Widespread hunger in the world is primarily related to poverty. It is not principally connected with food production at all. Indeed, over the course of the last quarter of a century, the prices of the principal staple foods (such as rice, wheat etc) have fallen by much more than half in 'real' terms. If there is more demand for food, in the present state of world technology and availability of resources, the production will correspondingly increase. The demand for food is restrained mainly by lack of income. And the same factor explains the large number of people who are hungry across the world. Given their income levels, they are not able to buy enough food, and as a consequence these people (including their family members) live with hunger.
But it is not adequate to look only at incomes. There is need to look also at the political circumstances that allow famine and hunger. If the survival of a government is threatened by the prevalence of hunger, the government has an incentive to deal with the situation. Incomes can be expanded both by policies that raise overall income and also by redistributive policies which provide employment, and thus tackle one of the principal reasons for hunger (to wit, unemployment in a country without an adequate social security system). In democratic countries, even very poor ones, the survival of the ruling government would be threatened by famine, since elections are not easy to win after famines; nor is it easy to withstand criticism of opposition parties and newspapers. That is why famine does not occur in democratic countries. Unfortunately, there are a great many countries in the world which do not yet have democratic systems.
Indeed, as a country like Zimbabwe ceases to be a functioning democracy, its earlier ability to avoid famines in very adverse food situations (for which Zimbabwe had an excellent record in the 1970s and 1980s) becomes weakened. A more authoritarian Zimbabwe is now facing considerable danger of famine. Alas, hunger in the non-acute form of endemic under-nourishment often turns out to be not particularly politically explosive. Even democratic governments can survive with a good deal of regular under-nourishment. For example, while famines have been eliminated in democratic India (they disappeared immediately in 1947, with Independence and multi-party elections), there is a remarkable continuation of endemic under-nourishment in a non-acute form. Deprivation of this kind can reduce life expectancy, increase the rate of morbidity, and even lead to under-development of mental capacities of children. If the political parties do not succeed in making endemic hunger into a politically active issue, hunger in this non-acute form can go on even in democratic countries.
What should rich countries do, and is trade liberalisation the answer?
The rich countries can do a great deal to reduce hunger in the world. First, the displacement of democracies in poor countries, particularly in Africa, often occurred during the Cold War with the connivance of the great powers. Whenever a military strongman displaced a democratic government, the new military dictatorship tended to get support from the Soviet Union (if the new military rulers were pro-Soviet) or from the United States and its allies (if the new rulers were anti-Soviet and pro-West). So there is culpability on the part of the dominant powers in the world, given past history, and there is some responsibility now for rich countries to help facilitate the expansion of democratic governance in the world.
Second, hunger is related to low income and often to unemployment. Poverty could be very substantially reduced if the richer countries were more welcoming to imports from poorer countries, rather than shutting them out by tariff barriers and other exclusions. Fairer trade can reduce poverty in the poor countries (as the recent Oxfam report Rigged Rules, Double Standards discusses in detail). Third, there is a need for a global alliance not just to combat terrorism in the world, but also for positive goals, such as combating illiteracy and reducing preventable illnesses that so disrupt economic and social lives in the poorer countries. Trade liberalisation on the part of the richer countries could certainly make a difference to employment and income prospects of poorer countries. The situation is a little more complex in the case of liberalisation of the poorer countries. Even those countries which have greatly benefited from the expansion of world trade (such as South Korea or China) often went through a phase of protecting industries before vigorous expansion of exports and trade. So, trade liberalisation is partly an answer, but the economic steps involved have to be carefully assessed: the policies cannot be driven by simple slogans.
What is the solution?
There is no 'magic bullet' to deal with the entrenched problem of hunger in the world. It requires political leadership in encouraging democratic governments in the world, including support for multi-party elections, open public discussions, elimination of press censorship, and also economic support for independent news media and rapid dissemination of information and analysis. It also requires visionary economic policies which both encourage trade (especially allowing exports from poorer countries into the markets of the rich), but also reforms (involving patent laws, technology transfer etc.) to dramatically reduce deprivation in the poorer countries. The problem of hunger has to be seen as being embedded in larger issues of global poverty and deprivation.
Countries of the South increasingly seek food self-sufficiency. Could this solve the problem of hunger and starvation?
Food self-sufficiency is a peculiarly obtuse way of thinking about food security. There is no particular problem, even without self-sufficiency, in achieving nutritional security through the elimination of poverty (so that people can buy food) and through the availability of food in the world market (so that countries can import food if there is not an adequate stock at home). The two problems get confused, because many countries which are desperately poor also happen to earn most of their income from food production. This is the case, for example, for many countries in Africa. But if these countries were able to produce a good deal of income (for example through diversification of production, including industrialisation), they can become free of hunger even without producing all the food that is needed for domestic consumption. The focus has to be on income and entitlement, and the ability to command food rather than on any fetishist concern about food self-sufficiency.
There are situations in which self-sufficiency is important, such as during wars. At one stage in the Second World War, there was a real danger of Britain not being able to get enough food into the country. But that is a very peculiar situation, and we are not in one like that now, nor are we likely to be in the near future. The real issue is whether a country can provide enough food for its citizens - either from domestic production or imports or both - and that is a very different issue from self-sufficiency. We have to look at ways and means of eliminating poverty, and to undertake the economic, social and political processes that can achieve that.
Amartya Sen, who won the Nobel Prize in Economics in 1998, is Master of Trinity College, Cambridge. This is a longer version of an article, expanded by the author, that appeared in Le Monde
Editorial
In August 2002 Gro Harlen Bruntland, Director General (DG) of WHO, announced that she would not seek a second term as DG. This issue of the EQUINET newsletter compiles some of the debates and papers that have been presented around her record at WHO, the candidates for the new DG and the selection process itself. The political moment created by the election of a new DG stimulates debate about WHO’s priorities and role in international and global health, as the leadership qualities sought in a new DG should reflect those roles.
Bruntland’s achievements at WHO are notable. She raised the profile of health in the global agenda, including within economic and political forums and is reported to have restored WHO’s credibility with donors. She launched a number of global health campaigns. During her period as DG, WHO has reasserted itself as an international standard-setting body around areas such as tobacco control, pre-qualification for procurement of antiretrovirals, food safety standards, and essential drugs. Bruntland had some success at negotiating partnerships with foundations and the private sector.
Yet the debate on WHO priorities and the realities of health from the perspective of a southern African network indicate that there are many unresolved issues. Whatever the changes that were achieved at global level, they have not been felt at country level. Poverty and unavoidable and unfair inequalities in opportunities for and access to health are pronounced and persistent. Despite this WHO is not perceived to have been a strong public advocate for health equity or for protecting public health in economic and trade policies. Neither is there a perception of the powerful advocacy of primary health care or of forms of health financing that enhance access to health care in poor communities, in women and other vulnerable groups. In contrast, in an environment of rapid and powerfully driven market reforms and privatization, there is some criticism of WHO unwillingness to confront commercial interests over patient interests in access to medicines under TRIPs, or protect national authority rights to regulate private health providers under the WTO GATS agreement.
Hence even while the Macroeconomic Commission on Health raised the profile of the US$27bn shortfall in global resources for health, and the Global Health Fund (GHF) created one vehicle for responding to this shortfall, the impact of these global shifts has been weak. Beyond the insufficient and poorly sustained funding of the GHF, WHO has not yet made clear or put its international policy weight behind the public policy measures needed nationally and globally to ensure that health services and systems spend more on those with greatest need. This has left a number of issues poorly addressed, such as for example the attrition and loss in health personnel from public to private sectors and from low to high income countries; the collapse of primary care level services in some countries; the shift in the burden of caring for HIV/AIDS to poor households and inability to secure treatment access in many low income countries, or the still weak link between public health and the wider systems of rights and procedural justice needed to manage the contestation over scarce resources for health.
The nature of the issues to be addressed, and their significance in Africa make the policies of the next DG a matter of some concern for Africans. The public policy shortfalls identified above do not simply call for business as usual with a bit more focus on Africa. In the same way as poor people’s health needs demand a wider review of public policy generally, so too does meeting the needs of health in Africa demand critical review of wider global, international and national health policies for where they generate vulnerability and impede public health authorities in Africa making coherent responses to ill health.
This editorial does not scrutinize the candidates – there are links to articles about the candidates at the end of this editorial. While effort has been made to make the process of selection of the DG more open to public debate through journal papers and email lists, in fact the process is still tightly controlled within the 32 health ministers in the Executive Board. It would however be important to make two comments. The first is to note the presence as a candidate of Pascal Mocumbi, a southern African who has championed health equity for many years, both working on ways of providing incentives for health equity and articulating equity oriented policies, including as at the 1997 Kasane meeting that launched EQUINET. The second is to note that while individual attributes, perspectives and experience are clearly important, the challenges to be addressed by the new DG call for wider alliances for health. Here perhaps WHO has untapped potential: A number of partnerships for service delivery have been built by WHO.
Bruntland has mobilized resources and raised the political profile of health. The challenge for a new DG is to bring in new strategic alliances and constituencies that advance WHOs role as global advocate for public health and that bridge global opportunity with national practice. Beyond the technical and political support that has been raised, this implies tapping into the massive social support that exists for health rights and values.
LINKS:
(Please note that links to articles from The Lancet require a short and easy registration process)
* AND THE NOMINEES FOR DG ARE …
http://www.thelancet.com/journal/vol360/iss9348/full/llan.360.9347.news.23403.1
* NINE CANDIDATES LINE UP FOR TOP POST
http://bmj.com/cgi/content/full/325/7375/1259?ijkey=l5xSvpnNpSrp6
* WHO’S NEXT DG – THE PERSON AND THE PROGRAMME
http://www.thelancet.com/journal/vol360/iss9348/full/llan.360.9348.editorial_and_review.23505.1
* HAVE THE LATEST REFORMS REVERSED THE WHO’S DECLINE
http://bmj.com/cgi/content/full/325/7372/1107?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=World+Health+Organisation+and+Bruntland&searchid=1040232817123_11702&stored_search=&FIRSTINDEX=0&fdate=12/1/1998&resourcetype=1,2,3,4,10
* ELECTION PROCEDURES LOW AND SECRETIVE
http://www.thelancet.com/journal/journal.isa
* LETTER TO THE LANCET ON ELECTION PROCEDURES
http://www.afronets.org/afronets-hma/afro-nets.200210/msg00057.php
When leaders at the 2015 G7 summit called the 2014 Ebola epidemic ‘a wake-up call for all of us’ they acknowledged that the global response had been too slow, with inadequate health leadership, coordination and emergency funding. At the same time, as argued in the May 2016 editorial in the newsletter, emergency responses cannot be delinked from the strength and authority of health systems to prevent, detect and respond to emerging public health threats, nor to their power to engage sectors on their role in the economic, social, environmental, trade and other determinants of these threats. Shortfalls in public health capacities, including those set in the 2005 International Health Regulations (IHRs) are a warning sign of future outbreaks, often due to neglected diseases or public health risks that get inadequate attention or resources until they trigger large-scale and highly expensive outbreaks.
The two new global financing mechanisms introduced in 2015 to support health emergency responses are thus important additional resources. These are the World Health Organisation (WHO)’s Contingency Fund for Emergencies (CFE) and the World Bank’s Pandemic Emergency Facility (PEF).
The CFE emerged from discussions on the IHRs and was adopted at the 2015 World Health Assembly. It aims to fill the gap from the first 72 hours of a declared health emergency until resources from other financing mechanisms begin to flow. It covers all countries regardless of income to prevent events that have substantial public health consequences. As defined in the IHR, these may be due to infectious agents, chemicals, radiation, food safety or other hazards that can escalate into a public health emergency of international concern. The fund is triggered by national request and the level of funding is decided on a case-by-case basis from a $100m fund. It can support personnel; information technology and information systems; medical supplies; and field and local government support. To date, the CFE has disbursed $8.5 million for interventions related to the Zika virus in South America, on yellow fever in central Africa, and drought related food insecurity in Asia.
The 2015 G7, indicating reasons of accountability and effectiveness, located the PEF at the World Bank. It is currently being finalized for launch at the end of 2016, uniquely as an insurance mechanism rather than a grant fund, to support follow up measures in emergencies after initial funding, such as from CFE. It is only focused on infectious disease outbreaks that could become cross border epidemics. Unlike the CFE, only low income countries are eligible for PEF financing. Funds are provided through two delivery windows: an insurance mechanism for up to $500 million per outbreak, and a cash injection between $50 and $100 million. The disbursement criteria are yet to be clarified. The World Bank expresses its anticipation that an insurance model will bring ‘greater discipline and rigor to pandemic preparedness and incentivize better pandemic response planning’, including by building ‘better core public health capabilities for disease surveillance and health systems strengthening, toward universal health coverage’. However it is both ambiguous and problematic that the PEF is yet to state the specific measures for supporting and measuring these aims.
Although born from different governance processes, the two funds do have some links. For example, the CFE intends to be a first response and the PEF a subsequent deeper resource package. They make reference to one another, recognizing the need to interact for coherence of emergency responses.
However, only the CFE has a formal relationship with the IHRs and its core capacities, only the CFE is universal in coverage of all countries, comprehensive in addressing the full spectrum of cross border public health risks enumerated in the IHRs, including radiation, chemical and other risks, and only the CFE is managed under intergovernmental funding rules and institutional frameworks, with explicit support for system functions such as health information, planning and health worker mobilization.
It is not clear why the PEF seemingly circumnavigates the institutional and intergovernmental mechanisms of the IHRs. Two explanations stand out: Firstly, the PEF is a product of G7 processes, which similar to the establishment of the Global Fund in 2000, have supported funds that are independent of WHO governance processes. Secondly the PEF seeks to create an insurance market that will incentivize certain health system conditions to access the funds. The funding mechanism involves reinsurance and proceeds of ‘catastrophe bonds’ (capital-at-risk notes) issued by the International Bank for Reconstruction and Development purchased by insurance-linked securities and catastrophe bond investors, with development partners and international agencies covering the cost of the premiums and bond coupons. As a new financing mechanism drawing in development funds the trigger criteria for funding and reforms to be incentivized, as yet unstated, need to be carefully reviewed.
G7 countries are presently encouraging G20 countries to financially back the PEF and its insurance agenda this September in Hangzhou. But what of the CFE? It covers a wider spectrum of public health risks, fits most comfortably within the IHR framework and aligns more clearly with efforts to strengthen core IHR capacities and national response plans. How far will the PEF, despite its role to fund the ‘deeper’ response, strengthen the health systems to be more effective in detecting and responding to emergencies, and even more importantly in preventing them. How will the PEF explicitly strengthen capacities for the IHR, provide direct funding support for system capacities and align with existing national plans and intergovernmental frameworks? How far will both funds strengthen the community literacy, networks and capacities and the primary health care systems that are needed for effective prevention, preparedness and containment, or link with the rising mobilization of resources and personnel from within Africa, noting the significant role these played in the last major Ebola epidemic.
The addition of new global resources for managing public health are welcome. However, global measures need to reach beyond measures for surveillance and containment if they are to stretch beyond a remedial securitization of global health. Securing health calls for local, national and regional capacities for and global investment in systems that can identify, prepare for, prevent and manage significant public health risks, and for a re-invigorated public health authority and capability to mobilise attention to those communities and action on those key determinants of health that are often ignored, until the onset of such mass scale events.
Please see the full brief at http://tinyurl.com/jsgsgnh and send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
The theme for the November 2015 62nd East, Central and Southern African Health Community (ECSA-HC) Health Ministers Conference on transitioning from Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs) provided a timely opportunity for countries in the region to frame priorities for health for the next 15 years. In his opening remarks to the Health Ministers Conference, the Minister of Health for Mauritius, the Honorable Anil Kumarsingh Gayan pointed to the SDGs as an ambitious framework that looked at health holistically in terms of healthy lives, including and beyond health care. As detailed also by the World Health Organisation representative Dr Rufaro Chatora at the conference, the transition is from a disease and poverty focused agenda to one that is more focused on the policy goals that apply to all countries. Hon Minister Gayan cautioned that the goals must not remain ‘in a state of aspiration’, and called for them to be addressed through ‘African solutions to African problems’.
While many of the SDGs contribute to health, SDG 3 raises the need to ‘ensure healthy lives and promote well-being for all at all ages’ and lists a daunting array of ambiguous targets (such as universal health coverage). Many of these are open to interpretation and strategic thinking in regards to their implementation, including in terms of how they are integrated into national, regional and continental development plans, such as the African Union’s Agenda 2063: ‘The Africa we want’. With global discussion underway on indicators, funding and other ways of operationalizing the SDGs, the region has a window of opportunity to shape these agendas, rather than react to those set outside the region.
Minister Gayan highlighted the importance of inspiring regional leadership and collective action across countries to steer the SDG agenda to advance health and address mutual concerns across countries in the region through an agenda set within the region. This, he indicated, called for regional organisations to be ‘innovative, responsive, imaginative and effective’.
The ECSA HC Best Practices Forum (BPF), Directors Joint Consultative Conference and Health Ministers Conference, this year involving about 150 delegates from ministries of health, health experts and researchers, heads of health research and training institutions from ECSA countries and diverse collaborating partners in and beyond the region, provided a unique opportunity to blend experience, evidence, exchange, policy review and networking to contribute to such features. It included inputs from diverse actors in the region on universal health coverage (UHC), on health financing, on regional collaboration in the surveillance and control of communicable diseases, on the situation and responses to non- communicable diseases (NCDs), on global health diplomacy and on innovations in health professional training.
The BPF conference raised a number of key recommendations aimed at supporting the transition from the MDGs to the SDGs, including; strengthening mandatory pre–payment for health, and monitoring, evaluation and shared learning across the ESCA-HC members on measures for this and on progress towards UHC; strengthening and sharing capacities and knowledge for tracking and reporting communicable diseases and for responding to outbreaks; increasing ECSA initiatives for health professional training and recognition of qualifications across countries in the region; strengthening regional capacity and evidence in global health negotiations; strengthening investment in research and the use of evidence in health policy, and facilitating ‘south-south knowledge exchange’ in various areas, including on multi-sectoral measures and capacities to detect and control NCDs and traumas; and in global health diplomacy.
Such regional exchange, co-ordination and voice was found in EQUINET’s research as one factor - amongst others- in effective engagement in global health negotiations. In the ECSA HC conference, regional co-operation was raised in various discussions as an important platform for solving a number of problems, including for countries with excess to deploy skilled professionals to countries with scarcities, or for more rapid deployment of capacities for response to emergencies. At the same time, EQUINET’s research also found that regional organisations are often bypassed or lack formal voice in global processes. It was thus interesting that the ECSA HC Director General Professor Yoswa Dambisya launched one of the few examples of a successfully secured regionally based Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GF) grant, which will align programs and provide increased capacity for tuberculosis monitoring and response in the region. This capacity will not only increase the ability of states in the region to detect new cases of tuberculosis, but also provides the possibility for new capacity scale-up to detect other neglected communicable diseases (NCDs) as laboratory resources and expertise increase.
There were, however, a number of signals on the challenges to further strengthen such regional roles. Minister Gayan in his opening speech pointed to how shortfalls in payment of membership fees to the regional body weakens the financial forecasting and planning needed to take forward a proactive agenda. The recent experience of weak implementation of the WHO Code of Practice on the International Recruitment of Health Personnel signaled deficits in technical follow through on policies. At the same time the conference also raised the role of domestic investment in country driven research and ministerial leadership to effectively support and coordinate such follow through.
With the long-term nature of the issues being tackled, these annual regional conferences need a consistency of focus on issues that are key for the region and strategic use of time to share and review the learning from implementation of regional recommendations as ‘African solution to African problems’. The involvement of many of the countries in several regional economic communities also necessitates co-ordination of efforts across these regional bodies.
Notwithstanding the challenges, the conference highlighted the potential of ECSA-HC and other regional processes in facilitating the exchange and sharing of policy relevant evidence and ‘south-south’ learning. The contribution of such institutional resources and processes should not be overlooked in asserting African health priorities in the global health agenda. While this is more a ‘marathon’ than a ‘sprint’, for the window of opportunity of current discussions on the SDG indicators and financing, the time to voice African health priorities in this global SDG process is now.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org. For further information on the ECSA HC Regional Conferences please visit the ECSA HC website at http://www.ecsahc.org/
In a changing global environment, African countries have made clear their intention for the World Health Assembly (WHA) to hold its global leadership in health. At the WHA in 2012, reforms of the World Health Organisation (WHO) were under discussion, with the aims of improving outcomes in agreed global health priorities, ensuring greater coherence in global health, and effective, efficient, responsive, objective, transparent and accountable performance. In a context of a multitude of new global institutions, foundations and alliances involved in health, African countries at the WHA collectively, through Senegal, raised that the WHO provides an organisational means for global processes to value multilateralism, inclusivity and respect for the authority of member states through the WHA. The Africa Group of countries called for the reform process to contribute “to the shaping of a stronger, more effective, more responsive and more responsible WHO.” In the discussion on the reforms, African countries unanimously urged for countries to ensure that whatever the reforms achieve, they must strengthen WHO’s position as the leading global agency for health.
Achieving this calls for more than rhetoric and statements of intent. In the past decades, the World Health Assembly provided a forum for states to review policies and strategies in health and make resolutions that they would implement. In recent years, a host of new players from non health sector agencies, non-governmental organizations, non-state providers of health, industry, faith-based organizations, civil society, foundations and corporates have become involved in decision making on and implementation of health strategies. Over the past decade more than 100 private global foundations have emerged working on different issues related to health. This multiplicity of actors bring multiple visions, mandates and modes of functioning to global policy processes. Alliances such as the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Health Workforce Alliance are now working on issues that the WHO has been working on over the years.
A Ugandan delegate to the 2012 WHA questioned the number of partnerships that WHO was now involved in, arguing that this detracted from its major mandate and role. African countries at the WHA observed that navigating this complex environment calls for WHO to rather strengthen its own intergovernmental nature and particularly the role of countries in its decision making processes. Permanent secretary of the Ministry of Health in Swaziland, Mr. Stephen Shongwe, said for example “As Swaziland we want to reiterate that the WHA is the supreme organ of the WHO and should have the final say in all the decisions. There should be flexibility for the WHA to make decisions. Resolutions should not just be crafted based on the recommendations of the Executive Board. Member states should be able to raise issues that may arise and not just be confined to the defined issues in the agenda.”
African countries’ concerns were addressed in part when the 65th WHA in 2012 resolved that any reform of the organisation be guided by the principle that the intergovernmental nature of WHO’s decision-making be paramount. The Director General was requested to present draft papers on WHO’s engagement with non governmental organisations and with private commercial entities.
However, while this may be a necessary condition for the organisation to claim global leadership in heath, will it be enough? Without the funds coming from the same member states, how will it deliver on its decisions? And will member states use their strengthened and collective decision making to safe guard public health, even in the face of corporates and foundations whose earnings exceed the GDP of many member states?
Global leadership in health demands an organisation that fearlessly and strategically protects public health. At a Special Session of the WHO Executive Board convened in November 2011 to consider the Reform Agenda, the WHO director General Margaret Chan then said that WHO, in "the interest of safeguarding public health", was "not afraid to speak out against entities that are far richer, more powerful, and better connected politically than health will ever be", adding that "we need to maintain vigilance against any real or perceived conflicts of interest."
Civil society actors at the WHA supported this role of public health protector, but questioned whether it is being delivered. They argued that the prospect of money has led the organisation to engage in partnerships that have weakened this leadership role. They held member states liable for this situation, observing that WHO can only become a stronger intergovernmental institution when member states increase their funding support.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
The massive inequalities in the distribution of resources for health globally will be brought increasingly into focus in the coming months, with the upcoming G8 meeting and the UN review of the Millenium development goals. With it will grow debates on the interpretation of the causes of and remedies for these inequalities, particularly for Africa. If we are to apply values of fairness and equity to this situation there is no doubt that global funds for health must flow southwards to African communities and public sector health services. As the editorial below by Vandana Shiva indicates, the situation calls for more however - it calls for social and economic justice. We must confront the deliberate policies that lead to net resource outflows from poor communities, underfunded public sector services and countries in Africa. EQUINET training, meetings and research in the coming months will focus on options for confronting these outflows in relation to health workers, health finances and trade policies. Please contact us at admin@equinetafrica.org if you would like to know more about any of these areas of work or visit our website at www.equinetafrica.org.
EQUINET in 1998 identified, as part of the understanding of equity in health, the importance of the relative control and authority that different people, communities and countries have over how the resources for health are distributed. At the end of the year, after the G8, after the UN Summit and after the WTO Hong Kong Ministerial, we will be asking ourselves - are African households, African public health planners and African countries more or less in control of the resources for health, including those we produce, but no longer consume, in Africa?
How To End Poverty: Making Poverty History And The History Of Poverty
Vandana Shiva
Source: www.zmag.org
http://www.zmag.org/Sustainers/Content/2005-05/11shiva.cfm
The cover story of the Time Magazine of March 14, 2005 was dedicated to the theme, "How to End Poverty". It was based on an essay by Jeffrey Sachs "The End of Poverty", from his book with the same title. The photos accompanying the essay are homeless children, scavengers in garbage dumps, heroin addicts. These are images of disposable people, people whose lives, resources, livelihoods have been snatched from them by a brutal, unjust, excluding process which generates poverty for the majority and prosperity for a few.
Garbage is the waste of a throwaway society - ecological societies have never had garbage. Homeless children are the consequences of impoverishment of communities and families who have lost their resources and livelihoods. These are images of the perversion and externalities of a non-sustainable, unjust, inequitable economic growth model.
In "Staying Alive, I had referred to a book entitled "Poverty: the Wealth of the People" in which an African writer draws a distinction between poverty as subsistence, and misery as deprivation. It is useful to separate a cultural conception of simple, sustainable living as poverty from the material experience of poverty that is a result of dispossession and deprivation.
Culturally perceived poverty need not be real material poverty: sustenance economies, which satisfy basic needs through self-provisioning, are not poor in the sense of being deprived. Yet the ideology of development declares them so because they do not participate overwhelmingly in the market economy, and do not consume commodities produced for and distributed through the market even though they might be satisfying those needs through self-provisioning mechanisms.
People are perceived as poor if they eat millets (grown by women) rather than commercially produced and distributed processed junk foods sold by global agri-business. They are seen as poor if they live in self-built housing made form ecologically adapted natural material like bamboo and mud rather than in cement houses. They are seen as poor if they wear handmade garments of natural fibre rather than synthetics.
Sustenance, as culturally perceived poverty, does not necessarily imply a low physical quality of life. On the contrary, because sustenance economies contribute to the growth of nature's economy and the social economy, they ensure a high quality of life measure in terms of right to food and water, sustainability of livelihoods, and robust social and cultural identity and meaning.
On the other hand, the poverty of the 1 billion hungry and the 1 billion malnutritioned people who are victims of obesity suffer from both cultural and material poverty. A system that creates denial and disease, while accumulating trillions of dollars of super profits for agribusiness, is a system for creating poverty for people. Poverty is a final state, not an initial state of an economic paradigm, which destroys ecological and social systems for maintaining life, health and sustenance of the planet and people.
And economic poverty is only one form of poverty. Cultural poverty, social poverty, ethical poverty, ecological poverty, spiritual poverty are other forms of poverty more prevalent in the so called rich North than in the so called poor South. And those other poverties cannot be overcome by dollars. They need compassion and justice, caring and sharing.
Ending poverty requires knowing how poverty is created. However, Jeffrey Sachs views poverty as the original sin. As he declares:
A few generations ago, almost everybody was poor. The Industrial Revolution led to new riches, but much of the world was left far behind.
This is totally false history of poverty, and cannot be the basis of making poverty history. Jeffrey Sachs has got it wrong. The poor are not those who were left behind, they are the ones who were pushed out and excluded from access to their own wealth and resources.
The "poor are not poor because they are lazy or their governments are corrupt". They are poor because their wealth has been appropriated and wealth creating capacity destroyed. The riches accumulated by Europe were based on riches appropriated from Asia, Africa and Latin America. Without the destruction of India's rich textile industry, without the take over of the spice trade, without the genocide of the native American tribes, without the Africa's slavery, the industrial revolution would not have led to new riches for Europe or the U.S. It was the violent take over of Third World resources and Third World markets that created wealth in the North - but it simultaneously created poverty in the South.
Two economic myths facilitate a separation between two intimately linked processes: the growth of affluence and the growth of poverty. Firstly, growth is viewed only as growth of capital. What goes unperceived is the destruction in nature and in people's sustenance economy that this growth creates. The two simultaneously created 'externalities' of growth - environmental destruction and poverty creation - are then casually linked, not to the processes of growth, but to each other. Poverty, it is stated, causes environmental destruction. The disease is then offered as a cure: growth will solve the problems of poverty and environmental crisis it has given rise to in the first place. This is the message of Jeffrey Sachs analysis.
The second myth that separates affluence from poverty, is the assumption that if you produce what you consume, you do not produce. This is the basis on which the production boundary is drawn for national accounting that measures economic growth. Both myths contribute to the mystification of growth and consumerism, but they also hide the real processes that create poverty.
First, the market economy dominated by capital is not the only economy, development has, however, been based on the growth of the market economy. The invisible costs of development have been the destruction of two other economies: nature's processes and people's survival. The ignorance or neglect of these two vital economies is the reason why development has posed a threat of ecological destruction and a threat to human survival, both of which, however, have remained 'hidden negative externalities' of the development process.
Instead of being seen as results of exclusion, they are presented as "those left behind". Instead of being viewed as those who suffer the worst burden of unjust growth in the form of poverty, they are false presented as those not touched by growth. This false separation of processes that create affluence from those that create poverty is at the core of Jeffrey Sachs analysis. His recipes will therefore aggravated and deepen poverty instead of ending it.
Trade and exchange of goods and services have always existed in human societies, but these were subjected to nature's and people's economies. The elevation of the domain of the market and man-made capital to the position of the highest organizing principle for societies has led to the neglect and destruction of the other two organizing principles - ecology and survival - which maintain and sustain life in nature and society.
Modern economies and concepts of development cover only a negligible part of the history of human interaction with nature. For centuries, principles of sustenance have given human societies the material basis of survival by deriving livelihoods directly from nature through self-provisioning mechanisms. Limits in nature have been respected and have guided the limits of human consumption. In most countries of the South large numbers of people continue to derive their sustenance in the survival economy which remains invisible to market-oriented development.
All people in all societies depend on nature's economy for survival. When the organizing principle for society's relationship with nature is sustenance, nature exists as a commons. It becomes a resource when profits and accumulation become the organizing principle for society's relationship with nature is sustenance, nature exists as a commons. It becomes a resource when profits and accumulation become the organizing principles and create an imperative for the exploitation of resources for the market.
Without clean water, fertile soils and crop and plant genetic diversity, human survival is not possible. These commons have been destroyed by economic development, resulting in the creation of a new contradiction between the economy of natural processes and the survival economy, because those people deprived of their traditional land and means of survival by development are forced to survive on an increasingly eroded nature.
People do not die for lack of incomes. They die for lack of access to resources. Here too Jeffrey Sacks is wrong when he says, "In a world of plenty, 1 billion people are so poor, their lives are in danger". The indigenous people in the Amazon, the mountain communities in the Himalaya, peasants whose land has not been appropriated and whose water and biodiversity has not been destroyed by debt creating industrial agriculture are ecologically rich, even though they do not earn a dollar a day.
On the other hand, even at five dollars a day, people are poor if they have to buy their basic needs at high prices. Indian peasants who have been made poor and pushed into debt over the past decade to create markets for costly seeds and agrichemicals through economic globalisation are ending their lives in thousands.
When seeds are patented and peasants will pay $1 trillion in royalties, they will be $1 trillion poorer. Patents on medicines increase costs of AIDS drugs from $200 to $20,000, and Cancer drugs from $2,400 to $36,000 for a year's treatment. When water is privatized, and global corporations make $1 trillion from commodification of water, the poor are poorer by $1 trillion.
The movements against economic globalisation and maldevelopment are movements to end poverty by ending the exclusions, injustices and ecological non-sustainability that are the root causes of poverty.
The $50 billion of "aid" North to South is a tenth of $500 billion flow South to North as interest payments and other unjust mechanisms in the global economy imposed by World Bank, IMF. With privatization of essential services and an unfair globalisation imposed through W.T.O, the poor are being made poorer.
Indian peasants are loosing $26 billion annually just in falling farm prices because of dumping and trade liberalization. As a result of unfair, unjust globalisation, which is leading to corporate, take over of food and water. More than $5 trillion will be transferred from poor people to rich countries just for food and water. The poor are financing the rich. If we are serious about ending poverty, we have to be serious about ending the unjust and violent systems for wealth creation which create poverty by robbing the poor of their resources, livelihoods and incomes.
Jeffrey Sachs deliberately ignores this "taking", and only addresses "giving", which is a mere 0.1% of the "taking" by the North. Ending poverty is more a matter of taking less than giving an insignificant amount more. Making poverty history needs getting the history of poverty right And Sachs has got it completely wrong.
We are starting a new year as the old one ended with a stark warning from Tedros Ghebreyesus, the WHO director-general. “We cannot delay action on climate change. We cannot sleepwalk through this health emergency any longer.”
A Lancet Countdown on Health and Climate Change reports that global warming is affecting every aspect of human life, not only in terms of extremes of weather but in terms of falling food security and access to safe drinking water and clean air.
In our region, where people are highly dependent on agriculture, vulnerable to drought and flooding and already facing a deficit in food security, safe water and clean energy, the impact is reported to be increasing already intense social inequality. WHO estimates that almost one in four premature deaths in Africa have environmental causes, and that climate change is likely to increase the number of health emergencies and disease outbreaks.
In November this year, African ministers for health and environment adopted a ten-year framework to direct funds toward joint health and environment initiatives. The Strategic Action Plan to Scale Up Health and Environmental Interventions in Africa 2019-2029 is expected to promote government investment in addressing environmental problems that affect human health, such as air pollution, contamination of water sources, and ecosystem damage.
These are important commitments. But in our region most governments are not yet fulfilling the commitment they made in 2011 to allocate 15% of domestic government spending on health. Underfunded health sectors struggle to balance the demand for promotion, prevention and medical care and often retreat into the latter.
Climate change demands global co-operation and resources. During the COP 16, the world's high income countries agreed to mobilize 100 billion US dollars per year by the year 2020 for adaptation and mitigation in low income countries, through a Green Climate Fund (GCF). We are nearly at 2020 and it is reported by IPS that only 10 billion US dollars has been mobilized so far since the establishment of the Fund in 2006.
Raising the health consequences of climate change is an important lever for attention and action on these concerns. It should also be a means to put people, social justice and solidarity at the centre of this. The opposite is feared to be happening. For example, at the November World Innovation for Health Summit it was noted that effects such as ‘environmental migrancy’, as people move away from harsh conditions, and the competition for resources can generate self-protection and discrimination. Vandana Singh, author and professor urges that these challenges not make us surrender “our imaginations, our creativity, our wonderful human capacity to work together, to negotiate and argue and brainstorm—on the altar of fear”. The solutions to these complex issues are not simply technical. They are inherently social and thus political.
So on this and the many other challenges that will certainly confront us in 2019, we wish you righteous anger, imagination and creativity and deepening opportunities to work together, negotiate, argue and brainstorm in the interest of our collective health and wellbeing.
As usual this is a short newsletter, given the time of year. Our newsletter is now on its 190th issue and we appreciate the range of creative work reported in all the 16 years of its existence. The 245 editorials written by a range of people from community, civil society, parliament, government, technical and research institutions provide comment and reflection on a diversity of health issues and debates. The over 11000 entries in the 190 newsletters all available in a searchable database on the EQUINET website carry a wide range of ideas, experiences, evidence, analysis and voice from and on east and southern Africa. The newsletter database is a rich searchable resource of how policy and publication focus has shifted over nearly two decades and of whether writing on the region is increasingly being led from the region.
We continue to encourage you to document your work and to send us send your blogs, and links to your reports, papers, news, conference announcements, videos or other forms of information so the newsletter can assist to share experience, evidence and learning from work on health equity in the region. As we said last year, 'Until the lions write their story, tales of the hunt will always glorify the hunter'. We encourage you to roar even louder in 2017!
Please send your blogs, and links to your reports, papers, news, conference announcements, videos or other forms of information from your work on health in the region, and we will be happy to share it.
We look forward to working with you in the coming year and wish you a healthy 2017, and a thoughtful, steady and exuberant progress in our struggles for health equity. .
At this time last year we wished you progress towards health and justice in the year.
Our editorials in 2017 reflect some of the mountains that have to be moved for this: At several points of the year - in February and June - contributors highlighted preoccupations with emergencies, bio-security and migration that trigger discrimination and exclusion, rather than solidarity and shared responsibility. In March and in September we heard about the increasing privatisation of public spaces, public institutions and public health services, and in April about the extraction of minerals and other resources from our countries without fair benefit for local communities.
However, the 2017 contributions also point to ideas and forces that move these mountains: such as the news in February of thousands of people gathering at Habitat3 around people’s right to the city and to healthy urban life; the demand in March by civil society to open up a closed world of global policy making; the claim in April for regional economic communities to set health standards in mining that should apply across the region; the organisation of collective African voice May’s World health assembly to more strongly advance ideas and interests from the region; and examples raised in September and October of how recognising and nurturing people’s rights, evidence and power generates a critical resource for health systems. In the beginning of 2017 one editorial painted a scenario of a future world where inclusion and investment in wellbeing is recognised not only as a matter of rights and justice, but as vital for our collective survival. So it was inspiring in the end of the year to hear a group of young contributors share ideas of urban futures that would overcome the significant differences in opportunities for wellbeing that they seek to demand, contribute to and achieve.
These ideas and forces are all rooted in the challenging conditions described. But they are also challenging these conditions, envisaging both a direction for change and a power to transform that lies in people’s hands. A Sudanese proverb says that we desire to bequeath two things to the next generation; the first one is roots, the other one is wings. Let’s move forward into 2018 with both!
* Text of a speech by Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, delivered at the University of Pennsylvania's Summit on Global Issues in Women's Health, Philadelphia, April 26, 2005
I well realize that this is a conference on women's global health, and everything I'm about to say will apply to that generic definition. But the more I thought of the subject matter, the more I want to use HIV/AIDS in Africa as a surrogate for every international issue of women's health, partly because it's what I know best; partly because it's an accurate reflection of reality.
I've been in the Envoy role for four years. Things are changing in an incremental, if painfully glacial way. It's now possible to feel merely catastrophic rather than apocalyptic. Initiatives on treatment, resources, training, capacity, infrastructure and prevention are underway. But one factor is largely impervious to change: the situation of women. On the ground, where it counts, where the wily words confront reality, the lives of women are as mercilessly desperate as they have always been in the last twenty plus years of the pandemic.
Just a few weeks ago, I was in Zambia, visiting a district well outside of Lusaka. We were taken to a rural village to see an "income generating project" run by a group of Women Living With AIDS. They were gathered under a large banner proclaiming their identity, some fifteen or twenty women, all living with the virus, all looking after orphans. They were standing proudly beside the income generating project ... a bountiful cabbage patch. After they had spoken volubly and eloquently about their needs and the needs of their children (as always, hunger led the litany), I asked about the cabbages. I assumed it supplemented their diet? Yes, they chorused. And you sell the surplus at market? An energetic nodding of heads. And I take it you make a profit? Yes again. What do you do with the profit? And this time there was an almost quizzical response as if to say what kind of ridiculous question is that ... surely you knew the answer before you asked: "We buy coffins of course; we never have enough coffins".
It's at moments like that when I feel the world has gone mad. That's no existential spasm on my part. I simply don't know how otherwise to characterize what we're doing to half of humankind.
I want to remind you that it took until the Bangkok AIDS conference in 2004 - more than twenty years into the pandemic - before the definitive report from UNAIDS disaggregated the statistics and commented, extensively, upon the devastating vulnerability of women. The phrase "AIDS has a woman's face" actually gained currency at the AIDS conference in Barcelona two years earlier, in 2002, and even then it was years late. Perhaps we should stop using it now as though it has a revelatory dimension. The women of Africa have always known whose face it is that's withered and aching from the virus.
I want to remind you that when the Millennium Development Goals were launched, there was no goal on sexual and reproductive health. How was that possible? Everyone is now scrambling to find a way to make sexual and reproductive health fit comfortably into HIV/AIDS or women's empowerment or maternal mortality. But it surely should have had a category, a goal, of its own. Interestingly, the primacy of women is rescued (albeit there's still no goal) in the Millennium Project document, authored by Jeffrey Sachs.
And while mentioning maternal mortality, allow me to point out that this issue has been haunting the lives of women for generations. I can remember back in the late 90s, when I was overseeing the publication of State of the World's Children for UNICEF, and we did a major piece on maternal mortality and realized that the same number of annual deaths - between 500 and 600 hundred thousand - had not changed for twenty years. And now it's thirty years. You can bet that if there was something called paternal mortality, the numbers wouldn't be frozen in time for three decades.
I want to remind you that within the UN system, there's something called the Task Force on Women and AIDS in Southern Africa. Permit me to tell you how it came about, and where it appears to be headed ... and I beg you to see this as descriptive rather than self-indulgent.
In January of 2003, I traveled with the Executive Director of the World Food Programme, James Morris, to four African countries beset by a combination of famine and AIDS: Zimbabwe, Zambia, Malawi and Lesotho. We had surmised, at the outset, that we would be dealing primarily with drought and erratic rainfall, but in the field it became apparent that to a devastating extent, agricultural productivity and household food security were being clobbered by AIDS. We were shocked by the human toll, the numbers of orphans, and the pervasive death amongst the female population. In fact, so distressed were we about the decimation of women, that we appealed to the Secretary-General of the United Nations to personally intervene.
And he did. He summoned a high level meeting on the 38th floor of the UN Secretariat, with TV conferencing outreach to James Morris in Rome and to the various UN agencies in Geneva, and after several agitated interventions, the Secretary-General struck a Task Force on Gender and AIDS in Southern Africa, to be chaired by Carol Bellamy of UNICEF.
If memory serves me, Carol Bellamy determined to focus on seven of the highest prevalence rate countries: studies were done, recommendations were made, costs of implementation were estimated, monographs were published. And here's what festers in the craw: the funding for implementation is not yet available. The needs and rights of women never command singular urgency.
There's an odd footnote to this. Within the last two months, a number of senior students at the University of Toronto Law School, compiled papers dealing with potential legal interventions on a number of issues related to HIV/AIDS in Africa. One of the issues was, predictably, gender. Not a single student, over the course of several weeks, whether on the internet or wider personal reading, came across the Secretary-General's Task Force (although one student said that she had a vague recollection that such a thing existed). The Task Force findings are clearly not something the UN promotes with messianic fervour.
I want to remind you that as recently as March, there was tabled, internationally, the Commission on Africa, chaired by Prime Minister Tony Blair ... indeed established by Tony Blair. It has received nothing but accolades, particularly for the analysis and recommendations on Official Development Assistance, on trade and on debt. The tributes are deserved. The document goes further down a progressive road than any other contemporary international compilation.
With one exception. I want it to be known - because it's not known - that the one aspect of this prestigious report which fails, lamentably, is the way in which it deals with women. There is the occasional obligatory paragraph which signals that the Commission recognizes that there are two sexes in the world, but by and large, given that women are absolutely central to the very integrity and survival of the African continent, they are dealt with as they are always dealt with in these auspicious studies: at the margins, in passing, pro forma. And it's not just HIV/AIDS; it's everything, from trade to agriculture to conflict to peace-building.
Maybe we should have guessed what was coming when there were only three women appointed out of seventeen commissioners. They had the whole world to choose from, and they could find only three women ... it doesn't even begin to meet the Beijing minimum target of thirty percent. We're not just climbing uphill; we might as well be facing the Himalayas.
I want to remind you, finally, of the arrangements we've made within the United Nations itself. HIV/AIDS is the worst plague this world is facing; it wrecks havoc on women and girls, and within the multilateral system, best-placed to confront the pandemic, we have absolutely no agency of power to promote women's development, to offer advice and technical assistance to governments on their behalf, and to oversee programmes, as well as representing the rights of women. We have no agency of authority to intervene on behalf of half the human race. Despite the mantra of 'Women's Rights are Human Rights', intoned at the International Conference on Human Rights in Vienna in 1993; despite the pugnacious assertion of the rights of women advanced at the Cairo International conference in 1994; despite the Beijing Conference on women in 1995; despite the existence of the Convention on the Elimination of Discrimination against Women, now ratified by over 150 countries; we have only UNIFEM, the UN Development Fund for Women, with an annual core budget in the vicinity of $20 million dollars, to represent the women of the world. There are several UNICEF offices in individual developing countries where the annual budget is greater than that of UNIFEM.
More, UNIFEM isn't even a free-standing entity. It's a department of the UNDP (the United Nations Development Programme). Its Executive Director ranks lower in grade than over a dozen of her colleagues within UNDP, and lower in rank than the vast majority of the Secretary-General's Special Representatives.
More still, because UNIFEM is so marginalized, there's nobody to represent women adequately on the group of co-sponsors convened by UNAIDS. You see, UNAIDS is a coordinating body: it coordinates the AIDS activities of UNICEF, UNDP, the World Bank, UNESCO, UNFPA, WHO, UNDCP (the Drug Agency), ILO and WFP. UNIFEM asked to be a co-sponsor, but it was denied that privilege.
So who, I ask, speaks for women at the heart of the pandemic? Well, UNFPA in part. And UNICEF, in part (a smaller part). And ostensibly UNDP (although from my observations in the field, "ostensible" is the operative word).
Let me be clear: what we have here is the most ferocious assault ever made by a communicable disease on women's health, and there is just no concerted coalition of forces to go to the barricades on women's behalf. We do have the Global Coalition on Women and AIDS, launched almost by way of desperation, by some international women leaders ... like Mary Robinson, like Geeta Rao Gupta, but they're struggling for significant sustainable funding, and their presence on the ground is inevitably peripheral.
I was listening to the presentations at the dinner last night, and thinking to myself, when in heaven's name does it end? Obstetric fistula causes such awful misery, and isn't it symptomatic that one of the largest - perhaps the largest -contributions to addressing this appalling condition has come not from a government but from Oprah Winfrey?
I was noting, just in the last 48 hours, that Save the Children in the UK has released a report pointing out that fully half of the three hundred thousand child soldiers in the world are girls. And if that isn't a maiming of health - in this case emotional and psychological health - then I don't know what is. And perhaps you notice the rancid irony: women have achieved parity on the receiving end of conflict and AIDS, but nowhere else.
Female genital mutilation, the contagion of violence against women, sexual violence in particular, rape as a weapon of war - Rwanda, Darfur, Northern Uganda, Eastern Congo - marital rape, child defilement, as it is called in Zambia, sexual trafficking, maternal mortality, early marriage ... I pause to point out that studies now show that in parts of Africa, the prevalence rates of HIV in marriage are often higher than they are for sexually active single women in the surrounding community; who would have thought that possible? ...
The overall subject matters you're tackling at this conference strike to the heart of the human condition. All my adult life I have accepted the feminist analysis of male power and authority. But perhaps because of an acute naiveté, I never imagined that the analysis would be overwhelmed by the objective historical realities. Of course the women's movement has had great successes, but the contemporary global struggle to secure women's health seems to me to be a challenge of almost insuperable dimension.
And because I believe that, and because I see the evidence month after month, week after week, day after day, in the unremitting carnage of women and AIDS - God it tears the heart from the body ... I just don't know how to convey it ... these young young women, who crave so desperately to live, who suddenly face a pox, a scourge which tears their life from them before they have a life ... who can't even get treatment because the men are first in line, or the treatment rolls out at such a paralytic snail's pace ... who are part of the 90% of pregnant women who have no access to the prevention of Mother to Child Transmission and so their infants are born positive ... who carry the entire burden of care even while they're sick, tending to the family, carrying the water, tilling the fields, looking after the orphans .... the women who lose their property, and have no inheritance rights, and no legal or jurisprudential infrastructure which will guarantee those rights .... no criminal code which will stop the violence ... because I have observed all of that, and have observed it for four years, and am driven to distraction by the recognition that it will continue, I want a kind of revolution in the world's response, not another stab at institutional reform, but a virtual revolution.
Let me, therefore, put before the conference, two quite pragmatic responses which will make a world of difference to women, and then a much more fundamental proposal.
Many at the conference will not know this, but the Kingdom of Swaziland recently made history when it received from the Global Fund on AIDS, Tuberculosis and Malaria, money to pay a stipend - modest of course, but of huge impact - to ten thousand caregivers, looking after orphans, the vast majority being women. The Swaziland National AIDS Commission (that may not be the precise name), reeling from the exploding orphan population, made the proposal for payment to the Global Fund, and it swept through the review process with nary a word. The amount is roughly $30/month, or a dollar a day .... not a lot to be sure, but clearly enough to make a great difference.
My recommendation is that this conference orchestrate the writing of a letter, to be signed by people like Mary Robinson, Geeta Rao Gupta, and prominent women from academia, and have that letter sent to every African Head of State and Minister of Health, urging them to ask for compensation for caregivers, using the Swaziland precedent.
And the second pragmatic proposal? I would recommend, with every fibre of persuasion at my command, that the conference collaborate directly with the International Partnership on Microbicides, whose remarkably effective Executive Director, Dr. Zeda Rosenberg, will be here on campus on Thursday. She will tell you what she needs and how to go about getting it. The prospect of a microbicide, in the form of a gel or cream or ring, which will prevent infection, while permitting conception - the partner need not even know of its presence - can save the lives of millions of women. The head of UNAIDS, Dr. Peter Piot, who will be known to many of you, recently suggested that the discovery of a microbicide may be only three to four years off. That's almost miraculous: short of a vaccine - and we must never stop the indefatigable hunt for a vaccine - a microbicide can transform the lives of women, and dramatically reduce their disproportionate vulnerability. What's needed is science and money. You can help with both.
On the more fundamental front, I want to suggest that the process of UN reform, now urgently underway, be confronted with arguments that spare no impatience.
I have heard the President of Botswana use the word extermination when he described what the country is battling. I have heard the Prime Minister of Lesotho use the word annihilation when he described what the country is battling. I sat with the President of Zambia and members of his cabinet not long ago, when he used the word holocaust to describe what the country is battling.
The words are true; there's no hyperbole. The words apply, overwhelmingly, to women. That being the case, there has to be a proportionate response. It seems to me that the response should proceed on two simultaneous fronts.
First, let me say that I was thrilled by the suggestion from Mary Robinson, and others, that Penn State act as a kind of coordinator for the surprising numbers of initiatives, unrelated one to the other, occurring under the auspices of many universities. The practice of twinning, the practice of using various Faculties as training centres, the practice of American and Canadian universities bridging the gap in capacity until the developing country can take over ... all of that is to the good, and it needs coordination. But there's more, I would submit, for you to do. Within multilateralism, that is within the UN system, wherein lies the best hope for leadership, there must be a change in the representation of women. There must emerge, for Women's Global Health, and certainly for HIV/AIDS, an agency, an organization, a powerful Think Tank, whatever the entity --- it can start on the outside, and then claim equal presence amongst the co-sponsors of UNAIDS, and thrust its advocacy upon the Secretariat, the Agencies, the member states, in unprecedented volume and urgency. Nor does this entity confine itself solely to women's global health, although that is the entry point. It insists on the 50% rule ... just start your evidence-gathering by identifying the numbers of senior women, agency by agency, secretariat department by secretariat department, diplomatic mission by diplomatic mission, and when you've recovered from the shock of learning that the multilateral citadel knows nothing of affirmative action, then begin your unrelenting advocacy. This must become a movement for social change. It needs leadership. Why not this University, why not this conference? And let me emphasize; there's nothing limiting about this concept. We're looking towards the day when governments are finally made to understand that women constitute half of everything that affects humankind, and must therefore be engaged in absolutely everything. Why would it not be possible to build a movement, committed to the rights of women, in the first instance amongst nursing and medical faculties across the world, and take the world by storm? You have resources, knowledge and influence available to no others. The terrible problem is that you've never marshalled your collective capacities.
Second, a similar movement must be directed, I would submit, to Africa itself. I'm hesitant here, because there are enough neo-colonial impulses around without my being presumptuous in making recommendations for Africa, and indeed for women. But I must bring myself to say what I know to be true: the African leadership, at the highest level, is not engaged when it comes to women's health. There's so much lip service; there's so much patronizing gobble-de-gook. The political leadership of Africa has to be lobbied with an almost maniacal intensity on the issues of this conference, or nothing will change for women.
That, too, will take a monumental effort. In my fantasies, I see a group of African women, moving country to country, President to President, identifying violations of women's health specific to that country, and demanding a change so profound that it shakes to the root the gender relationships of the society. I know that African women leaders like Wangari Matthai and Graça Machel and many prominent cabinet ministers, committed activists and professionals think in those terms; what is needed is a massive outpouring of international support from their sisters and brothers on the planet.
I'm 67 years old. I'm a man. I've spent time in politics, diplomacy and multilateralism. I know a little of how this man's world works, but I still find much of it inexplicable. I don't really care anymore about whom I might offend or what line I cross: that's what's useful about inching into one's dotage.
I know only that this world is off its rocker when it comes to women. I must admit that I live in such a state of perpetual rage at what I see happening to women in the pandemic, that I would like to throttle those responsible, those who've waited so unendurably long to act, those who can find infinite resources for war but never sufficient resources to ameliorate the human condition.
I'm excited of course about the Millennium Development Goals, and I'm equally excited that with the leadership of the British, this next G8 Summit in the summer might just possibly spawn a breakthrough. And there are countless numbers of people working to that end.
But I have to say that I can't get the images of women I've met, unbearably ill, out of my mind. And I don't have it in me either to forgive or to forget. I have it in me only to join with all of you in the greatest liberation struggle there is: the struggle on behalf of the women of the world.