Examination of Witnesses (Questions 200
TUESDAY 27 JUNE 2000
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
201. Clearly we have got a long way to go, have
(Mr Stirling) We have a long way to go.
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
(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.
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 knowand
you might not have the figures now but when you do have them perhaps
they could be passed onif 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
(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.
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
(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.
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.
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
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.
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.