Last month, I spent two weeks touring four countries in Southern Africa: Lesotho, Zimbabwe, Malawi and Zambia. The primary purpose was to view the link between hunger and AIDS. I want to look back at that visit, because little will have changed between then and now (except, perhaps, that things will have deteriorated further), and then look forward to the prospects for addressing the pandemic in 2003.
At the outset, however, let me express, yet again, the fundamental conviction I have every time I visit Africa: there is no question that the pandemic can be defeated. No matter how terrible the scourge of AIDS, no matter how limited the capacity to respond, no matter how devastating the human toll, it is absolutely certain that the pandemic can be turned around with a joint and Herculean effort between the African countries themselves and the international community.
I am weary to the point of exasperated impatience at the endless expressions of doubt about Africa’s resolve and Africa’s intentions and Africa’s capacities. The truth is that all over the continent, even in the most extreme of circumstances, such as those which prevail today in the four nations I visited, Africans are engaged in endless numbers of initiatives and projects and programmes and models which, if taken to scale, if generalized throughout the country, would halt the pandemic, and prolong and save millions of lives.
What is required is a combination of political will and resources. The political will is increasingly there; the money is not. A major newspaper in the United States, reflecting on the paucity of resources, used the startling phrase “murder by complacency”. I differ in only one particular: it’s mass murder by complacency.
You will forgive me for the strong language. But as we enter the year 2003, the time for polite, even agitated entreaties is over. This pandemic cannot be allowed to continue, and those who watch it unfold with a kind of pathological equanimity must be held to account. There may yet come a day when we have peacetime tribunals to deal with this particular version of crimes against humanity.
As bad as things are in Southern Africa - and they are terrible - every country I visited exhibited particular strengths and hopes.
The little country of Lesotho has a most impressive political leadership, but is absolutely impoverished. If it had some significant additional resources, with which to build capacity, it could begin to rescue countless lives. I vividly remember the Prime Minister of Lesotho saying to me: “We’re told repeatedly by donors that we don’t have capacity. I know we have no capacity; give us some help and we’ll build the capacity.” It’s worth remembering that Lesotho has a population greater than that of Namibia and Botswana, but it has nowhere near the same pockets of wealth. It has, however, one of the highest prevalence rates for HIV on the continent, higher than Namibia; almost as high as Botswana, and is fatally compromised in its response by the lack of resources.
Zimbabwe, whatever the levels of political turbulence, has created a sturdy municipal infrastructure for the purpose of dealing with AIDS. You will know that for the last couple of years, Zimbabwe has had a 3% surtax on corporate and personal income, devoted to work on AIDS. A good part of that money has been channelled down to district and village level, through a complex array of committees and structures which actually get the money to the grassroots. It’s visible in the work of youth peer educators, outreach workers and home care through community-based and faith-based organisations. In other words, for all the convulsions to which Zimbabwe is subject, there remains an elaborate capacity to implement programmes, if only there were more programmes to implement.
In Malawi, we may be about to see the most interesting of experiments in the provision of anti-retroviral treatment in the public sector. The Government of Malawi had originally intended to treat 25,000 people based on receipt of monies from the Global Fund. They then realized that the calculation of 25,000 was based on the purchase of patent drugs, but now that it is possible to purchase generic drugs, the numbers eligible for treatment could rise to 50,000. There has been, predictably, a great deal of skepticism in the donor and other communities. However, while we were in Malawi, the country was visited by a WHO team which carefully examined the capacity and delivery issues, and came to the conclusion that treating 50,000 people, phased in of course, was entirely possible. This is an exciting prospect: the treatments are meant to be free of charge, and delivered through the public health sector.
Zambia, whatever the difficulties - and they are overwhelming - is emerging from the bleak and dark ages of denial into the light of recognition. The bitter truth is that in the regime of the previous President, nothing was done. He spent his time disavowing the reality of AIDS, and hurling obstacles in the way of those who were desperate to confront the pandemic. I can recall personally attending an annual OAU Summit on behalf of UNICEF, and sitting down with the then President Chiluba, and asking him what he intended to do about AIDS, and he simply wouldn’t talk to me about it. Well there’s a new President in Zambia. And although he’s been in place for only one year, everyone agrees that there’s a dramatic change in the voice of political leadership around the subject of AIDS.
The fact is that in every country, even under the most appalling of human circumstance, there are signs of determination and hope. Whether they can be harnessed in the name of social change will be known in the year 2003. God knows, there are incredible hurdles to leap.
Editorial
In August 2002 Gro Harlen Bruntland, Director General (DG) of WHO, announced that she would not seek a second term as DG. This issue of the EQUINET newsletter compiles some of the debates and papers that have been presented around her record at WHO, the candidates for the new DG and the selection process itself. The political moment created by the election of a new DG stimulates debate about WHO’s priorities and role in international and global health, as the leadership qualities sought in a new DG should reflect those roles.
Bruntland’s achievements at WHO are notable. She raised the profile of health in the global agenda, including within economic and political forums and is reported to have restored WHO’s credibility with donors. She launched a number of global health campaigns. During her period as DG, WHO has reasserted itself as an international standard-setting body around areas such as tobacco control, pre-qualification for procurement of antiretrovirals, food safety standards, and essential drugs. Bruntland had some success at negotiating partnerships with foundations and the private sector.
Yet the debate on WHO priorities and the realities of health from the perspective of a southern African network indicate that there are many unresolved issues. Whatever the changes that were achieved at global level, they have not been felt at country level. Poverty and unavoidable and unfair inequalities in opportunities for and access to health are pronounced and persistent. Despite this WHO is not perceived to have been a strong public advocate for health equity or for protecting public health in economic and trade policies. Neither is there a perception of the powerful advocacy of primary health care or of forms of health financing that enhance access to health care in poor communities, in women and other vulnerable groups. In contrast, in an environment of rapid and powerfully driven market reforms and privatization, there is some criticism of WHO unwillingness to confront commercial interests over patient interests in access to medicines under TRIPs, or protect national authority rights to regulate private health providers under the WTO GATS agreement.
Hence even while the Macroeconomic Commission on Health raised the profile of the US$27bn shortfall in global resources for health, and the Global Health Fund (GHF) created one vehicle for responding to this shortfall, the impact of these global shifts has been weak. Beyond the insufficient and poorly sustained funding of the GHF, WHO has not yet made clear or put its international policy weight behind the public policy measures needed nationally and globally to ensure that health services and systems spend more on those with greatest need. This has left a number of issues poorly addressed, such as for example the attrition and loss in health personnel from public to private sectors and from low to high income countries; the collapse of primary care level services in some countries; the shift in the burden of caring for HIV/AIDS to poor households and inability to secure treatment access in many low income countries, or the still weak link between public health and the wider systems of rights and procedural justice needed to manage the contestation over scarce resources for health.
The nature of the issues to be addressed, and their significance in Africa make the policies of the next DG a matter of some concern for Africans. The public policy shortfalls identified above do not simply call for business as usual with a bit more focus on Africa. In the same way as poor people’s health needs demand a wider review of public policy generally, so too does meeting the needs of health in Africa demand critical review of wider global, international and national health policies for where they generate vulnerability and impede public health authorities in Africa making coherent responses to ill health.
This editorial does not scrutinize the candidates – there are links to articles about the candidates at the end of this editorial. While effort has been made to make the process of selection of the DG more open to public debate through journal papers and email lists, in fact the process is still tightly controlled within the 32 health ministers in the Executive Board. It would however be important to make two comments. The first is to note the presence as a candidate of Pascal Mocumbi, a southern African who has championed health equity for many years, both working on ways of providing incentives for health equity and articulating equity oriented policies, including as at the 1997 Kasane meeting that launched EQUINET. The second is to note that while individual attributes, perspectives and experience are clearly important, the challenges to be addressed by the new DG call for wider alliances for health. Here perhaps WHO has untapped potential: A number of partnerships for service delivery have been built by WHO.
Bruntland has mobilized resources and raised the political profile of health. The challenge for a new DG is to bring in new strategic alliances and constituencies that advance WHOs role as global advocate for public health and that bridge global opportunity with national practice. Beyond the technical and political support that has been raised, this implies tapping into the massive social support that exists for health rights and values.
LINKS:
(Please note that links to articles from The Lancet require a short and easy registration process)
* AND THE NOMINEES FOR DG ARE …
http://www.thelancet.com/journal/vol360/iss9348/full/llan.360.9347.news.23403.1
* NINE CANDIDATES LINE UP FOR TOP POST
http://bmj.com/cgi/content/full/325/7375/1259?ijkey=l5xSvpnNpSrp6
* WHO’S NEXT DG – THE PERSON AND THE PROGRAMME
http://www.thelancet.com/journal/vol360/iss9348/full/llan.360.9348.editorial_and_review.23505.1
* HAVE THE LATEST REFORMS REVERSED THE WHO’S DECLINE
http://bmj.com/cgi/content/full/325/7372/1107?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=World+Health+Organisation+and+Bruntland&searchid=1040232817123_11702&stored_search=&FIRSTINDEX=0&fdate=12/1/1998&resourcetype=1,2,3,4,10
* ELECTION PROCEDURES LOW AND SECRETIVE
http://www.thelancet.com/journal/journal.isa
* LETTER TO THE LANCET ON ELECTION PROCEDURES
http://www.afronets.org/afronets-hma/afro-nets.200210/msg00057.php
A third of the world’s population still has no access to essential drugs. In the poorest countries of Africa and Asia this figure rises to half. With the global agreement on intellectual property rights (TRIPS) forcing countries to introduce new patent protection laws over the next decade, this situation could worsen, according to a new report from the London-based Panos Institute.
Developing countries have until 2005 or 2016 to implement TRIPS-compliant legislation on pharmaceuticals. So far many governments have drafted or enacted legislation that seems to prioritise patent rights over public health. Some countries are being pressurised into adopting policies that go further than TRIPS in protecting patents. Patents give big international pharmaceutical firms monopoly over production of new drugs, including, for example, those needed to treat HIV/AIDS.
There is concern they may push up prices, and the TRIPS rules could thus limit poor countries’ freedom to buy cheaper “generic” versions of patented drugs. For example, in January 2001, South African HIV/AIDS treatment activist Zackie Ahmat went to Thailand to buy 5,000 pills of the generic version of an anti-fungal drug patented by the US pharmaceutical giant Pfizer. He paid $0.21 a pill. The price of the patented version in South Africa was $13.
The Panos Report, 'Patents, Pills and Public Health: can TRIPS deliver?' warns that patent legislation is not being debated widely enough in most developing countries, and the process of introducing it needs to be more consultative and transparent. In Uganda, for example, American consultants were brought in to review the country’s patent laws and make proposals for reform. The result was the drafting of laws which, according to local campaigners, are skewed in favour of business interests rather than social or development needs. The principle of extending access to essential drugs in poor countries is widely supported, but the means of doing this is still hotly disputed, says the report.
According to the World Bank, middle-income countries may benefit from increased foreign investment, but if the cost of drugs rises as a result of patent systems spreading throughout the developing world, there is a real danger of restricting access to drugs, such as anti-AIDS drugs, where they are most needed. The World Health Organisation suggests that implementing patent protection where it did not already exist would result in the average price of drugs rising, with projected increases ranging from 12 to 200 percent.
The pharmaceutical industry argues that patent systems promote innovation and investment in research and development. Without patents, new ones would not be developed to tackle diseases such as tuberculosis and HIV/AIDS. They believe the real barriers to making drugs more available are poverty, weak political leadership, lack of trained health personnel and poor health infrastructures.
The report examines alternative approaches and gives examples where differential pricing (where poorer countries pay considerably less for a product than wealthier ones) and compulsory licensing (where a patent is overridden in return for a payment of a royalty) have potential, although they are not free of problems. Two countries highlighted in the report, show how differently patent protection can impact on the nation’s public health: Brazil is seen as a model for other countries of what can be achieved for public health by boosting local production of drugs such as the anti-AIDS drug AZT, lowering prices through competition and negotiating discounts on patented drugs. Between 1996 and 2001 around 358,000 AIDS hospitalisations were prevented, saving around $1.1 billion. On the other hand, Thailand’s capacity to provide essential drugs for its people has been severely limited in the last decade due to relentless pressure from the US to tighten up its patent laws which, they complained, meant the loss of $30 million a year in sales for the American pharmaceutical industry because it referred only to pharmaceutical processes and not products. The US went as far as imposing $165 millions’ worth of sanctions on eight Thai products exported to the US. The US continued to exert pressure until the patent laws were changed and made even more restrictive than the international TRIPS agreement requires.
“This report should be a wake-up call to developing countries to look carefully at how they go about complying with TRIPS legislation and make sure that access to essential drugs is kept as an overriding right for the entire population – not just a wealthy few” says Martin Foreman, author of the Panos report.
* The full report and additional country studies can be downloaded from this website http://www.panos.org.uk/
* The Panos Institute is an independent, non-profit organisation specialising in communication for development. It works to catalyse informed public debate, particularly in developing countries. It has 12 offices in Africa, Asia, Europe and the Caribbean.
A Speech to the HIV/AIDS and "Next Wave" Countries Conference, the Centre for Strategic and International Studies Washington, DC, October 4, 2002, on the US National Intelligence Council report, 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', published September 1 2002.*
For more than a decade now, those who have chronicled the sweep of the pandemic have warned about the excruciating consequences of societies falling apart. Now, more than ever, we have groups coming together to fashion scenarios of what will happen in the future. The Next Wave study repeats in several places, that: "The rise of HIV/AIDS in the next wave countries is likely to have significant economic, social, political and military implications". That seems to me to be unarguable.
But if the present teaches anything about the future, then just draw back and look at what is happening in Southern Africa. It has been established that 14.4 million people are at risk of starvation in six countries: Zimbabwe, Zambia, Lesotho, Swaziland, Malawi and Mozambique. Now allow me to be personal for a moment. Last week, I met with Mr. James Morris, head of the World Food Programme, who had just returned from a mission, as Special Envoy, to the six beleaguered countries. He was a man physically and emotionally reeling from what he'd seen. He had instantly recognized that food was only part of the problem; the heart of the problem was AIDS.
That should ring one of the most piercing alarm bells that we've yet heard during the course of the pandemic. If you read the Mission report, it's like a revelation: "What the mission team found was shocking. There is a dramatic and complex crisis unfolding in Southern Africa. Erratic rainfall and drought can be identified as contributing factors to acute vulnerability, but in many cases the causes of the crisis can be linked to other sources. Worst of all, Southern Africa is being devastated by the HIV/AIDS pandemic. HIV/AIDS is a fundamental, underlying cause of vulnerability in the region, and represents the single largest threat to its people and societies".
And then, over and over again, in country after country, the report chronicles the way in which AIDS exacerbates the crisis. The language is startling, allow me to quote one other section: "The relationship between the HIV/AIDS pandemic and the reduced capacity of the people and governments of Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems".
I've read the report carefully. I've talked to numerous colleagues. I've discussed the matter with three people who were on the UN mission. I've consulted a notable academic who is the pre-eminent scholar on AIDS in Southern Africa. Let me tell you what I think - I obviously cannot prove - but what I think has happened. I think it is reasonable to argue that AIDS has caused the famine; that what we all feared one day would happen, is happening. So many people, particularly women, have died, or are desperately ill, or whose immune systems are like shrinking parchment, that there simply aren't enough farmers left to plant the seeds, till the soil, harvest the crops, provide the food. We may be witness to one of those appalling, traumatic societal upheavals where the world shifts on its axis.
We've been predicting that you can't ravage the 15 to 49 year-old productive age group forever, without reaping the whirlwind. The whirlwind is in Southern Africa. And surely that has huge implications for the next wave. If you watch while your educational systems are shattered, your health infrastructure is frayed, your agriculturalists are dying, your militaries and police have astronomic levels of infection, your private sector is atrophying, then it becomes impossible to escape the economic and social and political and military consequences. For the so-called next wave countries, there is no time left to contemplate. There is only time left to act. Southern Africa is the canary in the pandemic […]
I want to re-emphasize my conviction that this pandemic, in all its multivarious forms in the countries with which we're dealing, can be turned around. There is tremendous knowledge and selflessness at the grass-roots; it just has to be given a chance. We - and it's the royal, generic 'we' - know a great deal, if only we can apply it. We know how to go about Voluntary Counselling and Testing; we know ways in which to reduce, dramatically, vertical (mother-to-child) transmission; we know how to administer anti-retroviral treatment; we know of excellent preventive interventions; we know the world of care at community level, provided by the women, and rooted in faith-based and community-based organizations; we know the knowledge and expertise that can be brought to bear by People Living with AIDS. We know, as well, the huge challenges of mobilizing the political leadership, galvanizing the religious leadership, fighting the curse of stigma and strengthening advocacy on all fronts.
What we don't have is the means to do it with. We don't have the dollars. I've knocked this particular nail through the wall so many times that even I feel a certain ad nauseam quality merely to mention it; in fact, I feel like a minor clone of Jeffrey Sachs. But the truth is that what's literally killing the women and men and children of Africa is the lack of resources.
Just two weeks ago, I was meeting in Arusha, Tanzania, with a group of women living with AIDS. I asked them, as I always do, to tell me what they most needed and wanted, and as always the same replies came back: food, because everyone is hungry, especially the children; money for school fees, and some kind of guarantee to keep their kids in school, because when they die they want their children to be assured of an education. And drugs. Anti-retroviral drugs to prolong life ... so as not to leave their children so prematurely-orphaned. To be quite honest, I never know what to say in such a situation. I'm strangled by the double standard between developed and developing countries. I'm haunted by the monies available for the war on terrorism, and doubtless to be available for the war on Iraq, but somehow never available for the human imperative.
I believe that all the things those women asked for could be provided, or at least provided in large measure, if we had the money. Next weekend, the Global Fund will pronounce on its financial needs. There will then ensue a tenacious, indefatigable effort to round up the dollars. I have no idea what to expect.
I know only that if the Next Wave is to escape the wretched fate of the last wave, then the world and its governments will have to come to their senses.
* 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', prepared for the National Intelligence Council of the CIA, highlights the rising HIV/AIDS problem in five countries of strategic importance to the United States: Nigeria, Ethiopia, Russia, India and China. It is available as a pdf file at: <a href=http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf>http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf<a/>
We, the SADC Health Ministers gathered at Roodevallei, Pretoria, on 30 August 2002 deliberated over the severe famine facing the SADC region [...]
We, the SADC Health Ministers [...] recognize that the famine is super-imposed on an already severe HIV/AIDS pandemic in the region. Both the famine and HIV will lead to deeper impoverishment of the people of the region, and further compound the magnitude of premature death of vulnerable groups namely children and women, from diseases aggravated by poverty like HIV/AIDS and malnutrition, such as malaria, TB and diarrhoeal diseases.
Notwithstanding the effect of the famine on productivity, combined with the HIV/AIDS pandemic household food security through reduced productivity is further compromised and an additional burden placed on already overstretched health systems.
We, the Ministers, recognise the current severe shortfall in food production and food availability in the region, with a cereal deficit of 4,071,300 metric tonnes (MTs) in the region. We also recognise the complex causes of the famine but identify the high levels of poverty in the region as a key factor underlying the current disaster. In the countries affected by the famine, between 1996 and 2001, the number of people living below the poverty line has stayed the same or increased, with on average 68% of the population living below the poverty line in 2001. We further recognise that poor people are most vulnerable to any adverse events.
We note with great concern, the environmental and agricultural factors as a cause of the drought and famine in Africa, with an estimated 500 million hectares affected by soil degradation since 1950, including as much as 65% of agricultural land. A combination of inequitable distribution of land, poor farming methods and unfavourable land tenure and ownership systems have led to the decline in productivity of grazing land, falling crops and diminishing returns from water supplied. Nearly two- thirds of Africa is semi -arid, and Southern Africa is one of the sub regions that is most affected. This dryness makes the land vulnerable to degradation.
Economic factors contribute significantly to this situation. High debt burdens and unequal trade have undermined effective responses by Southern African countries. In particular, greatly increased subsidies to U.S. and European farmers threaten the viability of farming in the region [...]
The urgent need for medicines to save lives, families and the fabric of our communities today impels a group of applicants (which includes the Treatment Action Campaign, unions and doctors) to launch a complaint with the Competition Commission in South Africa against two major international drug companies, GlaxoSmithKline (GSK) and Boehringer Ingelheim (BI). The complaint charges these corporations with excessive pricing in respect of several key drugs for the treatment of AIDS. The drugs are: RetrovirAE (zidovudine or AZT), 3TCAE (lamivudine), CombivirAE (AZT/lamivudine) and ViramuneAE (nevirapine).
This is a novel step that engages South Africa's sophisticated competition regulatory system in an effort to secure justice and rationality in drug pricing in the AIDS epidemic. Tens of thousands of people in our country are dying every year because of excessive prices for these medicines and because of government's lack of determined action to reduce the prices.
People living with HIV/AIDS, our doctors and nurses, the Treatment Action Campaign (TAC), the Congress of South African Trade Unions (Cosatu) and the Chemical Energy Paper, Printing, Wood and Allied Workers Union (CEPPAWU) have decided to act jointly against continued, unjust and insupportable drug company profiteering. South Africa needs affordable medicines now.
According to the World Health Organisation, the most commonly recommended triple drug therapy for HIV/AIDS is the combination of CombivirAE AZT/lamivudine) and ViramuneAE (nevirapine). We are placing the following powerful evidence before the Competition Commission: a month's supply of this treatment regimen at retail prices costs R1176.00 from Glaxo and Boehringer. By contrasts, the best-priced generic internationally cost R276.00 per month. The stark fact is that for the cost of one treatment from the brand name companies four people with AIDS can be treated on generics. We have additional evidence of excessive pricing for individual drugs.
Excessive pricing or profiteering by GlaxoSmithKline and Boehringer Ingelheim is directly responsible for premature, predictable and avoidable deaths of people living with HIV/AIDS, both children and adults.
For nearly four years, TAC and our allies have campaigned globally for drug companies to issue unconditional voluntary licences, against a royalty payable to the corporations of 4-5%, to allow generic competition and the lowest prices. This is a rational, fair and life-saving proposal. The drug companies have ignored it. Now we are asking the Competition Commission to investigate the complaint and to refer it to the Competition Tribunal.
We seek the following relief:
An order that GlaxoSmithKline and Boehringer Ingelheim stop the excessive pricing practices; A declaration that the excessive pricing conduct is a prohibited practice for purposes of damages claims by all persons who can establish that they have suffered loss or damage as a result of the prohibitive practice concerned; and An administrative penalty against the companies.
We are taking this action to ensure that:
The right to life is placed before profiteering; People living with HIV/AIDS who work can afford to buy medicines to save their lives; Children living with HIV/AIDS will get access to antiretroviral medicines; Medical schemes can afford to treat people living with HIV/AIDS without going bankrupt; Employers can treat their workers on a sustainable basis; and that Government shakes off the denialist paralysis and develop a national treatment plan.
We call on all people in South Africa and across the world to support this action taken by people living with HIV/AIDS, health care professionals, TAC, Cosatu and Ceppawu. We urge everyone to call on all drug companies to immediately issue unconditional voluntary licences for antiretroviral medicines to save the lives of millions in our country and across the world.
* Note: Equinet jointly with Oxfam GB will shortly be putting out a call for applicants for a grant looking at equity issues in relation to HIV/AIDS and particularly treatment access.
Thumida Maistry will be leaving Equinet as at the end of October 2002. Equinet is grateful to Thumida for her energetic commitment to the network. She has been working for the past three months on background work for an advocacy plan for Equinet that will be more substantively taken up in 2003. Programme co-ordination will continue to managed through TARSC as always and communications should be directed to admin@equinetafrica.org.
The World Summit on Sustainable Development included a strong civil society presence, although one, tellingly, kept separate from the governmental proceedings of the main conference. In hosting their own Peoples Summit, civil society groups drafted proposals that were aimed to feed directly into the governmental discussions on a daily basis.
Groups at the Peoples Summit were gathered according to geographic or issue commonality. Equinet was represented in the health, womens and Africa caucus. As the summit drew to a close it became increasingly apparent that whilst NGOs achieved a great deal in their own deliberations, these discussions were becoming increasingly irrelevant in relation to influencing the outcomes within the main Sandton-based governmental discussions. This drew a great deal of anger from civil society groups, with many feeling forced to disassociate themselves from the event. At the same time others, under the banner of the Summit Civil Society Secretariat, seemed to display greater willingness to concede success for the summit, despite clear indications that the critical issues for civil society and sustainable development were being blatantly ignored.
For the Africa caucus, this division paralleled differing views held on the effectiveness of NEPAD. Despite much discussion and agreement on a number of priority areas, their declaration, printed in full below, failed to agree on a unified position and it was eventually agreed that, where NEPAD is mentioned, the draft should contain both points of view.
The Johannesburg Declaration of African Civil Society Organisations
We representatives of African Civil Society organisations meeting during the World Summit on Sustainable Development reaffirm our demand for commitment to the achievement of sustainable and equitable development in Africa.
The Rio Summit marked international commitment to providing political, financial, and technological support for its version of achieving the interlinked goals for human centred, environmentally sustainable and culturally sensitive development, and, poverty reduction.
A decade later, it is evident that the development situation particularly, poverty in Africa has escalated. There has been insufficient commitment by African governments to the ideals of Rio and inadequate financial and technological support by development partners for Africa’s development priorities. The capacity of the people of Africa to lift themselves out of poverty, food insecurity and illiteracy has been undermined by many factors, including declining levels and terms of trade, increasing debt burden, declining overseas development assistance and private investment flows, increasing marginalisation in world relations from globalisation, unfavourable prescriptive donor policies, environmental deterioration, partly from increased exploitation of the natural resource base of the continent, HIV/AIDS prevalence, and, conflict and wars.
We resolve to fully utilise the opportunity offered by the Johannesburg commitment on sustainable development to work towards ensuring urgent and renewed commitment, by African governments and development partners, backed by time bound implementation actions, monitorable deliverable and identified sources and levels of resources, that will assure the achievement of the Millenium Development Goals and Targets in Africa and accelerate the realisation of our sustainable development vision for Africa within ten years.
We, civil society organisations of Africa, envision an African society, characterised by unity in diversity, equality, equity and justice that guarantees the fundamental needs of its people, is participatory and accommodates the interests of all stakeholders in decision-making processes, including the empowerment of women in all areas, and ensures democracy and human rights in which poverty is reduced to a minimal level through knowledge based, culture sensitive and people centred development that is environmentally, socially and economically sustainable..
We recognise the UN secretary General Kofi Annan’s WEHAB initiative as a contribution to the Draft Plan of Implementation of the Johannesburg summit for the WSSD while it seeks to provide focus and impetus to action in the key thematic areas of Water, Energy, Health, Agriculture and Biodiversity that are integral to a global approach to the implementation of sustainable development.
We call for clear processes and transparent criteria to be defined and adopted through the participation of stakeholders in the implementation of partnerships emerging from the Johannesburg Summit
We urge all African Governments to commit themselves to the challenges posed in the “Earth Charter”.
We acknowledge that for the WSSD to ensure the achievement of our vision of Africa it should address the following issues:
a) poverty eradication, b)emergence of African regional groupings and alliances, including the Africa Union and NEPAD c.)human resource development including education, health and combating HIV/AIDS, TB, Malaria and avoidable diseases of poverty, d)Africa and globalisation, e.)sustainable agriculture and food security, f.) water and sanitation, g)natural resource management, including desertification and land degradation, h.)energy, I) science and technology including indigenous knowledge systems and the legal recognition of the rights of local communities, j) democratic governance, k) rule of law, respect for human rights and freedoms, l) gender equity, m) armed conflict and warfare
We call for a commitment by all Governments to reach agreement for a timetable for the phasing out of harmful subsidies of fossil fuels and agree on targets and timeframes for increasing the share of renewable energy supply for Africa.
We recognise that achieving our sustainable development goals requires a supportive international environment, particularly in the areas of macro-economic policy, market access and fair trade, debt relief, ODA and conditions for leveraging private capital flows, human development, technology transfer, capacity development and full implementation of multilateral environmental and sustainable development Conventions and their Protocols. We call for strong and immediate action.
We recognise that while globalisation may bring new opportunities and challenges for sustainable development in Africa, the uneven distribution of wealth and apparent benefits further marginalizes the continent’s role in the world economy. Special attention should be given to grassroots communities where such benefits do accrue.
We acknowledge that peace is a prerequisite for sustainable development and call on African Governments and the international community to adopt measures to ensure a peaceful and stable environment for Africa’s sustainable development.
We reaffirm our engagement with NEPAD, despite our insufficient involvement in its formulation, and urge African leaders to partner with African Civil Society organisations in all processes for its refinement, implementation and monitoring. We are concerned that NEPAD does not replicate structural adjustment programmes, which have increased poverty and inequality on the Continent.
We reaffirm that sustainable development requires active participation of women and men on equal footing at all levels of decision making, implementation. Monitoring and evaluation. We call for the integration of gender equity in all aspects encompassed within Agenda 21, the Millenium Development Goals and the Johannesburg commitment on Sustainable Development.
We reaffirm the unconditional need for African Governments themselves to initiate appropriate steps to ensure good governance as a major prerequisite for sustainable development.
We commit ourselves to the monitoring of the implementation of Agenda 21, the Millenium Development Goals and the Johannesburg commitment on Sustainable Development through existing and newly formed African regional, National and Local NGO coalitions on sustainable development.
International Trade and Gender Network Bulletin, Volume 2, No. 7, July 2002
There are many opportunities and challenges facing women in the upcoming World Summit on Sustainable Development. Perhaps it is worth reflecting on the whole notion of what our forefathers and foremothers meant when they conceptualised what freedom and emancipation for the African people would mean to future generations in Africa.
The most common word we heard in terms of development during the independence explosion, and the fight to decolonise and kill apartheid in South Africa, was self-determination. Where has this discourse gone? What is the difference between sustainable development and self-determination? It is critical to reflect on this in order to locate the gender perspectives in the upcoming summit.
Self-determination is the right to determine our future, to shape it, nurture it in ways that reflect our desires, goals and aspirations as African people. Self-determination opens the space for us to innovate, experiment with new ideas, to fail and from these failures reconceptualise our destiny until it fulfils the vision we have as a people. The vision and hope of preserving the sky, the land, and placing adequate food for everybody to consume not just a few, security of body, mind and soul above everything a peaceful stable environment where everybody can earn a living. Some people call this idealism and are skeptical about attaining this equilibrium.
Sustainable development is a new term. It takes on different nuances depending on who happens to be articulating this concept. How do women fit into this agenda? What sort of development are we sustaining? Is this notion of sustainable development an environment that can promote gender equality?
In reading through the Chairperson’s text towards the summit on sustainable development a number of concerns arise. I want to flag just a few issues that need to be interrogated by gender activists in general and feminists specifically.
1. The concept of sustainable development as framed in for WSSD repositions development perspectives within economic globalisation. This is extremely problematic for women because research is emerging that women have experienced globalisation more negatively than other sectors of society. There is increased feminisation of poverty. Increased flexible labour among women and more women have entered the informal sector. The privatisation of services like water, electricity, healthcare and education has increased rather than decreased women’s work as more people fall through the social safety net. Repositioning development within globalisation introduces a new form of sustainability - sustaining poverty, not eradicating it, and sustaining debt relief, not debt cancellation.
2. The Chairperson’s text reinterprets sustainable development within the neoliberal trade paradigm and the liberalised trade system. This is happening with the background of Africa experiencing the worst terms of trade. For example, industrialised countries control 68.4% of global trade with 15% of the world population.
3. Developing countries control 27.5% of global trade with a world population of 75%. Africa’s share of this is 1.6% with 11% of world population. Africa produces the bulk of raw materials in the world. Women produce sugar, corn, coffee, cotton, tea and many other products yet, the prices of these products has declined steadily in terms of the way they are traded. It is not the producers who set the prices, but the stock exchange in London and New York. There is no access for women farmers to these institutions. Women have no power to negotiate the price of these products. The returns on their products in monetary terms are not sufficient to sustain livelihoods nor bring about development in the true sense.
It is critical to note that the repositioning of development in the WSSD also creates a relocation of development issues from the United Nations to other institutions. This is an important shift for gender activists to study. The World Bank and the World Trade Organisation specifically are the two institutions that are in explicit and implicit ways taking over the development agenda as we once knew it. Under the new term of global governance the World Trade Organisation in particular is attempting to take on issues of environment, labour, and agriculture to name a few. In the meantime, the World Bank is whittling away the power of the state through its’ policy advise. It is advising countries to privatise basic social services through, for example, introducing user fees to healthcare services and education. It is advising countries to sell water, electricity and telecommunications to the private sector. Using the efficiency argument it is convincing governments that the state has no capacity to provide basic services and that this function should be taken over by the private sector. After all, the World Bank claims the private sector has a tradition of running business more efficiently than governments and governments, it says, are corrupt. This dysfunctional ideology of placing profit before people’s development, and gender equality particularly reinforces the exclusionary manner in which the state treats women.
Linked to NEPAD, the New Partnership for Africa’s Development, the new development framework offers the same market-oriented economies that are not compatible with the protection of women’s rights, nor do they promote gender equality in Africa. Framed with a neoliberal stance, this plan strengthens the principle of private property. African women have never had any entitlements under this paradigm. NEPAD, like the new development framework being put forth at the upcoming World Summit on Sustainable Development, does not address the social relations within the market in terms of women’s access to and control of resources in this space. The World Summit on Sustainable Development must be a space that allows for the self-determination of peoples and nation states and promotes sustainable development that incorporates human development and gender equality into its definition and implementation. However, as it currently stands the WSSD further pushes the Northern trade agenda and role of the International Financial Institutions while marginalizing the role of the United Nations. This process will further threaten national sovereignty and further marginalize women.
Widespread hunger in the world is primarily related to poverty. It is not principally connected with food production at all. Indeed, over the course of the last quarter of a century, the prices of the principal staple foods (such as rice, wheat etc) have fallen by much more than half in 'real' terms. If there is more demand for food, in the present state of world technology and availability of resources, the production will correspondingly increase. The demand for food is restrained mainly by lack of income. And the same factor explains the large number of people who are hungry across the world. Given their income levels, they are not able to buy enough food, and as a consequence these people (including their family members) live with hunger.
But it is not adequate to look only at incomes. There is need to look also at the political circumstances that allow famine and hunger. If the survival of a government is threatened by the prevalence of hunger, the government has an incentive to deal with the situation. Incomes can be expanded both by policies that raise overall income and also by redistributive policies which provide employment, and thus tackle one of the principal reasons for hunger (to wit, unemployment in a country without an adequate social security system). In democratic countries, even very poor ones, the survival of the ruling government would be threatened by famine, since elections are not easy to win after famines; nor is it easy to withstand criticism of opposition parties and newspapers. That is why famine does not occur in democratic countries. Unfortunately, there are a great many countries in the world which do not yet have democratic systems.
Indeed, as a country like Zimbabwe ceases to be a functioning democracy, its earlier ability to avoid famines in very adverse food situations (for which Zimbabwe had an excellent record in the 1970s and 1980s) becomes weakened. A more authoritarian Zimbabwe is now facing considerable danger of famine. Alas, hunger in the non-acute form of endemic under-nourishment often turns out to be not particularly politically explosive. Even democratic governments can survive with a good deal of regular under-nourishment. For example, while famines have been eliminated in democratic India (they disappeared immediately in 1947, with Independence and multi-party elections), there is a remarkable continuation of endemic under-nourishment in a non-acute form. Deprivation of this kind can reduce life expectancy, increase the rate of morbidity, and even lead to under-development of mental capacities of children. If the political parties do not succeed in making endemic hunger into a politically active issue, hunger in this non-acute form can go on even in democratic countries.
What should rich countries do, and is trade liberalisation the answer?
The rich countries can do a great deal to reduce hunger in the world. First, the displacement of democracies in poor countries, particularly in Africa, often occurred during the Cold War with the connivance of the great powers. Whenever a military strongman displaced a democratic government, the new military dictatorship tended to get support from the Soviet Union (if the new military rulers were pro-Soviet) or from the United States and its allies (if the new rulers were anti-Soviet and pro-West). So there is culpability on the part of the dominant powers in the world, given past history, and there is some responsibility now for rich countries to help facilitate the expansion of democratic governance in the world.
Second, hunger is related to low income and often to unemployment. Poverty could be very substantially reduced if the richer countries were more welcoming to imports from poorer countries, rather than shutting them out by tariff barriers and other exclusions. Fairer trade can reduce poverty in the poor countries (as the recent Oxfam report Rigged Rules, Double Standards discusses in detail). Third, there is a need for a global alliance not just to combat terrorism in the world, but also for positive goals, such as combating illiteracy and reducing preventable illnesses that so disrupt economic and social lives in the poorer countries. Trade liberalisation on the part of the richer countries could certainly make a difference to employment and income prospects of poorer countries. The situation is a little more complex in the case of liberalisation of the poorer countries. Even those countries which have greatly benefited from the expansion of world trade (such as South Korea or China) often went through a phase of protecting industries before vigorous expansion of exports and trade. So, trade liberalisation is partly an answer, but the economic steps involved have to be carefully assessed: the policies cannot be driven by simple slogans.
What is the solution?
There is no 'magic bullet' to deal with the entrenched problem of hunger in the world. It requires political leadership in encouraging democratic governments in the world, including support for multi-party elections, open public discussions, elimination of press censorship, and also economic support for independent news media and rapid dissemination of information and analysis. It also requires visionary economic policies which both encourage trade (especially allowing exports from poorer countries into the markets of the rich), but also reforms (involving patent laws, technology transfer etc.) to dramatically reduce deprivation in the poorer countries. The problem of hunger has to be seen as being embedded in larger issues of global poverty and deprivation.
Countries of the South increasingly seek food self-sufficiency. Could this solve the problem of hunger and starvation?
Food self-sufficiency is a peculiarly obtuse way of thinking about food security. There is no particular problem, even without self-sufficiency, in achieving nutritional security through the elimination of poverty (so that people can buy food) and through the availability of food in the world market (so that countries can import food if there is not an adequate stock at home). The two problems get confused, because many countries which are desperately poor also happen to earn most of their income from food production. This is the case, for example, for many countries in Africa. But if these countries were able to produce a good deal of income (for example through diversification of production, including industrialisation), they can become free of hunger even without producing all the food that is needed for domestic consumption. The focus has to be on income and entitlement, and the ability to command food rather than on any fetishist concern about food self-sufficiency.
There are situations in which self-sufficiency is important, such as during wars. At one stage in the Second World War, there was a real danger of Britain not being able to get enough food into the country. But that is a very peculiar situation, and we are not in one like that now, nor are we likely to be in the near future. The real issue is whether a country can provide enough food for its citizens - either from domestic production or imports or both - and that is a very different issue from self-sufficiency. We have to look at ways and means of eliminating poverty, and to undertake the economic, social and political processes that can achieve that.
Amartya Sen, who won the Nobel Prize in Economics in 1998, is Master of Trinity College, Cambridge. This is a longer version of an article, expanded by the author, that appeared in Le Monde