The No-Nonsense Guide to World Health

The forward, table of contents and chapter 1 are available for The No-Nonsense Guide to World Health on our website. This title is also available as an e-book. 

NN World HealthThe No-Nonsense Guide to World Health
by Shereen Usdin

When I first sat down to write The No-Nonsense Guide to World Health, I knew that Big Business had a lot to answer for. I didn’t expect though, that with each passing chapter, so many roads would lead to its doorstep. I wrote the book before the world was shaken by the economic tsunami that resulted in a global recession. Banks and investors played with fire and the whole world got burnt. You would think that faith in the unfettered free market would be shattered. But for many, state regulation remains a dirty word. The rule is to have no rules (unless to protect the rich) or at the most, weak ones. Food speculation is a case in point. The growing role of banks, hedge and pension funds in the commodities markets, with risky and secretive financial bets on food prices is increasing world hunger. Other factors contribute to volatile prices and it is clear that excessive speculation is responsible in part of drastic price swings in staple foods.

The World Bank’s Food Price Index, which measures global prices, is 36% above its level a year earlier. Key increases include maize (74%), wheat (69%) and soybeans (36%). In many countries, vegetables, meats, fruits and cooking oil are also on the increase.

Gambling on food prices in the financial market has devastating effects. The maths is simple – less food equals poor health, disease and even death. Malnutrition increases as people spend more on staple food and have less to spend on other essentials for a balanced diet such as dairy, meat, fruit and vegetables. People sell precious assets to stave off hunger. There is less money to spend on health and education. The knock on effect on health and development is paid for in this generation and in generations to come.

According to the World Development Movement (WDM), it works like this: ‘“Futures contracts” were created in US financial markets to help farmers deal with the uncertainty of growing crops (such as unforeseen weather conditions). A futures contract enables farmers to sell their crops at a future date at a guaranteed price. However, these contracts can also be bought and sold by bankers who have little or no involvement in the actual food being traded, but bet on food prices to make money. During the 1990s and early 2000s, aggressive lobbying by bankers led to weaker regulations over food speculation. New and complicated financial products were created to allow more ways to make money from betting on food. Banks such as Goldman Sachs created special index funds to help financial companies make money from food prices, just like they do from share prices.’

The net gain is to the wealthy few. Inflation increases, squeezing consumers in richer countries but for the world’s poorest people even basic foods become unaffordable.

Goldman Sachs has dismissed their claims as ludicrous, but the WDM has used figures in Goldman Sachs’ own annual report to calculate that the bank made a profit of $1bn (£650m) through speculating on food last year.

The Dodd Frank Financial Reform Act, passed in the US last year, includes rules to tackle excessive food speculation, but there is still huge opposition to meaningful change. Street lobbyists are targeting the Commodities Futures Trading Commission (CFTC), the body that will decide how the Act is implemented, to water down the rules.

Banks argue that financial market derivatives are an important mechanism to allow farmers to hedge their risks so that consumers get the benefit of greater price stability. But according to the Fairtrade Foundation, ‘such markets do not allow smaller farmers to hedge. Rather, the price swings harm them because they are often net buyers of food yet cannot take advantage of short-term price spikes in products they are growing for sale.’

While the rich continue to oppose meaningful regulation of commodities futures markets, time is running out for the world to meet its commitments to the Millennium Development Goals (MDGs). Goal 1 is to eradicate ‘extreme poverty and hunger’. The actual target set is ‘to reduce by half the proportion of people who suffer from hunger.’

According to The World Bank’s recently released Food Price Watch, 44 million people were driven into poverty since last June as a result of food spikes. It maintains that a further 10% increase in global prices could drive an additional 10 million people below the $1.25 extreme poverty line. A 30% price hike could lead to 34 million more poor. Currently 1.2 billion people are living below the poverty line of US $1.25 a day.

As the world struggles to reach the MDGs and is set to readjust the goal posts of time, we need to ask ourselves when do we start to put the majority of people and their health before profit for the world’s richest few? The world almost hit rock bottom through reckless gambling on the world markets. When will we wake up and start to take our medicine?

Acts of conscience

Zackie Achmat, the South African political activist most famous for his stand on AIDS, has inspired many. But if you ask him for his source of inspiration, he will credit his grandfather: ‘His example instilled in me the importance of treating all people with equal human dignity and respect.’ These values have shaped Zackie’s life as an activist, which began when he rallied fellow students in the Cape to stand in solidarity with their comrades in Soweto during the Student Uprisings of 1976. He was imprisoned frequently for his anti-apartheid activities and it became impossible to complete his schooling. Despite this he was given special permission to complete a university degree some years later and was active in underground work in support of the African National Congress.

With the overthrow of apartheid, Zackie was key in ensuring the equality clause in the new South African Constitution extended to all ‘regardless of sexual orientation’. He formed the country’s first Gay and Lesbian coalition and began to develop the tools that would later be used in the HIV/AIDS struggle – a combination of mass education, community mobilization and legal action based on the Constitution.

Already active in AIDS work, Zackie discovered he was HIV positive. Antiretroviral drugs (ARVs) had transformed HIV into a chronic, manageable condition in the North but their cost was prohibitive for the South. Those who could afford to pay for them lived, and those who couldn’t died.

The death of gay rights activist Simon Nkoli in 1998 precipitated the launch of the Treatment Action Campaign (TAC). A small group of committed activists soon grew into a truly grassroots mass movement. Their anger reflected the pain and fury of people who believed in social justice, many of whom were experiencing this unfolding tragedy first hand. To the amazement of all except those who knew him well, Zackie declared he would not take ARVs himself until all South Africans were able to do so through the public health service. Everyone, including former President Nelson Mandela, tried to persuade him otherwise. But as Zackie told the _Los Angeles Times_: ‘It wasn’t just a protest action, it was an act of conscience.’ He relented in 2003 when it was clear that the Government would proceed with an ARV rollout.

Zackie has been honoured with many awards for his courage. But few people can claim to have been nominated both for the Nobel Peace Prize (with TAC) and accused of genocide. In 2006, AIDS denialist Anthony Brink charged Zackie (and the TAC) at the International Criminal Court in the Hague with ‘causing the death of millions’ through the promotion of ARVs. No-one took this absurd charge seriously. In fact, it only served to confirm Zackie’s status as an indefatigable fighter for justice. His grandfather would be proud.

*Shereen Usdin*

State of siege

During South Africa’s transition to democracy the world watched in awe as apartheid crumbled and a nation with a soul emerged. Archbishop Desmond Tutu — in a burst of post-apartheid euphoria — described South Africa as the ‘Rainbow nation’. For a moment it felt like that’s exactly what we were. Now, a decade later, as the dust settles the country has become famous for other things. As well as being at the centre of the global AIDS epidemic (one in ten South Africans is HIV positive) we have the dubious honour of being the rape capital of the world. It is becoming clear that violence against women is fueling the epidemic. Take Joyce Malope, a 30-year old Johannesburg activist infected with the virus after a brutal encounter. ‘I was walking home from work when he drove up to me. He was dressed as a priest, soft-spoken and sweet. There was even a bible on the seat of his car. I said: ?Father, how can I help you?? He asked directions to a church. It was close to my place. I thought to myself, why shouldn’t I help this priest, only to find later, he was going to be my rapist? ‘En route, another guy jumped inside. He pulled out a gun and said: ?If you scream I’m going to kill you.? They put a plastic bag over my head. All I could see was lights. He put the gun into my mouth. At the time, I didn’t think of HIV, I just thought, ?as long as you don’t kill me...? ‘After, they dropped me on the pavement near my place. No-one stopped to help. I heard people say, ?maybe she was beaten up by her husband. Probably he found her sleeping with someone else.? Like that justified everything. Finally a man stopped and took me to hospital. My first HIV test was negative. I was told to come back after the ?window period? (the period during which one is infected but the virus is not yet detectable in the blood). It was then that I found out I was positive.’ With the high rate of HIV infection in South Africa, the odds of Joyce becoming infected were high. The violent nature of rape increases this risk. But more women are infected by their husbands or boyfriends, where violence or fear of it determines how and when sex occurs. Despite a constitution which enshrines a woman’s right to live ‘free of violence in both public and _private_ spheres’, the home is probably the most unsafe place for women in South Africa. According to UNAIDS, up to 80 per cent of HIV-positive women in long-term relationships acquired the virus from their partners. This in a society where men having multiple sex partners is the accepted norm. Ironically, marriage is one of the greatest risk factors for women today. Neither gender violence nor AIDS are unique to Africa. But for women the combination of gender violence, patriarchy, poverty, female biological vulnerability, and a virulent strain of the HIV virus makes for a lethal cocktail. In sub-Saharan Africa, an estimated 12.2 million women carry the virus compared with 10.1 million men. According to a recent UN Development Fund report: ‘There is now a fast-growing understanding that gender inequality heightens women’s vulnerability to the epidemic and leaves them with untenable burdens when HIV/AIDS enters households and communities.’ In Africa the problem is rooted in a patriarchal society. According to Karen Dzumbira of Women in Law and Development in Africa (WLDAF), cultural systems give men rights over women and violence is commonly condoned as a way of maintaining control. This ranges from female genital cutting, wife inheritance (where a woman must marry her late husband’s brother), polygamy and bride price (in southern Africa called _lobola_). ‘The lobola system reinforces the idea that a woman is a man’s property and he can do with her what he wishes,’ says Karen Dzumbira. Most women are in no position to bargain. It is almost impossible to negotiate any form of protection with a partner who believes that it is his right to expect his partner’s obedience. Joyce Malope was also raped by her husband: ‘He was often forcing himself on me. There was nothing I could do. It is not easy in our culture to protect yourself from your husband — because he can use violence on you. ‘Men take you as a slut if you ask them to wear a condom. They accuse you of sleeping around or they say: ?You don’t trust me.? Some will just beat you up. When it comes to using a condom, men complain they won’t ?eat a sweet with its wrapper on?.’ It’s also widely believed that vaginal lubrication signifies infidelity. To avoid violent punishment many women insert herbs and other substances inside their vaginas to ‘dry up’. Dry sex makes abrasions and trauma more likely and increases the risk of HIV transmission. Many women are financially dependent on men and are trapped in abusive relationships that expose them to HIV. The way Joyce describes it: ‘You have to listen — your choice is to stay and get beaten or he leaves. To survive, you end up protecting the very person who is killing you.’ And it is perpetuated through generations. ‘Boys see their fathers doing it, so they take it as normal. Even our mums will say: ?If he beats you, try to change your attitude.?’ Violence against women fuels the epidemic and the epidemic fuels violence against women. Ironically, because many women discover their status when pregnant, they are the ones accused of ‘bringing AIDS home’. Violence is a common consequence. As a result most women will not disclose their status. In a recent study in Tanzania, fear of violence and abandonment was cited as the main reason women had not told their partners that they were positive. Nearly 39 per cent said they had been physically abused by a partner and 17 per cent had been sexually abused. For 24-year-old Thembane from Soweto the consequences were bleak: ‘When I told my husband he said: ?You are lying.? He beat me in my face because of the HIV thing. He didn’t want me to say anything to him or anyone else.’ Thembane’s husband refused to go for a test and eventually left her. Fear also prevents women from seeking counselling or treatment. Disclosing one’s status is often perceived as ‘bringing shame’ on families and communities. So many women remain silent and don’t seek the help they need to stay healthy. A much publicized story was that of Gugu Dlamini — a young woman in Durban who was murdered by her neighbours after she publicly disclosed her status. Africa has responded to the crisis in varying ways, some practical, others potentially damaging. An example of the latter has been the revival of ‘virginity testing’, where young girls’ genitalia are inspected at public ceremonies and certificates given to those who make the grade. In Swaziland, women protested the re-introduction of _umchwasho_ — where young girls wear woollen tassels in public to signify their virginity and commitment to abstinence. Some projects look to revive positive cultural practices such as non-penetrative forms of sexual release promoted amongst youth in the past. Obviously a vaccine will protect women but that is a long way off. One of the more sensible ideas being explored is the development of vaginally inserted microbiocides — which will kill the virus and can be administered without a partner’s knowledge. Similarly, the female condom. Activists are also pushing for rape survivors to have legislated access to antiretroviral treatment.

Ironically, marriage is one of the greatest HIV risk factors for women

However, these solutions don’t address the root of the problem — gender inequality. That’s why programmes focusing on the empowerment of women, human-rights education and raising self-esteem are growing throughout the continent. Empilisweni Centre, for example, was established as an AIDS and health-education project in an impoverished rural area of the Eastern Cape. Founded by Elizabeth Musaba, the project focuses on decreasing women’s economic dependence on men — as well as highlighting the link between sexual violence and AIDS. But what about the men? The jury is still out on the effectiveness of counselling abusive men. More projects are engaging men to shift social norms. But many gender activists complain that programmes focusing on men take away scarce resources that should be for women. Musaba, whose project involves men, says this misses the point: ‘In Zambia in the 1980s we got nowhere with our family-planning programme until we began to incorporate men. We will get nowhere with AIDS if we exclude them. We mustn’t lose sight of the ultimate goal, which is to build the capacity of women, but we can only succeed if the two are done simultaneously.’ Alice Munyua of FEMNET, a broad network of African organizations advocating women’s rights, agrees: ‘We believe we have to bring men on board because they hold the power and authority.’ The network is facilitating a process of ‘Men Against Gender Based Violence’ which involves projects in Namibia, Malawi, Kenya and South Africa. McDonald Chapalapata of the Malawi project believes this work is already bearing fruit. ‘Our project brings on board influential men from the judiciary, police, politicians and churches to speak out publicly against gender violence. We have pastors who are preaching respect for women’s rights. We run workshops on gender equality and help form village committees which focus on women’s rights and the law. ‘We are definitely starting to see results. In the southern lake-shore district of Malawi, the village committee arrested a police officer who beat up his wife after she tried to leave him. It took great courage to arrest a policeman.’ Violence against women and the AIDS epidemic sit together like a bad marriage. While the merits of individual counselling may be debated, the tide of both epidemics will not turn unless we counsel society as a whole.

*Shereen Usdin* is a doctor and health-communication specialist. She helped found the Soul City Institute for Health and Development Communication in South Africa. Thanks to Matthew Krouse who assisted with background research.

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