500 days and counting: Progress for girls and women means progress for all
During the 2014 International AIDS conference, The Lancet medical journal released a series of articles focused exclusively on HIV and sex work. One study by Kate Shannon et al., demonstrates that decriminalization of sex work could reduce HIV infections by 33 to 46 percent over the next decade. Shannon’s team showed that “multi-pronged structural and community-led interventions” are essential to promoting the human rights of sex workers, as well as improving their access to HIV prevention and treatment. Dr. Chris Beyrer, the researcher who coordinated this Lancet series, told AIDS conference participants that“[e]fforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic,” drawing an irrefutable line between the social, legal, and economic injustices sex workers face and their subsequent vulnerability to HIV.
The Lancet series authors join many other prominent public health voices in identifying the decriminalization of sex work as vital to preventing the spread of human immunodeficiency virus (HIV) and of acquired immune deficiency syndrome (AIDS). For two decades, sex workers rights’ activists throughout the world have pushed human rights, public health, and HIV and AIDS response leaders to recognize that they, along with people who inject drugs and men who have sex with men, are “key populations” without whom an effective HIV and AIDS response is impossible. In 2012, the World Health Organization (WHO) declared that “all countries should work toward decriminalization of sex work and elimination of the unjust application of non-criminal laws and regulations against sex workers.” In South Africa (with the largest population of people living with HIV in the world), the National AIDS Council is urging its government to decriminalize sex work—a demand that advocates and health policy professionals are making in dozens of other countries as well. Amnesty International, Human Rights Watch, and the UN’s Global Commission on HIV and the Law all endorse this position. The latter points out “the impossibility of governments stigmatizing people on one hand, while simultaneously actually helping to reduce their risk of HIV transmission or exposure on the other.”
Sex work has been decriminalized in New Zealand and one province (New South Wales) in Australia leaving sex work businesses subject to standard occupational health and safety regulations. Law enforcement treats the sale of sex as it does any other business, without any intrusion or interruption unless existing laws are being violated.
Decriminalization has resulted in higher rates of condom use and enables sex workers to organize community-based health practices that demonstrably improve health and reduce HIV risk. It also makes it possible for sex workers to report and for the police to address illegal acts as they occur, such as assault, theft of services, employment of minors, or client coercion. In this decriminalized setting, sex workers can be strong allies in the fight against trafficking, intimate partner violence, and child abuse since they can report incidents to the police and social service agencies without putting themselves at risk of arrest.
So, why is the HIV-AIDS field only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries? The following are three contributing factors.
Public debate around sex work in the United States increasingly focuses on people who have been trafficked or otherwise coerced into the sex trade. Anti-trafficking advocates conflate sex work (people choosing to sell sexual services from among employment options available to them) with trafficking (people being forced into the sex industry against their will). Laws that criminalize all people selling sex (voluntarily or involuntarily) violate the rights of the former and undermine efforts to identify and assist the latter. The Global Commission on HIV and the Law states unequivocally that, “Sex work and sex trafficking are not the same. The difference is that the former is consensual, whereas the latter is coercive.”
A commentary by Steen et al. in the recent Lancet series notes that “repressive and counterproductive police action,” including the arrest and incarceration of trafficking victims for the purposes of “rescue,” has overtaken far more effective responses in several countries. The understandable, but destructively over-simplified, mandate to “rescue and restore” sex workers is also being imposed in public health settings where providers are now charged with identifying and intervening with potential victims of trafficking in the sex trade. Certainly, health-care providers have a duty to watch for and help patients in abusive situations of all kinds. They also have a duty to understand the complexities of human experience, respond to patient-identified needs, and maintain that patients are experts of their own lives, whatever that may look like.
Providing access to health-care services targeted to consumers’ needs is a vital part of any country’s HIV response. Without it, those most in need of prevention, care, and treatment are least likely to get it.
In a 2010 survey, 53 percent of medical students said they were not adequately trained to address their patients’ sexual issues comfortably. Far fewer professional medical curricula explicitly prepare students to understand that they will encounter sex workers as patients who, like all other patients, are individuals with a wide range of experiences, backgrounds, and needs that can best be treated with patient-centered care.
When sex workers receive demeaning and unprofessional treatment in health-care settings, they see health-care providers as an extension of the larger system that criminalizes them. A survey by the New York City-based Persist Health Project found that few sex workers disclosed their occupation to their health-care provider; only one study participant reported a positive experience after doing so. As one respondent explained, “I think for security reasons, I don’t usually disclose. Mainly because I don’t trust doctors … I sort of treat them like law enforcement.” Another noted that most health-care providers “have no clue who you are, no clue about your background, you can’t read them or know that they’re not going to try to lecture you or give you a stink-eye.”
St. James Infirmary, a peer-based occupational safety and health clinic for sex workers in San Francisco, corroborates these findings. Of their incoming patients, 70 percent had never previously disclosed their occupation to a medical provider for feared of bad treatment. Providing sex-worker friendly health care requires training health-care workers appropriately and supporting services designed specifically with and for the communities they serve.
People usually envision a sex worker as someone soliciting on the street, but only about 20 percent of U.S. sex workers are street-based. The vast majority see clients in other venues including massage parlors, brothels, apartments they share with other sex workers, or a client’s hotel room. Many connect with clients online.
HIV risk is high among street-based sex workers who experience high levels of violence at the hands of clients and abusive law enforcement personnel. One important way they reduce this risk is assessing a potential client before getting into his car—looking for signals that he might be violent and relaying his license number to a colleague in case the worker disappears. This assessment time is also used to negotiate price and condom use. Law enforcement crack-downs compel sex workers to complete their negotiations quickly (in order to avoid arrest), depriving them of the time needed for assessment and negotiation.
Street-based sex workers have little or no protection if a client becomes violent or refuses to use a condom. Of the street-based workers surveyed in The Lancet study by Shannon et al., 25 percent reported being pressured by clients to have sex without a condom. Those working in remote areas (such as industrial parks) to escape local policing were three times more likely to report being pressured into having sex without a condom than the study population overall. The recent Lancet series data also shows that, in some countries, up to one-third of sex workers do not carry an adequate supply of condoms due to “condoms as evidence” policies that allow police to seize a sex worker’s condom supply and use it as evidence of their intent to engaged in sex work—a widely-used policy in several U.S. cities.
Punitive laws against sex work are in place in 116 countries, including the United States, creating, according to the Open Society Foundations, “a state-sanctioned culture of stigma, discrimination, exploitation, and police and client violence against sex workers.”
Decriminalizing sex work in the United States is a long and challenging process, but there is a path to follow. The 1988 ban on federal funding for syringe exchange remained in place for 20 years and, after briefly lifting it in 2009, the Obama administration agreed to its reinstatement in 2011 at Congress’ insistence. Advocacy pressure to overturn it continues.
Thanks to the efforts of dedicated researchers and activists during the two decades between 1988-2009, public health professionals, medical institutions and virtually everyone working in the HIV-AIDS field learned why harm reduction practices are essential. Services to people who use drugs began to improve, although they are still inadequate, primarily because they are grossly under-funded. Progress has been made.
The U.S. National Institutes of Health (NIH) issued a consensus statement that addressed the need for syringe exchange but also observed that “[p]rograms targeting sex workers have been highly efficacious in other countries, but [in the U.S., programs] will encounter cultural and political barriers.” The public silence maintained on this issue for the last 17 years is emblematic of those barriers.
But sex workers’ rights organizations in most U.S. cities, though heavily marginalized, have not been silent. They are struggling to end “condoms as evidence” practices, train health-care providers, find or establish sex worker-friendly health-care services, and demand their rightful place as invaluable allies in ending human trafficking and preventing the spread of HIV. Like the harm reductionists who set up the first syringe exchange sites in the United States, they need the support of mainstream sexual and reproductive health advocates willing to learn from them and join them. Like the early harm reductionists, they need the rest of us to bring our money, skills, and political support this human rights struggle.
We can’t stop HIV in the United States without sustainable and long-term solutions to end the arrest, detention, and incarceration of sex workers in the United States, as well as end the violations against sex workers within the correctional system. A meta-analysis of more than 800 other studies and reports, published in the recent Lancet series, listed abuse experienced by sex workers as including “homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing.” It added “protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and well-being.”
Expert voices in support of community-led, sex worker-centered health care in the fight against HIV are becoming more and more numerous. When will the mainstream HIV and AIDS organizations and women’s health advocacy communities join loudly in this demand?
by Anna Forbes and Sarah Elspeth Patterson
13 August 2014
Fears have been raised that the schoolgirls kidnapped by Boko Haram militants earlier this year are being used as suicide bombers.
The speculation has arisen after a number of female suicide bombings in Nigeria's biggest city of Kano, while a ten-year-old girl wearing explosives was also discovered in Katsina state.
The latest attack came on Wednesday when a female suicide bomber blew herself up at a college in Kano, killing six people. According to reports, the bomber was a female teenager.
It was the fourth suicide bombing carried out by a female in the city in the past week.
There was no immediate claim of responsibility, although militant group Boko Haram, which is fighting for an Islamic state in religiously-mixed Nigeria, has repeatedly bombed Kano as it radiates attacks outwards from its northeast heartlands.
Government spokesman Mike Omeria said security forces arrested three Boko Haram suspects in Katsina state, two of them female, on Tuesday.
One was a 10-year-old girl who had an explosive belt strapped to her by the others, he said.
Using female suicide bombers in the city appears to be a new tactic of Boko Haram, although they have used them on occasion for years in the northeast.
Two female suicide bombers blew themselves up at a trade show and a petrol station in Kano on Monday, killing one other person and injuring at least six others.
On Sunday, a female suicide bomber killed herself but no one else while trying to target police officers.
Concerns have now been raised the militant group is using the schoolgirls kidnapped earlier this year in Chibok in the suicide bombings.
Former education minister Oby Ezekwesili has warned the kidnapped girls may be 'indoctrinated or coerced into being used as suicide bombers', according to the International Business Times.
On Sunday Ms Ezekwesili tweeted: 'This new trend&serial pattern of "FEMALE SUICIDE BOMBERS" surely should PARTICULARLY worry us. It worries me stiff cos of our #ChibokGirls.'
The following day she wrote: 'Kano again and again. Female suicide bombers again and again – becoming trend. Our #ChibokGirls still in the enemy den. Are we THINKING?'
Meanwhile, the Human Rights Writers Association of Nigeria has urged the government to investigate the identity of the suicide bombers, the International Business Times reported.
In a statement, it said: 'In the event that these female suicide bombers are identified to have been the same kidnapped girls then the government should immediately deploy all resources and strategies to bring to an end, once and for all, this shameful scenario since the military have repeatedly stated that they are aware of the whereabouts of the kidnapped Chibok girls.'
In a separate incident on Tuesday, two suicide bombers killed 13 people in attacks on two mosques in the town of Potiskum, in Yobe state in the northeast, medical official Bala Afuwa, who received the bodies at a local hospital, told Reuters by telephone on Wednesday.
'Two of my uncles were killed,' said resident Mohammed Abubakar, whose family home is next to one of the mosques that were attacked. 'They had just returned from the mosque.'
President Goodluck Jonathan, who has come under heavy criticism for failing to end the five-year-old rebellion, pledged $500 million on Wednesday towards Nigerians living in states that are worst affected by Boko Haram violence.
Earlier this month kidnapped Nigerian schoolgirls who managed to escape from their Islamic extremist captors were reunited with the president.
He heard tales from some of the 57 who escaped after their abduction on April 15 before assuring them of his determination that those still in captivity ‘are brought out alive’.
Around 57 students managed to flee shortly after they were captured, but a committee investigating their disappearance said 219 of the girls are still missing.
According to a mediator working with Boko Haram two of the girls have died of snake bites while around 20 have fallen ill.
Boko Haram is demanding a swap for detained fighters in exchange for the girls.
Most of the schoolgirls are still believed to be held in the Sambisa Forest – a wildlife reserve that includes a mixture of thick jungle and open savannah.
The forest borders on sand dunes marking the edge of the Sahara Desert.
Sightings of the girls and their captors have been reported in neighboring Cameroon and Chad.
Chibok and nearby villages are targets because they are enclaves of staunch Christians in predominantly Muslim north Nigeria.
By James Rush
1 August 2014
Pretoria – The Department of Health has welcomed findings that South Africa is one of the 16 sub-Saharan countries that stand a chance of meeting the Millennium Development Goal (MDG) on maternal mortality by 2015.
According to the findings of the study undertaken by the University of Cape Town’s Hatter Institute for Cardiovascular Research in Africa, in conjunction with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, the number of maternal deaths has dropped from about 376 000 in 1990 to about 293 000 in 2013.
Maternal mortality in the country has dropped by almost 7% a year over the past decade – at 171.4 maternal deaths per 100 000 live births.
The study showed that 30 countries had annual reductions in the Maternal Mortality Rate (MMR) of MDG 5 pace or better from 2003 to 2013.
“Eight of which were in sub-Saharan Africa (Botswana, Burundi, Kenya, Malawi, Namibia, Rwanda, South Africa, and Swaziland) and 10 in central and eastern Europe (Albania, Belarus, Bosnia and Herzegovina, Bulgaria, Estonia, Latvia, Lithuania, Poland, Romania, and Russia,” according to the findings.
However, the study noted that despite reductions in the number of maternal deaths, only 16 countries, seven of which are developing countries, are expected to achieve the MDG 5 target of a 75% reduction in the MMR by 2015.
Speaking to the GCIS Radio Bulletin, health spokesperson Joe Maila stressed the need to work very hard to make sure that the numbers decline even further.
“The numbers that are there right now are not as good and we want them to be less than what it is. We need to make sure that we work very hard to make sure that it indeed declines further.
“If we work together with all the people involved, one of the things we can do is to make sure that mothers – as soon as they are pregnant – come to our facilities within 14 weeks. That (way), we would be able to know what is it that we can do to make sure that we restore their health,” said Maila.
The findings were part of a study into maternal mortality across the globe over the past two decades. The study aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.
MDG 5 established the goal of a 75% reduction in the number of maternal deaths per 100 000 live births between 1990 and 2015.
According to the 20 Year Review released by The Presidency in February, life expectancy in the country has increased from 52.7 years in 2002 to 59.6 years in 2013. The Infant Mortality Rate has decreased from 63.5 deaths per 1 000 live births in 2002, to 41.7 deaths per live births in 2013.
The under-five mortality rate has also decreased from 92.9 deaths per 1 000 live births in 2002 to 56.6 deaths per 1 000 live births in 2013. Severe malnutrition among children has decreased from 88 971 in 2001 to 23 521 in 2011. –SAnews.gov.za
Dr. Annie Sparrow, a paediatrician and public health expert, is an Assistant Professor of Global Health and Deputy Director of the Human Rights Program at Icahn School of Medicine at Mount Sinai in New York City.