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Message: Someone thought you might be interested in this entry at Exquisite Safaris. http://www.exquisitesafaris.com/index.php/journal/more/africa_struggle_for_gender_equality_and_aids/ Africa: Struggle for Gender Equality and AIDS The following is an excerpt of a speech by Stephen Lewis, the U.N.'s special envoy for HIV/AIDS in Africa, at a meeting of the Toronto branch of the Women's Legal Education and Action Fund (LEAF) in 2005. At what point does the world understand that this is a life and death struggle, that is seeping inexorably from continent to continent? I have believed all my adult life that the struggle for gender equality is the single most difficult struggle on the planet. I believe it's more difficult than racial equality. And I must say that I have never felt that with a greater intensity than in the work I'm now doing in the field of the pandemic of HIV and AIDS in Africa. I've been doing that job for something more 3 1/2 years, and I was at the International AIDS conference in Bangkok (in July, 2004) , listening carefully and absorbing a number of unmistakable truths about the weight and force of the pandemic. Number 1, that the spread is irreversible. The assumption that a great many people, among them notable epidemiologists, made that somehow we would contain this pandemic in a relatively brief period of time has not come to pass. The most dramatic rise in the prevalence rates are today in Russia, Belarus and Ukraine,where a combination of drug use on the one hand and heterosexual activity on the other, is emerging as a kind of Hecate's brew of horror. It is implanted deeply in Haiti and Jamaica and the Dominic Republic and other parts of the Caribbean and Central America. There are profound pockets of grief in Brazil and Argentina and Chili and Peru. No western country is exempt. In Canada, among aboriginal populations, the spread of HIV and AIDS amongst aboriginal women, in particular, is grievously profound. And of course the epicentre is the continent of Africa. Number 2, it was understood at Bangkok that what has happened now is the cumulative impact of the disease. I can't really convey it adequately. The people who were infected in the late 1980s and early 1990s are now dying in astronomic numbers. You visit almost any of the hospitals in Southern Africa, you go to the adult male and female medical wards, and there are two and three patients to a bed. And under every bed on the concrete floor lies another patient. In the women's wards the sense of carnage is hallucinatory. You're in the ward and episodically, regularly, they wheel in aluminum coffins to take out those who have most recently died. Eighty to 90 per cent, sometimes 95 per cent of the cases in the hospitals are now AIDS-related. You go into the pediatric wards like the one at the University Teaching Hospital in Lusaka, Zambia, and as you walk through the ward with the magnificent superintendent of the hospital, every 10 minutes there is an anguished howl that sears the psyche and you turn around and there's a woman kneeling by a cot, four and five infant kids in the cot, a combination of AIDS and famine in that particular situation. And she's weeping, and the nurse comes in with a white sheet and covers up the infant babe and takes the child away. The sense of death is everywhere, as the pandemic has taken a hold. You drive down the streets of many of the southern cities and you see a clutch of children in brightly coloured uniforms standing by the side of the road and you think they're in a schoolyard, and they part for a moment and you realize they're in a cemetery. And number 3, is the sense of lost capacity. That, too, has taken a methodical and accumulative toll on country after country. You see, if you have prevalence rates between the ages of 15 and 49 of 10 per cent, 15 per cent, 30 per cent, 35 per cent, 40 per cent, year after year after year, it eats away at the capacity of the country. You lose the productive age groups between 15 and 49. In the case of this brutal, communicable disease it's the people in the middle generations who have gone. The teachers, the doctors, the civil servants, the agricultural workers, sector after sector stripped of its economic and social integrity. The struggle to maintain an infrastructure is overwhelming. Number 4, there are the orphans. We have never, in human history, been ready for such an onslaught of orphans. There's absolutely no precedent anywhere in the annals of humankind that has given us a sense of what to do about millions of orphans, in country after country. These are lovely kids, like every kid everywhere in the world, but they feel bewildered and abandoned and angry and sometimes anti social and they crave nurture and love like you cannot believe. And the terrible thing about orphans in Africa, as a consequence of AIDS, is that they're not orphaned when their parents die, they become orphans while their parents are dying. They wash their mothers as the mothers are dying. They clean up their mothers. They find an aspirin to attempt to alleviate an opportunistic infection. They try to find a new mat for the mother to lie on. And then they stand in the huts and they watch their mothers die and I've never been able to understand how you repair the emotional structure of those kids, how they function later on. Many of them are now old enough that they're having children of their own. How do you bring up children if you have no sense of parenting? And the communities try desperately to absorb these kids. They try everything in their power to set up surrogate families or foster families but the communities are so incredibly impoverished, living individually on less than a dollar a day, to bring in one or two extra mouths pushes the family right over the edge. And so you have this phenomenon which violates all the natural rhythms of life where the grandmothers bury their own children and then they look after their grandchildren. When the grandmothers die there's no one coming up behind so you have the phenomenon of child-headed households where the oldest sibling in the family looks after the younger children. I was in Swaziland recently, meeting with the cabinet, we were discussing matters of public policy. The Minister of Labour jumped to his feet in a state of considerable agitation and said, "Mr. Lewis, enough of policy. Do you not understand we have wall to wall orphans in Swaziland? We have thousands of child headed households where the age of the child heading the household is eight." And I thought to myself, has the world gone mad? How is this possible at the beginning of the 21st Century? How have we come to this? How have we permitted it to happen? Let us not for a moment exempt African leadership from responsibility for years of silence and denial. But that silence and denial has been overcome in the last several years. They are energized and yearning to turn things around. But what emerged most concretely from Bangkok in ways that were absolutely unmistakable and shattering was the growing evidence that the pandemic has a woman's face and that, that's particularly true on the continent of Africa. The figures are reasonably well known but they always stun me a little, even in the repetition, that of the 25 million people living with the virus in sub Saharan Africa between the ages of 15 and 49, 58 per cent are women. And if you narrow the category to the ages of 15 to 24 where there are 6 to 8 million people living with the virus, 75 per cent are young women and girls. The virus, and most people agree on this, is largely driven by predatory male sexual behaviour. And it's important to recognize that in sub Saharan Africa, as in many of the developing countries, women have no right to say no to sexual overtures. They can't say wear a condom. They can't negotiate safe sex. Indeed one of the realities that has emerged most strongly in the last couple of years, is that one of the greatest areas of risk for a women is to be married, because the virus is brought into the marriage by the male partner and the prevalence rates in marriage in several parts of Africa are higher for women than the prevalence rates of individual women in the surrounding community. And it's so often the reality of young girls marrying older men and the young girls have absolutely no way to withstand the sexual relations pressed by the man. And all of the mantra of A, B, C, which we have used as the major preventive apparatus in dealing with the pandemic, doesn't work for marriage. A) Is for abstinence B) is for be faithful C) is for using a condom. Abstinence is neither desirable or possible in marriage. Being faithful is assumed, and wearing a condom is not something the young woman can insist upon when the sexual relations are so starkly unfair. Recently in Addis Ababa in Ethiopia there was a gathering of political leaders and academics and scientists at a commission looking at questions of governance. They were trying to decide what do you do down the road when you simply don't have in the ministries of your country, in the public apparatus of the public sector, if you no longer have people to perform the jobs, what happens to household food security? When agricultural workers are too sick and are dying in such larger numbers that you can't maintain agricultural productivity? What happens to your kids when the teachers are dying and cannot service the classrooms? What happens to the integrity of the health system when the health workers are dying? Above all what happens to the girls and women of a country? How can you depopulate a country of its women and young girls? One of the people at the conference was the former Prime Minister of Mozambique, a tremendously principled and eloquent man, Pascoal Mocumbi. In the course of his remarks to the commission that was meeting he said, "The interaction of poverty, gender and adolescence is utterly devastating. Being born a girl is major risk factor cutting across even outweighing poverty. Biologically, girls and women are more vulnerable to and suffer more devastating consequences from sexually transmitted diseases than boys and men. "Gender based violence is endemic and even condoned. A country that loses skilled manpower at a faster rate than its capacity to produce it faces a downward spiral. Health and education systems that are already weak are getting weaker by the day. States with meagre resources and weak institutional infrastructures, heavily constrained by foreign debt are now charged with societies that are too hollowed out to increase the stock of human and social capital." These countries are struggling for survival. At what point does the world understand that this is a life and death struggle, that is seeping inexorably from continent to continent. On the African continent, and particularly when it comes to the predicament of women, there is no apparent immediate answer. And the other thing that must be understood and remembered about the women's reality is that they carry the entire burden of care. The husband gets infected in the city; he comes back to the rural village to die. The woman looks after him, the wife, the partner looks after him. She gets ill. She looks after herself, she looks after her neighbours and friends who are sick in the village. She looks after the orphaned children. It's all uncompensated, it's all unacknowledged. The woman handles the entire burden of care. There is nothing like the legacy of LEAF in Canada, where there is a legal jurisprudential infrastructure. There is no pattern of property rights and inherent rights and laws against sexual violence, laws that are enforced. All of that is in the most formative stage and the vulnerability of women is therefore more and more pronounced. The inability of man to relinquish power and authority is everywhere evident. That doesn't mean that you don't spend alot of time attempting to educate the men in many societies around the pandemic, of course you do. But we don't have a couple of generations to change sexual behaviour. The women are dying now, today. They don't have time! And the empowerment must be virtually instantaneous and yet the world has been so slow to embrace it. It wasn't until this year 2004 that the major United Nations AIDS report, tabled at Bangkok, had sections identifying women's vulnerability. It wasn't until 2004 that there was finally formed a global coalition on women's and AIDS bringing together some of the strongest and most concerned women's advocates around the world in order to fight the good fight on behalf of women. The truth is that at village level and community level, right across the continent of Africa, there is tremendous sophistication one should never underestimate it. The women, in particular, are knowledgeable, they are resourceful, and there is a tremendous solidarity and generosity. And we know how to do treatment using generic antiretroviral drugs and prolonging life for years, And we know innovative and creative vehicles for prevention and we know how to do home based care to keep people alive. It isn't that we haven't got the apparatus in place, it's simply that we have not found the political leadership and the financial resources in order to rescue millions of people. There are five interventions emerging on behalf of women, which are truly important and the world should understand. Number 1: all across Africa now, and indeed in many parts of the developing world, there are prevention of mother to child transmission clinics where the wonder drug Nevirapineis given to women in the final stages of the birthing process, one pill to the mother in the last few hours, the liquid equivalent to the infant in the first 48 hours, and you can reduce the transmission of the virus by 53 percent. But then the mothers always say, "What about us? We'll do anything in the world to save our infants, but what about us?" And so there has emerged, what they call PMTCT Plus, prevention of mother to child transmission plus, where the plus indicates treatment for the mother and treatment for the partner and treatment for the child, if the child is also infected. Number 2: there is a tremendous scientific quest underway to find a microbicide. Alas, the question of discovering a vaccine still seems many years off despite all the extraordinary effort that's been put into it. And what I have learned is that it is possible that within five to seven years that we might have a microbicide in place. Microbicides are primarily, at the moment gels, which the woman applies to herself and can prevent the transmission of a virus. But scientists are also working on an intravaginal ring, which can discharge medication over three or four months, and which obviously the man need not have any knowledge of. It simply gives to the woman power over her sexual autonomy . Number 3: Swaziland has so many orphans that they went to the global fund on AIDS, tuberculosis and malaria with a proposal to have 10,000 women deal with the special needs of the orphaned population in Swaziland. And they asked that the women be paid. Not a lot of money but $30 a month, which in Swazi terms is significant. So there in Swaziland we have 10,000 caregivers who are actually going to be compensated for their otherwise unacknowledged work. Finally what amounts to conscripted labour will be recognized as the work that it is. Number 4, there is a very strong focus on making sure that as treatment begins to roll out, using the World Health Organization's visionary target of putting 3 million people into treatment by the end of 2005, that women have access to the treatment in disproportionate numbers that reflect the levels of infection. And finally, and I was thinking that LEAF's astonishing compendium of knowledge might well be shared with some of the struggling legal activities in these countries where lawyers are gathering to begin to put together laws to create the infrastructure for the legal and legislative framework which can give women protection. I'm always conscious of the fact, and this isn't some ideological spasm, that by the end of 2005 we will have spent internationally well over $200 billion dollars on wars in Iraq and Afghanistan and reconstructing those economies. And we cannot find a microscopic smidgen of that to save millions of lives every year. And I wonder about the nature of the moral default, the moral vacuum in international society. 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