From: matthew@ooc.uva.nl (Matthew Lewis)
Subject: Conference Newspaper - Thursday 23 July - part 3
Note: non-commercial reproduction.
Archive-Number: 5775
Organization: Center for Innovation and Cooperative Technology, University of Amsterdam
Date: 24 Jul 92 12:47:23 GMT

(article continued from part 2)

Debrework Zewdie, Harvard University Center for Population 
Studies/ Steering Group of the Global AIDS Policy Coalition

...

"I didn't sell my daughter. She saw me suffer and she wanted to 
help. It was when we were about to lose our ricefields because of 
the drought that my daughter decided to go. I couldn't stop her. I 
have nothing better to give her."1 
This girl was probably little more than 12 when she went to work 
in a brothel in Bangkok or one of the other large towns in Thailand. 
Thousands like her tread the same path every year, sold by their 
parents into prostitution, to help their families earn enough to 
survive.
Stories such as hers have led to a growing belief that poverty is 
fuelling the spread of HIV. Lars Kallings, advisor on policy and 
scientific affairs to the director of the WHO's Global Programme on 
AIDS, says: "The economic situation of these families gives them 
little option but to send their children to work in the big cities." 
AIDS is not solely a health problem, it is also an economic problem. 
It has both economic consequences and economic causes. 
Poor people are more likely to resort to behavioural strategies that 
put them at risk of infection; poor countries, already crippled by 
debts, may not have the resources to mount the health and 
education services that would help combat the spread of the virus. 
Connection
Many AIDS researchers are firmly convinced of the connection 
between poverty and AIDS. In the least developed countries, the 
annual per capita budget for health is about $3. Lack of funds leads 
to inadequate health services - and numerous studies have 
suggested that lack of money to pay for diagnosis and treatment of 
STDs is contributing to the spread of HIV. 
Many researchers also blame poverty at the individual level for 
creating conditions that foster the spread of HIV. Debrework 
Zewdie, a member of the steering group of the Global AIDS Policy 
Coalition, points out that the group at highest risk in Africa is 
prostitutes. Almost all the prostitutes she has worked with in 
Ethiopia took this option because they could not survive otherwise. 
Men go to prostitutes when they are forced to leave their homes to 
look for work, Zewdie says. Because the family is so short of money, 
the wife also often resorts to prostitution. 
"But poverty is the initial reason why the family splits up." 
Malcolm Potts, president of International Family Health, a British 
charity concerned with family planning and AIDS prevention, says 
there is a clear link between poverty, exploitation of women and 
heterosexual spread of AIDS. Women and girls are bought and sold 
like cattle in many parts of Asia, he says. "Some are captured, some 
are sold by their families, others have been deserted by their 
husbands or partners and they need to support their children. 
Selling sex is the only choice they have." 
Other researchers point out that some women struggling for 
economic survival must pay with sex to get their produce on a lorry 
into town or across the border. 
Kallings says examples such as these show that encouraging people 
to modify their sexual behaviour will have little impact on the 
spread of HIV unless the reasons why they behave as they do are 
also addressed. "It is meaningless to educate children who have 
been sold to brothels to have fewer sexual partners; what must be 
tackled is poverty, the underlying cause." 
It is no coincidence, Kallings says, that the HIV pandemic has hit 
subSaharan Africa so hard and that the virus is now spreading so 
rapidly in many Asian countries. Of all new HIV infections, 90 % are 
in poor countries. 
Anecdotal evidence of the kind quoted above is not enough to 
satisfy economists, however. Mead Over, economist in the 
population and human resources department of the World Bank, 
says: "I agree that there is evidence from Nairobi, for example, that 
the prostitutes who charge the least have the most sexual 
encounters and are at greatest risk of HIV infection. But it is also 
true that in study after study, the prevalence of infection in men is 
greater at higher income levels. It is almost certainly false to say 
that poverty causes AIDS in men." Over says the female partners of 
the more educated men were similarly shown to be at higher risk 
of HIV infection than the female partners of less well-educated 
men.  
One hypothesis, Over says, is that sex is a desirable commodity and 
that as men have higher incomes, higher educations and higher 
social status, they consume more of it. A recent study by the WHO, 
he says, looked at the average sexual behaviour of four groups of 
men - uneducated, primary-educated, secondary-educated and 
university-educated - in four African countries. It found that the 
higher their level of education, the greater the number of casual 
sexual partners the men had had in the past 12 months.  
Even among women, the possible links between poverty and AIDS 
are much more complex than they might at first appear, Over says. 
"To single out poverty as the cause of frequent sexual partner 
change is an unfortunate oversimplification." While it is true, he 
adds, that poor women might turn to prostitution as a survival 
strategy, in the past prostitution has been a mechanism to save 
them from poverty. In some cultures, many single women with 
children have supported themselves by receiving gifts from several 
regular sexual partners. Ironically, reduced demand by men for 
sexual partners because of AIDS could act to increase their poverty. 
Education
He also points to a study by himself and Peter Piot of the Institute 
for Tropical Medicine in Antwerp, which showed that 
seroprevalence rates in urban centres were likely to be higher in 
cities where there was a lower ratio of women with secondary 
school education to men with secondary school education. In 
addition, the lower the ratio of women to men (in the age group 20 
to 29) in the city, the higher the seroprevalence rate. 
Over says: "It seems that if there are a greater number of women 
relative to men in urban centres, there is more scope for normal 
partnering and less need of prostitutes." Women with secondary 
school education are more likely to have other opportunities to 
earn money  than through prostitution. 
Such studies suggest to Over that a longer term policy to reduce 
the spread of HIV should include measures to improve the 
education of women and create more job opportunities for them in 
urban centres. The latter strategy would not only reduce the 
likelihood of their taking up prostitution, it would also attract more 
women to the cities, helping to reduce the imbalance in the sex 
ratio there. 
Many of the countries in which HIV has spread or is now spreading 
so rapidly are burdened by debts (see sidebar). Kallings believes 
that attempts by the World Bank and the International Monetary 
Fund to assist such countries by en-couraging a market economy - a 
process called structural adjustment - have often had adverse 
effects on health and education services.  
Kallings says: "Governments forced to cut expenditure for these 
reasons have cut in 'soft' areas such as social services, education 
and health, rather than in national security, the police and the 
army. So the areas that suffer are exactly those ones which need to 
be strengthened to prevent the spread of HIV." 
Gill Gordon, who works in the AIDS Prevention Unit at the 
International Planned Parenthood Federation in London, says many 
people in Ghana blame the deterioration in the health service on 
the structural adjustment policies that the government had to 
follow as a condition of its loans from the World Bank. 
Cuts in education services can also have a detrimental effect on 
efforts aimed at preventing the spread of HIV, Kallings says. 
Education on STDs and how to prevent them should start at school, 
he says. "But in many of these countries, children do not go to 
school every day and then only for a few years. Many parents cannot 
afford to send their children, particularly not the girls." 
Some ministers of state lay the blame for cuts in health and 
education services squarely on the structural adjustment policies 
they have had to comply with. Dr James Mokumbi, Minister of 
Health in Uganda, recently told the BBC's Money Programme: 
"Some measures dictated by structural adjustment are so harsh that 
it becomes very difficult to run some of the social services, like 
health delivery. If a budget has to be trimmed by 60 to 70 % just to 
measure up to the requirements of structural adjustment, then one 
sees how difficult it is to deliver services." 
Despite such accusations, the World Bank says it is up to 
governments who receive its loans to work out how to balance their 
books. John Clark, international relations officer with the bank, 
who used to work for Oxfam, says: "The World Bank can give advice, 
but it is up to the government concerned whether it takes that 
advice. Very often the bank and the IMF will advise cutting the 
military budget, cutting spending on prestigious projects such as 
conference centres and subsidies that go to the rich, and 
increasing taxes on the rich. 
Unpalatable
But governments might find that these measures are unpalatable to 
the rich and powerful people in their countries, many of whom pay 
much lower taxes than people in many industrialised countries. So 
they cut other services that benefit the poor, who have a weaker 
political voice." 
Yet some adjustment is necessary and should be tailored to help the 
poor, he says. 
Michael Walton, economic advisor at the World Bank, says the bank 
has, since last year, had a policy of taking the impact on the poor 
into account when designing its structural adjustment programmes. 
He says recent loans have had explicit conditions on them that 
education and health budgets should be protected. Many 
economists are quick to point out that countries do not become 
impoverished because they took out loans; they took out loans 
because they were poor. Rather than trying to prove that structural 
adjustment has caused health and education services to collapse in 
many developing countries, they say, it is more helpful to look at 
how much more countries could do for their
populations if they were relieved of their debts. 
Over, however, dismisses the idea that debt relief would play a role 
in making prevention more effective. Studies by the World Bank 
have shown that three measures are cost-effective in preventing the 
spread of HIV: treatment of STDs, education and information 
programmes targetted at groups who are highly sexually active and 
screening of donated blood (in areas where seroprevalence is quite 
high). 
These interventions are more cost-effective than mass information 
campaigns about AIDS and, in many cases, than many other health 
care measures, including those to tackle malaria, Over says. "So the 
trick is for countries to reallocate expenditures in a much more 
targetted way. Doing that would have a very big impact on the 
epidemic - and on the epidemic of orphans 10 years from now." 
And one can argue, he says, that the amounts of money involved 
come nowhere near the national debts of many severely affected 
countries. 
Would countries be more likely to devote resources to such 
interventions if they were relieved of their debts? Over says: "In 
general, anything that releases the budget constraints of developing 
countries can be useful - provided that the extra money released is 
spent wisely."  
On that point, Zewdie agrees with him. She says: "Getting rid of 
debts would be appreciated but on its own it would not be enough. 
Social and economic changes in these countries are mandatory if 
we are to make any dent in this epidemic. Unless countries admit 
that the status of women is a problem, then we are just window-
dressing the whole issue." She remains adamant that poverty is at 
the root of much of the behaviour that spreads HIV. "No one has 
tried to put the two together and come up with cause and effect. 
That does not mean that the link is not there."
	
1 Sanisuda Ekachai. Behind the smile: voices of Thailand. Thai 
Development Support Committee, 530 Soi St Louis 3, South 
Sathorn Road, Bangkok 10120, Thailand. 

***********

FACTFILE ON DEBT

% The debt of subSaharan Africa is currently around $150 billion, or 
100 % of these countries' gross national products.

% Africa has 9.5 % of the world's population, but between 1960 and 
1989, the continent's share of global GNP dropped from 1.9 % to 
1.2 %.

% In 1983-1989, rich creditors received $242 billion in net 
transfers on long-term lending from indebted developing countries.

% Between 1985 and 1989, the International Monetary Fund's net 
contribution to subSaharan Africa was to drain an average of $700 
million a year.

% Total African debt grew by 10 % a year throughout the 1980s.

% Only one quarter of aid goes to the 10 countries that together have 
about three-quarters of the world's poorest people.

% Plans for official donors to forgive debts have been suggested, but 
little action has been taken.

% Under the "Trinidad proposals", two-thirds of the debt would be 
cancelled and the rest rescheduled over 25 years, with a five-year 
period of grace.

Source: Human Development Report 1992, UNDP, Oxford 
University Press, 1992.

***************

Human rights violations: 
part of life when you're HIV-positive 

For HIV-infected people in Asia or Africa, fear of job loss and 
ostracism loom large if their infection becomes known. Infected 
intravenous drug users face inhuman treatment in any country, 
especially from the prison system. In developed countries, 
violations of personal rights can be on a more subtle and individual 
level.  By Simon Rozendaal.

...

John Mordeaunt:
On the edges of society

In 1986, John Mordeaunt was not at all prepared to hear that he 
had AIDS. "There was no pre-test counseling or anything like that. 
The doctor just walked in, told me I had AIDS and knocked me out 
with a valium injection." For Mordeaunt this was one more way of 
violating the human rights of drug users. He knows. For many years 
Mordeaunt was a member of the drug scene in Dublin, Amsterdam, 
Paris - all over Europe.
"Drug users live on the edges of society. Therefore their human 
rights are offended all the time. The seropositive person most 
likely to be locked up is a drug-user. Go to New York City. You see 
latino and black drug users with AIDS literally dying in the streets. 
Users in prison can choose between solitary confinement and an 
HIV test - whether they want it or not."
After he found out that he had AIDS, Mordeaunt says it was over and 
done with heroin and cocaine. "That diagnosis snapped me out of 
15 years of drug use."
Mordeaunt, who now lives in London, battles for the civil rights of 
drug users with HIV. His activism was inspired by a brief and not-
so-pleasant visit to China. "As soon as I was diagnosed with AIDS I 
decided to fullfil a life-long ambition: to take a stroll on the Great 
Wall, the only man-made structure you can see from space."
He went in the spring of 1987. Four months before going he called 
the Chinese embassy in Ireland and asked if someone who was HIV-
positive could visit China. No problem, they said. Mordeaunt got his 
visa and left.
The first day, while walking on the Great Wall, he had a small 
accident and was taken to a special clinic for infectious diseases. 
There, he was interrogated for six hours.
"They kept shouting at me: we do not want AIDS in China. No AIDS 
in China." Although he had already told them he had AIDS, they 
took a blood sample. "Because of my drug use it is not easy to find 
my veins. They had to hold me with five men. I do not know what it 
is like to be raped but I suppose this was something like it."
Mordeaunt, who holds an Irish passport, was expelled from China. 
A Boeing 747 flew him to London. The plane was completely empty 
except for the crew and Mordeaunt. "When I asked for something 
to eat, it was put on a plate and broom-handled to me."
Mordeaunt documented his experiences in a book called Facing Up 
to AIDS, and helped to form self-help groups for drug users. "I had 
the feeling a whole country had spat on me."

(article continued in part 4)
-- 
Matthew Lewis, University of Amsterdam		Grote Bickersstraat 72
+31-20-52 51 220				1013 KS  Amsterdam
Internet: matthew@ooc.uva.nl			The Netherlands
Newsgroups: sci.med.aids