Tuesday, 19 August 2008


By JULIA DAY, STEPS Centre member

Sanitation was dubbed “one of the biggest scandals of all time” by the UN’s water chief this week as World Water Week got underway in Stockholm.

At a time when billions of people live without sustainable access to safe drinking water or suffer ill health due to poor sanitation, when food crises, bio-energy crops and climate change place ever-increasing demands on water resources, 2,500 water experts have gathered in the Swedish capital.

"Sanitation is one of the biggest scandals of all times. It's something that we have to put on our radar screen," insisted Prince Willem-Alexander of the Netherlands, who heads up the UN Secretary General's Advisory Board on Water and Sanitation.

"7,500 people die every day due to this lack of sanitation," he said, pointing out that "the situation is the same as seven years ago." According to the United Nations 30 per cent of the planet's population will face water shortages by 2025.

In an attempt to inject some urgency into this situation during this International Year of Sanitation, the conference is focussing on how the lack of water supply impacts sanitation and health and has already heard calls for radical changes in behaviour and mentality when it comes to water usage.

At the ESRC STEPS Centre, our research on water and sanitation is seeking to promote changes in the ways in which water and sanitation are viewed and sustainable practical and policy solutions designed.

Why, as Prince Willem-Alexander pointed out in Stockholm, has there been no movement towards better sanitation for years, despite many interventions and international action? The STEPS Centre’s researchers believe there is a big disconnect between global rhetoric and the everyday experiences of poor and marginalised people. And until this disconnect is properly addressed, the problems of water and sanitation will remain unresolved.

Take the case of large dams, often considered to be the panacea to water scarcity but the source of great controversy around the world with the Narmada in India, Three Gorges in China and Epupa Falls in Namibia among the most high profile dam controversies.

Builders and planners have often ignored the high social and environmental costs of large dams, with benefits often going to large farmers and irrigators. The poor and marginalised are left to face displacement from river-valleys, impoverishment, destruction of ancestral homes and cultural attachments to land and river resources and unintended consequences, such as disease outbreaks.

The focus on water as an economic good can overshadow other, particularly cultural and symbolic, meanings and roles of water. The engineering and public health domination of sanitation can obscure local level priorities, needs and socio-cultural practices. For example, villagers in Merka, western India, prefer local sources of water (e.g. the tank and wells) to the ostensibly ‘improved’ government-supplied piped water.

Views that see water and sanitation problems in aggregate, technical terms, ignore the social, political and distributional issues that often underlie what may appear as water ‘scarcity’. These views often have little to do with local users’ rights and interests. Consequently, despite good intentions, many projects fail.

The UN undoubtedly has good intentions. It has set a target for halving the number of people without access to sanitation by 2015; on current trends it won't be reached until 2076.

Download STEPS Working Paper 6: "Liquid Dynamics: challenges for sustainability in water and sanitation" (pdf 566kb)
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By JULIA DAY, STEPS Centre member

At a time when billions of people live without sustainable access to safe drinking water or suffer ill health due to poor sanitation, when worsening food crisis battles bioenergy for land and water resources, and when global climate change is shaking the overall water balance, 2008's World Water Week gets underway in Stockholm, Sweden. Photo: Community-Led Total Sanitation toilet

The conference theme this year - Progress and Prospects on Water: For A Clean and Healthy World with Special Focus on Sanitation - is focussing on how lacking water supply impacts sanitation and hygiene. The conference has already heard calls for radical changes in behaviour and mentality when it comes to water usage.

"We've had a luxurious lifestyle during the last 25 years, not caring at all about the environment. It's necessary to change the way people consume, buy, eat," said British professor John Anthony Allan, winner of the 2008 Stockholm Water Prize.

Almost half of the world's population lacks proper toilet facilities, a situation that can have dire consequences on public health and which poses a challenge to resolve since water is becoming an increasingly scarce resource.Twenty percent of the planet's population face water shortages, a figure that is expected to hit 30 percent by 2025, according to the United Nations which has declared 2008 the International Year of Sanitation.

"Sanitation is one of the biggest scandals of all times. It's something that we have to put on our radar screen," insisted Prince Willem-Alexander of the Netherlands, who heads up the UN Secretary General's Advisory Board on Water and Sanitation.

He said some "7,500 people die every day due to this lack of sanitation," pointing out that "the situation is the same as seven years ago."

More news as it happens from Stockholm .
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Tuesday, 12 August 2008


By JULIA DAY, STEPS Centre member

The eyes of the world are focussed firmly on China as the Olympic Games get into full swing. A television audience of a billion souls witnessed the unrivalled razmatazz of Beijing's opening ceremony in the space-age 'Bird's Nest' stadium, in a city seemingly full of dazzling architecture and heady nationalistic pride.

But what are some of the challenges facing poorer people in the China beyond the pristine Olympic showcase of Beijing?

Watch Gerry Bloom, the STEPS Centre's health convenor, talk about some of the issues facing people in rural China.
And for more on development in China, take a look at the IDS spotlight on China.
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Thursday, 7 August 2008

International AIDS Conference, Mexico, Day 4

Shockingly the 4th day of the International AIDS Conference marked the first ever plenary on children and HIV. That we could get to a point where there are 2 million people under 15 living with HIV and 30 million who have lost one or more parents and still not have had an address to conference on this topic shows a glaring lack of leadership in this area. Children and HIV was a topic picked up at a later satellite session ‘Beyond the Orphan Crisis: Findings of the Joint Learning Initiative on Children and AIDS’ at which Jerker Edstrom, STEPS Centre member, spoke.

The Joint Learning Initiative on Children and AIDS has been conducting research into family centred approaches to mitigating the impact of HIV on children. They argue that we fail to put children at the centre of the response to AIDS and the effect of this is immeasurable, particularly in its emotional impact. The solution, they believe is to place families at the centre of interventions by; abolishing school fees, creating cash transfer programmes, campaigning for comprehensive and integrated family services and responding to the psychosocial needs of children.
Their research has shown that families bear 90% of the cost of care and support for children affected by AIDS – which encompass not just children who have lost parents but all vulnerable children living in communities where AIDS is having an impact. Caring for these children is stretching already weakened coping mechanisms. Focusing on orphans alone is creating skewed systems that can leave other family members vulnerable and impoverished. Institutional care is no match for family structures in most cases. Yet in many cases opportunities for strengthening family systems are being missed.

The session heard of a successful family focused social protection programme that has been rolled out in Mexico. This intervention was rigorously evaluated and showed:
• A 34% increase in living standards
• A 6.4% increase in calories consumed by children
• A 56% increase in families taking fortified food
• 20% less anemia
• A 12% increase in earning potential for life amongst children who received the intervention
• A large drop in catastrophic expenditure on health care.
The programme achieved this by offering cash transfers linked to the nutrition of children under 5 and pregnant and breastfeeding women. Another transfer is linked to schooling and rises each year of attendance and is available until the age of 21. Girls receive a higher educational grant than boys in the light of the increased pressure upon them to work to support their families. Upon graduation young people receive a lump sum which is conditional upon opening a bank account. Later in the programme a transfer was added for families supporting an elderly relative. All transfers go to the woman of the household which has been seen to change gender norms and reduce levels of intimate partner violence. All cash transfers are conditional upon taking nutritional supplements, attending health services and schooling. Panelists at the session commented that, ‘AIDS has been the engine for health system strengthening – let’s make it the driver for social protection’.

Jerker Edstrom spoke on the intergenerational transmission of not just poverty but vulnerability to HIV infection. He argued that simplistic approaches to HIV prevention with children affected by AIDS – such as the ABC, abstain, be faithful, use condoms – are failing these children. What is needed is social protection that takes vulnerability to infection into account and efforts to build social capital outside the family. Papers from this research will be published in an upcoming edition of the IDS Bulletin.

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Wednesday, 6 August 2008

International AIDS Conference, Mexico, Day 4

The conference has heard a lot about what we have learned in the past in terms of approaches to tackling HIV and AIDS. But a session today made the case that it is important to look to the future of the epidemic to predict what action will be needed.

Looking to the Future – The epidemic in 2031
AIDS is unique because it is a crisis – several 1000 people die every day – but it is also a long wave event. Peter Piot, Executive Director of UNAIDS, suggested some directions in which the epidemic is travelling and how we might need to respond.

Piot pointed to new waves of infections which are incredibly diverse and treatment and prevention efforts that are lagging behind. To respond we need to know where the next 1000 infections are going to happen – not be looking to who is coming for treatment as the pattern of infection may well have changed. For example, in Thailand the highest rate of new infections is amongst married women rather than sex workers, people who inject drugs and men who have sex with men.

He explained that the universal access targets are a means to get to our real goal which is a world where nobody dies of AIDS and people living with HIV have a happy and healthy life. For this to happen far more people need to know their HIV status and we need to stop late diagnosis. We require better second and third line drugs and we need equitable access to them.

For Piot Southern Africa is a special case when it comes to HIV and AIDS. There is no technical fix for the situation there, it will require a society wide shift to tackle it. Leadership and altering social norms will be crucial in this.

Where is HIV prevention headed?
Piot feels that we should aggressively pursue the complete elimination of mother to child transmission as this is a realistic goal. But it will require the integration of SRH and HIV services and much better access to services. Post Exposure Prophylaxis should be better understood and used.

Prevention needs to be innovative using information communication technologies such as mobile phones and web based social networking applications – billboards will not appeal to the young people who need the information. Combination prevention needs to be more tailored to particular communities.

We need to use more business like methods but ground these in community action and knowledge. Bringing in business professionals, for example marketers, is key although it may be expensive. As Piot says, ‘the epidemic is too serious to be left to cottage industry, improvisation and amateurism’.

Funding the response
Piot suggested that international solidarity should continue but developing countries need to make evidence informed policy decisions about the appropriate allocation of domestic resources even when it is politically unpalatable – when it needs to go to the most marginalised.

We need pension funds rather than insurance programmes. Insurance is for the unknown – pensions are for what we know will happen. We know that many more people will need AIDS treatment. If we think it has been tough up until now consider what is to come. We need to act now so that people do not look back in 2031 and wonder what we have done.

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Tuesday, 5 August 2008

International AIDS Conference, Mexico, Day 3

The links between violence against women and vulnerability to HIV infection are well known. But what interventions should we put in place to combat violence and its HIV related outcomes? This was a question addressed at a side session at the International AIDS Conference today. The solutions are far from clear cut. Links between violence against women and HIV go beyond the way that sexual violence, or rape, increases biological vulnerability to HIV infection.

Economic abuse, physical violence (particularly by intimate partners) and psychological abuse lead to situations where women can’t control how, where, when and with whom sex takes place. Fear of violence or actual violence from partners can prevent women finding out their HIV status or accessing treatment and care services. Child sexual abuse can lead to higher risk taking behaviour in adulthood. To compound matters men who are violently abusive are more likely to have more sex partners, sexually transmitted infections, suffer from alcoholism and to refuse to use condoms. WHO studies show in many regions young women have high levels of forced first sex - the earlier sex occurred the more likely it was to be forced.

Sex workers, transgendered women, women who inject drugs and lesbians are targets of violence from the state and community not just their intimate partners. This is an area that is often neglected in interventions to address violence. Policy makers who champion the criminalisation of sex work undermine their own HIV prevention policies as sex workers are often driven underground where work is more dangeropus and opportunities to access medical services more difficult.

Suggestions made at the conference session for preventing violence included;
• integrating action against violence into HIV programmes,
• promoting gender equality particularly with men to make them take responsibility
• finding male champions in positions of power in the community or faith structures
• quality and comprehensive sexual and reproductive health education before sexual debut,
• policy and law reform,
• sensitisation of healthcare providers,
• encouraging domestic violence services to integrate HIV work
• decriminalising sex work.

However, the evidence for these interventions is weak and few promising programmes have been taken to scale – so it is clear that more research is needed.

Law and policy reform won’t work if it is not enforced or the enforcers are the perpetrators of violence. Similarly placing the responsibility for combating violence in the hands of healthcare workers is problematic in settings where they are the perpetrators of abuse for example in the forced STI and HIV testing of sex workers or sterilisation of women living with HIV.

The link between HIV, violence and conflict was not a focus for the presentations.

Finally the session failed to comprehensively address structural interventions to assist men who wish to assert a style of masculinity outside the norm. Something that has been picked up in the latest issue of the Institute of Development Studies In Focus Series on Men, Sex and HIV: Directions for Politicising Masculinities. It also failed to suggest services for troubled men to address the personal difficulties that may drive their aggression.
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International AIDS Conference, Mexico, Day 2

The second day of the International AIDS Conference saw what was possibly the shortest side session in its history. Entitled ‘Sex workers are everywhere’ Andrew Hunter of the Asia Pacific Network of Sex Workers addressed the delegates and explained that due to the political opportunity afforded elsewhere in the conference there was a change to the planned agenda. Impassioned, he introduced the process behind, and content of, a new UNAIDS Guidance Note on Sex Work – a policy that will shape the UN’s response to sex work and influence other actors programming in this area. This is a piece of policy that the sex worker rights movement vehemently disagree with.

With this in mind Andrew encouraged delegates of an activist bent to attend a session that was in progress in the next room to try and encourage Peter Piot of UNAIDS to offer some explanation on the status of the guidance note. Others were directed to a session at which Meena Seshu of SANGRAM was presenting on the advocacy work that has accompanied the development of this document.

Meena explained how when they began drafting the guidance note in 2006 UNAIDS conducted a meaningful and representative consultation process with sex workers. This is in line with their own policies about involving affected populations in the development of laws and policies that affect their lives - a concept that is often referred to as ‘nothing about us without us’. However, sex workers were disappointed upon reading the first draft of the policy to see that their recommendations had not been taken on board and the guidance concentrated on preventing sex work rather than HIV. To this end it prioritises encouraging sex workers to abandon their occupation and preventing people from entering the industry in the first place. It does not focus on harm reduction with people working in the sex industry – for which there is an evidence base. Interventions based around this would include information for sex workers and their clients, access to prevention commodities (for example, contraceptives, food, clean water, medication), safe spaces for sex workers, psychosocial support, voluntary counselling and HIV testing, antiretroviral treatment etc.

Sex workers point out that rescue and rehabilitation programmes have sometimes been used as a cover for state sanctioned sexual and other violence, illegal detention and denial of the human rights of sex workers. Increasingly these type of programmes are funded by the US Government which has a policy that requires all funding recipients to sign a pledge opposing sex work. Sex workers believe that, although not finalised, the Guidance Note has had an influence on UN agency’s actions in developing countries. They cite UNICEF’s sponsorship of recent anti-trafficking legislation in Cambodia as an example.

In response the Guidance Note sex workers conducted a worldwide advocacy campaign to push for its revision. As a result the issue was discussed at the UNAIDS Programme Co-ordinating Board who passed a motion calling for the policy to be reviewed but as yet sex workers do not know what the final outcome will be.

Among other things, the story of the Guidance Note on Sex Work points to the way in which United States policy on HIV and AIDS is shaping the response to the epidemic in ways that further abuse the rights of some of the most marginalised. With the recent reauthorisation of the US President's Emergency Plan for AIDS Relief (PEPFAR) this pattern looks set to continue.

For more on this please see the Guardian online.
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International AIDS Conference, Mexico City

The role of pleasure in encouraging safer sex

With over 20,000 participants and a plethora of formal abstract driven sessions and cultural events the International AIDS Conference, currently taking place in Mexico City, offers a bamboozling array of learning from the response to the epidemic.

The first day opened with a range of satellite sessions one of which was hosted by the IDS ally the Pleasure Project. The session marked the launch of The Global Mapping of Pleasure a review of safer sex programmes that take a pleasure approach. The Global Mapping was sponsored by Realising Rights a DFID financed Research Programme Consortium.

Speakers at the session described their successes in improving the uptake of HIV prevention and safer sex messages by concentrating on the positive aspects of sexuality rather than using negative messages. As Craig Darden, condom social marketer for DKT, put it, ‘Condoms are generally associated with diseases, unwanted pregnancy, infidelity, barriers, failure and slippage.’ DKT have taken a positive approach to their condom advertising in Asia, Latin America and Africa by using positive images and product positioning.

Speakers talked of the reluctance of many AIDS actors to use a pleasure approach as it sometimes throws up challenging situations or challenging narratives. Melissa Gera, of the St James Infirmary in San Francisco, talked about their work with sex workers which incorporates spaces to talk about pleasure. One study that they undertook on HIV, sexual health and stigma and discrimination found that 42% of the women sampled said that they enjoyed sex with their clients 50% or more of the time. Their enjoyment came from sexual pleasure but also the independence that sex work gave them – particularly in negotiating the terms of the exchange of sex and in being self employed. The sex workers had been reluctant to mention the pleasure that their work gave them to healthcare workers in the past as they believed it would lead to discrimination. They felt that the only way that they could gain access to services was to deny that they wanted to sell sex. The problem with this is it means that many sex workers may not be getting appropriate sex education as a result and passing this knowledge on to their clients.

Challenging assumptions about what gives pleasure was a theme that also emerged in Kavitha Potturi, of the Hinduastan Latex Family Planning Trust’s, presentation. Their online surveys into what gave women pleasure found that talking, watching a steamy film, making up after a fight, getting away from it all for the weekend and kissing and cuddling all came top. Sexual intercourse didn’t come into it at all . Talking openly about what we like and allowing men and women to share their thoughts can provide a useful starting point for discussions around integrating safer sex into ones sexual repertoire.

The Conference programme points to a number of upcoming sessions at which issues of pleasure and sexuality will be addressed. Whether this will be reflected in the formal plenary sessions remains to be seen.
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