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This makes the events at Durban all the more relevant and urgently demanding. An effective global agreement to tackle climate change can no longer be delayed. Obviously this must include provision to assist the poorest countries and the most vulnerable people within those countries. The green climate fund is an imperative. What exactly are the Government doing to pursue innovative sources of finance to fund it-for example, a levy on global shipping or a tax on international financial transactions? As we listen to the Chancellor it seems very little, if anything. Indeed, there seems to be an entrenched ideological opposition to some of these proposals. This is inexcusable. How does the noble Baroness, with her past advocacy of precisely such measures, feel about that as the position of the Government? Do not all negative arguments about taxes on financial transactions, for example, fall into insignificance against the developing human nightmare? A minute rate of tax on financial transactions could produce very large resources for the battle for humanity.

One of the greatest obstacles to the implementation of the millennium goals on schedule is certainly the 1.5 billion people who live in states affected by conflict and fragility. I understand that, in response to this, a new deal has been proposed at the High Level Forum this week. Can the noble Baroness confirm that this is indeed the case and that the UK is meaningfully and not just rhetorically behind it? I gather it has five objectives: fostering inclusive and legitimate politics; establishing and strengthening people's security and justice; promoting employment and livelihoods; ensuring fairer social services delivery; and better financial management. I, for one, would be cheered if all this can be confirmed. If it is agreed that aid in more fragile states should focus on achieving peace, it will mean that ensuring that conflict, security and justice issues, which have been absent from the current MDG agenda, are brought fully into the discussions also about what follows MDG in 2015.

Success in moving forward will depend upon the new deal becoming not only a deal between national governments and international donors but a deal between them and the people living in conflict-affected communities, ensuring that these people themselves have genuine ownership of development and peace-building processes. If countries are to make a successful transition to peace, it will be essential that dialogue processes are genuinely inclusive and sufficiently independent to bring in a meaningful range of differing perspectives and to keep the most sensitive issues on the table. The new deal must on no account limit itself to legitimising the use of aid for "train and equip"-style security and justice programmes. If it is to support sustainable peace, it must focus on not only the capacity of state institutions but on their culture and professionalism and how they behave. It is vital that they also focus on what matters to the people living in conflict-affected countries-less exposure to violence, greater confidence in their safety, access to justice, services and livelihoods, and political freedom and inclusiveness.

If I have become convinced of anything in a lifetime of work in these spheres, both in Parliament and outside it, it is that sustainable peace cannot be imposed or manipulated. It has to be built from the community

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upwards; building in widespread inclusiveness in the process and a real sense of ownership of that process and its outcomes by the parties to the conflict is absolutely essential. After all, the process began to move in Northern Ireland when the political wing of the IRA became part of it.

2.11 pm

Lord Roberts of Llandudno: My Lords, I appreciate the opportunity given us by the noble Earl, Lord Sandwich, to discuss once again this crucial issue. I was reading recently about the potato famine 150 years ago in Ireland and how 1 million people starved to death there and 1 million more emigrated. There was such poverty in some of the south Wales valleys, and then there was the cotton famine in Lancashire and its horrendous consequences. In many other places, such as the Highlands with its crofting problems, we realise that we ourselves have in the past been touched by such poverty. Possibly it is comparable to the worst poverty that we can see in the world today.

We have people who are humane and want to move in and help those in need. Sometimes the need arises because of the scourge of diseases, as in Africa at present, or the failure of the crop year after year, as has happened with the potato crop in Ireland-or else you have the greed of mine owners or mill owners or others who are the masters of their communities. There are so many reasons and often it is those reasons, some of which are very presentable, that cause such hardship for millions and millions of people. In the mid-1930s, the Duke of Windsor, then the Prince of Wales, visited Merthyr Tydfil and other places in south Wales and saw the devastation and said, "Something must be done". It is easy to say. Today we see the Horn of Africa and the devastation in parts of Asia and the tremendous need in other parts of the world. Something must be done. In the south Wales valleys that something was done by intervention from outside. Often the people who are weakened and have no more motivation left-people who do not even have the energy to think of their futures-rely on outside aid.

I welcomed the other day the autumn Statement, which really confirmed this 0.7 per cent for international aid. We need it and it must be used, but we can also remember our tremendous debt to voluntary giving-and the noble Lord, Lord Judd, was part of that great movement. CAFOD, Oxfam, Save the Children, UNICEF and Christian Aid have done tremendous work, as have countless smaller charities that we may not know anything about, in parishes and communities-people who see the concern. I remember being involved about 20 years ago in the Ethiopian famine, when we had to thank the press and television for the way in which exposure at that level made people want to give. I remember standing with a milk churn in Llangollen after one such programme had shown the great need from some area in the world, and people queued up to donate.

I remember also how we tried to get pure and safe drinking water for children in Rwanda. We had the appeal and there was some individual sacrifice. I wish I had a copy of the letter with me now from one lady from south Wales, who said:



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"All my wedding presents have gone. I am living in one-room accommodation and all I have is the vase that my husband gave me on my wedding day. I am selling that vase because the need of the children of Rwanda is greater than my need".

That is sacrificial giving. We should always say "Thank you" not only to the big organisations but to those whose hearts are, to use a Methodist phrase, strangely warmed when they see the need and want to respond to that need.

While some people are giving and giving most generously, this week I have heard of one or two examples that I dare not mention in this Chamber, which show how people respond to the needs and suffering of other people. Some are giving but others are taking and are trying to make a profit from the most vulnerable people and the poorest nations in the world. I am grateful to the Guardian newspaper for showing last weekend how venture capitalism had become vulture capitalism and how certain organisations and finance organisations are trying to milk the situation for their own benefit and the profit of their own people.

I have a reference to the Democratic Republic of Congo and the demand by venture capitalists for the repayment of £100 million debt, which is equal to giving 500,000 children schooling or giving 8 million people safe drinking water. The choice is there, but somehow the compassion of ordinary people is often not shared by these organisations.

I am grateful to a Methodist colleague of mine, Dr Mike Long, in Llandudno, who recently researched the situation in Zambia. I will not go into the details, and most noble Lords know it in any case. In 1979, Zambia was given credit by Romania for $15 million to buy agricultural machinery and vehicles. Zambia was unable to repay. We should remember that life expectancy in Zambia is 39.8 years. This debt mounted and in the end the demand was for $53 million by one of these venture capitalist organisations. It has been reduced to $15 million in a court case. But the people of Zambia find it so difficult.

In Lusaka, a declaration by the Christian churches of all denominations stated that:

"Zambia cannot pay back because the debt burden is economically exhausting. It blocks future development. Zambia will not pay back because the debt burden is politically destabilising. It threatens social harmony. Zambia should not pay back because the debt burden is ethically unacceptable. It hurts the poorest in our midst".

We-the majority-give, and others are ready to reap the benefit from the most vulnerable and poorest people and nations of the world.

I thank the Labour Government of 2010 for their Debt Relief (Developing Countries) Act 2010, which might clear the debts of 40 of the poorest nations in the world. However, there are loopholes, one of which is Jersey. I hope that the Minister, who is a noble friend of mine of long standing, can give me some assurance that Her Majesty's Government will somehow or other try to bring the courts of Jersey into the embrace of that Act.

With those few words, I therefore say that we are joining other nations to give the poorest countries in

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the world a fresh start by breaking the chain of poverty. For many, it will be a beginning that they never dreamt was possible.

2.20 pm

Lord Harries of Pentregarth: Like other noble Lords, I am grateful to the noble Earl for initiating this debate on such an important subject. It will be a particular pleasure to be able to listen to the noble Lord, Lord Singh.

I strongly agree with many of the points made by previous speakers, but I shall focus exclusively on the second part of the Motion regarding the proposals on the situation of the Dalits. Everyone is aware in general terms of the situation of the Dalits-the former untouchables-but it is difficult for us fully to take on board the extent and seriousness of their plight. To take, for example, the extent, more than 260 million people in the world continue to suffer from practices linked to caste, and of those, 170 million are Dalits living in India. As to the seriousness of their situation, more than 200 years ago William Wilberforce described what he referred to as "the cruel shackles" of the caste system as,

Since Wilberforce's time, one form of slavery has been abolished, as we know, but not that associated with caste. It is properly described as a form of slavery. As the Prime Minister of India, Dr Manmohan Singh, said in 2008,

He described it as being parallel to apartheid. Manual scavenging, of which all noble Lords have heard, is just one of the many forms of degradation to which Dalits are subject.

In the light of this, it is obvious that it is not possible to consider issues of education, health and poverty reduction in India or other countries such as Bangladesh or Nepal where the caste system operates without highlighting and prioritising in policy terms the issue of caste and its terrible effect on the most vulnerable. Studies show that Dalits suffer quite disproportionately in education at every level, in health at every stage of their lives, and in access to benefits. There is absolutely no hope of achieving the millennium development goals without ensuring that every aspect of development policy takes fully into account the dire effects of caste with an appropriate focus on those suffering most as a result. DfID is of course aware of this, but does that awareness drive every aspect of policy in a concerted and consistent way and is the effect of this monitored?

More specifically, does DfID explicitly address caste exclusion across all the civil society programmes that it funds, developing clear benchmarks and indicators to monitor this? Furthermore, does DfID integrate social exclusion into all its programmes, beyond those of civil society? Does DfID support excluded groups in their advocacy and help them increase the accountability of Governments to the most excluded? In order that we might be clear that we are practising what we are preaching, does DfID ensure that in its own employment practices it has a team that is fully inclusive and representative? Following on from that, does DfID,

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throughout its India office, build understanding of social exclusion? Without positive answers to these and other questions, all attempts at poverty reduction will be undermined, as a growing body of research increasingly shows.

DfID also has a key role to play in influencing other donors, such as the Asian Development Bank, the European Community, the World Bank, the UNDP, and so on, better to understand and address these issues. DfID has a key role in ensuring that all UK NGOs and foreign investors adopt best employment practices in their policies. There is evidence in the past of some employment agencies used by NGOs excluding certain Dalit and Muslim names before passing on selected candidates.

I have mentioned that there are at least three key areas-education, health and access to benefits. I know that the noble Lord, Lord Avebury, will address education in particular and how Dalits are heavily disadvantaged in every aspect of education. I shall not therefore deal with that. However, I will briefly mention another area-children's health. A recent study of children under 12 being treated showed that Dalit children were discriminated against in a variety of ways. By every indicator, this discrimination was shown to affect between 80 per cent and 90 per cent of encounters between Dalit children and those charged with providing them with some kind of medical help. I shall give some small examples. Medicine was placed in the hand without the person giving it actually touching the hand; or the medicine would be put on the floor or window sill; they were given less time with doctors and nurses; and the children were called names and treated roughly. It is not surprising that infant mortality-high in India as a whole-is particularly high among Dalits.

There is another particular area that the noble Baroness, Lady Cox, would have highlighted if she had been able to speak in the debate. I refer to the human trafficking and slavery of India's Dalits. For example, there may be as many as 20 million people in Indian bonded labour, of whom between 80 per cent and 98 per cent are Dalits. In addition, children, particularly Dalit children, are being trafficked into domestic servitude and prostitution, with 40 per cent of India's sex workers being children. Then there is ritualised prostitution and bride trafficking. In all these areas, it is Dalits who are most at risk and find it almost impossible to obtain redress. Often they do not have identity papers, they have difficulty being believed, and-believe it or not-a third of rural police stations do not even allow Dalits to cross the threshold. DfID has done well to institute the human trafficking in south Asia programme, but at the moment its resources are too small to make the impact that is needed-not just in cross-border trafficking but in India itself.

My point is therefore very simple. It is impossible to tackle the subject of poverty, particularly in India, Nepal and Bangladesh, without highlighting and prioritising the issue of Dalits and expressing those priorities in real policy terms. DfID is aware of this, but is that awareness driving every aspect of policy in a concerted and consistent way? Is the effect of this policy on the Dalits being properly monitored?



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2.29 pm

The Lord Bishop of Ripon and Leeds: My Lords, I, too, am deeply grateful to the noble Earl, Lord Sandwich, for achieving this debate and for his powerful opening speech emphasising the positive contribution that aid can make to breaking the "chains of poverty", to use the phrase of the noble Lord, Lord Roberts. Yet, we heard from the noble and right reverend Lord, Lord Harries, of that continuing failure to tackle discrimination based on work, descent and caste. I therefore welcome the renewed emphasis on the situation of Dalits in south Asia, and look to ways in which international development policy can be used to affirm and develop human rights for those who are so savagely damaged by descent and caste.

I hope that we will not be lulled, if that is the right word, into thinking that this is a problem for India and south Asia alone. We need to watch the ways in which such discrimination exists in other societies, including our own, and I therefore welcome the determination of the UN Decade of Dalit Rights to identify and connect with the diaspora of those affected by discrimination based on descent and caste.

Like others, I want specifically to welcome the Government's defence of their international aid budget of 0.7 per cent of GDP even though that involves some diminution in the actual amount of aid. But to defend that figure through tough economic times is a major tribute to the work of the Minister and of the Government as a whole. I hope that she and they will hear our congratulations on achieving that continued figure. I hope that in her reply the Minister will report on what she expects of the high-level forum on aid effectiveness in Bhutan, to which others have already referred.

I also welcome the establishment of the department's faith working group, which recognises the importance of faith in many communities around the world and the need to explore how faith can contribute to the success of policies tackling discrimination-not just the work of faith bodies in this country, which I acknowledge and am very grateful for, but the contribution made by religious organisations and faiths throughout the world. In that context it is particularly good to be able to be part of a debate in which the noble Lord, Lord Singh of Wimbledon, is taking part, someone from whom I and many others have learnt much of the place of faith in societies all over the world. I should be grateful for comment on what progress the faith working group has made and whether any concrete steps have been taken as a result of its work.

The UK has a strong record on seeking an international aid policy which will have real impact. In particular, I want to both stress and encourage the new moves being made, not just here but throughout Europe, for greater transparency in the extractives sector. Tearfund's recent report, Unearth the Truth, gives examples of the need to use natural resources for the real benefit of our poorest communities across the world. Exports from extractive industries are worth something like nine times the value of aid to Africa. Tearfund cites Sierra Leone and also Colombia as countries where conditions could be transformed if the revenue from the

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extractives sector was reinvested in meeting millennium development goals and in providing basic services such as health, water and sanitation.

I hope that the Minister will be able to comment on how we can have a more transparent picture of the way in which the extractives industry affects relationships with some of the poorest countries of the world and ways in which aid can be directed so that it can provide support and encouragement in the development of those countries.

The condition of the Dalits and of others discriminated against by work or descent must be a wake-up call for all those who believe in fundamental human rights. I am grateful for the stance of successive Governments in the crucial use of international aid to promote the care of the poorest in our world and I look forward to a renewed expression of the Government's commitment to the breaking of those chains which bind not just those who are themselves in a situation of poverty but all of us in the worldwide culture in which we share.

2.36 pm

Lord Singh of Wimbledon: My Lords, it is with a feeling of humility and trepidation that I rise to speak for the first time in this House, particularly after having listened to the earlier words and speeches that were put so movingly.

I shall say a few words on where I am coming from, and what I hope to bring to the House. I started life as a mining engineer, but not long after qualifying, was told by the then National Coal Board that British miners would never accept a Sikh mine manager. I was offered a job in the scientific department but politely declined, seeing it as an opportunity to go and see a bit of India, a country that I left as an infant. Surely people there would welcome me. They did not. I was seen as a Punjabi, and not welcome in the mines of West Bengal, but I stubbornly dug my heels in and gradually became accepted.

I returned to England to take up a post in a civil engineering management consultancy, and though there was some initial hostility, I was soon respected and valued and even assisted in taking a year off to do an MBA. It was while I was with this company that I noticed a strange end-of-day ritual that made me see the lighter side of our attitude to those we see as different.

We were on the fifth and sixth floors of an eight-storey building. Above us were the overseas civil engineers, who clearly thought themselves superior. They would go about with briefcases carrying labels of exotic places visited. At the end of the day they would get into the lift to go home. When the lift got to our floors, a curious thing would happen; those inside would unconsciously stick out their stomachs to give the impression that the lift was a little fuller than it actually was. We would barge in none the less; the stomachs would gradually recede and we all became fellow work colleagues.

The lift would then move to the floors below, occupied by the Department of Health and Social Security. We all joined in in sticking out our stomachs to deter what, in our bigotry, we saw as a lower form of life

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entering our lift. However, again, they took no notice and got in; the stomachs would grudgingly recede and we all got to the ground floor as fellow human beings-until the next day.

This strengthening of common identity by looking negatively at others is all too common. We see it all too often with a group of people who have been speaking together on a street corner. If one goes away, you can be sure that those remaining will often make some negative comment about the person who has just left, to strengthen their newfound sense of unity. We see it in the behaviour of football crowds. In its most serious form, it can lead to the active persecution of those we call different.

Guru Nanak, the founder of the Sikh faith, saw it in the India of his day some 500 years ago. He reminded us that we are all, men and women, equal members of the same human family and he criticised all notions and distinctions of race, caste or gender. These are 21st-century values being put forward in the 15th century. This theme has been central to my own life: from campaigning against apartheid in South Africa when it was unfashionable to do so, to supporting dissidents in the former Soviet Union and working with Amnesty International, and others, for greater social and political justice for all members of our human family. In this context, I fully endorse all the comments of the noble and right reverend Lord, Lord Harries, about Dalits, and the other remarks made by other speakers.

Some of us are quick to criticise some aspects of life in the United Kingdom but when we go abroad, even to our countries of origin, we see that this country is way ahead of much of the rest of the world-light years ahead in its freedoms, and its understanding and respect of different cultures and ways of life. Our country can take justifiable pride in the way that it has welcomed many from other lands and the lead it has taken in extending human rights, social justice and economic well-being to other parts of the world.

Moving to the central theme of today's debate, some 10 years ago I was invited to join a working group of DfID. I went as a cynic but was soon converted by the passion and genuine commitment of all those involved including, as has been mentioned, many voluntary organisations. I persuaded Sikhs to buy bonds of the GAVI alliance for the mass vaccination of 500 million people and urged the community to support the humanitarian work of DfID with its characteristic generosity. We also established Khalsa Aid, a Sikh charity.

At this time of economic recession, it is tempting to look to our need and ignore the suffering of others; in biblical terms, to cross to the other side of the street. Yet, as the continuing success of Children in Need showed, this is not the way of the British people. The euro crisis, economic difficulties in the United States and the emergence of new, major competitors also remind us that our economic future is inextricably linked to that of other nations, including the very poor. Britain is unique in the way it has led on many issues of justice and in the fight against poverty. It is a tribute to Britain that we are continuing to give assistance, with international development the highest priority. In

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the past year, Britain's development budget of just short of 0.6 per cent of GDP helped to train more than 95,000 teachers, build or refurbish 10, 000 classrooms, train more than 65,000 health professionals and provide clean drinking water to more than 1.5 million people.

In addition to the ethical arguments, there are strong economic and geopolitical imperatives for helping the poor climb out of poverty. These include the development of soft power and influence in key areas. By 2050, Africa will be a key trading partner, rich in resources with a population of over 2 billion. Understandable reservations about the misuse of aid should be tackled by more stringent checks and never be used as an excuse for doing less or doing nothing.

I could go on, but I am conscious that a maiden speech should be brief. Before I finish, I would like to thank your Lordships for your extraordinary kindness in making me feel so welcome, with particular thanks to the noble and right reverend Lord, Lord Carey, and the noble Baroness, Lady Kennedy, in introducing me to your Lordships.

2.45 pm

Lord Avebury: My Lords, I am particularly delighted to be the first to congratulate the noble Lord, Lord Singh, on his thoughtful and practical maiden speech, graced as it was with touches of humour. The noble Lord and I are old friends from years back, so it gives me particular pleasure to welcome him to this House today. He has had a very distinguished career, not only as a chartered engineer and management consultant-backgrounds that I share with him-but as an effective promoter of interfaith understanding, for which he received the Templeton Prize in 1989. The noble Lord was also awarded the interfaith medallion for services to religious broadcasting in 1991.

The field of work in which I have known him best is in his services to the prisons. He was the Sikh representative on the Chaplain-General's consultation with other faiths back in the mid-1990s. When that was developed into the present Chaplaincy Council he continued to serve on it as the Sikh adviser to NOMS, in which capacity I know he has made a significant contribution-not always on the side of the establishment. The noble Lord has been the editor of the Sikh Messenger since 1984 and director of the Network of Sikh Organisations since 1995. He brings wisdom and the insights of the Sikh faith to our deliberations based, among other principles, on sharing with others whose needs are greatest and the equality of all human beings, as he mentioned. We look forward with eager anticipation to hearing from the noble Lord often in the future.

The noble Earl, Lord Sandwich, has given us a welcome opportunity of looking at DfID's policy on aid to India and what we are doing to help the Government of India in promoting equality, particularly for the most severely disadvantaged communities. Even though untouchability was formally prohibited by the Constitution of India in 1950, it is so firmly embedded in the culture that 60 years on, the 170 million Dalits still endure extreme forms of social and economic exclusion and discrimination, as we heard from the noble and right reverend Lord, Lord Harries. We need to consider whether, and if so how, DflD's policies

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could be geared towards helping India to eliminate the severe handicaps that Dalits have to endure, perhaps bearing in mind the saying of the Guru Nanak, the founder of the Sikh religion that, in his mother's womb no man knows his caste.

We would agree that DfID's work should be refocused on the poorest, and that concentrating aid on state partnerships in Bihar, Madhya Pradesh and Orissa, but with some elements stretching to five other states, is a simple if rather crude way of achieving that objective. The Dalit Solidarity Network-UK and the National Campaign on Dalit Human Rights in Delhi urge that we review our policies from a human rights perspective, in light of the fact that Dalits are not benefiting proportionally in the remarkable economic advance being made by India as a whole. We should therefore address caste-based exclusion and deprivation across the whole of the civil society programmes that we fund, developing clear benchmarks and indicators to monitor progress and ensure that we are getting value for money, as the noble and right reverend Lord, Lord Harries, has also said.

I doubt that there can be, as the Government response to the Select Committee report implies, an abrupt transition from a level £280 million yearly aid programme from now until 2015 to a partnership based on critical global issues. I would be grateful for an assurance that projects specifically geared towards alleviating caste discrimination will continue to be supported. UNICEF, for instance, has a knowledge partnership with the Indian Institute of Dalit Studies to unpack policy concerns of relevance to children. It is looking at the barriers that limit access by Dalit children to healthcare, which were also mentioned by the noble and right reverend Lord, Lord Harries, leading to high levels of morbidity and mortality in these communities.

The Select Committee says that DfID's new Indian programme should have a strong focus on reducing child and neonatal deaths, and the Government agree with them-although they also agree that resources should be switched from health, which now absorbs 40 per cent of the budget, to sanitation, to which only 1 per cent is allocated.

Although India has reduced the under-five mortality rate from 118 to 66 per thousand births between 1990 and 2009, it is not on track to achieving the reduction by two thirds of this rate by 2015, called for in the millennium development goals. In the UN's 2010 report on the MDGs, it says that revitalising efforts against pneumonia and diarrhoea, while bolstering nutrition, could save millions of children's lives. The Global Alliance for Vaccination and Immunisation, GAVI, referred to by the noble Lord, Lord Singh, and to which the UK is the largest contributor in the world, is funding the adoption of vaccines against these diseases in an increasing number of countries. We promised $485 million out of the total of $1.5 billion subscribed at the pledging conference in London last June, believing, as we do, on solid evidence that this is one of the most cost-effective ways of spending aid money to help attain MDG4.

Paradoxically India still has the largest number of unimmunised children globally-7.2 million in 2010-even though it is the world's largest manufacturer of vaccines. It has introduced measles vaccine in about half the

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states and is making some good progress with Pentavalent, but only in two states as compared with the original plan for 10; while as yet it has no plans for rolling out vaccination against pneumococcal disease and rotavirus, which are the two biggest killers of children worldwide.

A delegation from the APPG Against Childhood Pneumonia, of which I have the honour to be co-chair, visited Bangladesh in November and was told it was on course to roll out all three of these vaccines nationally over the next few years. Penta is already being delivered, as the delegation saw on a visit to a village 50 kilometres from Dhaka. GAVI estimates that the second measles vaccine will start in 2012, followed by pneumococcal conjugate vaccine in 2013 and rotavirus in 2014.

It is not therefore altogether clear to me why India lags behind on saving children's lives when the potential is so clearly there. Will my noble friend say whether the plan for Pentavalent has been scaled back because GAVI had yet to be satisfied that vaccines could be effectively delivered and administered in India? Will she also say whether DfID can help India to solve any of the logistical problems that are delaying these programmes? I gather that more than 25,000 cold chain points have been established, but that active management of their proper functioning and timely repair is critical. If this is blocking approval by GAVI of the programmes, is it something on which DfID could offer technical assistance, bearing in mind our very substantial investment in GAVI itself?

I would be grateful if my noble friend could also say what monitoring there is of the existing immunisation programmes in Bihar and Madhya Pradesh where less than 50 per cent of children were covered in a 2009 survey, and in Orissa where the coverage was under 60 per cent, to ensure that Dalit children were being protected, at least in proportion to their numbers. If, as one might suspect from the UNICEF study already referred to, discrimination and the fear of discrimination inhibits access to healthcare generally for Dalits, the probability is that the existing programmes are not reaching these deprived people. In Bihar, for instance, the reason given for the partial information of a third of those missed was an awareness and information gap, which was far more likely to affect Dalits than the rest of the population. Would DfID be able to help to design local awareness-raising campaigns in our three target states, possibly with the help of experts in communication from the Dalit diaspora?

The Select Committee recommended that DfID should fund the collection of data on caste, tribal and religious affiliation of those who access maternal services or have institutional deliveries, but the Government's response was that adequate disaggregated data were available without further studies. Are they equally confident that disaggregated data exist for access to vaccination and immunisation programmes and if not, will they consider funding a pilot study in the three target states?

On education, the Select Committee had nothing to say about Dalits except indirectly, where it particularly welcomed DfID's new focus on girls' education. In their reply, the Government said they would use the opportunity of India's request to support their flagship secondary education initiative to look at,



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According to a UNICEF study from 2006, the dropout rate of Indian Dalit children from primary education was 44 per cent, and the National Commission for Scheduled Castes and Scheduled Tribes says that for girls this rises to an astonishing 75 per cent. There is no doubt that Dalit girls suffer even more extreme discrimination, prejudice and persecution than boys. Stories about the rape, violent assault and murder of Dalit girls appear regularly in the media. To mention one: when five boys were frustrated in their attempt to rape a 17 year-old Dalit girl in Lucknow last August, they poured kerosene over her and set her on fire. AsiaNews reported the comment of Anulraj Anthony of the Justice and Peace Commission of the Catholic Bishops Conference. He said that two aspects revealed the vulnerability of the victim: "She is a girl and a Dalit". So it hardly surprising that vulnerable girls from these communities have an uphill struggle to get anywhere in the educational system.

The UN Special Rapporteur on the Right to Education has made special reference in his 2006 report to the needs of girls from communities that experience discrimination, and says that literacy is as low as 9 per cent for the Mushahar women of Bihar state. Surely one way of improving Dalit girls' access to secondary education is to reduce their dropout rates from primary education and to promote MDG2A, to ensure that girls as well as boys complete a full course of primary education. The empowerment of women everywhere starts with literacy, and this is an absolute imperative in a society where there are ancient cultural barriers to the equality of particular communities.

We have our own problems here with deprivation of children from Gypsy and Traveller communities, and I am often struck by the parallels with the caste system. So it is not in a spirit of criticism that I want DfID to do more to help India to address the acute disadvantage suffered by the Dalits in health, education and, indeed, access to public services in general. It would be presumptuous to say that we can make more than a minor contribution to helping them to eliminate dysfunctional cultural norms that have persisted for millennia, but I hope that our aid to India can be concentrated on helping it to meet its own objectives.

2.58 pm

Viscount Craigavon: My Lords, I am grateful to my noble friend Lord Sandwich for obtaining this Cross Bench day debate on this subject and allowing our noble friend Lord Singh to participate. Some of us are more familiar with him on the morning "Today" programme, when we are not entirely awake, hearing his few words of wisdom. Now I am fully awake, I realise that his words are even more wise. I believe we should be grateful to the present Government for the direction of progress by this department since the election. That obviously includes the funding commitments, even with the latest adjustments.

The structure of the millennium development goals allows us to make international comparisons, and I am aware that the Commonwealth representatives are currently discussing MDGs in a conference at Westminster.

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One of their concerns is the fast-approaching deadline of 2015, and what happens after that. In this large area, I would like to focus particularly on the importance of MDG5, and mainly on 5B, which is about achieving universal access to reproductive health by 2015. We should be grateful that the Minister, Andrew Mitchell, even in his shadow role before the election, appreciated the importance of this field of reproductive health; and we are very fortunate now to have as a spokesperson in this House, the noble Baroness, Lady Northover, whom we know-as the noble Lord, Lord Judd, said-is an expert in the whole field of international development as well reproductive health. I also welcome the noble Baroness, Lady Kinnock, to these debates from her Front Bench.

As I am sure the noble Baroness, Lady Northover, will confirm, we had good news on Tuesday from her Under-Secretary of State, Stephen O'Brien, at a family planning conference in Senegal, where DfID has committed £35 million of new money for contraception in an area of the world that is particularly able to benefit from it. It is helping to save thousands of women's lives. He is quoted as saying:

"Family planning is a smart, simple and extremely cost effective investment of aid. It is at the centre of all our development work and we are going to ensure more women are given the choices they want and deserve".

That statement is very encouraging, and I hope that it leads to further such initiatives, as well as informing the practice of the other parts of the department. That is a very good instance of one of the main concerns, which is meeting the unmet global need of an estimated 215 million women who want to avoid or delay pregnancy, but who have no access to any effective methods.

To return to the department as a whole, we have recently had the opportunity to read the financial management reports of the Auditor General, the Commons Public Accounts Committee following that, and the reports and recommendations of the Independent Commission for Aid Impact, which was initiated by the department. Parts of these examined such things as effectiveness, value for money, leakage through fraud or corruption, running costs, delivery chains and suchlike. This is not the place to follow up those considerations in detail, but it is useful to have an independent opinion on such things.

Even on a cursory reading, one realises the full complexity and problems of successful and effective delivery, especially into other less developed countries, of the services required. One of the issues raised, partly in the context of bilateral versus multilateral spending, was the rather unusual,

which was mentioned by the noble Earl, Lord Sandwich. When money might be available, but the skills, facilities and manpower to deliver bilateral aid programmes effectively are not there, it might be easier to support multilateral programmes instead, when effectiveness and value for money would be more difficult to assess.

The large proportion of money that is required to be donated through EU channels can also suffer from a lack of accountability. I understand that a new agreement is up for negotiation, and I hope that we

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can take the lead among our European partners in helping to frame new uses for that money, over which we can have more oversight. Maybe the noble Lord, Lord Hannay, who will follow me, will be able to add to that,

I mentioned MDG5 at the beginning. That is, by common consent, the most off-target of the MDGs and, given that the target year is 2015, the hope now is that these aims will continue to be pursued beyond that year. Some progress in that MDG has recently been reported. The recent figure of 500,000 maternal pregnancy-related deaths, has now been reduced to 360,000. According to the Guttmacher Institute, 30 per cent of such deaths can be reduced by the provision of good family planning.

Normally in addressing this subject I try to avoid what one might call the numbers game. However, recently we have had the rather stark reminder of the world population reaching 7 billion, with attendant future upward projections. That has resulted in journalistic and more learned diagnoses of how serious or otherwise that milestone is. As we invoke population numbers as a contributing factor to climate change, we must always be aware that our western environmental footprint is many times that of most of the developing world. For example, one figure is that our footprint is 20 times more damaging to the environment than an Indian's. The Indian Health Minister said that the birth of the 7 billionth child was a great worry and told the Times of India that all celebrations should be put on hold until the population stabilises. As we know, that is some way off for India.

I am always astonished when people casually mention, quite commonly, the inevitability of wars being caused by the shortage of water. There are many other essential commodities in danger of becoming scarce, particularly with the increasing demand from countries such as China, which understandably want to raise their standard of living. Last weekend, the Times had an article with the headline:

"Standing between the world and starvation".

It was about the increasing price of and demand for phosphorous fertiliser being produced in China and its inevitable exhaustion, which is, admittedly, some years away. However, that is the basis of what might be unsustainable agriculture in many parts of the world, which often includes GM crops.

I am afraid that it might be human nature to hope for some magic solution to all these problems-that is, until they are palpably upon us. It is similar, but even more so, with the population numbers. If there is any magic solution there, it is simply the offer of choice, mainly to women, rather than any talk of coercion, as there might have been in the past. This is part of the sustainability debate, and I hope that the department can take it as its task to lead us in anticipating such crisis situations in the future.

When earlier I said that I normally avoided talking about numbers in this field, it was partly because of my belief that, even more importantly, we should focus on the quality of life, rather than quantity. In marking the 7-billion milestone in debates in the UN in New York, the rather unfortunate phrase "the bottom billion" seemed to emerge. It refers to the poorest, who

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have little or no access to basic needs. While not wishing to give currency to that phrase, maybe we should be as concerned about them as we are about the increasing numbers. It is encouraging that the department now seems to be targeting a reduced number of poorer states, as well as identifying fragile states for special attention.

I referred earlier to people expecting magic solutions to save us from ourselves. Sometimes that takes the form of comforting myths as to why we need not address population growth seriously. As a member of the All-Party Group on Population, Development and Reproductive Health, I hope I may recommend a recent publication, which was co-authored by one of its vice-chairs, Richard Ottaway MP, who is also chair of the Foreign Affairs Committee in the House of Commons. It is a highly readable and attractive publication, called Sex, Ideology, Religion: 10 Myths about World Population Growth. This was published about a month ago and will shortly be available online on the group's website, which is on the All-Party Group's list. It deals more concisely and eloquently than I can now with why we should continue to take population growth seriously. I am sure that the department will continue to do that, along with its many other responsibilities, which we have heard about today.

3.08 pm

Lord Hannay of Chiswick: My Lords, I warmly congratulate my noble friend Lord Sandwich on obtaining this debate on international development policy. I sometimes feel that we devote too little time to foreign affairs and development as we apply ourselves to our primary task of scrutinising and improving the Government's legislative proposals. I never felt that more strongly than yesterday, when the Foreign Secretary's Statement on relations with Iran was not repeated in this House. I have no intention of diverting this debate on to that ground, other than to say that it was a lamentable decision. If we want to be regarded as a mere superfluous appendage to the other place, that is the surest way to go about it.

I should also like to congratulate my noble friend Lord Singh on his extremely graceful maiden speech. Ten years ago I chose to make my maiden speech in a debate on international development, so I cannot but congratulate him on his choice of subject matter.

The coalition Government's decision to ring-fence our overseas aid from the spending cuts was a courageous one when it was first made and is all the more so now that they are sticking to it in the face of much discouraging economic news. Through all the cacophony of press criticism of that decision, I have yet to hear one respectable argument for making developing countries far poorer than we are suffer because of an economic crisis for which they have absolutely no responsibility. In any case, they are already suffering from the slowing of the global economy.

I am certainly not going to cheer the decision of two days ago to reduce the sums earmarked for aid in the latter part of the current spending period. However we are-and this I do welcome-sticking to our Gleneagles and UN commitments. That 0.7 per

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cent of our gross national income is going to be a good deal less than was earlier anticipated is, I fear, an ineluctable fact. I hope that the Minister replying to the debate will be able to say what we are doing to hold other developed countries to their Gleneagles and UN commitments, which some of them are missing by a very wide margin indeed. We should not spare their blushes, however much they would like us to do so. What plans do we have to use next year's G8 and G20 meetings to get those commitments back on track?

I was encouraged to hear that the Secretary of State for International Development had recently been to China to discuss the scope for co-operation between us in helping developing countries. Can the Minister say something about the outcome of that visit? Did the Chinese respond positively? What sort of programmes and projects could we work on together? I hope, too, that we are working on similar trilateral co-operation with countries such as India and Brazil, which are just beginning to mount serious aid programmes. Some time back I suggested that co-operation over aid could be one of the best ways of thickening up our relations with those emerging powers. Are we doing that now in a systematic way? Brazil in particular has many links with African countries, both cultural and economic, and it has devised imaginative and effective programmes for bringing its own poorer citizens out of the abject conditions in which many of them lived, so it would surely be an ideal partner if we could agree to work together. Have we got anywhere down that road?

I return briefly to a question that I put to the Minister recently: namely, the plight of UNESCO following the lamentable US decision to withdraw all its support from that organisation when Palestine was admitted as a member. I hope that we have not concealed our disagreement with that deplorable move. Why on earth should developing countries around the world be punished for giving the Palestinians a status that is no different from that which we all, including the US Administration, believe is our right? That sort of behaviour is a throwback to the worse mistakes of the previous Administration. I know that it is mandated under US law, but that is an explanation not an excuse.

Be that as it may, I hope that when we come to consider our own future support for UNESCO we will take all that into account. I very much support the broad thrust of our policy of holding UN agencies to account for the quality and effectiveness of their development work, but no organisation can take a cut such as UNESCO has had to take overnight without a lot of disruption and some damage to its overall performance. Can the Minister say how we are planning to respond? With some sympathy, I hope.

I am sorry to disappoint my noble friend Lord Craigavon but I am not going to say anything about EU aid. Having taken the afternoon off from the festivities in the Moses Room and chosen to participate in your Lordships' debate on this aid programme, I thought that I might as well go the whole hog. Therefore, I will not refer to the EU's programme but I will follow my noble friend by drawing attention to the 2015 deadline for achieving the millennium development goals-a deadline that is now well above the horizon.



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A lot has been achieved and more certainly will be in the next three years, but it is already clear as daylight that we will fall short, and by a substantial margin. Moreover, too many of the successes have been concentrated in too few of the developing countries, so it is surely high time for us to clear our own minds about what we will aim to achieve after the 2015 deadline. I suggest that we will need a better focused, less broad-brush approach and that it should concentrate on what Professor Paul Collier has so eloquently called the "bottom billion". I am sorry if the phrase offended my noble friend. Our decision to ring-fence our aid puts us surely in pole position to lead the search for an improved MDG mark 2. I hope that the Minister can tell us that we are already at work with that in mind. If so, can she give us some idea of where we think the main emphasis of those future programmes should be?

One other point I would like to raise is the question of failing or failed states. Last July DfID produced an excellent paper on this tricky subject which I could not fault, partly because it followed so closely the path set out in a number of preceding reports, not least that of the UN reform panel on which I had the honour to serve. Prevention is better than waiting for countries to go over a cliff and then trying to catch them in mid-air or, more often, picking up the pieces in the aftermath of the disaster. It not only costs less but saves many lives that would otherwise be lost.

Is this a proper task for development agencies or should they, as some critics suggest, concentrate exclusively on the alleviation of poverty? I suspect that this is in any case something of a false choice. The poverty of failing or failed states is in many cases dire. One of the characteristics of those states is that for purely political reasons their poverty cannot be alleviated by classic developmental policies. Are we just to let them stew? I would say not. Moreover, it is essential to demonstrate that the international community's responsibility to protect-R2P, as it is called-is not just a recipe for military intervention but a call in the first instance for strengthened policies of prevention. Therefore, I argue that helping those states to avoid failure is very much a proper object of our development policy. I hope that the Minister will say something about how the department is following up and implementing that first-class paper of last July.

In conclusion, I very much welcome the recent decision by DfID to put more resources into the BBC's World Service Trust. The fact that much of the World Service's output has genuine developmental value is surely not in doubt and has been quantified. It is high time to recognise this potential as another facet of our development policy. It should have happened a good time ago, as some of us in this House urged last winter, but better late than never. Back-Benchers are supposed to get more pleasure out of criticism than praise, but I am truly pleased to speak so positively about the coalition Government's development policies-more positively, I suspect, than some of their supporters in another place would have done. I hope that that will be some small encouragement to the Government to stick to the path they have chosen to follow.



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3.17 pm

Baroness Kinnock of Holyhead: My Lords, I also add my thanks to the noble Earl, Lord Sandwich, for initiating this debate, and indeed for his lifelong, strong commitment to international development. I also congratulate the noble Lord, Lord Singh of Wimbledon. He clearly brings great wisdom and experience to the work of this House, and as his maiden speech has shown today, we can look forward to many more interventions of that calibre from the noble Lord.

This is a timely opportunity to consider how best to implement international development objectives in what is, as many noble Lords have intimated, a rapidly changing and deteriorating international environment. Today, we are discussing these issues against the backdrop of faltering progress towards meeting the MDGs and in the knowledge that most of the world's poorest countries will not meet the 2015 targets, as well as knowledge of the emerging and growing threats linked to climate change, food security, and a very disappointing record on aid.

One particular statistic has called into question whether the MDGs are actually able to reach the most marginalised, disadvantaged and hard-to-reach poor. We now know that 75 per cent of the world's 1.3 billion poor people actually live in middle-income countries, and that in fact 20 years ago, 93 per cent of poor people lived in lower-income countries. We have seen a huge shift in that period. Does this evidence not then dictate that we need to focus more on poor people, not just on poor countries? We can tick the boxes when we use MDGs as our benchmarks, but social exclusion, environmental sustainability, and governance are just not factored in to the MDGs. The MDGs are formulated in terms of average progress, and fail to assess whether progress has been broad-based or indeed equitable. MDGs' assessment processes tend to obscure what is happening within countries.

All the evidence shows that the most disadvantaged people-who have been referred to by many noble Lords today-are being left further and further behind. Social disparities are seriously holding back progress. With that MDG focus on aggregate progress, we will not deal with those intersecting inequalities which are so resistant to change, and when such uneven progress is being disguised by the process used by the MDGs. Meanwhile, as Ban Ki-Moon said recently,

All of this sits very well with both aspects of the debate: international development and the Dalits. The work of the Institute of Development Studies in Sussex and the Overseas Development Institute is very clear and very good indeed, and I recommend it.

In Latin America, for example, extreme poverty is much higher among indigenous and Afro-descendent populations compared with the white Latino population. The region's poor earn only 3 per cent of the total regional income, and make up 25 per cent of the population. Remarkable progress has been made, however, by Governments in Brazil, Chile, and Malaysia.

Noble Lords have drawn attention to the plight of the Dalits, who are denied fundamental rights and opportunities. This evidence clearly makes the case for

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challenging discrimination which leads to entrenched poverty and indeed to terrible suffering. In Nigeria, only 4 per cent of mothers in the predominantly Muslim north-west are delivered in a health facility, compared with 73.9 per cent in the predominantly Christian south-east. In Kenya, minority ethnic groups have lower immunisation levels and higher under-fives mortality rates. A poor indigenous woman in Guatemala has one year of education compared with the national average of almost six years.

In every country and in every region, people are being denied their right to play their part in social and economic developments. This is on the basis of gender, race, ethnicity, religion, and often location-if people live far away from the capital, it is much easier for their needs to be ignored. This is systematic social, economic, and political discrimination, and leaves people literally and metaphorically at the end of the road. This calls for an expansion in developing countries of, for instance, social protection, access to decent work, minimum wages, and many other opportunities which people need if they are to see real progress.

In 2000, the millennium summit identified the need for social justice. Does the Minister agree that dealing with inequalities is the key to realising that aspiration, of which we have somehow lost sight?

Global aid budgets are critical to the achievement of the MDGs. We are obviously very clear that the achievements of this Government in getting agreement across the whole party on overseas development are extremely important, but we want some clarity on the reduction in overseas development aid. A reduction of something like £1.17 billion seems to be on the cards. That is enough to vaccinate millions of children against deadly diseases and, for example, to cover the training of midwives, who would be able to save many lives. Will the Minister give some detail on which budget lines will be affected by this reduction in funding? Bilateral programmes depend on long-term sustainable financing. Incidentally, this is a core effectiveness principle which the Government have signed up to in Busan. Will the Minister give an assurance that bilateral funding for country programmes will not be reduced?

Will the Minister perhaps also indicate whether the World Bank allocation will be reduced? In the context of the Durban conference, will he clarify whether it is the intention to take money for climate change adaptation and mitigation? Will the Government give an assurance that this will be additional money and that it is not the intention to take the necessary resources from the DfID budget? Of course, the Labour Government made a very strong commitment to 90 per cent of funding for climate change being additional funding, with 10 per cent being not additional but focused on poverty reduction. Are the Government also prepared to agree to that arrangement?

My final point is on the prospect of a commitment to the financial transaction tax-referred to by my noble friend Lord Judd-which I think it has been proven does not have to be global. The FTT is seen increasingly as not only desirable but feasible. It has been endorsed by Bill Gates, by a clutch of Nobel peace laureates, by UNICEF and the UNDP, and by many other economists and others, as well as, as the

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Minister knows, the Liberal Democrat manifesto before the last election. Robert Peston has recently said that an FTT,

Does the Minister agree with this view? I look forward to her response.

3.27 pm

Baroness Northover: My Lords, I, too, thank the noble Earl, Lord Sandwich, for securing this debate and for introducing it, as ever, so cogently. As others have also said, he has an outstanding record of work in this area. Once again, the depth of experience among noble Lords has shone through. I was struck by the very wise maiden speech of the noble Lord, Lord Singh of Wimbledon, which I thoroughly enjoyed. I am sure that we all look forward very much indeed to his future contributions.

This debate-in its title, at least-spans all that the Department for International Development does and has an especial and additional focus on Dalits. In some ways, their plight serves to show up all that we should be doing: if we are not addressing the needs of the most marginal people, then what is our purpose? Underlying all this is fairness. Across the world, too many people live in conditions that are anything but fair. In sub-Saharan Africa, one child in seven does not live to see their fifth birthday simply because of unsanitary conditions and dirty water. Every year, more than 1 million children lose their mothers simply because those women did not receive adequate care during pregnancy and childbirth. Each day, 69 million children do not have the chance to go to school.

As the right reverend Prelate the Bishop of Ripon and Leeds said, we know that what we are doing to help people out of poverty is right, but we also know that it is in everyone's interest. The noble Lord, Lord Hannay, played his part in the UN high-level panel, which made very clear that particular link. If we fail to tackle the root causes of the global challenges that face us, whether they be economic instability, conflict and insecurity, climate change or migration, then we will all suffer the consequences. That is why I am very pleased that, despite our economic situation, the coalition has kept to its commitment to spend 0.7 per cent of GNI on aid from 2013. I thank noble Lords for the welcome that they have given to that commitment, as well as for the very kind words that have been expressed to me by noble Lords.

I can also assure noble Lords that, as well as meeting their promise on the quantity of British aid, the Government are determined to ensure the quality of British aid. We are doing what we can to encourage other countries to meet their promises. It is in extremely difficult circumstances that this is the case, as noble Lords will appreciate, and we are also, as referred to by the noble Lord, Lord Hannay, trying to bring in the BRIC countries. My right honourable friend the Secretary of State received a positive response when he was in China and I look forward to hearing more from him on this issue.

On the quality of aid, the coalition Government undertook the bilateral and multilateral reviews referred to by noble Lords. The noble Earl, Lord Sandwich, in particular, asked about specifics, particularly in relation

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to the bilateral review. All DfID's programmes were assessed against need, effectiveness and other factors, including what was being done by other donors. DfID concluded that British aid should in future be focused on 27 countries, which together account for three-quarters of global maternal mortality, nearly three-quarters of global malaria deaths and almost two-thirds of children out of school. This tighter focus will ensure that we concentrate our efforts where the need is the greatest, increase our impact on fragile or conflict-affected states and deliver in the places where most poor people live. Aid to Russia and China has been stopped, while another 14 countries will see their existing aid programmes closed by 2016.

The noble Earl, Lord Sandwich, asked about Kosovo. I can assure him that DfID's graduation from Kosovo will be a phased process, honouring existing commitments and exiting responsibly. After 2012, the British embassy will continue to support Kosovo and UK funding will continue through the EU and other multilateral agencies. The noble Earl will no doubt note how well the EU came out of the multilateral review, and we are very glad that the UK can continue its strong funding through that, which will support Kosovo.

In the multilateral aid review, DfID assessed 43 international funds and organisations to which the UK contributes. Nine organisations, including UNICEF and GAVI, were assessed as providing very good value for money and therefore we are increasing their funding. The noble Earl asked whether there was a particular proportion that would go between bilateral and multilateral countries. There is not a fixed proportion. In the multilateral review, four organisations were deemed to be underperforming and have been placed on special measures. We are pressing for UNESCO, the Food and Agriculture Organisation, the Commonwealth Secretariat and the International Organisation for Migration to improve their performance. Should we see no improvement when these organisations are re-assessed in 2013, the UK will reconsider its support.

I hear very much what the noble Lord, Lord Hannay, said about UNESCO, which we did indeed discuss at Question Time the other day. I have written to him on that subject and I hope that he will receive that letter shortly. We bear in mind the balance between the challenges facing UNESCO in this regard and its need to make sure that it delivers more effectively than thus far.

These are extremely difficult times for the United Kingdom. Therefore, it is even more important that people can see that the aid that they are supporting through their taxes is targeted, focused on the poorest, and makes a difference. The noble Earl is quite right that there is great public support for aid.

The noble Lord, Lord Judd, is right to flag up whether the emphasis on results puts the longer-term programmes under some question. The answer is that we are acutely aware that development is a long-term process. We are fully committed to that. The concentration on education, health, girls' education and so on underlies that commitment, but it is also important that people can see the end-result of their aid giving so that we can ensure that we can maintain the percentage to which we have committed this Government.



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No other Government thus far have managed to achieve that. I bear in mind what the noble Baroness, Lady Kinnock, said about there not being as much money available, even when we meet the 0.7 per cent, as if we had a really flourishing economy. That is enormously to be regretted, but I note what other noble Lords said about the achievement of reaching even 0.7 per cent. I pay tribute to the previous Government for helping us on that way, but this coalition Government are committed to that.

Just as DfID has scrutinised multilateral donors, it is offering itself for scrutiny because that is very important in people understanding where this money is going-hence the new Independent Commission for Aid Impact, ICAI, which published its reports recently, and DfID's new aid transparency guarantee. The focus on results does not mean that we do not understand how development is a long-term effort.

We also know that the concentration on fragile states will not easily produce instant results, but we are acutely aware that conflict breeds poverty. No low-income, fragile country has yet achieved a single millennium development goal. I hope that I can assure the noble Baroness, Lady Kinnock, that we are making plans for after 2015. Although at the moment there is tremendous focus on trying to ensure that as many elements of those MDGs as possible can be delivered, we are looking beyond that.

We are increasing the level of funding for fragile states to 30 per cent of development aid by 2014-15, while the building stability overseas unit, which is based jointly with DfID, the Foreign Office and the Ministry of Defence, is focusing on upstream prevention. Some of the lessons learnt from the lack of development awareness in the early days in Afghanistan, for example, must surely be applied in the future, as well as some of the lessons from Iraq. For example, not destroying the infrastructure needed to support the civilian population once the initial conflict was over is one lesson that was carried through, with the building stability overseas unit emphasising that that was to be the way that things were approached in Libya.

I know that noble Lords will understand and commend DfID's focus on women and girls, recognising that daughters, mothers and wives tend to reinvest gains in their own families and communities, completing a virtuous cycle of development. We will also invest in girls' education. One extra year of schooling can increase a girl's wages by 10 to 20 per cent, helping to end the transition of poverty from one generation to the next. We will maintain a particular focus on maternal health, saving the lives of 50,000 women in pregnancy and childbirth.

I hope that the noble Viscount, Lord Craigavon, will welcome the fact, as he seems to have done, that we will also give at least 10 million more girls and women access to family planning. Contraception costs less than £1 a year. The noble Viscount noted that the global population figure now stands at 7 billion, which shows how important the policy is. That cannot be overstated.

More generally, we are seeking to provide people with the means to pull themselves out of poverty. Wealth creation is the engine of long-term growth, as

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we have seen in parts of Asia, and so we are putting in place the conditions-land reform, better transport links, fairer legal systems and improved internet access-that we hope will encourage that development. Within DfID, a new private sector department is helping to promote this. We will redouble our efforts to open global market opportunities to developing countries, pressing the EU to do all that it can to make sure that poor countries benefit. We will continue to lobby G20 countries to provide 100 per cent duty free, quota free, market access for the least developed countries.

Where British companies invest in developing countries we will make sure that they do so in an open, transparent and accountable manner. The new Bribery Act helps to reinforce that. We strongly encourage businesses to respect human rights and the environment and we provide support for international standards, such as the OECD guidelines for multinational enterprises.

I was asked about the extractive industries. UK support for that has contributed to 11 countries reaching compliance status and 22 other candidate countries going through the validation process by September 2011. The right reverend Prelate is absolutely right that it is extremely important to look at the economic development of these countries and to make sure that that is occurring in a way that assists the population at every level, down to the bottom billion to which reference has been made, and not simply to those at the top, and that we do not concentrate simply on aid.

Good health is a basic starting point for people who are trying to lift themselves out of poverty. That, too, is an area on which we very much focus. At the moment, there is a strong emphasis on malaria in all our country programmes with a view to helping halve malaria deaths in the 10 worst affected countries. On this World AIDS Day, the British Government remain at the forefront of global efforts to tackle HIV/AIDS, on which I note that I have another debate immediately after this. Although we have made huge progress, there are still more than 34 million people living each day with HIV. Our main focus is on women and Africa where there is the highest incidence and the greatest vulnerability.

Alongside all our proactive work on governance, health, education and economic growth, we will continue to respond to humanitarian emergencies. As noble Lords know, more than 13 million people are experiencing the worst effects of the drought that has spread across the Horn of Africa. UK aid is providing much-needed support, including food, vaccinations and clear water and sanitation. Our response to humanitarian crises has also been reviewed by my noble friend Lord Ashdown-a review that has been widely welcomed internationally. The incidence and severity of natural disasters is likely to increase due to climate change. We know that the poorest and most marginal will be hit the hardest and worst. The noble Lord, Lord Judd, is absolutely right about that and it is a major focus of DfID.

Time is running short, and I want to turn now to the Dalits. Noble Lords have rightly made the point that members of the Dalit caste suffer from the most severe forms of poverty, deprivation and exclusion.

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Often living apart from the rest of society they routinely face discrimination in accessing basic services and are barred from undertaking certain occupations. The case of the Dalit girl mentioned by my noble friend Lord Avebury brings that graphically home to us. We have heard much about their plight from noble Lords-in particular, the noble and right reverend Prelate, Lord Harries of Pentregarth, and my noble friend Lord Avebury, who have been doughty champions of Dalits in this House in terms of those overseas and those in the United Kingdom.

Britain is committed to helping India to eradicate caste discrimination. Indeed, as noble Lords know, discrimination on the grounds of caste was abolished by the constitution of India in 1950, but we recognise that there is a long way to go. The UK regularly raises such issues with the Government of India, about which the noble Earl, Lord Sandwich, asked. It was last discussed in September on a ministerial visit by my noble friend Lady Warsi.

DfID's development programme is specifically designed to benefit the poorest and most excluded, including Dalit women and girls. We are seeking to increase the number of Dalit children, especially girls, enrolled in school. My right honourable friend the Secretary of State for International Development is due to visit India shortly and plans to meet Dalit girls while he is there and seek to address how we can ensure that more of them are in school and able to see school through.

At a strategic level we are supporting civil society programmes, such as the poorest areas civil society programme and the international partnerships programme. Both are aimed at tackling discrimination, and together the two programmes should help more than 25 million excluded people.

DfID is also working with Dalit groups in Bangladesh and Nepal to help them access basic services, such as health and education. DfID Nepal is working with the Dalit NGO Federation and my honourable friend in the other place, Lynne Featherstone, visited Nepal in June this year in her capacity as champion on violence against women, and engaged with Dalit women there. The noble Earl, Lord Sandwich will remember that when we were in Nepal a few years ago through DfID, we also met Dalit groups and I certainly found that extremely informative.

I am aware that I am running out of time and have numerous questions from right across the House. My best strategy is to write to noble Lords in answer to the numerous questions raised. To conclude, as ever this has been an extremely stimulating, wide-ranging and constructive debate, which has amply demonstrated the House's understanding of the many complex challenges which we face in our efforts to alleviate poverty and suffering across the world. We know there are major challenges facing all of us, we know we are all inter-linked and the noble Lord, Lord Singh, put that beautifully. Something happening in one area of the world will have an impact elsewhere. We know it is a challenge maintaining aid when we are in the midst of our own economic problems. We also know that, whatever those problems are, those who are the most

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vulnerable are those who are already at the margins-the poorest and especially the women and children among them. I know that view is shared right across the House.

3.47 pm

The Earl of Sandwich: My Lords, I do not want to stand in the way of another important debate, on HIV/AIDS-a very relevant and connected debate, albeit in the United Kingdom-so I will be brief.

This has been a very heartening debate because it is encouraging to know about programmes that are really working and to hear people who are sympathetic and instrumentally involved in seeing policy through. I was very encouraged by that.

It is a Cross-Bench day so I thank all the Cross-Benchers, if not for electing me, for electing the subject of the debate and also the subject of the Dalits, raised by the noble and right reverend Lord, Lord Harries, which I think strengthened the content of the debate. It is a very wide canvas and it is almost impossible to fill in all the areas. I hope that he will be recruiting from Members of the House for his new all-party group on Dalits; it will have a lot of impact on legislation here, where the Dalits are also discriminated against.

I thank the Minister for her stamina, not least because she was up late last night, as was I, and saw what was happening. She now has another debate to respond to. The 0.7 per cent target is still there. I was hoping for a fuller answer on the multilateral agencies. I am slightly alarmed to think that the IOM as well as UNESCO, mentioned by the noble Lord, Lord Hannay, are on trial in some way in the aid programme, because they have such a reputation, and as he said, they need support day by day.

I must thank my noble friend Lord Singh for his maiden speech. I was a student in India years ago and the gurdwara was the place to go when you were really down and out-I remember that so well. We think in our childhood culture of the bearded as being wise. I am sure that he has always been told that he is wise, but, more than that, he is a mining engineer. We need those to give real strength to our debates.

I thank the noble Lord, Lord Avebury, who always brings up interesting subjects, and the noble Lord, Lord Judd, whom I have known for many years. I thank all your Lordships.

Motion agreed.

HIV and AIDS in the UK

Copy of the Report

Debate

3.51 pm

Moved By Lord Fowler

Lord Fowler: My Lords, I am grateful to the authorities for finding room for this debate on World AIDS Day. Perhaps I may first offer some thanks. I thank the committee, which was a mixture of old campaigners-

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I must be careful how I say that these days, but the noble Baroness, Lady Trumpington, is not here-and Members who were very much new to the area but who made a major contribution. I am delighted to see so many of the committee here, late on a Thursday afternoon, including my noble friend Lady Ritchie. I thank the clerks, Mark Davies and Matt Smith, for their invaluable work and tremendous effort. I also thank all those people who were witnesses, many of whom are the heroes of the struggle against HIV and AIDS-the clinicians, the Health Protection Agency, the department and voluntary organisations, without which, frankly, we would not be able to manage in this country.

It is 25 years almost to the week that we had our first debate on HIV and AIDS in Parliament. It was on Friday 21 November 1986. Reading that debate, I see that, as Health Secretary, I had the support of Michael Meacher for Labour and of Archy Kirkwood for the Liberal Democrats. I even had the support of Bill Cash-I have not often been able to say that in my political career. All the parties combined to make it an entirely non-partisan debate, and so it has remained-as, too, have many of the issues raised in it; public education, treatment and research are still the issues today.

However, there is of course one enormous difference between now and then. At that stage, AIDS was a death sentence. We had neither drugs nor vaccines. In the hospital wards, we found young men dying as doctors and nurses looked on helplessly. That was why we took the decision then to mount a very high-profile public education campaign using television, radio and press, while sending leaflets to every household in the country. If we wanted the public to know of the dangers, it was the only course open to us.

Of course, not everyone at that time agreed. They said that it would offend the public-there was little evidence afterwards that it had done that-and that the Government should stand well clear of such a controversial and, to them, distasteful error. My view and that of my colleagues on the special Cabinet committee that we had set up under the brilliant chairmanship of Willie Whitelaw was that that was not the case. Disease was disease, suffering was suffering, and we had a moral and human obligation to treat sexual disease just like any other and, above all, to try to prevent its spread.

The aim of our Select Committee has been to examine the progress that has been made in the 25 years that have intervened. The greatest change in every meaning of that word is the availability of effective drugs. Antiretroviral drugs have transformed the life expectancy of those with HIV. Provided that people are treated early, there is no reason why they cannot live long lives. In this country we are fortunate that such drugs are freely available, a position that even today after more than 25 million deaths worldwide is still not the case in many parts of the world. In Britain the drugs are there and the death toll has been drastically reduced. Perhaps that is why one of the most common questions that I get asked today is, "Is it still a problem?". The answer is an unequivocal yes. It is not only a problem, it is a growing problem. The evidence that the Select Committee received on this was utterly

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clear. Today almost 100,000 people in this country are living with HIV, the number of HIV patients has trebled in the past 10 years, a quarter of those with HIV do not know that they are infected and continue to spread the disease, and although we have drugs to prolong life there is still no cure and no vaccine.

This point should be emphasised; those with HIV, despite the drugs, face a lifetime of treatment and, even worse, the threat of discrimination in jobs and normal social life. The stigma has not been removed. It is not consequence free. A few months ago I received a letter from a man who had just been diagnosed with HIV. He said: "Last year I was diagnosed with the disease and it almost drove me to suicide. I would not want someone else to go through the pain I have. I am now seeing a psychiatrist and talking through how to deal with the disease". More happily he went on to say that he had now started the medication and his viral level was almost undetectable. That gives some indication of the kind of pressure and suffering that can be caused, even today, to those with HIV.

The real tragedy is that HIV is entirely preventable. Thanks to medical advance, very few babies in this country are now born with the condition. It is not like asthma or epilepsy. To be blunt, we have seen in the past decade a failure in our efforts to reduce the spread. One reason for that failure is clear enough; as a nation we spend more than £750 million a year on drugs to treat HIV, and in contrast the Government spend a miserable £2.9 million trying to prevent it. That is the failure of the policy and the direct and unavoidable challenge to this Government.

The basis of our report is that priority should be given to preventing HIV and AIDS in the United Kingdom. So far, the effort has been wholly inadequate over the past decade and a new priority must now be given to prevention policies if the epidemic is to be stemmed. Our belief is that HIV and AIDS remain one of the most serious public health issues confronting the Government at the start of the 21st century.

In principle I am encouraged by the Government's proposals to set up a new public health body with a ring-fenced budget; it is an excellent idea, although we will obviously have to ensure that the detail of the proposal lives up to the promise. However, I say to them that it is essential that much greater priority is given to prevention in areas such as HIV. At the moment we have a health system that is financed to treat the casualties but is simply not resourced to prevent those casualties coming about. Before Ministers say that this is simply a plea for money, let me remind them what can be saved by successful prevention policy. It is estimated that a lifetime's treatment costs between £280,000 and £360,000 for every patient. If we can prevent just 1,000 new infections, we are talking about savings of around £300 million. That is good news for the NHS budget, and it is exceptional news for the people spared a lifetime of treatment.

In entirely practical terms, I refer Ministers to paragraph 229 of our report, where we challenge the local procurement policies at present being pursued inside the health service and propose that antiretroviral drugs should be purchased on a national scale using the purchasing clout of the health service. The

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Government should reconsider their position and, in so doing, they would do well to read the debate in this House last Thursday, particularly the speech of the noble Lord, Lord Sugar, who made exactly that point about purchasing generally.

Of course, not everything costs vast amounts of new money. One of the undoubted reasons why HIV is spreading is that too many people are not tested; a quarter of the 100,000 with HIV do not know that that is their condition. That is obviously bad for the people who do not test, because the longer it goes on undiagnosed the worse the outcome for the individual. It is certainly bad for the country, because every undiagnosed person represents a public health hazard. It is a sure way of spreading the virus.

We have a series of proposals, but I shall pick out only three. Home testing kits are already available on the internet, but it is a trade that is unregulated and unchecked. The committee took the view that home testing was a sensible extension of testing generally, provided that such tests were accurate and under a licensing system. I am glad that the Government agree with that and I congratulate them on accepting it.

The second proposal concerns general practitioner testing. We should involve general practitioners much more and certainly ensure that people who sign up with GPs for the first time are tested. That point was made this week also by the Health Protection Agency, which points out that of the 680 people with HIV who died in 2010, two-thirds were diagnosed late.

The third area concerns prisons. I am less sure, to be frank, what the Government's attitude is here, having read their response. We know that the incidence of HIV in prisons is above the average. It would seem almost an automatic step for prisoners to be tested for their own sake so that treatment can be given, and certainly for the health of other prisoners. I will welcome the Minister's guidance on this. Overall, the aim of policy should be that HIV testing should be a normal part of medical care.

Let me return to 1986 and make a comparison between one feature that has improved markedly and another that has not improved to anything like the same extent. The good news comes from drugs. It was not entirely unanimous inside the Thatcher Government that we should introduce clean needle exchanges for injecting drug users. I could put it more strongly than that. There were fears that it might be seen as condoning criminality and that drug crime would rise. Nevertheless, we went ahead and the result has been consistently successful. Only about 2 per cent of HIV cases in the United Kingdom come from injecting drugs and we have received no evidence from the police that it has led to any increase in criminality.

I add this; we were set up certainly to look at HIV/AIDS in the United Kingdom, but we cannot ignore what is happening in the rest of the world-not only in sub-Saharan Africa but in countries such as Russia and Ukraine. There the HIV epidemic is driven by injecting drug users and is at an alarming level. In Russia, more than one-third of drug users are living with HIV; in Ukraine the position is even worse. Conceivably, our experience here might be of help. Can the Minister say what efforts we are making to make our experience available overseas?



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The part of our experience that is less encouraging is that the stigma and discrimination that surround HIV testing have not remotely disappeared. We were told of examples in employment and even of graffiti being daubed on homes and people being forced to move away. I do not say that this is general but I do say that it occurs too often. Noble Lords will know, of course, the teaching of the Christian Church-and, indeed, of every other religion-of love thy neighbour. In that context, it is interesting to look at the Ipsos MORI poll carried out in 2010 for the National AIDS Trust. Respondents were asked whether they agreed with the statement, "If I found my neighbour was HIV positive it would not damage my relationship with them". Thirty-three per cent strongly agreed with that, while 30 per cent tended to agree, but 23 per cent either disagreed or strongly disagreed. That position had actually got worse since 2007.

The stigma surrounding HIV is one further reason why the whole issue should be tackled early, and we should take relationship education seriously and not be dictated to by the bigots who say that it is all a plot to force explicit sex education down the throats of four year-olds. People who campaign on that sort of falsehood should hang their heads in shame.

It is interesting to see from the same survey that young people in particular are interested in hearing more about the reality of HIV and that many confess to ignorance in this area. In 1986, the campaign was "AIDS: Don't Die of Ignorance". Of course, the challenge today is different, but no one can dispute that there is a challenge or that ignorance of HIV remains an issue. Frankly, I do not agree with the Government that no new campaign in this area is worth while. There is a real danger that we drift into worse problems by our complacency. Of course, I understand the restraints on spending. It may come as a surprise to the Front Bench that in Margaret Thatcher's Government we also had restraints on public spending. What we did not have was a budget of £120 billion. Prevention, either against HIV or in any other area, is not one of the most costly programmes for the health service. We need a new prevention initiative. That is good financial investment for the health service, but above all it is a good human investment in that it can avoid so much avoidable suffering and distress.

4.06 pm

Baroness Gould of Potternewton: My Lords, I start by thanking the noble Lord, Lord Fowler, for making the meetings enjoyable, friendly and determined. We were absolutely sure that we were going to come to the right conclusions. The people out there who work in the field have welcomed the report. I have not heard one negative remark about the report and that says an awful lot, in many ways, about how the noble Lord, Lord Fowler, guided us through those many days. I support the noble Lord in his thanks for the staff. Sometimes we overburdened them but nevertheless they were absolutely wonderful with us. It was certainly a very concerted effort-every Tuesday morning for eight months. As one noble Lord said to me when it was over, he was suffering from Tuesday morning withdrawal symptoms-I am looking straight at him.

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I think that that applied to many others. If I raise any criticism of the response, this is in no way a criticism of the officials in the Department of Health, with whom I have worked for many years, and all of whom are fully committed to building the sexual health services, including for HIV, from the Cinderella service that it was to the improved service that we have today. Even the response goes in the right direction of travel. At this point, I declare an interest, among many, as chair of the Sexual Health Forum and as chair of the All-Party Parliamentary Group on Sexual and Reproductive Health.

I reiterate what the noble Lord, Lord Fowler, said-that the Select Committee was right to focus on prevention as a theme of the report, whether relating it to raising awareness, education, testing or treatment. It cannot be said too often that HIV remains the most serious infectious disease affecting the UK and prevention is the only way we will make that change. We had an interesting short debate during the passage of the Health and Social Care Bill on the need for national sponsored awareness-raising campaigns. But as with the response to the Select Committee report, I did not get any real assurance that national campaigns were on the agenda. While accepting the need in some instances for targeted campaigns-£2.9 million has been spent on those campaigns-there appeared to be a complete rejection of the idea of campaigns directed at the general public. That is a serious mistake as it does not take into account the rising number of UK-acquired infections among people not in the high-risk groups, who now account for more than 25 per cent of newly diagnosed infections each year. However, I was pleased to see the welcome given to the National Aids Trust website, HIV Aware, which directs its messages of prevention and awareness specifically to the general public. This is a classic example of the important role that the third sector plays in the alleviation of HIV and support for those affected. Has thought been given by the department or the Government as to how we could nationally disseminate the themes of the HIV Aware campaign more locally so that there is uniformity of message throughout the country? It would cover high prevalence groups as well as the wider audience. It would raise awareness and provide information and advice at very little cost. I do not think the argument against that can relate to cost.

Also in terms of awareness-raising, I was pleased to note the work taking place among faith leaders. As our visit to Leeds highlighted, it was possible to have dialogue with some faiths, but in other instances it proved to be very difficult. It is terribly important that this work is expanded for us to influence what is happening among some of the groups who find it difficult to accept HIV.

Overall, the public have become less aware of HIV and that has created widespread public ignorance. As the noble Lord, Lord Fowler, said, the lack of awareness by the public is one of the reasons why stigma persists and why there are so many mistaken beliefs on the supposed dangers of HIV. This creates a negative and judgmental attitude towards people with HIV. Stigma is still a daily reality for many people living with HIV. As in the instance given by the noble Lord, Lord Fowler, it can have a devastating effect on the life of

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someone with HIV and can often be compounded by profound health inequalities-for HIV is also about health inequalities.

Most importantly and crucially, stigma can deter someone from being tested. Ignorance makes people very frightened of being tested in case they then have to face the consequences that go with it. Preventing the spread of HIV has to involve the promotion of early testing and the widening of the scope of venues where testing can take place in order dramatically to reduce the estimated 22,000 people who have HIV but do not know it-the 25 per cent who are undiagnosed but might be furthering transmission.

As the Select Committee Report states, HIV testing must become normalised. An offer should be made to newly registered patients in general practice as well as to general and acute medical admissions. The Department of Health's important screening pilots have shown that staff and patients welcome more HIV testing in hospitals and in primary care and community settings. However, for the future, it will be for healthcare professionals and local authorities, when they take over in 2013, to follow that work through. I am putting a positive slant on the Government's response that they will consider favourably the Time to Test report. Perhaps the Minister can confirm that I am right to be optimistic.

The evidence of success of this approach is made forcibly by the success rate of antenatal clinics where an offer is automatically made and, as a consequence, mother-to-child transmission is at a very low level. I heard this morning at a meeting of how, when the fathers turn up at the clinics, staff can try to persuade them to have an HIV test. Many have previously been resistant to that. They are examples to learn from. The high level of acceptance of an offered test makes economic as well as medical sense and that message needs to be repeated. Prevention of half those undiagnosed cases would save the country £1.2 billion in healthcare costs. More than half the people are diagnosed late and some are already very ill, which again leads to far higher annual treatment costs. If we could have early testing, we could have early treatment and reduced costs.

The work being undertaken by MedFash, referred to in the Government's response, will, I am sure, be invaluable in providing an interactive tool to support GPs and primary care staff in offering HIV testing as it will enable those staff, among whom there is great nervousness about making an offer, to do so. That barrier needs to be looked at much earlier and we must think about having discussion of HIV in medical schools and nurse training, so that when staff are faced with such questions, they know the answers. Instead, they are finding it very difficult.

It is also very important that we look for a positive outcome to the public health outcomes framework indicator on late diagnosis. I appreciate that many are being considered in the public health field and I know that the Minister cannot give me an answer. However, I am hoping that she will say that I can be optimistic.

One of my concerns about the new structure-although I am a strong advocate of public health moving into local government-is the design of the new commissioning

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structure and the inter-relationship between the different elements that make up that structure. This is particularly important for HIV because of the expected split between treatment and care and between prevention and testing. The split of functions may be inevitable, or it may not be; it might still be changed. I understand the case made by the Government in relation to other infectious diseases. I welcome the commitment that prevention work will not become isolated from treatment services. However, I would like to hear a little more about how that will happen in practice. Perhaps the Minister can elaborate on the mechanisms that will ensure that that prevention work does not become isolated from treatment services.

In conclusion, I should like to make three short points. On standards, the response indicates that the provisions set out in the Health and Social Care Bill allow for the development of quality standards for social care and public health, opening up the possibility of quality standards that fully support integrated care pathways. The question that follows, however, is whether comprehensive guidelines will be produced to make that system consistent and effective or will it be left to each locality to determine how that works. In some it might and in others it might not.

The committee recommended that NICE be commissioned to develop treatment and care standards for HIV specifically. While there are excellent standards produced by BHIVA, they do not address the need to co-ordinate specialist health HIV services with other services. I hope that the Government might reconsider and take up the recommendation that was in our report.

My next point relates to charging for HIV treatment and care and the recommendation that HIV should be added to the list of conditions in the NHS (Charges to Overseas Visitors) Regulations 1989. This is a matter which the noble Lord, Lord Fowler, the noble Baroness, Lady Masham, and myself will be raising during the passage of the Health and Social Care Bill. I am not asking for an answer to that today. However, I understand that a review is being undertaken and it might be helpful if we could know when the review is to be concluded.

Finally, I want to say a few words about tariffs. The response indicates that funding methods such as block contracts provide no incentive for organisations to improve patient care. In the light of that clear and positive statement in the response, can the Minister clarify the decision in the Health and Social Care Bill not to allow national tariffs for public health, including sexual health? Not to allow a level of flexibility of tariffs will almost inevitably mean a return to block contracts and therefore, as the response says, diminished patient care. There is a clear contradiction here and I think that it needs clarification.

Much has been achieved in the past. However, if we are to maintain momentum and respond effectively to the challenges of a growing epidemic, we need a national, holistic strategy on HIV, a view endorsed by the HPA in its report earlier this week. We need a strategy that encompasses the findings of the Select Committee report: early diagnosis, effective treatment

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and social care, HIV prevention and testing in a wide range of settings, laws and policies to eliminate stigma and discrimination, a well-trained workforce and the reduction of health inequalities. That is the approach that I hope we will see in the planned sexual health policy framework, which gets a number of mentions in the response to the report. Only then can we be assured that the momentum that has been achieved can and will be maintained.

4.19 pm

Baroness Tonge: My Lords, I begin by congratulating the noble Lord, Lord Fowler, and the committee, of which I was a member, on this report. I consider it to be a very important piece of work and I would have hoped that the Government would have accepted all of our recommendations. Perhaps that was a bit too much to ask for; sadly, we have a little more persuading to do. I want to talk about two or three aspects of the report and I make no apology for repeating some figures that we have already heard, because they are very important and need to be engrained on everyone's mind.

HIV infection is growing in the United Kingdom. By next year, there will be more than 100,000 people living with the disease in this country and in AIDS treatment, one of the great medical successes in recent years-a quite fantastic medical success-the costs are now approaching £1 billion a year. Yet we still have to remember the title of the committee's report: No Vaccine, No Cure. It is not curable but for the fortunate people who are diagnosed early, this disease has become a rather nasty long-term condition, which can be controlled with the right treatment, so that people can go on to live a relatively normal lifespan. We have already heard about early testing being desirable. Unfortunately, this has led to a young generation growing up now who think that AIDS can be cured, like any other STD. It is, "No worries, then"-you go to the doctor.

It was 25 years ago that the noble Lord, Lord Fowler, as Secretary of State for Health, launched the never-to-be-forgotten "Don't Die of Ignorance" campaign, with its collapsing tombstones. My children trembled in front of the television set during that campaign. It had impact. They have never forgotten it, and it certainly slowed the spread of that disease in the UK. The noble Lord should always be remembered for his courage in pushing through that campaign, against what I know was some pretty tough opposition.

I do not know how much that campaign cost, but I know how inadequate spending on prevention is today. We have heard that £2.9 million is being spent on prevention-the cost of a house in my old constituency-despite the Government using "prevention" 35 times in their response to the report. I counted each mention because I am a pretty sad person sometimes. Despite those 35 times, only £2.9 million has been spent on prevention yet, as we have heard, nearly £1 billion is spent on treatment in one year. On another preventable statistic, as we have heard, a lifetime of treatment is estimated to cost between £250,000 and £350,000. For the individual and for the Treasury, prevention has to be and is better than cure.



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I want to emphasise a few more aspects of prevention, which may not have occurred to some people. AIDS is one of many sexually transmitted diseases and in my view we should not single out one disease for a campaign, as we did recently with chlamydia. That was a wasted opportunity. AIDS is a very serious disease, but I repeat that we have a sexually active population. Sexual images are everywhere and much advertising uses them. Heterosexual and homosexual activity is on our TV screens, in the cinema, and on the internet and YouTube. I do not watch YouTube but I know that young people watch it a lot. That activity is everywhere and young people are immersed in it, but whoever has seen an actor talk about condoms or sexually transmitted disease before hopping into bed with the leading lady? I never have in my lifetime.

I do not want to sound like an old prude but we have to accept that this is the way people behave. They must have the freedom to live their lives, heterosexual or homosexual, as they wish-so long as their actions do not affect others, which sexually transmitted disease does. That is good John Stuart Mill stuff: they are limiting the freedom of people to enjoy their lives. Therefore, people must be given the right warnings and information, and they must be given to all sections of the population, not just the target groups. I have talked to some AIDS campaigning groups about this, and I can say that a spin-off from this more generalised approach to the whole population may help to diminish the stigma which AIDS sufferers have to contend with. I repeat: it is a sexually transmitted disease like gonorrhoea, syphilis, trichomonas, chlamydia and even warts. Are your Lordships feeling uneasy yet, sitting on your red Benches? They are all sexually transmitted diseases and can be prevented. Let us be open about them all and push preventive messages for all of them, especially AIDS.

In their response to the report, the Government said at page 8 that they do,

Where is the evidence? I do not think we saw that evidence and we should if it exists. There should be no ifs and buts from the Government. We must massively increase preventive campaigns or face huge bills and destroyed lives. We must also have statutory sex-and-relationships education in our schools, covering all aspects of sexual activity. Stop caving in to the religious lobbies-state education must provide this.

We have another problem however-I hope on a lighter note-even if we got the Government to agree on these issues. It is the reorganisation of the health service which, as noble Lords probably know, is not one of my favourite topics. The Health and Social Care Bill will have a huge impact on the treatment, care and prevention of AIDS and every other sexually transmitted disease, because everything is being broken up. Treatment of the disease is to be commissioned by the national Commissioning Board and provided nationally. HIV prevention will be commissioned by Public Health England, I think either via or with local authorities. Sexual health promotion generally will become the responsibility of local authorities. Genito-urinary clinics, many of which treat AIDS patients too

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at the moment, will be the responsibility of local authorities, but the AIDS bit will somehow have to be funded by the national Commissioning Board.

AIDS testing will be done by local authorities. GPs will be encouraged to monitor and maintain AIDS patients already being treated, but the cost of their drugs will be commissioned nationally. Failed asylum seekers with AIDS, still sexually active in the population, are currently denied free treatment. Who will be responsible for them? Do noble Lords get my drift? Said quickly, it all begins to sound like a Gilbert and Sullivan patter song. During the Christmas holidays, I am going to work on the NHS reorganisation plans to make a nice little ditty out of all those various quangos and the way in which they will connect with one another.

For example, why should cash-strapped local authorities-I have been a member of one-or Public Health England get excited about testing for AIDS or prevention of AIDS if the budget for treatment lies with another body? In reality, they will be one phase removed. Arguments about savings "in the long term" in my experience in management, fall on deaf ears because all budgets are short term and even Governments seldom look beyond the next election. Ah, but I hear you cry, we shall encourage integration and co-operation. This, I suppose, is where the health and well-being boards come in, but without representation on those boards from the national Commissioning Board responsible for AIDS treatment, how will they integrate? What about a local authority which has a particular religious majority, or just plain old-fashioned stigma, prejudice, ideology or disapproval? What about that authority? This may severely restrict the choices made and the services it provides.

As well as the health and well-being boards, health services require full staffing and plenty of resources for those staff to find the time to contact colleagues in other services to integrate and co-operate with. Call me an old cynic but I was in the thick of it for many years in the NHS and I know the reality. These words and phrases are pushed out so easily but are so difficult to implement in practice. Noble Lords will have gathered that I am disappointed by the Government's response, but I am prepared to accept that it may be different once they get to grips with the consequences of their own health reforms.

4.30 pm

Baroness Masham of Ilton: My Lords, I should like to congratulate the noble Lord, Lord Fowler, on securing the Select Committee on HIV and AIDS in the UK. Now we have the Government's response to the committee's report and this debate on 1 December. I think the noble Lord is Lord Fix-it. I was pleased to be a member of the Select Committee and thank the staff for their very hard work.

I have been a member of the All-Party Group on HIV/AIDS since its formation in 1987. In the early days of HIV/AIDS, the noble Lord, Lord Fowler, was Secretary of State for Health and instigated the campaign to warn people against the dangers of HIV/AIDS. To this day, many of us remember the lilies and the

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tombstones. Some of us, who were in at the beginning of this serious virus, know that there is no vaccine and no cure, and that great effort should be put into prevention and research. The USA undertakes a huge amount of research but there is still no vaccine.

Spending on prevention is seriously inadequate. HIV is entirely preventable but the latest figures show that the Government spent only £2.9 million on national prevention programmes, compared with £762 million on treatment. In a number of cases, general sex or health campaigns have made no mention of HIV, so the public think that it is not a problem. There has been little in the press that confirms their idea that the virus has gone away. This disparity of spending persists despite the fact that preventing one infection avoids a lifetime of treatment, estimated to cost between £280,000 and £360,000. We recommend that a new national campaign should be mounted to tackle the ignorance and misunderstanding that still exist.

As I said, many members of the public think that HIV/AIDS is no longer a problem; they are wrong. There are many people living in the community who are HIV positive and do not know it. They may be infecting others unknowingly. Late diagnosis is a huge problem. People are diagnosed when they are seriously ill and often die within a year or are very expensive to treat. Our Select Committee suggested that there should be wider testing facilities, for example in GPs' surgeries.

A few years ago the very good GP surgery Lambeth Walk, which I visited, conducted a pilot scheme in testing for HIV. It was ideally suited because the surgery is close to St Thomas's Hospital, which has an HIV/AIDS unit for secondary care. I have heard that the pilot scheme ended and the testing did not continue. Will the Minister please look into why this project did not continue? Perhaps she would write to me.

We took evidence from many people who work for organisations that are involved with HIV/AIDS. One such body was the Health Protection Agency, which does an excellent job, working with infections. There is concern because in the Health and Social Care Bill now before your Lordships' House nobody seems to know what is happening to this independent body, which advises the Government and is well thought of throughout the world. I think the HPA falls into the category of, "If it ain't broke, don't fix it". Could the Minister please tell the House what will happen to the HPA? We have the very difficult situation of drug resistance and the very problematical HIV virus which mutates. Research is so important and should be shared with the rest of the world in order to find a vaccine.

The HPA, or whatever it becomes, should still be able to do research and receive grants. There was concern that if it is absorbed into the Department of Health or Public Health England its independence may be lost. People with HIV can be very susceptible to tuberculosis and again there are strains of TB which are resistant to antibiotics. This is an increasing danger. Our report says that data on HIV in prisons must be improved. The Health Protection Agency should utilise surveillance and profile HIV within the prison population. At the same time a review exercise

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into offender health services in public prisons is under way. The Government should supplement this with a review of the extent and nature of HIV prevention, testing and treatment services within the public prisons to determine the levels of provision across the country.

The Government's answer is that the Department of Health has worked with the Health Protection Agency to improve disease surveillance in prisons and provide prison-specific data on STIs, including HIV. The department and the HPA are aiming to disaggregate data on prison diagnoses next year. What will happen if the HPA is disbanded? I need an answer, being a member of the All-Party Parliamentary Group on Prison Health.

Throughout the process of taking evidence we found that stigma kept on coming up. HIV stigma is still a daily reality for many people living with HIV. A recent National AIDS Trust survey revealed that 69 per cent of people agree that there is still a great deal of HIV stigma in the UK. In a large-scale east London study, one in three people living with HIV had experienced discrimination. Half of all discrimination was in healthcare. The Department of Health must take a lead on this and develop training resources aimed at stopping such discrimination to be used by all current and new NHS and professional bodies.

One of our recommendations is that the Government, local authorities and health commissioners build on work already taking place within faith groups to enlist their support for the effective and truthful communication of HIV prevention messages. The Government agree but I read in the Evening Standard of 25 November that the London Church has been putting lives at risk by telling HIV-positive worshippers to stop taking their medication because God had cured them. After a healing process in which the pastor sprayed water in their faces and shouted over them, asking for the devil to come out, the patients were told that they could discard their medication. This is a death sentence but illustrates that there are many problems still to be overcome.

We found some excellent services and dedicated staff and volunteers when we visited Leeds, the Chelsea and Westminster Hospital, the Homerton Hospital and Brighton. I want to mention a gem that some of us visited in Brighton. High up on a hill overlooking the city, with a wonderful view, is the Beacon: a splendid, beautifully adapted house where people with HIV/AIDS can stay after they have been in hospital for a short time to rehabilitate before they go home. There should be more Beacons across the country for all sorts of long-term conditions. One finds good ideas often come out of HIV/AIDS treatment, and there are many aspects that would have been good for us to look at, such as children's facilities-children can become HIV positive from mothers giving breast milk-and end-of-life resources, but time did not allow for this..

I hope the report will be of use. There is something special about HIV/AIDS, as the virus and drugs are complicated. The priority aim should always be prevention. We must not forget that last year there were an estimated 3,800 UK-acquired HIV cases diagnosed.



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4.41 pm

The Lord Bishop of Wakefield: My Lords, I am particularly nervous to follow the comments on the particular church background that the noble Baroness mentioned a moment ago. I would like to start with an example of where the church and church agencies have been rather more positive. Almost 20 years ago when I was in Rome for a series of meetings, I was taken to two or three projects in Trastevere, in the heart of the city. These included a language school for illegal immigrants, a soup kitchen and a hostel for children born with HIV/AIDS. It was a powerful experience, meeting the children and their mothers. The unit had been opened about a year before by Desmond Tutu and was entirely the initiative of the Community of Sant'Egidio, a lay community which now works throughout the world on the same sort of projects.

This commitment to HIV and AIDS was mirrored in this country by the churches in the early days of the Mildmay Hospital, the London Lighthouse and other early AIDS projects. Of course, there was some element of enlightened self-interest in this work. The churches, not least through their priests, have been affected by these diseases just as much as other organisations and agencies. Looking back to my experience in Rome, I was stimulated to think further about the complexity of this task and the way that that agency had found itself dealing with illegal immigrants at the same time as HIV/AIDS, and so on. Migration and the spread of the disease and other viruses have been a key part of all this, as indeed has the enormous growth in international travel. This automatically presents us with issues about the treatment of all people with HIV, regardless of where they come from or indeed their present resident status. Humanitarian concern places an imperative on us to make sure that all who are living with HIV/AIDS receive proper care and treatment. This point has already been made by noble Lords in this debate. Again, there is, of course, an element of enlightened self-interest in this. If we are selective in the way we face this continuing issue, we may indeed be storing up further trouble for our own society in the coming years. Disease and infection know no boundaries, either morally or internationally.

Just two months ago I welcomed representatives from across the Anglican Communion, and especially from Africa, to a day consultation at Lambeth Palace on this very subject. I had been well briefed having spent two weeks in Tanzania only a month earlier, where I was introduced to projects. The focus at this consultation at Lambeth was particularly on sub-Saharan Africa, to which the noble Lord, Lord Fowler, referred earlier. It struck me at the time that in what I was saying to that consultation, I could equally well have been speaking to myself and to our own situation here in the UK. The situation is not something that we can take for granted, and that seems to have been made perfectly clear in all the speeches that we have heard so far in this debate. The situation here is as serious as it ever was. The figure of 100,000 that we heard at the beginning is terrifying, and it is increasing.

The Church of England is committed to the fight against HIV/AIDS through its community work in many places. In my own neck of the woods in the

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diocese of Wakefield, the St Augustine's project in Halifax provides help for asylum seekers, refugees and EU migrants, and to all those resident in the local community who need assistance. HIV and AIDS is, of course, an integral part of this, so we do work from first-hand knowledge in each locality.

In 2004, the Church of England produced a report which we called simply Telling the Story: Being Positive about HIV/AIDS. In a useful and concise manner it focused on many of the problems that we still face-for example, the question of openness about the crisis. It read:

"At the heart of the AIDS crisis lies the sin of stigmatization. Unless and until we address this central issue, whether it is manifested in our communities, expressed in our personal or national attitudes or, as in the case of Africa, is directed towards an entire continent, stigmatization will remain the single most resistant defence against any fulfilment of our promise to future generations".

What the report said remains just as true now as it was then. It went on to say:

"If the Church's response is to be effective ... then we will need to understand that the only way that we can work for an AIDS-free world is to work for stigma-free hearts, individually, nationally and globally".

Any one of us who has encountered people living with HIV/AIDS will know only too well of the difficulties that they have in finding the courage to be open about what has afflicted them and is threatening their lives.

Earlier, I noted that our attitudes to AIDS are related not simply to stigmatisation but to enlightened self-interest. This means that there are at least three practical ways in which we must respond to be effective. First, with regard to public health, new evidence shows that effective HIV treatment results in a 96 per cent reduction in onward transmission. Therefore, ensuring that everyone who needs treatment receives it is the key to tackling the UK HIV epidemic. Charging for such treatment deters people both from being tested for HIV and from seeking treatment.

Secondly, ending charging for HIV will, in the end, save the NHS money by preventing new infections and identifying HIV early, as the noble Lord, Lord Fowler, noted in his introductory speech. Then it can be effectively treated. This will reduce hospital costs and, indeed, expensive high-tech treatment. Thirdly, there is no evidence to support the claim that there is a market in HIV "health tourism", or indeed to suggest that the ending of charging in this country would lead in that direction.

I have mentioned once or twice issues of enlightened self-interest but ultimately the issues behind this debate take us to a far deeper level-to what is essential to our common humanity. Universally we owe it to each other to offer free and effective care in response to an epidemic which has wiped out whole populations in sub-Saharan Africa but which has also been, and remains, critical within our own society. Such fear still exists, so people are unprepared to talk about their condition and others are too frightened to face it when dealing with people pastorally or medically.

I remember, as I am sure do many other noble Lords, that some 25 years ago people whispered about the terrifying implications of the growth of AIDS.

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Such whispering began on the boundaries of some of the homosexual communities in North America. Now, a generation on, this is no matter for whispering about, nor indeed is it the rumour of an impending crisis. The crisis is already upon us and it is also no longer an issue for homosexuals alone; it affects all parts of our community. The crisis is upon us and we owe it to each other as a society to respond with all the resources that we can effectively muster.

4.50 pm

Baroness Healy of Primrose Hill: First, I congratulate the noble Lord, Lord Fowler, on securing this important debate on World Aids Day and must say how privileged I was to have served on the Select Committee that was so expertly chaired by him.

The report calls for urgent action by the Government and I wish to highlight two recommendations in particular. Recommendation 72 states:

"HIV awareness should be incorporated into wider national sexual health campaigns, both to promote public health and to prevent stigmatisation of groups at highest risk of infection. We recommend that there should be a presumption in favour of including HIV prevention in all sexual health campaigns commissioned by the Department of Health".

Recommendation 139 states:

"Ensuring that as many young people as possible can access good quality SRE"-

sex and relationship education-

personal, social, health and economic education-

The report makes it clear that although there is a widespread assumption that the danger has gone away, nothing could be further from the truth. Thousands of people are still being infected every year and the number of those diagnosed with HIV continues to grow relentlessly. Next year it is estimated that there will be 100,000 people with HIV in the UK. Although medical advances have ensured much better treatment and enabled those diagnosed with the illness to live much longer thankfully, serious medical and mental health problems remain for many with HIV.

As the report states:

"Patients can now live with HIV, but all those infected would prefer to be without a disease, which can still cut short life and cast a shadow over their everyday living".

I highlight those two recommendations as part of the way forward to help prevent the disease and to increase understanding and tolerance by the public for those who have contracted the virus. The problem of stigma has already been raised by the noble Lord, Lord Fowler. It leads to isolation and fear of getting treatment and possibly prevents people seeking a test in case they are found positive and excluded by their community. Our report argues that the awareness of responsibility and risk must extend to the population as a whole, and general campaigns may be necessary to educate the wider population. Evidence from charities noted by the Select Committee suggests that a general HIV prevention campaign would be valuable. As the report says in paragraph 100:



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"Discrimination against those affected by HIV is based, at best, on ignorance and, at worst, on prejudice, and we unreservedly condemn it. This underlines the need for a general public awareness campaign on HIV".

I am particularly disappointed that the Government have responded to this by saying:

"We do not support the Committee's recommendations on the need for a national campaign aimed at the general public as there is little evidence that this would be effective".

I hope they will think further on this and that with the publication of their new sexual health policy framework planned for 2012 they will have reassessed,

Complacency is not an option when looking at the scale of infection in the UK. As the report states:

"There has also been a dramatic increase in the yearly number of new HIV diagnoses since the late 1990s. This peaked in 2005, with more than 7,800 new diagnoses ... In 2010, there was a year-on-year increase for the first time since then, with an estimated 6,750 people diagnosed".

By next year, the report states, and I repeat, that the figure for people living with HIV is likely to be above 100,000.

The need to increase awareness remains, and so does the need to ensure that young people are taught about the illness and how to guard against it. The committee heard evidence of the increase in numbers of young people contracting the virus. The Health Protection Agency report of 6 June 2011 states that,

-men who have sex with men-

According to the HPA, in 2009 10 per cent of diagnoses for HIV were among those aged between 15 and 24 years old. The National AIDS Trust has highlighted that since 2000 new HIV diagnoses among 15 to 24 year-olds have risen by nearly 70 per cent and among young gay men they have more than doubled. As a generation grows up without memories of the widespread health promotion messages of the 1980s, spearheaded by the then Secretary of State, now our formidable chairman of this Select Committee, the noble Lord, Lord Fowler, reliable HIV information for young people remains essential.

Given the lack of either a vaccine or a cure, then,

as Dr John Middleton, vice-president of the UK Faculty of Public Health said. One of the best means of prevention lies in education. Present teaching looks at HIV and AIDS within the science curriculum. However, the separate subject of SRE, with its focus on broader social issues, which can increase levels of safe sexual behaviour according to the Sex Education Forum, should also be considered as part of HIV and AIDS prevention methods. While the report calls for the mandatory teaching of SRE in schools, the Government have indicated that that was,

and that it was,



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Yet a recent survey commissioned by Brook, the charity, found that 43 per cent of young people said that their SRE was unsatisfactory or non-existent. More alarming is the recent Sex Education Forum research, which found that one in four young people did not learn about HIV in school, which was described by a government Minister, Nick Gibb, as "unforgivable".

The Select Committee report states that,

and recommends that the internal government review of PSHE considers access to SRE as a central theme. In a report in 2010, Ofsted highlighted SRE as an area for improvement, finding that in a third of schools visited students' knowledge of SRE was no better than satisfactory. In a previous report, Ofsted expressed concerns about teaching around HIV and stated specifically:

"In particular, schools gave insufficient emphasis to teaching about HIV/AIDS. Despite the fact that it remains a significant health problem, pupils appear to be less concerned about HIV/AIDS than in the past".

I am pleased to see that the government response to this report states:

"The reviews of the National Curriculum and of PSHE by the Department for Education will take account of the Committee's recommendation",

but where compulsion is not appropriate I return to the report's call for a national sexual health campaign. We cannot afford to let public awareness of HIV and AIDS fade away, and young people must be given the information either through such a campaign or by better education in schools or preferably both. It will help young people to learn to look after themselves and their health better and to increase their understanding and tolerance of those who live with the illness. The success of the "Don't Die of Ignorance" campaign in the 1980s should serve as a lesson to the Government to ensure that young people do not live in ignorance today.

4.59 pm

Lord Lexden: My Lords, I join other noble Lords in congratulating my noble friend Lord Fowler most fervently on the excellent work of the Select Committee that he has chaired and on securing this debate on World AIDS Day. I approach any event involving my noble friend with trepidation. To my shame, I did not always have the answers to the perfectly straightforward questions that he asked me at Conservative Central Office, where I worked when he was party chairman nearly 20 years ago, yet with his customary kindness he always seemed to forgive me.

This is an immensely important occasion that should be noted by people and organisations that share the deep concerns that have been expressed so movingly in this House today. The Motion before us refers to the whole United Kingdom. The matters that we are considering affect all parts of our country. I am above all conscious of their impact on Northern Ireland, the place that has been closest to my heart since the 1960s when I began to study its history and went on to teach, along with British history, at Queen's University Belfast. Political responsibility for all health services rests of

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course with the devolved Northern Ireland Executive, but on this day above all the interests of those suffering as a result of HIV/AIDS in the Province should surely form part of our general UK deliberations.

Northern Ireland has just one laboratory dealing with the results of tests carried out throughout the Province. It therefore enjoys a high degree of accuracy in its data. Equally importantly, the lab can gather evidence of rates of testing from all sources, enabling it to pinpoint areas where the most rapid improvement can be made. Over the years, Northern Ireland has enjoyed a relatively low prevalence of diagnosed HIV, but recent trends suggest that this may well be changing. The Health Protection Agency recorded 79 new diagnoses of HIV in Northern Ireland in 2010, which is a 316 per cent increase on new diagnoses in 2001. The increase for the United Kingdom as a whole over the same period was around 20 per cent. Rates of testing in Northern Ireland are not increasing in response to the state of affairs as rapidly as they should. Less than 10 per cent of all HIV tests are being performed in primary care settings. The vast majority are being done in clinics or in hospital.

As our Select Committee's report has made clear in comments endorsed so firmly by noble Lords speaking in this debate, the stigma and discrimination that continues to surround HIV must be eliminated. That is absolutely crucial in Northern Ireland if the number of tests performed in GP surgeries is to increase significantly. As my noble friend Lord Fowler stressed, and as other noble Lords have said, early diagnosis improves the chances of more effective management of this disease. Too many deaths of HIV positive adults are due to the diagnosis coming too late for effective treatment. As has also been pointed out, early diagnosis of a patient is also of major importance in preventing the spread of infection to others.

How might earlier diagnosis be promoted in Northern Ireland? First, there is a strong case for the increased availability and accessibility of testing in areas where people might otherwise go untested. Almost one-fifth of GP practices in Northern Ireland did not perform a single HIV test last year. Of those that did, half performed three or fewer. In some places, the story is more encouraging. Northern Ireland's south-eastern trust has made particularly good progress in increasing primary care testing, with a new clinic being established to serve the local community. It will be instructive to take note of the successes of the south-eastern trust and to consider how its innovations might best be extended to the rest of the Province.

There is also a strong case for the advocacy of point-of-care testing among targeted groups. Point-of-care tests such as the well known "determine" are easy to perform and can offer results within 15 minutes, which can be life-saving where time is of the essence. At-risk groups, such as the homeless, are not easy to contact and help if longer tests are employed, but we will not get the major increases in testing and early diagnosis that are needed in Northern Ireland without increased awareness among clinicians and staff of the issues surrounding HIV and AIDS, which often include the difference between them and the dispelling of misinformation.



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Here too, there is some good news in the Province. The in-service HIV awareness training project began in Belfast during the hard-hitting campaigns of the 1980s initiated by noble friend when he was Secretary of State for Health. The project has made steady progress ever since. Around 60 HIV awareness trainers help staff and practitioners to understand the basic issues surrounding HIV and AIDS. They promote methods of early detection and diagnosis and address the changing character of the virus.

Since the project began, more than 40,000 staff have received training and the project has expanded to take in the south-eastern and southern trusts. The Belfast trust hopes that by 2013 the entire Province will be able to benefit from the training, which is devised in consultation with a wide range of organisations. In areas such as healthcare, which can have a high turnover of staff, projects such as this are vital in securing the quality and, importantly, the continuity of care that patients faced with an HIV diagnosis need.

In Northern Ireland, as in the rest of the United Kingdom, the advances that we have seen in medicines that help people to cope with HIV and AIDS must be accompanied by similar advances in the public understanding of the disease. If that does not happen, the disgraceful social stigmas that surround the issue will persist. The social aspects of HIV and AIDS are central if the goals advocated by this widely applauded report are to be met.

Public understanding, as we have heard, has certainly increased, but many of the stigmas that campaigns during the 1980s highlighted still persist for those with a positive diagnosis. Research carried out by the HIV support centre in Belfast on 40 of its clients reveals that over half have been verbally assaulted, harassed or threatened in the past 12 months as a result of their HIV status, and over 25 per cent had felt suicidal. One respondent to the 2010 people living with HIV stigma index said, "We are all afraid of rejection. The moment you tell someone you are HIV positive they just run a mile and never look back".

These are the attitudes that we must change. Not only are they hurtful and harmful to people with a diagnosis, they are also likely to deter people from seeking a test in the first place. It is shocking to think that someone might prefer to wait until a test is carried out in an intensive care unit than come forward at an early point because of the risk of being stigmatised and rejected bythose around them, including their families and friends. Sadly in Northern Ireland this remains all too common.

If only we could create new antiretroviral medicines overnight. Sadly, as we have heard in this debate, it could be many years before the next great leap forward in helping people to live with HIV and AIDS. What we can begin overnight is a redoubled commitment to increasing public education on HIV and AIDS, a commitment to reducing the stigmas that HIV-positive people face, and a commitment to preventative messages and projects such as needle exchanges as highlighted in this report.

We must continue to press for three things. First, more accessible testing is needed in places where people are unlikely to go to a clinic or hospital until it is too

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late for effective treatment. Secondly, more training is needed for staff and professionals in order to increase the level of testing that is being performed outside hospitals or clinics. Finally, unequivocal support must be given to organisations, voluntary or publicly funded, that are helping to break down the barriers associated with HIV and AIDS today, and helping those struggling with the condition to lead happier lives. We must end the situation in which people considering being tested must perform some kind of social versus medical cost-benefit analysis. Only then will people with HIV receive all the benefits of early diagnosis. Only then will the public at large become fully aware of the true nature of HIV in the United Kingdom and the great steps forward that have been taken. Only then will those who follow us in the next generation be adequately equipped to protect themselves against its threat.

Keats's beautiful poem, To Hope, contains the following poignant lines, which seem particularly apt today, and I conclude with them:

"Whene'er the fate of those I hold most dearTells to my fearful breast a tale of sorrow,O bright-eyed Hope, our morbid fancy cheer;Let me awhile thy sweetest comforts borrow".
5.09 pm

Lord Rea: I thank the noble Lord, Lord Lexden, for his contribution and congratulate him on it. It was very refreshing to have someone who was not on the committee bring us some fresh insights and information from a part of the world which we did not visit.

Like all speakers, I congratulate the noble Lord, Lord Fowler, not only on his excellent introductory speech and on securing this debate on this day, but, more than this, on his dogged persistence with this issue over the past quarter of a century and his courage and correct judgment in putting HIV/AIDS so startlingly on the map in the mid- 1980s. As my noble professional friend Lady Tonge said, he faced strong disapproval and opposition from powerful members of the establishment, despite getting all-party support. He wisely persisted with the tombstone public education campaign as well as the controversial but highly successful needle exchange scheme which he has told us about. As result, the UK became the most successful country in the world in curbing the epidemic. In the developing world and some developed countries, the epidemic has continued to spread and, in sub-Saharan Africa, has resulted in the expectation of life for the whole population being reduced by 10 to 15 years with serious socioeconomic effects. But that is another debate, although a highly important one.

It was a privilege to serve on the Select Committee. I thank not only our chairman and our specialist adviser, Professor Anne Johnson, but also our two brilliant, dedicated clerks and, last but not least, our highly efficient secretary Deborah Bonfante, who handled the mountains of printed paper which passed before our eyes smoothly and effectively. Our witnesses, whether scientists, clinicians, voluntary sector workers or patients, were always knowledgeable and helpful.

I shall concentrate on some clinical and epidemiological aspects of the epidemic, emphasising, as all speakers have done, the imperative need for better prevention.

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This was the common thread which drew all our witnesses together and is the theme of the report. It is often said that the persistence of HIV in the developed world is at least partly due, as the noble Baroness, Lady Tonge, said, to the availability since the mid-1990s of antiretroviral treatment that prevents HIV developing into AIDS, and that this has resulted in greater risks being taken by some sections of the sexually active population now that HIV is no longer a death sentence. Even if this was only partly true, it indicates widespread ignorance of the burden that living with HIV can cause, as several noble Lords have most vividly described, even when ARV treatment is being correctly given. Though some of them will live a full lifespan, others will not be so fortunate. There are often unpleasant side-effects, though they are now less common since combination antiretrovirals have become more refined.

The future health and lifespan of HIV-infected people receiving ARV depends very much on the stage that the infection has reached when treatment is started. Early diagnosis after infection is thus extremely important. ARV drugs are much less effective when there is a high viral load, so that full blown AIDS symptoms which are difficult and expensive to treat can develop, even when the subject is on ARV treatment. Fifty per cent of newly diagnosed cases in the UK are classified by the HPA as being at a late stage of infection, with a CD4 cell count of less than 350 per cubic millimetre, just over half of which are severely immunocompromised, with a CD4 count of less than 200. The late diagnosis rate varies from group to group, being highest among heterosexual men-63 per cent of them. It is estimated by the HPA that 22,200 people are living with HIV infection in the UK who are undiagnosed. Most of them are unaware of their condition; some of them are developing high viral loads which means that they will respond less well eventually to treatment as well as acting as a reservoir of infection.

HIV carriers who are being successfully treated, on the other hand, have a very low infectivity of 1 per cent or 2 per cent but even this low rate means that they must still use a condom or take other steps to reduce the chance of passing on their infection. So while acquiring HIV infection is no longer an automatic death sentence it is still a life sentence-it means a lifetime of medication and the other serious drawbacks I have described-a much worse fate than that of other sexually transmitted diseases which can now mostly be treated and cured.

In addition, as the noble Lord pointed out so vividly, people living with HIV are subject to a number of social consequences. We heard from several of our HIV-positive witnesses examples of stigma against people with HIV in employment and in social settings, despite successful ongoing treatment. Frequently there are psychological symptoms, sometimes very severe, including suicide. Life insurance policies and mortgages are difficult or impossible to obtain by HIV-positive people, according to the Terrence Higgins Trust. If after perseverance a policy is agreed, the premium is highly loaded and no cover will be given for illness or death from an HIV-related condition. That puts people at a huge disadvantage when attempting to live a full life, and buying a house, for instance.



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The noble Lord, Lord Fowler, and others have described the increasing financial burden caused by HIV infection, particularly the cost of drugs. This cost is increased if HIV is detected late and complications have to be treated in hospital. But the main cost of HIV comes from the persistence and spread of the epidemic through sexual contact with HIV carriers who are not aware of their HIV status. As other noble Lords have pointed out, this is why one of the main messages from our witnesses and the report is the need to widen the screening net by testing in more settings than previously. In fact I suggest testing wherever a blood test is being carried out for any reason and on certain other occasions, for instance when a patient is having a health assessment or being registered at a general practice, for hospital out-patients or in-patients and in STD clinics even when a blood test was not originally planned.

The case for this policy is very well argued in the Time to Testfor HIV report, mentioned by the noble Baroness, Lady Gould, published this year-or was it last year?-by the HPA. We visited a group practice in Brighton where routine HIV testing was done as well as the carrying out of general healthcare of HIV patients being followed for their HIV and treated by at the HIV unit at Royal Sussex County Hospital. When a positive test result meant that someone had a fatal disease there was a policy of only testing when suitable counselling for this eventuality was made available. Now that a positive test does not have quite such a dramatic meaning, it is acceptable for the test to be carried out by any suitably trained professional, providing of course that the consent of the patient is first obtained; an opt-out possibility must always be offered.

I have not covered our recommendations at all systematically. There are 53 of them; each has been covered by the Government's response and many of the report's recommendations have been accepted. I am particularly pleased that the recommendation to make home testing legal and quality controlled has been accepted. This was the suggestion of many of our witnesses. Also welcome is the lifting of the requirement for all overseas visitors to have to pay for HIV treatment. Lifting this charge makes good public health sense.

I was, however, disappointed in the Government's response-other noble Lords have mentioned this-to paragraphs 236 and 237 of the report, which called for the integration of HIV and sexually transmitted disease services. This is particularly relevant in the light of the changes envisaged in the Health and Social Care Bill now in Committee in your Lordships' House. I hope that the noble Baroness who is replying to this debate will be able to raise in Committee some of the issues that I am about to describe.

We heard justifiable concerns about the split between HIV treatment services to be commissioned by the National Commissioning Board, and the provision of prevention services for HIV and other STIs in genitourinary medicine clinics to be provided by local authorities-through their ring-fenced public health budgets, presumably. The proposed changes claim to enable integration between the services, but in this case it seems that the reverse is being proposed. Many

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PCTs have increasingly brought HIV and STI services together under the same roof, as they logically should be. In this case the opposite seems most likely to occur. Perhaps the noble Baroness can tell us the department's latest thinking on this particular problem.

I was going to speak also about the future of the HPA, but that has been covered extremely well by the noble Baroness, Lady Masham, and, as I have now been speaking for 12 minutes, I shall end on that point.

5.21 pm

Lord May of Oxford: My Lords, I begin by paying tribute to the noble Lord, Lord Fowler, with sincerity undiminished by the repetition. He did a superb job of chairing an excellent committee. I thought I would be unique in paying tribute to our special adviser, but the noble Lord, Lord Rea, anticipated me. Anne Johnson, with whom I have had the privilege of working and publishing, for that job, was not merely the best person in Europe but the best person, arguably, in the world. She was absolutely superb. She has a connection with this House that is not widely appreciated. If my memory is correct, she is the niece of a very distinguished late Member of the House.

I think the Government's response to our report was basically a good one. That must be borne in mind as I now go on to air the respects in which I found it disappointing. My speech will be perhaps a little different in that it will be more academic. However, it will be no less impassioned.

I have on a previous occasion drawn a graph with my hand and scattered my papers down the aisle and I risk doing it again. It is worth reminding the House what has happened not only with HIV but with sexually transmitted diseases. When HIV first appeared it was mainly among men who had sex with men and among drug users, and its incidence rapidly went down in this country, Australia and New Zealand because of effective measures such as those we have heard about. It then, for about 15 years, ticked along at a low level, slowly further declining among drug users and men who have sex with men and slowly increasing among heterosexuals to keep it at a roughly constant low level. However, over the past six, seven, eight years it has begun an upswing that shows no sign of diminishing. The question before us, which we have heard a lot about, is: why is this?

It is a fact that many studies of people-particularly young people-reveal that they are less well informed and less concerned about sexual health than was the case 20 years ago. As our report says, this is possibly because diagnosed early the majority of people with HIV can expect a near normal life expectancy. That is true and good and it needs emphasis, not least because it has a complicated and curious association with the stigmatisation initially that HIV was a death sentence. While that is true and good at the moment, it is not quite as simple as it is presented. We do not yet have clear sight of a vaccine. I declare an interest in this subject as I am co-author of the first and contentious prediction of the demographic impact of HIV on sub-Saharan Africa that was grossly pessimistically at odds with the World Health Organisation and

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others, whose models were much more elaborate but epidemiologically stupid. To my great regret, we were right.

I have a continuing interest in a fact not commonly appreciated in debates such as this. Although our almost magical understanding of the interaction between an individual virus and the immune system cells can enable us to design a drug or sequence of drugs that suppresses viral replication, we still do not have an agreed understanding of the pathogenesis-of how the initial infection is handled. Escape mutants appear and at first they are handled, then finally the immune system goes down. My view is that it will be difficult to have a vaccine before we have an understanding that matches the brilliant descriptive molecular biology with a more complex sense of the incredibly complex dynamics of the immune system and the many escape variants that it is trying to handle.

At first, we could not handle the resistance that quickly evolved to the first antiretrovirals. My research group, among others, was involved in that in the 1990s. We now have a mixture of a richer panoply of drugs, combined with a better understanding of how to use them, and we can keep people alive-but how long that is going to last is not something that anyone can sign off on. It is not a question of whether eventually, as with any set of such agents, we will finally run into a barrier; it is not a question of whether but of when, in relation to the timescale of when we have a vaccine. One thing that we sought in our discussions was an estimate of that. I am pleased to say that very good people working on this are of the view-which I share-that we probably will have a vaccine before we run into the wall. But we do not have a guarantee.

We have a very good reason, well beyond that of simple compassion or the financial details that we have heard about, not to take our foot off the pedal but to keep emphasising the need to slow down and reverse the increase in the incidence. This is a three-pronged thing. We need uninfected people to appreciate the need to be more careful; we need infected people to be diagnosed earlier so that they can be treated earlier, which will make them less infectious to a degree; but to do that, the third prong, we need infected people to know that they are infected. That brings us to some of the key recommendations that did not get the in-your-face affirmation that I would have wished.

The first recommendation is that:

"HIV testing should be routinely offered and recommended, on an opt-out"-

not an opt-in-


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