Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 200 - 219)



Mr Khabra

  200. Going back to the previous question, when we were in Mozambique we were told that when there were deaths which took place because of HIV/AIDS in rural areas people were very reluctant to accept that it was because of HIV/AIDS. Therefore, those deaths were not recorded as due to HIV/AIDS. What are you doing about the number itself, that the number is not recorded as death by AIDS?
  (Mr Stirling) The critical issue that we need to address is to enable a much more public and open discussion about HIV, publicly but also within our own lives. Unfortunately, the reality exists that for people who are HIV positive they very often experience violence against themselves and exclusion. They pay for being public in the admission of their own HIV status. It is part of their protective strategy that people do not come out and declare themselves. Amongst doctors there is a reluctance to tell people that they are HIV positive. This has been experienced as well. At the bottom line much of this is that there has got to be the creation of a more supportive environments for HIV positive which means encouraging some people who are HIV positive to take a much stronger role in talking about providing peer education and of mobilising religious leaders, Christian and Muslim leaders to talk about these issues and give their people confidence in dealing with HIV. The issue of whether deaths are directly recorded as AIDS or not is important that there be an acknowledgement of the damage that AIDS is doing within our society and within our families. AIDS however is an acquired immunity deficiency syndrome which allows something else to kill you. It is the combination. This enables your death to be due to TB, to malaria, to pneumonia. While I think that I would not be particularly concerned about having this announced as an AIDS death, I think it is very important that people acknowledge that this death was underlain by AIDS and that could have been prevented and better care could have been provided if we were more open and honest in dealing with HIV.


  201. Clearly we have got a long way to go, have we not?
  (Mr Stirling) We have a long way to go.

Mr Rowe

  202. Until that last comment of yours I have been very struck by the fact that witnesses who have come before us and people who have sent us memoranda virtually never mention the faith communities at all. Given that, for example, when we were in Rwanda, even despite the lamentable record of most of the churches in that genocide, still some colossal proportion of the population went to church every Sunday, it does seem to me that they are central to dealing with this issue. I wonder whether you would like to tell us a little bit first of all about how helpful they are because in many areas of the world a lot of what they teach and the way they go about these things is positively unhelpful, it seems to me, and secondly, what is actually happening? What are the United Nations family doing to mobilise and assist the faith communities, which are still much the best way of communicating in large tracts of the developing world, to play a positive part in this?
  (Mr Stirling) From my experience working at a country level what has UNICEF done with other organisations? There is a considerable investment in time, talking to bishops, to imams, to religious leaders about HIV and the leadership roles of those influences. There has been very considerable progress amongst many of these people in gaining their support and active participation in that struggle. At the base much of the discussion very often comes back to the role of the Catholic church and the Catholic church's position on the use of condoms and contraceptives. Whilst at the level of bishops our experience has been that they will not condone the use of condoms and they will not make public statements, what we have seen is people working at the base helping people deal with contra infection, maybe not with contraception but with finding ways to enable people to have access to these essential services. I know sisters, I know nuns, I know fathers, who walk around with pockets full of condoms. The church has found ways to deal with these contradictions within their body. In some of our work it has been, "Do not antagonise the top if the bottom is doing good work and only address the top if there is critical constraint which is stopping those people at the base doing work." Some of the challenges within Africa I feel at the moment are much more amongst Muslim communities and also amongst some of the fundamentalist Christian groups which have now emerged, which are much more conservative and self-righteous in their positions and so much more unforgiving in finding ways and solutions to enable particularly young people to live in safety.
  (Ms Bellamy) I think that is an accurate reflection globally, what Mark has just said, when I think about some of the activities in Latin America and also in Asia.

Ms King

  203. First of all could I apologise that I am speaking in a debate shortly and cannot be here for the whole morning. I want to pick up on two points. The first was that, Mark, you mentioned that during the nineties there had been a reduction in the amount of investment spend per person on AIDS. For the purposes of our report it would be helpful for us to know—and you might not have the figures now but when you do have them perhaps they could be passed on—if that remains the case given the exponential increase in the numbers affected by AIDS. In other words is there today still a reduction per person infected with the virus as compared to 10 years ago? On the second point, coming back to the female condom, I remain staggered that research is not going into this more. I asked the previous witnesses about that and they mentioned that there might be medical impediments, but I find it impossible to believe that if you can put a man on the moon you cannot work out a female condom that can work, say, for a week at a time if not a month at a time. Could UNICEF pick this up as an issue to take forward?
  (Ms Bellamy) We keep being asked this. We can raise it. Scientific activity and medical research is not an area that UNICEF necessarily would focus on. It is just that historically it has not been in our area.

  204. But in terms of the protection of the mothers—
  (Ms Bellamy) But in terms of the impact of protection of the girl and the woman, and again in Africa now more girls and women are infected now than men and boys, it clearly is an area that our community ought to look at and see what we can do. I am just trying to explain that from a scientific point of view whether there will come a breakthrough in terms of some new product is not an area that we concentrate very much on. We can get you some figures, but I think one has to look at the spending almost on a country by country basis. One of the reasons spending has gone down is the increasing amount of armed conflict, for example, the implications for debt in some areas, and spending generally on basic social services has deteriorated and therefore so has the spending on HIV/AIDS. Clearly however there are countries now where there is some movement and you see it more broadly. It may be in your health spending but it may also be in your communications, it may be in education, so there is additional spending going on.
  (Mr Stirling) What UNICEF would urge is that specific commitments be made by governments on specific actions which we know work on HIV. More money is required but also more specific targets within those budgets and more specific objectives which can be publicly monitored and accountable. The study is a Harvard Study by UN AIDS which we can get for you.

Mr Worthington

  205. On education support, who is to do it? You have got in these countries generally speaking very weak state health services that find it very difficult to offer the most basic services, and NGOs that have not really been geared up. If we think of the NGOs, we have got generalist NGOs and small specialists NGOs like Marie Stopes or Population Concern and so on. From where is this education to come? Where is it effective? Who is doing it well?
  (Mr Stirling) The first and critical thing is for governments to make it clear that it is a priority for education systems to provide an education where those children can grow up well informed and safe. That means good sexual education at a very early age and a continuing life skills education through the balance of their years in school. That is important because it defines the commitment and the obligation of government and it also sets basic standards and enables the establishment of methods and materials for use. Once that is done there needs to be a strengthening partnership in providing that education. There is nothing stopping it and there are lots of good experiences (but small scale) of involving a local religious leader with the local girls or the local NGOs in providing different parts of that education in school, but also to support different activities out of school. Likewise, for many of our populations of children who are not lucky enough to be in school, and for example in the case of Mozambique nearly two-thirds of our kids are not in school, there is a very important role for non-governmental organisations and community groups to organise to provide that kind of information and education, counselling and support for young people. It is not either/or; it must be a partnership of both, but I think there is a very important role here of governments helping to define, to set the pace, the standards, and also to go out there and start to groom some of the partnerships. This has been an area which has been relatively weak.

  206. Who has done it well?
  (Mr Stirling) Zimbabwe has done some very good work through the Ministry of Education, but they are not so strong on the NGO linkages. Out of school approaches have probably been stronger there. In Zambia there has been some good work out of school, not so strong internally. Each country has different strengths and weaknesses. I know somebody who is in this room who might be a good resource person to talk to this.
  (Ms Bellamy) Namibia has a good combination of life skills and communication programme. That is somewhere where most of the kids are in schools so they are able to use the schools in that case.
  (Mr Stirling) Different countries have different experiences. What has not taken place is trying to do it at an intensity and on a scale and with an involvement of all of the best practices. That is what has been missing. What has been found in Uganda is the intensity of the level of education, information and support for young people has made a difference to HIV infection rights.

  207. But the point I am making, and you have talked about this 20-year situation and it is developing and it is now extremely grave, is that one of the reasons we have been bad on this is that the NGOs have been not appropriately structured, that you had some generalist development NGOs, big NGOs, that have not seen AIDS as their concern and reproductive health NGOs which have been concentrated on their traditional areas, and that AIDS has been nobody's particular responsibility. Does there need to be some change in the way the NGOs are organised and function in order to attack this problem seriously?
  (Mr Stirling) I think so, yes. To look at the evidence, those countries which have proven a reduction in levels of HIV infection amongst young people, that is Uganda, Thailand, Senegal, parts now emerging in Zambia, have been those where there has been an intensity of action of government, civil society, religious groups and NGOs, and dedicated specifically on some very focussed outcomes. I think you are right. Whenever there is a tendency to blur and to mainstream HIV as everything and to lose it within poverty, it becomes too diffuse and actions are not focussed enough, there is not a critical mass built.
  (Ms Bellamy) But even with the refocusing of the NGOs, and I think that gap has existed, if the Government is not there and the commitment then we are all just drops in the bucket here.

  208. I think we have accepted that point. I am looking beyond that at what else needs to be done and that seems to me to be an area where the focusing from the international community has not been acute. Your recommendation is that this be targeted on AIDS rather than on being general reproductive health services?
  (Mr Stirling) Reproductive health services are important for a number of things: improving health, reducing maternal mortality, but if you are going to address HIV you have to do more than just reproductive health services. There need to be specific objectives and priorities established to address HIV. Carol has signalled some of the objectives we have seen addressed last year in terms of increasing access to information, education and basic services for young people to be able to address this.

  209. You would particular emphasis on peer education?
  (Mr Stirling) As an effective strategy that is something that has worked well.
  (Ms Bellamy) We also work in societies where these are issues that are not discussed between the parents and their children, so if you can begin to get the young people themselves to be actors in this then there is at least some credibility in an ability for information to be passed on.

  210. In terms of the countries that we are talking about, particular sub-Saharan Africa, what actual access do young people have to condoms? How is it done? In our travels you could not say that this was a service that was available.
  (Mr Stirling) It differs very much by country. Along the major transport routes, commercial corridors, urban centres and places like Zambia now, certainly in Uganda, condoms are available. In rural areas it is much more difficult. Those countries which have had more success in getting access to condoms for young people have relied on public distribution, private distribution through the PSI approach, the social marketing approaches, but also expanding services through youth clubs and peer education programmes. They have adopted a mixture of distribution approaches. Those which have been less successful have tried to do it only through the public sector and not involving youth organisations, private sector and others. It is greatly variable. In Mozambique, for example, in Maputo, it is not a problem, but if you go into Niassa, there is not a condom to be seen in days of travel.

Mr Rowe

  211. It did occur to me that if the United Nations family is going to start taking this issue as seriously as you say they should, and I agree with you, is there less scope for example to target some of these drama and arts programmes in this direction? On Friday we finished the largest arts festival for schools ever staged in this country, and the thing that impressed me most was how strongly the messages were getting across through the art that the children were creating, and we saw some very good drama when we were abroad which seemed to be getting the message across very effectively. It seemed to me that perhaps this is an area in which the United Nations family could start concentrating some resource on.
  (Ms Bellamy) Theatre and art and various communications means can be very effective and particularly with young people. I would only say that you need to reach them. You need to be on the ground and operational. UNESCO is less operational on the ground and more a normative agency, but the techniques absolutely are very important techniques. These are the ways in which you reach people generally and certainly young people, by increasing use of radio, increasing use of television in some places, and in messages in ways that will relate to young people. If it is done by young people it is related to young people, it is done in their language, it is a very good way to reach them.


  212. At what age should safer sex education begin in your view?
  (Ms Bellamy) I do not know.
  (Mr Stirling) That will depend on the community and what is happening within the community. As a general average we are talking about trying to introduce these life skills issues as young as eight or nine years of age.
  (Ms Bellamy) We are talking about young girls. The sexual violence against young girls is happening at a younger and younger age.

  213. So it has to be done at primary school?
  (Mr Stirling) Very much, and this is a critical role of UNESCO. If they do have that strength and enormity of role then they perhaps could be playing a stronger role in getting more explicit, better sex education at earlier ages. This is an issue on which they could be providing great support.

Ann Clwyd

  214. I first of all want to ask you about Mozambique. Some of us were in Mozambique fairly recently. We met the Prime Minister who is a doctor himself and we discussed HIV/AIDS. He admitted that they have not been as active in political leadership as they might have been. I know Mozambique has had other things to think about recently, but is there any evidence that there is any greater activity on the part of political leaders in Mozambique to deal with this issue?
  (Mr Stirling) Yes. I think it is unfortunate that this last six months there have been the floods, which have been a terrific distraction for many things. At the end of last year Mozambique finalised a national strategic plan which was developed out of very strong participation and consultation with the private sector, religious groups, political organisations, national and sub-national levels, which was very strongly supported by the United Nations system. It is a difficult document to read but it is a very good plan and has strong ownership amongst all of the right people in Mozambique. Through the process of preparing that plan the positions of the President, the Prime Minister and a number of other key leaders have certainly been strengthened. On 1 June, the International Day of the Child, they announced the formation of the National AIDS Secretariat. They appointed Janet Mondlane, who is an extremely influential and important figure, to lead the struggle. I think they are very serious and they are expressing this through the right decisions. The issue now for us, and I think this comes back to some of the other issues, is that for her to be successful or for this plan to be successful they need solidarity of support, large levels of support immediately provided to be able to act on the promises made within that strategic plan. This is where, in places like Mozambique, where institutional capacities are stretched, often distracted and not particularly strong, there is a need for a strong solidarity and operational involvement for external partners to make it work.

  215. How does one activate other political leaders? There are countries where there is practically no political leadership on this issue. Is it from peer pressure, from other political leaders who are more aware?
  (Mr Stirling) All of the above. Every and any figure that we can find to encourage their excitement on HIV we should be pursuing. Most of my colleagues are spending a huge amount of their time just talking to people, helping them understand, to learn more, about HIV, and to define more clearly what their particular contribution could be. Very often we talk about the leadership challenge. We do not define what might be those specific leadership acts which could make a difference and which you have power to bring about. I think we very often talk about leadership, leadership, leadership, without actually defining those specific contributions and how those specific contributions might vary across different leaderships. I think it will need more careful identification of the roles of leadership, of the obligations of leaders in helping them move forward with a defined strategy.
  (Ms Bellamy) We look for every instance. UNICEF's five point programme begins with mobilisation, so every time some kind of leader, whether it is a political leader or a leader in industry, takes a strong stand on action to prevent HIV/AIDS, it brings a breakthrough. As Mark mentioned before, the OAU will have a specific session devoted to this. So does SADC coming up. These are the African leaders themselves. Lest we just leave it with Africa again, Asia and the Mekong area of China, India, the Caribbean area, we keep trying to build a group of individuals. Our Progress of Nations report, our flagship report this year, will have as its lead essay an essay on HIV/AIDS. We will launch it at the Durban conference. Craa Machel will join us at this conference. It is just that drum beat, trying to add on and add on.

  216. Can I ask about mother to child transmission? You mentioned half a million children were infected with the virus last year probably. The majority of those are mother to child transmission cases. What is your policy on infant feeding options for HIV positive mothers? What sort of message do you give them?
  (Ms Bellamy) UNICEF's strong position on breast feeding continues. We think breast feeding must continue to be protected, promoted and supported in all populations irrespective of HIV prevalence rates. Implementation of the International Code of Marketing breast milk and substitutes is important in our view to continue to promote breast feeding as the healthiest, most effective, nutritious food for the baby up to the age of six months. We have to take into account the implications of mother to child transmission. This is an area where we have pilot projects in 11 countries now.
  (Mr Stirling) There is work ongoing in 11 or 12 countries now on this. UNICEF's policy and position on breast feeding is clear. The issue with regard to HIV comes to enabling women to have access to testing services to understand their status. Then, in supporting them in taking those decisions, to act in the best interests of kids, they have certain options which they need to be considered and counselled on. The critical definer is not what UNICEF's policy is but the woman having access to testing services and then to counselling advice to help her decide what she considers to be the best course of action in bringing up her child.

  217. If you promote infant feeding formula as an alternative to breast feeding when that is necessary, how can you be sure it does not spill over so that mothers who are able to breast feed and are not infected do not use infant formula with all the difficulties that might cause the child?
  (Mr Stirling) There was a very important meeting in March in Gaborone, looking at the early experiences of this MTCT project. This was one of the issues which came out of that. Very strong recommendations came out of that meeting on the need to intensify and accelerate work on the adoption of the Code of Marketing of Breastmilk Substitutes, to make sure that all countries adopt that code with understanding; that there be mechanisms put in place to monitor the implementation of the code and particularly to signal violations of the code. There are also actions proposed to expand breast feeding counselling services which have waned a bit in the last couple of years and to reinitiate work on the baby friendly hospital initiative, which was promoting breast feeding, but to link that much more with the work being done on prevention of mother to child transmission. It is a critical issue which health professionals and people involved with these programmes are very concerned about but there have been clear recommendations made to try to protect the environment from that abuse.
  (Ms Bellamy) The use of infant formula substitutes has also to take into account the lack of access to clean water in many countries in which we are working. There is a range of difficulties that need to be confronted here and there not easy options. Again, it is a matter of trying to make sure that the woman has some support and ability for the counselling.

Ms Kingham

  218. There are certain myths that are still adhering to the issue of mother to child transmission concerning HIV. Could you be very explicit and tell us what evidence there is and what level of risk there is about transmission of HIV through breast milk from mother to child? Could you also tell us, in terms of the threat of overspill into mothers who are not at risk of HIV and who may still wish to breast feed, what kind of studies are being done or is anybody keeping a watching brief on the comparisons between the danger to children of transmission through breast milk but also the dangers of not mixing infant formula with clean water? Is anybody watching the activities of some of the baby milk companies to ensure that we are not just trying to clear up one problem but shifting it to another area and these women or children are going to be at greater risk because they are using unsafe water to mix the food? Is anybody monitoring that carefully?
  (Ms Bellamy) Some of this was discussed at the Gaborone meeting, as I recall. To our best knowledge, there is transmission from mother to child. We are very much involved in this. We care enormously about this. We are not a scientific organisation so we are not in a position to offer scientific evidence one way or the other, but based on the existing knowledge and our experience it is not a myth that there is transmission.

  219. What level of transmission? Do you know what percentage it is?
  (Ms Bellamy) About a third.
  (Mr Stirling) The problem is that this is a relatively new area of research. A number of studies have been done and there is quite a significant range in the results of those studies. Out of that comes roughly the third as a result. The other part of your question relates to is there a need for further research on the one hand, understanding how best to manage breast feeding amongst HIV positive children. There is a considerable amount of research being done on that at the moment. Unfortunately however, some of the results are not quite complementary. There are contradictions in the results and there is a lot of discussion over the methodologies, the objectives and so on. There is need for more time and more scientific guidance on the structuring and the implementation of those services, and also for scientists and others to be a little more responsible in not just pointing out the contradictions between these results but also where there is firm ground upon which policy positions can be devoted. These are looking at infection rates, whether it is exclusively breast fed, for different period, but also the relationship between breast feeding plus the use of other, non-breast food. All the issues of dilution of foods, of contamination of foods, frequency of feeding are being investigated.

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