a rate of over 1,400 maternal deaths each day. At least 7 million women who survive childbirth suffer serious health problems, and a further 50 million women suffer adverse health consequences after childbirth. The overwhelming majority of these deaths and complications occur in developing countries. Most of the deaths and some of the severe complications could be prevented by cost-effective health interventions. The probability of maternal death faced by an average woman over her reproductive life-span varies from 1 in 7 women in Ethiopia, to 1 in 130 in Brazil, to 1 to 90 in the Philippines, to 1 in 8,700 women in Canada. Globally, maternal mortality ratios present the largest discrepancy in any public health statistics between developed and developing countries.

States have made legal and political commitments to protect the health of women, children and families through different human rights, expressed through their national laws and membership in international human rights treaties. However, the reality of high levels of preventable maternal mortality remains.

PURPOSE

The purpose of this discussion document is to explore how human rights, long established in national constitutional laws and other national laws, and international human rights treaties, can be applied to advance safe motherhood. The intention is to contribute to national initiatives to promote compliance with human rights principles, and national and international dialogues on how a human rights approach to advance safe motherhood might be developed and applied.

EDITOR'S NOTE:

Half of this book of 176 pages consists of a remarkable collection of statistics, notes, citations and resources to support, detail and document the argument - an argument that is irrefutable, widely known and completely ignored by all decision makers specifically all men with the power to effect change.

Take the World Bank and its presidents. Mr. Conable started to organize the Safe Motherhood Conferences in 1984 (see WIN NEWS, spring of 1984). But maternal deaths have only increased since, because all the money was spent on meetings in luxury hotels, instead of making childbirth safer locally. Hundreds of useless publications have not been able to cover up the total failure of the entire "SAFE MOTHERHOOD INITIATIVE" and its expensive publications while women in rural areas were dying for lack of any trained help or necessary medicines.

But of course no one would dream of going to work on the grassroots level to train groups of health workers to go to villages in Africa and Asia and set up local health centers and most of all to supply local hospitals with tools and medicines and train local birth attendants to visit villages and work with local people. What is needed is to teach men about their responsibilites concerning safe motherhood: but of course men and their failure to take care of their wives and children is NEVER mentioned in any of the hundreds of expensive pamphlets produced by the "Safe Motherhood Programs" which have never reached any local or rural women anywhere. In the meantime deaths from childbirth are increasing in all developing countries while all the money for 'Safe Motherhood' is wasted.

To relate Safe Motherhood to Human Rights sounds all very nice as a topic for high level conferences in Luxury Hotels and we appreciate the effort of the author - but having visited dozens of maternity hospitals and talked to midwives all over Africa this is anothr sophisticated but completely useless theoretical discussion and waste of money. (80% of women in rural Africa cant read!)

What is needed is a 'SAFE BIRTH CORPS' - following the model of the US Peace Corps which has over the years provided a remarkable service on the grass roots level in villages and for all kinds of people. It has even managed to survive the Washington Buraucracy which is supposed to guide its activities. Such a 'Safe Birth Corps" should not only work in villages and on the local level, but should train its own successors to continue their work after the term of service of the volunteers from overseas is finished. Much as the Peace Corps a 'Safe Birth Corps' needs the support of the local government and should include local volunteers - for instance university students who will be rewarded with free education by their governments. Men should be included from the start especially local men. That is to make childbirth safer - truly a local activity - one must start at the local level.

MEDICAL WOMEN'S INTERNATIONAL ASSOCIATION - MWIA

SECRETARIAT: Wilhelm-Brand-Strasse 3, 44141 Dortmund, GERMANY

e-mail: MWIA@aol.com; website: http://members.aol.com/mwia/index.htm

"Medical Women's International Association (MWIA) is an association of medical women representing women doctors from all five continents founded in New York in 1919.

The Aims of MWIA are:

- To encourage communication between women doctors worldwide.

- To encourage the entry of women into the medical and allied sciences.

- To assist medical women with postgraduate studies.

- To overcome discrimination between male and female physicians.

- To promote Health for All worldwide with particular interest in Women Health and Development.

STRUCTURE

The Association is a federation of national associations of women doctors in 43 countries in all five continents.

The Association is composed of 8 geographical regions. Each region is represented on the Executive Committee by its Vice-President.

- Northern Europe - Latin America - Central Europe - Near East and Africa - Southern Europe - Central Asia - North America - Western Pacific

The President, President-Elect, Treasurer, Secretary-General and the Vice-Presidents are elected by the members. The MWIA Secretariat in Dortmund, Germany, coordinates the interests and activities of the Organisation.

ACTIVITIES

International Congresses and General Assemblies are held every 3 years in various countries of the world. At the scientific meetings of Congresses papers are presented on a chosen topic. The General Assemblies decide upon administrative policy.

The Association sponsors a Scholarship Programme for postgraduate education for its members. The Association has consultative status with the Economic and Social Council of the United Nations and is in official relations with the World Health Organisation.

The present Aims of MWIA are:

* to afford Medical Women the opportunity to meet at stated times to consider common problems together and to gain the cooperation of Medical Women in matters of international Health.

* to foster friendship, respect and understanding among Medical Women throughout the world without regard to race, religion or political views.

* to stimulate, encourage and promote the entry of women into the medical and allied sciences throughout the world and assist its members in optimum utilization of their medical training.

The aims of the Association are realized through International Congresses every three years where a specific area of interest - for example Maternal Morbidity 1924, Sexual Instruction for Children and Adolescents 1929, Genetic and Environmental Factors and Behavioural Differences 1984 - is dealt with by Scientific Presentations, Work Shops, and Round Table Discussions. The last International Congress was held in Sao Paulo, Brazil, 1998 with the theme of 'Women's Health in the XXI Century'. . .

MWIA has permanent representatives at the United Nation Centers in New York and Geneva and is also represented at the annual World Health Assembly, Geneva, and at the WHO Regional Meetings.

The Medical Women's International Association provides its members with the opportunity to exchange ideas medically and personally, and to exchang experiences with colleagues from other nations.. ."

ALRA: CAMPAIGNING FOR A WOMAN'S RIGHT TO CHOOSE ON ABORTION ABORTION LAW REFORM ASSOCIATION (ALRA)

2-12 Pentonville Rd., London N1 9FP, UNITED KINGDOM; fax: 020 7278 5236

CONTENTS:

"Seachanges // Opinions... Views...Polls...Elections...2001 // France // An Ulster TV Internet Poll // Ireland // Switzerland // ALRA Campaigns for Choice."

NAPWA HEAD OPPOSES CONDOM REJECTION BY CATHOLIC CHURCH

NAPWA - NATIONAL ASSOCIATION OF PEOPLE LIVING WITH AIDS

FROM 'WHP REVIEW', SOUTH AFRICAN INSTITUTE FOR MEDICAL RESEARCH

P.O. Box 1038. Johannesburg, 2000, SOUTH AFRICA; fax: (011)489-9922

e-mail: womenhp@sn.apc.org

"The role of the Catholic Church in the struggle against HIV/AIDS leaves much to be desired and raises great concern and disappointment, according to Alosha Ray Ray Ntsane, Chairperson of the National Association of People Living With AIDS (NAPWA) in the Western Cape.

Ntsane, an HIV/AIDS lobbyist who subscribes to the Catholic faith, spoke out against the South African Catholic Bishops Conferences's (SACBC) recent rejection of condom use.

The SACBC rejection of condoms is erroneously bases on the premise that only unmarried persons make use of condoms, even though experience shows that marriage does not provide automatic protection from infection. The church claim that condoms help escalate the HIV/AIDS epidemic is without empirical evidence and highly opinionated as it ignores the effectiveness of condoms in preventing sexually transmitted infections. In addition, while abstinence can be encouraged, the church needs to take cognisance of the fact that unmarried people engage in sexual intercourse and need education on preventative measures, Ntsane says.

Ntsane called on the church to become responsible in addressing the problems of HIV/AIDS by:

* providing education on the prevention of HIV/AIDS and strategies for living positively with the virus;

* protecting women who are mostly affected by the church's position on reproductive health;

* fighting for affordable treatment in South and Southern Africa where poverty determines access to treatment; and

* lobbying for the protection of people living with AIDS through addressing the stigmatisation and discrimination associated with the epidemic."

MOTHERS STILL DYING AT ALARMING RATES DURING CHILDBIRTH

Reproductive Freedom News, October 2001

"UNICEF - The United Children's Fund recently reported that while the last ten years has brought a wave of jargon from world leaders about the need to decrease maternal mortality rates, little if any progress has been made.

While the world's ambitions were great, the reality provides a frightening testament to failure. In 2000, there were 400 maternal deaths for every 100,000 live births, and 515,000 women continue to die each year from pregnancy and childbirth. Sub-Saharan Africa continues to lead the world in maternal mortality rates with one in 13 women likely to die from pregnancy and childbirth related complications, says the UN agency. In South Asia, that figure was one in 54 women; in the Middle East and Northern Africa, one in 55 women; and in Latin America and the Caribbean, one in 157 women.

The contrast between women in rich and poor nations is stark. Women in industrialized nations have a one in 4,084 chance of dying during pregnancy and childbirth, compared to a one in 16 chance for women in the least developed countries.

Worldwide, a woman has a one in 75 chance of dying during pregnancy or childbirth.

Most women are left with little if any medical supervision during childbirth. In 2000, trained attendants were present at only 20% of births in South Asia and 37% of births in sub-Saharan Africa. However, the report notes that in 53 countries where maternal mortality is 'generally less severe,' there has been a 'small increase' in the percentage of births that are attended by skilled personnel. Worldwide, trained individuals attended 56% of all births.

Family planning services showed some progress. The report states that contraceptive prevalence has increased by 10% worldwide and doubled in the 'least developed' countries. However, the report notes that only 23% of married women in sub-Saharan Africa use contraceptives, and access to reproductive health education remains lacking with adolescents giving birth to 15 million infants each year."

EDITOR'S NOTE: Sub-Saharan Africa leads in maternal mortality rates. The reason is Female Genital Mutilation: It continues to be widely practiced in Nigeria, Mali, Burkina Faso, Guinea, Sierra Leone, Kenya, Ethiopia, also in Egypt, Somalia, Eritrea and many other countries. But the well financed Family

Planning Programs - especially those supported by USAID, the World Bank deliberately ignore FGM.

INDIA: DESPITE EFFORTS, MATERNAL DEATHS CONTINUE

FROM 'POPULATION BRIEFS', POPULATION COUNCIL

e-mail: pubinfo@popcouncil.org

One Dag Hammarskjold Plaza, New York, NY 10017

fax: 212-755-6052 http//www.popcouncil.org

"In 1992, India's government launched the Child Survival and Safe Motherhood Program in an effort to address the major causes of death and disease in women and children, building on earlier efforts. The program aimed to reduce maternal deaths to 200 per 100,000 live births by the year 2000. Estimates of maternal deaths released in 2000, however, indicate that currently about 407 maternal deaths occur in India per 100,000 live births.

Researchers examined data collected from Agra and Sitapur, rural districts of Uttar Pradesh, to assess the government program's readiness to provide safe motherhood services.

CHILD SURVIVAL AND SAFE MOTHERHOOD

The Child Survival and Safe Motherhood Program has focused on the early detection and treatment of such complications as anemia, preeclampsia, and obstructed labor.

Traditional birth attendants were taught the importance of clean delivery practices. The program also endeavored to provide referrals for hospital deliveries for women with a high risk for complications.

An assessment of the program done five years after its launch showed that these goals were not being met. The Council's recent research suggests that much more work remains to be done before significant improvements are seen in maternal mortality in India. . .Tetanus toxoid injections, which are recommended to prevent tetanus from unsanitary deliveries, were given to only 35 percent of women in Sitapur and 45 percent of women in Agra.

More than 90 percent of deliveries in Sitapur and nearly 75 percent in Agra took place in the home; often these deliveries were attended solely by family members. These untrained birth attendants may not be ready or able to identify and respond to obstetric complications. . .

CLINIC READINESS

Getting more women to health centers with trained attendants, however, may not be the only answer, the research showed. The investigators studied the ability of primary health centers to deal with five specific conditions that often lead to maternal death: hypertension, hemorrhage, obstructed labor, sepsis and anemia.

They found that in almost every instance, the clinics and their staff lacked the proper equipment, supplies and knowledge to handle these obstetric complications. 'Many women do not deliver in clinics; even if they did go there the clinics often lack the skills to help them,' says RamaRao, lead author of the study. 'The equipment and technical competence to provide safe motherhood services in rural Uttar Pradesh are inadequate at present.'

The researchers proposed a three-pronged strategy for strengthening the government's Child Survival and Safe Motherhood Program.

First, auxiliary nurse midwives should be taught practical life-saving skills, emphasizing detection of complications and referral, in addition to routine care. In addition, hospitals should acquire more of the necessary emergency obstetric care equipment. The investigators also suggest working intensively with community members to encourage women and their families to enlist the aid of trained attendants at deliveries and to increase the number of women who seek antenatal care. Communities also need to be educated to identify problem situations. . .

Finally, the researchers argue that health care workers should take advantage of women s antenatal visits as a crucial point of contact between health services and pregnant women. These visits can teach women about danger signs and hygienic practices, and to provide them with micronutrient supplementation.

UGANDA TO PROVIDE FREE HIV/AIDS DRUGS TO PREGNANT WOMEN

UN WIRE: www.unfoundation.org

"Some 35,000 babies are born annually with HIV/AIDS in Uganda. The Ugandan government will begin providing free anti-retroviral drugs to pregnant mothers with HIV/AIDS, Ugandan Health Minister Crispus Kiyonga said at the 18th international AIDS candlelight memorial ceremony in Kampala.

The program aims to reduce the mother-to-child infection rate by 32%. According to Commissioner for Clinical and Medical Services Sam Zaramba, program participants 'will have to be monitored on a regular basis to improve their immunity.' The event also witnessed the launch of a private sector initiative under the aegis of the Uganda Business Council on HIV/AIDS. 'Now that the private sector has joined us, we will bring anti-retroviral drug companies so that more people can access the drugs,' Kiyonga said.

According to the Uganda AIDS Commission, the HIV/AIDS rate in the country has fallen from 35% in 1990 to 8.3%."

BRIEFING ON THE SPREAD OF HIV/AIDS IN AFRICA - OCTOBER 13, 2001

THE HUNGER PROJECT, 15 East 26th St., New York, NY 10010

fax: 1-212-532-9785; website: www.thp.org

ESTIMATED PERCENTAGE OF ADULTS (15-49) INFECTED WITH HIV, 2000

"Data Unavailable: Algeria // Egypt // Libya // Morocco // Somalia // Western Sahara

0 - 1%: Madagascar // Mauritania

1 - 5%: Angola // Benin // Chad // Eritrea // Ghana // Guinea // Guinea Bissau // Liberia // Senegal // Sierra Leone

5 - 10%: Tanzania // Uganda

10 - 20%: Burkina Faso // Burundi // Cameroon // Congo // D.R. of Congo // Nigeria // Togo

20 - 36%: Botswana // Central African Republic // Cote D'Ivoire // Ethiopia // Kenya // Lesotho // Malawi // Mozambique // Namibia // South Africa // Swaziland // Zambia // Zimbabwe"

CONTENTS:

"HIV/AIDS is the Deadliest Epidemic in World History // The Scale of the Crisis // HIV/AIDS Affects Every Aspect of Development // A Vicious Cycle // Eight-Point Strategy to Stop the Spread of HIV/AIDS // The Hunger Project in Action."

"EIGHT-POINT STRATEGY TO STOP THE SPREAD OF HIV/AIDS

There are eight critical elements in a strategy that will make great strides in stopping the spread of HIV/AIDS in Africa:

1. Leadership at the highest political level: Top political leadership is needed to mobilize and effective, strategic, multisectoral response.

2. A fundamental change in gender relations: Both men and women must be at the forefront of change, responsibility and leadership.

3. Breaking the silence: People must overcome the denial and avoidance of discussing HIV/AIDS.

4. Overcoming the stigma: People living with HIV/AIDS need to live in an environment of understanding and acceptance.

5. Community and religious leaders: They must pave the way in confronting AIDS. . .

6. Widespread provision of services: People must have access to vital services, including condom supply and distribution, HIV counseling and testing.

7. Health-related strategies and care services: There is an immediate need to invest in health strategies both prevention and care.

8. International solidarity and partnership: The mobilization of resources is urgently needed. . .

A FUNDAMENTAL CHANGE IN GENDER RELATIONS - INEQUALITY IS FUELING SPREAD OF HIV

Sub-Saharan Africa is the only region in the world in which more women than men are infected with HIV - 55 percent of infected adults are women. Teenage girls in sub-Saharan Africa are five times more likely to be infected than boys.

HIV in Africa is spread 90 percent through heterosexual sex. For biological reasons, women are more vulnerable to HIV than men. Women are also at special risk because they lack the power to determine how, when, where and, all too often, with whom sex takes place.

In sub-Saharan Africa, the roots of the AIDS crisis are to be found in traditional attitudes and beliefs about masculinity that encourage men to have multiple sex partners. . .Working with men to change their behavior and attitudes has tremendous potential to slow down the epidemic. Harmful concepts of masculinity must be challenged and attitudes changed, including the way men view risk. . ."

EDITOR'S NOTE:

Rape is considered by African men as their right to assert their manhood and women especially young women are their ready made prey. AIDS will continue to spread until most of the African population is infected or dead. Clearly the action is up to African males who basically have a choice of killing themselves and most of the African people or controlling their sexuality and behavior. Since all African leaders engage in the same rapist behavior none of them are providing any leadership. The African male's choice is rape or life: they can't have both. Women have no choice: they are always victims.

SOUTH AFRICA: THE CONTINUING SPREAD OF AIDS

THE NEW YORK TIMES, Nov. 25, 2001

"President Mbeki's advisers say the world's largest drug companies are exaggerating the epidemic to expand markets for AIDS drugs. The companies deny those charges, but Mr. Mbeki has vowed to investigate the accuracy of H.I.V. statistics 'that are regularly peddled as a true representation.' His skepticism is unfathomable to many scientists and health officials...

Some critics suspect that Mr. Mbeki wants to avoid diverting scarce resources toward costly AIDS drugs... Others believe that he cannot bear to admit that the nation's black government stood by while its supporters were dying.

Here in Hlabisa, in the desperately crowded clinics and hospital wards, the scale of the epidemic is clear enough. This district of 250,000 people sits amid the hills of KwaZulu Natal Province, which has the highest adult rate of H.I.V. infection of any province in South Africa, according to the government.

It is one of the few communities in South Africa in which government researchers have kept statistics on H.I.V infection rates for nearly a decade. Its story offers a rare look at a community ravaged by the plague. The virus is invisible, people say, but its fingerprints are everywhere.

The virus also haunts the sandy courtyard of the Gwegwede School, where hundreds of students run with abandon, the boys in black ties and the girls in pleated skirts, their books swinging, oblivious to the health threat. In 1994, the school had 21 teachers. Today it has 18...'We thought we were going to have changes and transformation, but we are dying in great numbers,' the principal said as he awaited the death certificate for one of the teachers who died recently.

The Medical Research Council, the South African equivalent of the National Institutes of Health, believes that AIDS is now the leading cause of death in South Africa. But even as scientists, doctors and church ministers ring the alarm bells, government officials continue to dither.

'We cannot afford any more blunders,' Dr. Malegapuru Makgoba, president of the Medical Research Council and the government's leading scientist, warned in a speech earlier this year. 'If, as Africans, we do not heed these examples and implications, history may judge us to have collaborated in the greatest genocide of all time."

In the last decade, the number of patients admitted each year to the public hospital here has nearly doubled. Inadequate financing, a shortage of health professionals and inept management resultt in a lack of doctors and nurses.

Yet many local high schools still fail to offer AIDS education programs, even though statistics show that at least a quarter of young women under 20 here are infected. When government researchers surveyed 20 local schools, they found that more than a third lacked such programs.

Even with some AIDS education, there is scant evidence to suggest that many people are changing their behavior. In a survey now under way here, only 26 percent of the 1,040 men interviewed so far have reported ever using a condom, the Medical Research Council says. Condoms are viewed as unmanly: only 14 percent said they had ever used a condom.

Doctors and scientists here and abroad have condemned Mr. Mbeki for questioning the link between H.I.V. and AIDS last year, saying he left many South Africans to wonder whether they truly needed to use condoms or to change their behavior. Stung by the criticism, Mr. Mbeki decided last year to stop discussing AIDS...

In 1994, when Nelson Mandela became South Africa's first black president, about 8 percent of adults in South Africa were infected with H.I.V. Today, the figure stands at 25 percent. More than half of this country's 15-year-olds will die of AIDS-related diseases, government officials say.

South Africa's first AIDS cases emerged in the early 1980's, chiefly among gay white men who presumably contracted the virus through homosexual contacts in the United States and Europe.

The black population's exposure was limited then by segregation and tight border controls with some neighboring countries where H.I.V was spreading faster. But in the early 1990's, the white government eased border restrictions. In a few years, the epidemic exploded among blacks, who make up about 78 percent of the population.

The subservient position of women, who have little power to negotiate in their sexual relationships, and a tradition of polygamy and multiple partners, particularly in rural South Africa, have also fueled the disease... After Mr. Mandela took power, the warnings were met with shock, denial and disbelief.

Doctors at Hlbisa Hospital were among the first to ring alarm bells here, producing annual statistics on H.I.V infection rates starting in 1992. But many traditional black leaders and politicians continue to assume that the disease primarily afflicts whites and foreigners...Some church leaders burn condoms and assail people with the virus as sinners.

Prominent community members wither and die in silence because the disease is considered so shameful. Hospital counselors and nonprofit groups regularly distribute condoms and offer awareness programs, but there is little evidence that their safe-sex messages are taking hold.

One recent morning, eight young women, all volunteer AIDS educators for Vusimpilo, a local nonprofit agency, gathered to practice the speeches they planned to present at community festivals and local schools. Use condoms, they said. Abstain from sex. Keep to one sexual partner.

But when asked whether they used those strategies themselves, not a single educator raised her hand. The women, in their 20's and early 30's, confessed that they felt educated, aware - and powerless.

'For us Zulus, it has been a tradition for men to have extra women,' Gugu Chakwe said helplessly. 'We do ask them to stop, but it's up to them to change. If he doesn't want to use condoms, I can't do anything. If I say no, he might go and take another lady.'.

Nomusa Manqele, who trains the young women, admitted that she, too, felt powerless. 'A lady asked me, 'What can I do if the boyfriend doesn't want to use condoms?' she said. 'I told her, 'You leave him'. 'She said, 'I can't leave. I need money from this boyfriend to support my children'.

Of the 50,000 people in Hlabisa believed to be infected with H.I.V., fewer than two dozen have made the disease 'manageable' - as in the West doctors say.' In the mud huts here, they are dying one by one..'"

SOUTH AFRICA: COURT ORDERS DRUG TO GO TO H.I.V. INFECTED MOTHERS

THE NEW YORK TIMES, Dec. 15, 2001

"In a rebuke of South Africa's AIDS policy, a judge ruled December 14 that pregnant women under state care who are H.I.V. infected are entitled to a drug that has been found to reduce a newborn's risk of contracting the virus.

The decision by Judge Chris Botha of the Pretoria High Court was praised by advocacy groups, which have accused President Thabo Mbeki and his government of moving too slowly in dealing with mother-to-child transmission of H.I.V., the virus that causes AIDS.

Members of one group, the Treatment Action Campaign, jumped from their seats and broke into applause as Judge Botha read his order. Then they walked quietly out of the room. 'We've made history today,' Mark Heywood, the group's national secretary, said outside the courthouse.

The ruling, which compels the state to expand access to the drug, nevirapine, far beyond the small pilot program begun this year, is only the beginning. Mr. Heywood stressed 'This judgment is significant, but it doesn't solve the problem of AIDS in South Africa by any means,' he said...South Africa's H.I.V-infected population, an estimated 4.6 million people, is larger than any other country's. President Mbeki has been criticized for challenging widely held findings about H.I.V. and for entertaining questions about whether the virus even causes AIDS. Mother-to-child transmission is considered a particularly troubling element of the epidemic in S Africa, where almost a quarter of all pregnant women carry the virus. An estimated 70,000 children are infected each year this way, according to documents filed in the case decided by Judge Botha.

Nevirapine, which has been found to cut the risk of transmission by half, is available only at a handful of the country's medical facilities, including 18 that are part of a government test program.

Even with today's judgment, women will not find the drug immediately available at every hospital or clinic. Judge Botha himself acknowledged that such an extensive and rapid distribution would be impossible. In his decision, Judge Botha said a nationwide program to prevent mother-to-child transmission is 'an inelectable obligation of the state.'

People taking nevirapine are known to experience some side effects, and government health officials have argued that extensive research must still be conducted on the drug to assess its immediate and long-term consequences. But many medical experts say that nevirapine's side effects are limited and that the risks for newborns are not nearly as bad as one possible alternative, H.I.V infection..."

Editor's Note: The drug is registered in South Africa and has been offered to the Government free of charge by the manufacturer for five years. To date the Government has not accepted.

AFRICA: FIVE COUNTRIES HAVE AT LEAST 2 MILLION EACH WITH HIV/AIDS

FROM 'POPULI', UNFPA (UNITED NATIONS POPULATION FUND) 220 East 42nd St., New York, NY 10017

"Five countries have at least two million people each living with AIDS or the HIV virus, according to a chart released by the United Nations Population Division. The affected countries are Ethiopia, Kenya, Nigeria and South Africa. In five other countries - Botswana, Lesotho, Swaziland, Zambia and Zimbabwe - at least 20 percent of the adult population is infected.

By 2005, life expectancy will have dropped by at least 17 years in those five countries as well as in Kenya, Namibia and South Africa, the chart showed. . .

The numbers show a worsening of the impact of the HIV/AIDS epidemic in terms of increased illness, deaths and population loss. . ."

EDITOR'S NOTE: Sub-Saharan African countries have the highest death and infection rates of HIV/AIDS: The majority of those infected and dying are young women - most of them due to rape. This is known yet, apparently, African leaders - all men - are ignoring this horrendous situation: they certainly have done nothing to initiate the necessary changes. When will African leaders finally tell the truth to their people: African men must change their behavior - the alternative is death.

DEVASTATING EFFECTS OF COOKING SMOKE ON WOMEN AND CHILDREN

FROM 'OUR PLANET', UNITED NATIONS ENVIRONMENT PROGRAMME (UNEP)

P.O. Box 30552, Nairobi, KENYA; fax: (254 2) 62-3692 or 62-3927; website: http://www.unep.org

"Concentrations of health-damaging air pollutants tend to be highest indoors in developing countries, contrary to the common perception that this is primarily an urban phenomenon associated with motor vehicles and industries.

A large proportion of developing country households rely on biomass fuels such as wood, animal dung and crop residues for cooking and heating. As a result, some 3.5 billion people, mostly in rural areas, are exposed to high levels of air pollutants in their homes.

Use of biomass fuels is projected to decline slowly overall, but they will remain the primary source of household energy in much of the developing world for the foreseeable future. According to some estimates, reliance on them may actually have increased recently in some poor areas.

Cooking areas tend to be poorly ventilated in many homes, most of which do not have a separate kitchen. Life revolves around the cooking area and women spend much of their time there. Cooking stoves are mostly simple - often just a pit or three pieces of brick - and burn biofuels inefficiently. Women and young children tend to be exposed to high levels of cooking smoke, far exceeding safe levels recommended by the World Health Organization.

The biomass smoke contains many noxious components, including respirable suspended particulates, carbon monoxide, nitrogen oxides, formaldehyde and polyaromatic hydrocarbons such as benao(a)pyrene. High exposure can damage the respiratory system, eyes and immune system responses - and make people more susceptible to infection and disease.

It has been linked to serious health problems, including tuberculosis, acute respiratory infections, chronic obstructive pulmonary disease and associated with asthma, blindness, anaemia and such adverse pregnancy outcomes as low birth weight and perinatal mortality.

Recent research suggests that people living in households that rely primarily on biofuels for cooking are two or three times more likely to have active tuberculosis than those in ones the use cleaner fuels. Cooking smoke can increase the risk of tuberculosis by reducing resistance to the initial infection or by promoting the development of active tuberculosis in people who are already infected, or both.

Pulmonary tuberculosis, the most common form of the disease, is transmitted by coughing, which is increased by the smoke.

Acute respiratory infection are the single most important cause of morbidity and mortality worldwide, killing more than 3 million children under five every year and accounting for an estimated 9 percent of the entire global disease burden.

Smoke from burning biomass contains large quantities of carbon monoxide (CO), which can bind with haemoglobin in the blood to make carboxyhaemoglobin (HbCO), effectively reducing the amount of oxygen reaching the body tissues and causing anaemia. . .

Women do most of the cooking and so are the most exposed to CO. There are no empirical studies linking cooking smoke to anaemia, but there is some evidence that links it to reduced foetal growth, low birth weight and perinatal mortality. . ."

COPYRIGHT 2002 Women's International Network
COPYRIGHT 2002 Gale Group