Examination of Witnesses (Questions 181
- 199)
TUESDAY 27 JUNE 2000
MS CAROL
BELLAMY AND
MR MARK
STIRLING
Chairman
181. Ms Bellamy, Mr Mark Stirling, you are extremely
welcome. We are very grateful to you for making the effort to
come along and talk to us about HIV/AIDS which both you and we
are deeply concerned about. We need very much to know in depth
your knowledge and your views on how we should proceed in the
future. We met you last, you will remember, Ms Bellamy, in New
York when we were talking on other matters but I do thank you
for coming this morning. It will help us a great deal in bringing
together this report which we hope will make a difference as to
how we deal with this horrifying epidemic. I understand that you
would each like to make an opening statement.
(Ms Bellamy) Thank you very much. I appreciate
the opportunity to appear before this Committee and we appreciate
the fact that this Committee is taking this issue on because it
has, I think it is fair to say, affected our work very much because
of the implications that it has generally for development. I would
like to make a few opening remarks and then Mark Stirling, who
has held a number of senior positions and is presently the UNICEF
representative in Mozambique, will make a few comments. I am quite
well aware that this Committee is familiar with the statistics
associated with this pandemic so I will not dwell on them although
I probably will mention a couple. I will just say that from UNICEF's
point of view we believe that HIV/AIDS is virtually reversing
the social and economic gains of past decades in many ways and
particularly in the impact it is having on child survival. In
our view HIV/AIDS currently represents the greatest threat to
the wellbeing of children in the developing world and I would
say particularly in Africa but I think it is important to recognise
that while the greatest numbers of people affected and infected
are in Africa this disease is not limited to one continent. In
terms of sheer numbers affected HIV/AIDS has become a greater
threat to children than the sum of armed conflict, malaria, floods
and famine. Young child mortality rates are expected to more than
double in the most severely affected countries of eastern and
southern Africa just over the course of the next few years. Unfortunately,
the first opportunity to address this unfolding tragedy has not
been grasped. Therefore, we believe that if the international
community does not take decisive action now we who are working
to promote development as well as the children of the poorest
countries in Africa, will not have a second chance. Let me touch
briefly on what we see as the impact of HIV/AIDS on children in
very simple terms. First, there is loss of family, love, protection
and care. It is estimated that there are already upwards of 11
million AIDS orphans, that is up from about eight million about
a year ago and it is expected to go to 13 million in the not too
distant future. Ninety five per cent of these orphans are in Africa.
They are subject to discrimination, stigma and abandonment. They
live under psychological and psycho-social distress. They may
be forced to separate from their siblings, to migrate far away
with loss of inheritance. It is a very bad picture. It is assumed
in many cases that these children themselves are not infected,
and they largely are not, but because of that they are often rejected
by their own communities. There is reduced opportunity for schooling
and increased demand for child labour. There is loss of health
care and deterioration in nutrition and diet due to a reduction
in the household income and due to higher health costs. Increased
sickness and malnutrition also occur. As a result of direct exposure
to HIV infection, maternal to child transmission and exposure
to HIV as a result of living on the streets, there is increased
risk of exploitation and abuse and that is particularly so when
it comes to girls. What is UNICEF's response? We have a five point
strategy and I will just tick off the five points. One is mobilisation.
We are trying to mobilise in each country that is affected by
HIV/AIDS a commitment at the highest levels of government and
throughout society. This is not just a government issue, this
is not just an issue that should be parked off in the ministry
of health. This really has to involve society broadly but certainly
starting at the highest levels of government in order to break
the conspiracy of silence and its associated stigma and discrimination.
Number two is prevention; first, prevention of HIV infection among
young people. They are at the centre of the pandemic. We also
believe that is where the hope is, where the potential is, because
young people, unlike we old fogeys (or me at least), young people
are the most open to behaviour change. Involving young people
as actors in the effort to reduce transmission is very important,
not just involving them as subjects but also as actors. Young
people are a force for change among their peers. We need to provide
them with the knowledge that they need to protect themselves and
to make sure that they have access to youth-friendly health services.
We believe the key in this area is voluntary HIV testing and counselling.
Third is prevention also but preventing mother to child transmission
of HIV. Half a million children were infected this way in 1999
alone. UNICEF is involved in providing and supporting voluntary
testing and counselling for pregnant women. Those who test positive
we think should have access to anti-reproviral drugs and advice
on infant feeding. Fourth is care for orphans. We support actions
to strengthen community capacity to identify and respond to the
needs of orphans. They need, as young children do, access to basic
health education and welfare services. Our fifth point is a point
that turns us inward because we also believe it is important to
support our own staff. We as an international organisation, highly
decentralised in the field, have had staff who have been infected
themselves or affected, both by their families being affected
or their friends, and so from internal programmes to trying to
provide family support we believe that is a key component to what
we are doing. We cannot ignore our own staff. I will conclude
by making a brief comment on what we think needs to be done by
your Government and others. The experience in Uganda, in Senegal
and in Thailand as examples, shows that effective response to
HIV/AIDS is possible. What is required is leadership, targeted
programmes, resources and speed. No more studies are needed. Action
is needed. We would urge this Government and other governments
and other leaders to commit to specific goals on HIV/AIDS prevention
and reduction, such as reduction of HIV infection rates among
young people by 25 per cent in highly endemic countries by the
year 2005. We would urge that all G8 leaders confirm their own
Governments' commitment to fight AIDS. We would urge all developing
leaders with whom this Government and others have interaction
to adopt and sustain a commitment to respond to the pandemic of
HIV/AIDS. We would urge that this Government uses its considerable
influence amongst the Bretton Woods institutions and other multilateral
institutions to make sure that HIV/AIDS is treated as a core concern.
Thank you.
182. You have covered many of the headings that
we have in our own briefing, but we will go through them in greater
depth. Mr Mark Stirling, you would like to say a few words.
(Mr Stirling) I think the reason I am here is that
I have spent the last 20 years in Eastern Southern Africa. The
course of my own life, my family life, but also my professional
life has been to accompany an unfolding tragedy which is taking
place of unprecedented proportions within that region of the world.
I started my career 20 years ago in Uganda and I have worked down
through most parts of eastern and southern Africa and have quite
a strong experience of working in this area. There is absolutely
no doubt that the impact of HIV is having a devastating effect
on the lives of everybody. It is devastating families and communities,
it is overwhelming health and other care systems, it is robbing
schools of teachers and denying children their education. Businesses
have certainly lost. Their personnel have become sick, they have
lost productivity, they have lost profits. Economic improvements
and growth have also been undermined by the same dynamics. Clearly
out of this development resources which could have been mobilised
to support sustained human development within this region, to
build peace and development, are being lost; they are being diverted.
In Mozambique where I live and work now some 50 per cent of today's
15-year-olds in Maputo are expected to be dead because of AIDS
by the age of 45. That is the reality not just of Maputo, of Mozambique,
but also of most of Southern and East Africa. Death rates are
extortionately high. In a country like Mozambique where we have
less than 10,000 kids in secondary school we are talking about
losing half of those young people. Is it possible for Mozambique
to develop the leadership, the technical expertise, the professional
capacities, the workers, required to sustain the leadership and
the economic progress, the security and stability of that country?
Clearly not. It is a tragedy and something which is having direct
and very severe impacts on life and stability. The question that
therefore arises is that if this pandemic is having such a huge
and devastating effect, why has there not been a response? Why
are we now, 20 years after the beginnings of this pandemic, having
sessions like this to try and work out what more we can do to
trigger a response which is adequate? Thinking in the future,
I am sure historians will dwell on these years and will probably
be probing why the human cost had to become so high before an
adequate response was mounted. They are going to question very
seriously what was done, what more could have been done, by local
and national leaders, and by the international community. The
international community does not have a passive role but what
more could have been done by them to respond? These are the issues
which now need to be faced by this group and by all of our governments.
With over two decades of work involved with the pandemic people
know what works and what needs to be done. Experience of a number
of countries where there has been significant change, particularly
in Uganda and other countries have shown that HIV infection rates
can be reduced, they can be significantly affected through investing
in information and life skills education for young people, by
promoting abstinence, safe sex and the use of condoms, by ensuring
early treatment of sexually transmitted diseases, by ensuring
that young people have access to voluntary and counselling testing
services to deal with HIV. We have also increasingly added the
importance of addressing issues of stigma, discrimination, of
creating empowering and enabling environment for people to address
HIV in their own lives. The question therefore stands. If we know
what works, why have we not done it? What have been the critical
constraints to governments, to communities, to take exceptional
action to address an exceptional threat? Perhaps part of the answer
to this lies in the fact that HIV and AIDS is largely about sex,
sometimes infidelity, unfaithfulness, and sometimes about sin.
It is about issues which many of us have a great deal of difficulty
with and have been conditioned not to talk about frankly, openly
and publicly. The reluctance and the discomfort of leaderships
are clear, but also those leaderships have clear responsibilities
to provide counselling, confidence and strength in times of danger
and need and this is in fact one of the greatest leadership challenges
which this century and the end of the last were confronted with.
In the early years of the epidemic very few leaders spoke out,
particularly in Africa, about HIV. We had the comments of Kenneth
Kaunda when he lost his son in the late 1980s, and Musebeni a
bit later on, when he started to see the impacts on the security
and development of Uganda, also became a strident strong leader.
But very few others followed. It is only recently, this last year
in fact, when we have seen much stronger signals from leaderships.
It is increasingly becoming a public issue. Statements of declarations
of states of emergency, wars of liberation against AIDS have now
been declared. This year in Africa the OAU, SADC, have dedicated
special sessions to talking about leadership and the Economic
Commission for Africa is holding a very important meeting in October
this year to talk about AIDS and the leadership challenge within
Africa, not just in government but also in civil society and the
private sector. There is a movement there amongst leaderships
in Africa to act on HIV and AIDS. It is hesitant, stronger amongst
some than others but there is a momentum developing. This is an
essential recognition. Another reason why there has been a lack
of action is that very often leaderships have lacked information
about the epidemic, about its impacts and about its consequences.
In the past there has been very little investment in surveillance
systems to understand the epidemics, impact studies were few,
and little attention has been devoted to monitoring and researching
the dynamics of the epidemic, and even less to monitoring and
understanding the effectiveness of responses. In recent years
these information gaps have been addressed, so there is movement
on this front. We now have more committed leaders, more aware
leaders, within Africa. In many countries in Africa plans have
been developed but their implementation has been extremely weak.
In most cases they have been under-resourced and this is a major
reason why the implementation has been weak. Very often, because
of a lack of resources dedicated to these issues, HIV has been
overshadowed by other, more pressing priorities, for example regional
wars, which have much less general cost than AIDS. To illustrate
this, during the 1990s there was a considerable reduction in the
amount invested in HIV. As the epidemic went from around 10 million
HIV positive people at the beginning of the 1990s to around 30
million HIV positive people at the end of the 1990s, investment
per person dropped from around 17 dollars per HIV positive person
at the beginning of the 1990s to about nine. Support within government
and also the international community largely failed. It has only
been this last year or two when there has been, through the international
partnership against AIDS, a recognition of the immensity of the
problem and the need to mobilise additional resources. I am sorry
for taking a long time but please bear with me for some more minutes.
The point I am trying to stress is that while national leaderships
are ultimately responsible for leading the fight against AIDS,
the experience of recent years has also shown that effective responses
require a very clear committed and sustained partnership of national
level leaders and international partners. They require this because
of the size of the problem, because of the complexity of the problem
and because of the importance of sustained solidarity in responding
to this threat. Over this last decade within Africa we have seen
a number of countries going through very difficult reforms, economic
and political reforms, which are now proving to be successful.
In a number of countries good progress has been made in bringing
about macro-economic stability. There has been progress made in
liberalising economies, in introducing Civil Service reforms,
in bringing about improvements in governance. Whilst certainly
these countries have been able to bring about these changes because
of strong leadership, it is equally true that it was required
because of strong international partnership, through particularly
organisations like the International Monetary Fund, the World
Bank, the G8 nations and donor supporters through consultative
groups, to find with countries certain development priorities
to address and then, often with some pressure and force, help
those governments develop the necessary decisions and the political
frameworks, the policy structures, required to address this work.
We saw this kind of international solidarity work in the anti-colonial
struggle. We saw it bring down apartheid. It is the same kind
of relationship of national and international forces and solidarity
which is required to address AIDS. If this is so then what I am
really calling for is a much stronger role of international partners
working with national authorities to bring about policy changes,
to put much more resources behind those national governments,
to work with civil society leaderships, the media, lobbying groups,
particularly people living with HIV and AIDS, so that they become
active pressure groups to ensure sustained priority on the issue
of AIDS. We need to move beyond an emergency declared in rhetoric
to an emergency declared in physical resources and I believe that
the Government of the United Kingdom and its people have a very
important role in not just stating this as an emergency but actively
working alongside affected countries to mobilise the resources
and decisions required to address it.
183. Thank you very much. We will be looking
at many of the issues you have raised in your opening statements
in our questions. There are one or two points of clarification
which we should start with. What are "children" in UNICEF's
definition?
(Ms Bellamy) We are guided by the Convention on the
Rights of the Child, so we define the child as an individual up
to the age of 18.
184. And what is an orphan?
(Ms Bellamy) We define an AIDS orphan as a child who
has lost either the mother or both parents to HIV/AIDS.
Chairman: That is interesting because
in this country we normally mean the loss of both parents but
that is a good point.
Mr Rowe
185. Ms Bellamy said, I thought, that while
the numbers of people infected in Africa were higher than in other
continents, my understanding was that the actual numbers infected
with HIV are higher in India than anywhere else.
(Ms Bellamy) I do not think we have that kind of data.
(Mr Stirling) The answer at the moment is no. The
large proportion of HIV positive people live in Africa but because
of the size of the population of India, once they have developed
the momentum of HIV infection they will have the greatest problems.
186. They will have? They have not got it now?
(Mr Stirling) No, not yet.
(Ms Bellamy) To the best of our knowledge. I would
say both India and China as well because it is an issue in China.
Mr Rowe: That is interesting. We have
had some evidence which conflicts with that.
Chairman
187. Can I first of all engage you in some questions
on the incidence and prevalence of HIV/AIDs amongst children?
What is the rate of new infection of HIV/AIDS amongst children
and how does it compare with the incidence amongst adults?
(Mr Stirling) The prevalence amongst adults in Africa
ranges very considerably, but within East and Southern Africa
we are talking of prevalence as slightly under 20 per cent, one
in five. This can range in some areas and some places, like northern
Botswana and Francistown, up to a prevalence amongst antenatal
attenders, pregnant women, of 60 per cent. Certain populations
and certain groups have extremely high prevalence rates. Amongst
adults generally it is around 20 per cent. As regards children
and infants, through vertical transmission roughly one third of
infants born to HIV positive mothers will acquire HIV, and of
that one third, which is round about 500,000 to 600,000 in the
world, roughly two-thirds will acquire it during pregnancy and
delivery, and the other third will be exposed to HIV through breast
feeding.
(Ms Bellamy) There are really two peaks of infection
of children. The first is children under the age of two years
old and this is due to mother to child transmission. The second
in children, which is particularly girls, is between the ages
of 12 and 18 and this is generally due to sexual transmission.
188. There is a difference between girls and
boys and that takes place after the age of puberty?
(Mr Stirling) There is HIV transferred through sex,
not through vertical transmission.
189. Is there a relationship to poverty? You
say there are differences in regions which you cannot explain,
I gather, but is it related to poverty?
(Ms Bellamy) Yes, I would say it is related to poverty
but there are a number of other factors. Poverty is going to create
an environment where probably your services are lacking or your
access to youth-friendly services are less, the potential for
violence is greater, the information that a pregnant woman might
have available to her, nothing exists in its entirety in those
communities that are most poverty stricken, but also children
who are affected by some other way, children who are internally
displaced, there are a number of other kinds of factors that are
also contributing to this.
190. Is there a difference between urban and
rural areas?
(Mr Stirling) Like every question, it is yes and no.
On the issue of poverty, it is about poverty but it is also about
disparity. If we look at the infection trails of how the pandemics
or the epidemics have grown in Africa, they are largely working
down the major transport corridors and the economic routes of
that continent. We are also seeing that the epicentre of the highest
levels of infection are around some of the richest areas of Namibia,
Botswana, South Africa, or some of the richer areas before, such
as Zimbabwe. It has got a lot to do with the movement of people,
of man mobility and money. It has also got to do with poverty
in terms of disparity. Young people and particularly young girls
are extremely vulnerable to HIV infection if they are poor because
of transactional sex, because of the need to survive. There is
a whole lot of things which relate to poverty within disparity
which make people more vulnerable to HIV infection.
(Ms Bellamy) I do not mean to drag this out but I
want to add one other thing to that because it is very important
to recognise that the impact in many countries is hitting very
much at that middle income community in many cases, the loss of
teachers, the loss of doctors, the loss of civil servants. That
does take it in some cases beyond it just being a matter of poverty.
With respect to the issue of urban and rural, I think the assumption
has been to date that it is more likely to be found in urban settings
but, as Mark says, it is yes and no. I believe that just this
week, and I must say I have not read it myself, there has been
a report issued that was co-authored with the UN AIDS Secretariat
and the Food and Agriculture Organisation, which indicated we
must not ignore the rural areas. I do not think they said it was
only in rural areas but that more attention has been given to
urban areas and that rural areas should not be ignored because
the prevalence of HIV/AIDS is growing there as well.
(Mr Stirling) There are different things also fuelling
the epidemic. Although much of it has been certainly on urban
transport corridors, civil conflict and displacement of populations
have fuelled it in large rural areas. For example, in Mozambique
during the war there was large scale displacement into Malawi,
into Zambia, into Zimbabwe, people went into those congested refugee
centres, and infection rates were extremely high. They returned
to rural areas. In Tete province, for example, in Mozambique,
85 per cent of the rural population was displaced and they have
gone back into rural areas. It is a similar dynamic that we have
seen taking place now in the Democratic Republic of Congo, the
consequences of war and how that fuels infiltration of the epidemic
into rural areas.
191. The sense of what you are both saying is
that whilst it may be spread in urban sectors, it is transposed
into rural areas by the people returning to their villages. As
I understand you, it is not being generated in the villages but
it is in the transmission to the villages.
(Mr Stirling) Where there is concentration or movement
of people is the one of the major exciters of HIV.
192. Is there an estimate of how many children
are dying each year from AIDS and how many adults are dying who
were infected when children?
(Ms Bellamy) I think we have the estimates. The latest
estimates I believe are being issued today or tomorrow out of
the Secretariat of UN AIDS. In terms of child deaths in children
living with HIV/AIDs in terms of 1999 estimates, we were talking
about 1.2 million; child deaths for HIV/AIDS in 1999, about half
a million, the cumulative number of child deaths as at the end
of 1999 was 3.6 million, and again it was estimated that in the
course of 1999 you had almost 600,000 children infected. These
were the estimates as of the most recent reporting. I think there
will be some slight updating of those numbers with the new material
that has come out from UN AIDS. We do not have it because it is
embargoed but it will come out over the next couple of weeks because
it is coming out in anticipation of the major conference in Durban
on HIV/AIDS which will take place in a couple of weeks. That is
giving you the trend. The likelihood is that there will be a slight
upward reassessment of those numbers.
Mr Worthington
193. Can I ask about the reliability of the
figures? We were hearing last week from South African people who
were giving evidence to us and they said that with regard to cause
of death the cause of death for the patient might be pneumonia
but there would be a tear-off slip which would be "HIV/AIDS-related".
What is happening in terms of knowledge about why people are ill,
because there has been a lot of concealing of HIV? Where do your
figures come from? Have you got causes of death or incidence?
In many cases you do not test for AIDS because that would keep
mothers away from the clinic. How reliable are these figures and
are we seeing something which is still under-reported rather than
over-reported?
(Mr Stirling) I think that is very much the case.
Ten days ago I was in Chimoio Hospital which is on the border
of Mozambique and Zimbabwe, and I was shocked to find that in
the ward there AIDS deaths are a third of all children admitted
to that hospital, but they were the only ones who were tested.
The estimate of the nurse was that all of the malnutrition which
that hospital is seeing, which is roughly another quarter of deaths,
were also HIV-related. There is huge under-reporting of the specific
cause of death because testing of HIV is so restricted. All of
these estimates which we are working with from UN AIDs and from
national systems are based on models, on surveillance systems
established within those countries and also on the case reporting.
Then a professional judgment is taken in trying to draw that picture.
I think that for people to say therefore there is a tendency to
be over-estimating the problem, and this is obviously an issue
which is raised by many, I think very much underestimates the
magnitude of the problem. The way forward on this must be strengthened
surveillance, sentinel site surveillance of infection rates and
amongst particular population groups. There must be also, probably
equally importantly, increased access to counselling and testing
services so that not only health providers but also individuals
know their status.
194. Is there not also a case, so that we know
about the reliability of the figures, for UNICEF to be having
a global policy about the recording of deaths and the way in which
the disease is monitored? At the moment it would seem each country
is going about it to some extent their own way because of the
problems associate with stigma and backing away from the problem.
(Mr Stirling) I am not sure what the answer to that
question is, but certainly it is something which needs to be worked
through.
(Ms Bellamy) I am not sure what it is either but it
might be something in the context of the UN AIDS collaborating
agencies. It might be something that we ought to take into consideration.
195. Can we move to preventive education and
support issues? The message that comes across in terms of prevention
is that there are two ways of prevention of disease. One is abstinence
and the other is condoms. How safe are condoms?
(Mr Stirling) I think you probably need to get this
answer qualified by somebody who knows, but I think it is 99.6
per cent or something. They are basically safe. We need to get
that checked.
(Ms Bellamy) You said either abstinence or safe sex,
but there is just a basic lack of knowledge and information in
some ways that one has almost to deal with even before that. You
talk to young girls and they say, "Can you get HIV/AIDS from
this man who looks healthy?" "Well, no, not if he looks
healthy, I cannot." This is a desperate lack of information
and lack of knowledge that one has to get through in the first
place, and in language and in ways that young people will understand.
(Mr Stirling) There is also a third option which you
did not raise which is abstinence, fidelity, and safe sex if you
are having multiple relationships.
196. There are many forms of sexual activity.
Are we only concerned with penetrative sex and the use of condoms,
or does the message need to be more complicated than it has been
so far?
(Mr Stirling) A number of more enlightened leaders
have talked of other ways of sexual fulfilment which is not penetrative
sex, yes, so that is something which has been talked about by
people involved within the struggle against HIV. Certainly that
is an alternative.
197. I am also puzzled by the emphasis on the
male condom and the lack of reference in the text to the female
condom in terms of tackling the spread of HIV/AIDS. Am I wrong
to be puzzled?
(Mr Stirling) No, I do not think you are wrong to
be puzzled. I think it has been easier and there has been more
experience of working with the male condom. It has also been considerably
cheaper. There has not been sufficient effort to expand the use
and adoption of the female condom and I think there has been linked
with that some concern over the higher cost, but again I think
there are probably people who can deal with this directly.
198. In terms of the vulnerability of women,
it just seems very strange that there has been so little emphasis
upon giving women power.
(Mr Stirling) It is true in that the level of development
in providing women with the tools to have control and safety in
their sexual lives is much less. Certainly within UN AIDS in the
work of the co-responses there is a specific programme of research
and support to improve the use of spermicidals, of the female
condom. You are correct in that there needs to be much more work
done in this area, like in many other areas.
199. Do you not feel that UNICEF should be leading
the way on this?
(Ms Bellamy) On the female condom are we talking about
at this stage? I think of the agencies on the ground we are, if
not the most, one of the most active agencies on the ground, but
I think that we probably could be doing more in a whole range
of areas. I look at the difference between what we are doing this
year as contrasted with a year ago. I said to myself, maybe I
should have done more, but I say why were we not doing more then?
This pandemic is virtually changing our activities in countries
around the world, obviously more so in Africa right now, but we
are designing our programmes with the governments around this
issue now. It has just become such an all-encompassing matter.
Yes, probably there is more but there has been an enormous movement
in the last year.
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