ATS resorts to terror tactics
Dr Sandeep Pandey
Rajasthan Police accompanied by Anti-Terrorist Squad (ATS) of Uttar Pradesh (UP) Police raided the house of Shahbaz Hussain, arrested in connection with blasts in Jaipur and now on Police remand there, in Molviganj, Lucknow for search past midnight on 29 August 2008 and house and office today, 30 August 2008, in the afternoon.
Shahbaz used to stay at his father-in-law Abdul Moid's house along with his wife and three little children. The police took away all literature present in the house including newspapers, a cheque for Rs 15,000 in the name of 'Zyna Computers' given by one the students and Rs 1000 cash from the purse of Shahbaz's wife Shadaf. Shahbaz used to run a computer training centre and a consultancy.
Today they took away a battery from the house and made Abdul Moid (father-in-law) sign on three blank papers. Upon receiving this information from Abdul Moid's son some of us rushed to the shop where the search was going on.
When we enquired from the Deputy Superintendent of Police (Dy SP) Sangram Singh, who had come for conducting the search operations from Rajasthan, about the purpose of getting Abdul Moid's signature on blank papers, he said they were going to draw the map of house and office on them. He didn't explain what the third paper will be used for. When we requested him to give a copy of what is written or drawn on these sheets of paper to Abdul Moid he told us to come to the ATS office after a couple of hours.
When Abdul Moid and myself reached ATS office, the officer from Rajasthan was gone. We insisted that we would like to speak to the officer in-charge. When we communicated the purpose of our being there to this officer, who came out to see us at the reception, he particularly got mad at the charge Rs 1000 being taken away from Abdul Moid's house. He raised his voice and said we were accusing him of theft. I suggested him not to raise his voice. He could have simply denied the charge. On this he ordered his men to throw us out of the office. I protested and said that he cannot take somebody's signature on blank piece of paper.
After this we were abused and pushed out of the premises of ATS office by his men. The ATS and Rajasthan Police are obviously busy concocting evidence and using their unlimited powers arrogantly. Whether Shahbaz was involved in the Jaipur blasts or not will be decided by the investigation and the judicial process but the high handed behaviour of police and ATS makes one suspect of how they implicate people.
Dr Sandeep Pandey
(The author is a Ramon Magsaysay Awardee (2002) for emergent leadership, heads the National Alliance of People's Movements (NAPM) and did his PhD from University of California, Berkeley in control theory which is applicable in missile technology. He taught at Indian Institute of Technology (IIT) Kanpur before devoting his life to strengthening people's movements. He can be contacted at: ashaashram@yahoo.com)
Contact Phone of Dr Sandeep Pandey: 0522 2347365, Mobile : 9415022772
Contact of Abdul Moid: 9792439090
Published in Tehelka
Universal Access – Challenges in the Asia Pacific Region
JVR Prasada Rao, Director of the UNAIDS Regional Support Team of the Asia and Pacific region, reiterated that “Universal Access is an achievable goal, and not just an aspirational goal”, all people should be able to access the services to live with health and dignity. Chairing the session on ‘Universal Access: What it takes to deliver in the Asia-Pacific Region’, Mr Rao stressed that countries in Asia need to think big and with confidence. Referring to the findings of the report ‘Redefining AIDS in Asia -- Crafting an Effective Response ‘, published by the Commission on AIDS in Asia, he stated that by pragmatically focusing prevention programmes on key populations – commercial sex workers and their clients, intravenous drug users (IDUs) and men having sex with other men (MSM), a considerable impact could be made by governments in halting and reversing the number of new infections across the Asia Pacific region.
At the UN high level meeting on AIDS in June 2006, the world committed itself to Universal Access to HIV prevention, treatment, care and support for all people in need by 2010. Following this, most countries organized consultations with key stakeholders, including civil society organizations, networks of people living with HIV, to agree on national universal access targets and on ways for overcoming the obstacles in achieving them. Since then, the commitment to universal access has galvanized AIDS responses around the world and reinforced the engagement to stand by those infected and affected by HIV. Specifically in the Asia-Pacific region, it is critical to make a breakthrough in prevention coverage among most at risk populations. In order to achieve this, countries will need to tackle legislative barriers and actively work with civil society organizations and people living with HIV to create an enabling environment and reach marginalized groups.
Michel Kazatchkine, Executive Director of the Global Fund for AIDS, TB and Malaria (GFATM), discussed the challenges to achieve Universal Access in the Asia Pacific. In the current scenario of global economic recession, resources are constrained even in the Asia Pacific region. But it is crucial that investment in the fight against HIV/AIDS continues. There is no excuse to decrease health spending, it is critical that gains made in the last eight years especially the progress made in scaling up prevention and treatment are not lost. Advocacy efforts are required at the national and global levels to continue the momentum and resource allocations for health. The Global Fund is currently providing support to 75 percent of those being treated for HIV in Asia. Asian economies even in this period of crisis are showing growth, and there is need for co-investment from multilateral organizations and the private sector.
Interventions have to be prioritized to reach high target groups, also protecting their human rights. More proposals that are dealing with vulnerable communities, IDU’s, MSM, Sex-workers needed to achieve Universal Access targets. Legal reforms are necessary in the region that truly protect PLHIV and work towards removing legislations that blocks universal access by criminalizing the lifestyles of vulnerable groups. Civil society partnerships are essential; communities need to be at the core of policy making, planning and programme delivery. It is vital that civil society organizations have support and funds.
HIV and TB co-infection and drug-resistant forms of tuberculosis present the greatest health challenges in the Asia Pacific. TB kills more people with HIV than any other disease. There is a growing emergence of Multidrug-resistance TB (MDR-TB) in this region; 10 of the 22 highest burden countries are in this region, and only a few cases are getting appropriate treatment. Need for urgent and aggressive scale up for effective interventions for the prevention, treatment and care of TB and MDR-TB in the Asia Pacific. Failure of Asian nations to combat MDR is a threat to global health.
One of the most significant barriers to achieving universal access to HIV-AIDS treatment and prevention is the lack of health infrastructure. In order to achieve universal access to comprehensive HIV prevention, treatment, care and support services; drastically cut maternal and child mortality; and achieve the other health-related Millennium Development Goals by 2010, strong health systems are essential. To strengthen and build sustainable health systems, long term commitments are required from all stakeholders in the Asia Pacific region. Ratu Joni Madraiwiwi, member of the Solomon Island Truth and Reconciliation Commission, believes that “to achieve universal access we must be rid of prejudice, engage civil society more, be culturally sensitive and have political commitment”.
Purnima Mane, Deputy Executive Director of the United Nations Populations Fund (UNFPA) stressed that the report of the independent Commission on AIDS in Asia published earlier this year found that it is vital that national responses are evidence-based and bring services to where it is most needed. Interventions are needed in marginalized groups – these include men who have sex with men, people who inject drugs, sex workers and their clients. Access to Sexual and Reproductive health services and information needs to be provided to youth and women living with HIV. Stating the slogan ‘Nothing About Us Without Us’, it is imperative that civil society be involved at each and every process in policy making and delivery on national programmes.
Ishdeep Kohli-CNS
At the UN high level meeting on AIDS in June 2006, the world committed itself to Universal Access to HIV prevention, treatment, care and support for all people in need by 2010. Following this, most countries organized consultations with key stakeholders, including civil society organizations, networks of people living with HIV, to agree on national universal access targets and on ways for overcoming the obstacles in achieving them. Since then, the commitment to universal access has galvanized AIDS responses around the world and reinforced the engagement to stand by those infected and affected by HIV. Specifically in the Asia-Pacific region, it is critical to make a breakthrough in prevention coverage among most at risk populations. In order to achieve this, countries will need to tackle legislative barriers and actively work with civil society organizations and people living with HIV to create an enabling environment and reach marginalized groups.
Michel Kazatchkine, Executive Director of the Global Fund for AIDS, TB and Malaria (GFATM), discussed the challenges to achieve Universal Access in the Asia Pacific. In the current scenario of global economic recession, resources are constrained even in the Asia Pacific region. But it is crucial that investment in the fight against HIV/AIDS continues. There is no excuse to decrease health spending, it is critical that gains made in the last eight years especially the progress made in scaling up prevention and treatment are not lost. Advocacy efforts are required at the national and global levels to continue the momentum and resource allocations for health. The Global Fund is currently providing support to 75 percent of those being treated for HIV in Asia. Asian economies even in this period of crisis are showing growth, and there is need for co-investment from multilateral organizations and the private sector.
Interventions have to be prioritized to reach high target groups, also protecting their human rights. More proposals that are dealing with vulnerable communities, IDU’s, MSM, Sex-workers needed to achieve Universal Access targets. Legal reforms are necessary in the region that truly protect PLHIV and work towards removing legislations that blocks universal access by criminalizing the lifestyles of vulnerable groups. Civil society partnerships are essential; communities need to be at the core of policy making, planning and programme delivery. It is vital that civil society organizations have support and funds.
HIV and TB co-infection and drug-resistant forms of tuberculosis present the greatest health challenges in the Asia Pacific. TB kills more people with HIV than any other disease. There is a growing emergence of Multidrug-resistance TB (MDR-TB) in this region; 10 of the 22 highest burden countries are in this region, and only a few cases are getting appropriate treatment. Need for urgent and aggressive scale up for effective interventions for the prevention, treatment and care of TB and MDR-TB in the Asia Pacific. Failure of Asian nations to combat MDR is a threat to global health.
One of the most significant barriers to achieving universal access to HIV-AIDS treatment and prevention is the lack of health infrastructure. In order to achieve universal access to comprehensive HIV prevention, treatment, care and support services; drastically cut maternal and child mortality; and achieve the other health-related Millennium Development Goals by 2010, strong health systems are essential. To strengthen and build sustainable health systems, long term commitments are required from all stakeholders in the Asia Pacific region. Ratu Joni Madraiwiwi, member of the Solomon Island Truth and Reconciliation Commission, believes that “to achieve universal access we must be rid of prejudice, engage civil society more, be culturally sensitive and have political commitment”.
Purnima Mane, Deputy Executive Director of the United Nations Populations Fund (UNFPA) stressed that the report of the independent Commission on AIDS in Asia published earlier this year found that it is vital that national responses are evidence-based and bring services to where it is most needed. Interventions are needed in marginalized groups – these include men who have sex with men, people who inject drugs, sex workers and their clients. Access to Sexual and Reproductive health services and information needs to be provided to youth and women living with HIV. Stating the slogan ‘Nothing About Us Without Us’, it is imperative that civil society be involved at each and every process in policy making and delivery on national programmes.
Ishdeep Kohli-CNS
Inequities are killing people on a "grand scale", reports WHO's Commission
Inequities are killing people
on a "grand scale"
reports WHO's Commission
World Health Organization (WHO)
28 August 2008
GENEVA -- A child born in a Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 kilometres away. A girl in Lesotho is likely to live 42 years less than
another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17 400; in Afghanistan, the odds are 1 in 8. Biology does not explain any of this. Instead, the differences between - and within - countries result from the social environment where people are born, live, grow, work and age.
These "social determinants of health" have been the focus of a three-year investigation by an eminent group of policy makers, academics, former heads of state and former ministers of health. Together, they comprise the World Health Organization's Commission on the Social Determinants of Health. Today, the Commission presents its findings to the WHO Director-General Dr Margaret Chan.
"(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible," the Commissioners write in Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. "Social injustice is killing people on a grand scale."
"Health inequity really is a matter of life and death," said Dr Chan today while welcoming the Report and congratulating the Commission. "But health systems will not naturally gravitate towards equity. Unprecedented leadership is needed that compels all actors, including those beyond the health sector, to examine their impact on health. Primary health care, which integrates health in all of government's policies, is the best framework for doing so."
Sir Michael Marmot, Commission Chair said: "Central to the Commission's recommendations is creating the conditions for people to be empowered, to have freedom to lead flourishing lives. Nowhere is lack of empowerment more obvious than in the plight of women in many parts of the world. Health suffers as a result. Following our recommendations would dramatically improve the health and life chances of billions of people."
Inequities within countries
Health inequities -- unfair, unjust and avoidable causes of ill health -- have long been measured between countries but the Commission documents "health gradients" within countries as well. For example:
* Life expectancy for Indigenous Australian males is shorter by 17 years than all other Australian males.
* Maternal mortality is 3--4 times higher among the poor compared to the rich in Indonesia. The difference in adult mortality between least and most deprived neighbourhoods in the UK is more than 2.5 times.
* Child mortality in the slums of Nairobi is 2.5 times higher than in other parts of the city. A baby born to a Bolivian mother with no education has 10% chance of dying, while one born to a woman with at least secondary education has a 0.4% chance.
* In the United States, 886 202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalized. (This contrasts to 176 633 lives saved in the US by medical advances in the same period.)
* In Uganda the death rate of children under 5 years in the richest fifth of households is 106 per 1000 live births but in the poorest fifth of households in Uganda it is even worse -- 192 deaths per 1000 live births -- that is nearly a fifth of all babies born alive to the poorest households destined to die before they reach their fifth birthday. Set this against an average death rate for under fives in high income countries of 7 deaths per 1000.
The Commission found evidence that demonstrates in general the poor are worse off than those less deprived, but they also found that the less deprived are in turn worse than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere -- not just in developing countries, but all countries, including the richest. The slope may be more or less steep in different countries, but the phenomenon is universal.
Wealth is not necessarily a determinant
Economic growth is raising incomes in many countries but increasing national wealth alone does not necessarily increase national health. Without equitable distribution of benefits, national growth can even exacerbate inequities.
While there has been enormous increase in global wealth, technology and living standards in recent years, the key question is how it is used for fair distribution of services and institution-building especially in low-income countries. In 1980, the richest countries with 10% of the population had a gross national income 60 times that of the poorest countries with 10% of the world's population. After 25 years of globalization, this difference increased to 122, reports the Commission. Worse, in the last 15 years, the poorest quintile in many low-income countries have shown a declining share in national consumption.
Wealth alone does not have to determine the health of a nation's population. Some low-income countries such as Cuba, Costa Rica, China, state of Kerala in India and Sri Lanka have achieved levels of good health despite relatively low national incomes. But, the Commission points out, wealth can be wisely used. Nordic countries, for example, have followed policies that encouraged equality of benefits and services, full employment, gender equity and low levels of social exclusion. This, said the Commission, is an outstanding example of what needs to be done everywhere.
Solutions from beyond the health sector
Much of the work to redress health inequities lies beyond the health sector. According to the Commission's report, "Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods." Consequently, the health sector -- globally and nationally -- needs to focus attention on addressing the root causes of inequities in health.
"We rely too much on medical interventions as a way of increasing life expectancy" explained Sir Michael. "A more effective way of increasing life expectancy and improving health would be for every government policy and programme to be assessed for its impact on health and health equity; to make health and health equity a marker for government performance."
Recommendations
Based on this compelling evidence, the Commission makes three overarching recommendations to tackle the "corrosive effects of inequality of life chances":
* Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age.
* Tackle the inequitable distribution of power, money and resources -- the structural drivers of those conditions -- globally, nationally and locally.
* Measure and understand the problem and assess the impact of action.
Recommendations for daily living
Improving daily living conditions begins at the start of life. The Commission recommends that countries set up an interagency mechanism to ensure effective collaboration and coherent policy between all sectors for early childhood development, and aim to provide early childhood services to all of their young citizens. Investing in early childhood development provides one of the best ways to reduce health inequities. Evidence shows that investment in the education of women pays for itself many times over.
Billions of people live without adequate shelter and clean water. The Commission's report pays particular attention to the increasing numbers of people who live in urban slums, and the impact of urban governance on health. The Commission joins other voices in calling for a renewed effort to ensure water, sanitation and electricity for all, as well as better urban planning to address the epidemic of chronic disease.
Health systems also have an important role to play. While the Commission report shows how the health sector can not reduce health inequities on its own, providing universal coverage and ensuring a focus on equity throughout health systems are important steps.
The report also highlights how over 100 million people are impoverished due to paying for health care -- a key contributor to health inequity. The Commission thus calls for health systems to be based on principles of equity, disease prevention and health promotion with universal coverage, based on primary health care.
Distribution of resources
Enacting the recommendations of the Commission to improve daily living conditions will also require tackling the inequitable distribution of resources. This requires far-reaching and systematic action.
The report foregrounds a range of recommendations aimed at ensuring fair financing, corporate social responsibility, gender equity and better governance. These include using health equity as an indicator of government performance and overall social development, the widespread use of health equity impact assessments, ensuring that rich countries honour their commitment to provide 0.7% of their GNP as aid, strengthening legislation to prohibit discrimination by gender and improving the capacity for all groups in society to participate in policy-making with space for civil society to work unencumbered to promote and protect political and social rights. At the global level, the Commission recommends that health equity should be a core development goal and that a social determinants of health framework should be used to monitor progress.
The Commission also highlights how implementing any of the above recommendations requires measurement of the existing problem of health inequity (where in many countries adequate data does not exist) and then monitoring the impact on health equity of the proposed interventions. To do this will require firstly investing in basic vital registration systems which have seen limited progress in the last thirty years. There is also a great need for training of policy-makers, health workers and workers in other sectors to understand the need for and how to act on the social determinants of health.
While more research is needed, enough is known for policy makers to initiate action. The feasibility of action is indicated in the change that is already occurring. Egypt has shown a remarkable drop in child mortality from 235 to 33 per 1000 in 30 years. Greece and Portugal reduced their child mortality from 50 per 1000 births to levels nearly as low as Japan, Sweden, and Iceland. Cuba achieved more than 99% coverage of its child development services in 2000. But trends showing improved health are not foreordained. In fact, without attention health can decline rapidly.
Is this feasible?
The Commission has already inspired and supported action in many parts of the world. Brazil, Canada, Chile, Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the UK have become 'country partners' on the basis of their commitment to make progress on the social determinants of health equity and are already developing policies across governments to tackle them. These examples show that change is possible through political will. There is a long way to go, but the direction is set, say the Commissioners, the path clear.
WHO will now make the report available to Member States which will determine how the health agency is to respond.
Comments from the Commissioners
Fran Baum, Head of Department and Professor of Public Health at Flinders University, Foundation Director of the South Australian Community Health Research Unit and Co-Chair of the Global Coordinating Council of the People's Health Movement: "It is wonderful to have global endorsement of the Australian Closing the Gap campaign from the CSDH established by the WHO. The CSDH sets Closing the Gap as a goal for the whole world and produces the evidence on how health inequities are a reflection of the way we organize society and distribute power and resources. The good news from the CSDH for Australia is that it provides plenty of ideas on how to set an agenda that will tackle the underlying determinants of health and create a healthier Australia for all of us"
Monique Begin, Professor at the School of Management, University of Ottawa, Canada, twice-appointed Minister of National Health and Welfare and the first woman from Quebec elected to the House of Commons: "Canada likes to brag that for seven years in a row the United Nations voted us "the best country in the world in which to live". Do all Canadians share equally in that great quality of life? No they don't. The truth is that our country is so wealthy that it manages to mask the reality of food banks in our cities, of unacceptable housing (1 in 5), of young Inuit adults very high suicide rates. This report is a wake up call for action towards truly living up to our reputation."
Giovanni Berlinguer, Member of the European Parliament, member of the International Bioethics Committee of UNESCO (2001--2007) and rapporteur of the project Universal Declaration on Bioethics: "A fairer world will be a healthier world. A health service and medical interventions are just one of the factors that influence population health. The growth of inequalities and the phenomena of increased injustice in health is present in low and middle income countries as well as across Europe. It would be a crime not to take every action possible to reduce them."
Mirai Chatterjee, Coordinator of Social Security for India's Self-Employed Women's Association, a trade union of over 900 000 self-employed women and recently appointed to the National Advisory Council and the National Commission for the Unorganised Sector: "The report suggests avenues for action from the local to national and global levels. It has been eagerly awaited by policy-makers, health officials, grassroot activists and their community-based organizations. Much of the research and evidence is of particular relevance to the South-East Asian region, where too many people struggle daily for justice and equity in health. The report will inspire the region to act and develop new policies and programmes."
Yan Guo, Professor of Public Health and Vice-President of the Peking University Health Science Centre, Vice-Chairman of the Chinese Rural Health Association and Vice-Director of the China Academy of Health Policy: "A man should not be concerned with whether he has enough possessions but whether possessions have been equally distributed", this is a time-honored teaching in China. Constructing a harmonious society is our shared aspiration, and equity, including health equity, composes the prerequisite for a harmonious development. Eliminating determinants that are adverse to health under the efforts from all of the society, promoting social justice, and advancing human health are our shared goals. Let's join our hands in this grand course!"
Kiyoshi Kurokawa, Professor at the National Graduate Institute for Policy Studies, Tokyo, Member of the Science and Technology Policy Committee of the Cabinet Office, formerly President of the Science Council of Japan and the Pacific Science Association: "The WHO Commission addresses one of the major issues of our global world - health inequity. The report's recommendations will be perceived, utilized and implemented as a major policy agenda at national and global levels. The issue will increase in importance as the general public become more engaged via civil society movements and multi-stakeholder involvement."
Alireza Marandi, Professor of Pediatrics at Shaheed Beheshti University, Islamic Republic of Iran, former two-term Minister of Health and Medical Education, former Deputy Minister and Advisor to the Minister and recently elected to be a member of the Iranian Parliament: "According to the Islamic ideology, social justice became a priority, when the Islamic revolution materialized in Iran. Establishing a solid Primary Health Care network in our country, not only improved our health statistics, but it was an excellent vehicle to move towards health equity. Now through the final report of the CSDH and implementing its recommendations we need to move much faster in our own country toward health equity."
Pascoal Mocumbi, High Representative of the European and Developing Countries Clinical Trials Partnership, former Prime Minister of the Republic of Mozambique, former head of the Ministry of Foreign Affairs and the Ministry of Health: "The Commission on Social Determinants of Health report will help African leaders adapt their national development strategies to address the challenges to health. These are derived from the current systemic changes taking place in the global economy that affects heavily on the poorest segments of Africa's population."
Amartya Sen, Lamont University Professor and Professor of Economics and Philosophy at Harvard University, awarded the Nobel Prize in Economics in 1998: "The primary object of development - for any country and for the world as a whole - is the elimination of 'unfreedoms' that reduce and impoverish the lives of people. Central to human deprivation is the failure of the capability to live long and healthy lives. This is much more than a medical problem. It relates to handicaps that have deep social roots. Under Michael Marmot's leadership, this WHO Commission has concentrated on the badly neglected causal linkages that have to be adequately understood and remedied. A fuller understanding is also a call for action."
David Satcher, Director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute Initiative, formerly the United States Surgeon General and Assistant Secretary for Health and also Director of the Centers for Disease Control and Prevention: "The United States of America spends more on health care than any other country in the world, yet it ranks 41st in terms of life expectancy. New Orleans and its experience with Hurricane Katrina illustrate why we need to target social determinants of health (SDH) --- including housing, education, working and learning conditions, and whether people are exposed to toxins---better than any place I can think of right now. By targeting the SDH, we can rapidly move towards closing the gap that unfairly and avoidably separates the health status of groups of different socio-economic status, social exclusion experience, and educational background."
Anna Tibaijuka, Executive Director of UN-HABITAT and founding Chairperson of the independent Tanzanian National Women's Council: "Health delivery is not possible for people living in squalor, in dehumanizing pathetic conditions prevailing in the ever growing slum settlements of cities and towns in developing countries. Investment in basic services such as water and education will always remain constrained if not wasted unless accompanied by requisite investment in decent housing with basic sanitation."
Denny Vagero", Professor of Medical Sociology, Director of CHESS (Centre for Health Equity Studies) in Sweden, member of the Royal Swedish Academy of Sciences and of its Standing Committee on Health: "Countries of the world are presently growing apart in health terms. This is very worrying. In many countries in the world social differences in health are also growing, and this is true in Europe. We have been one-sidedly focused on economic growth, disregarding negative consequences for health and climate. We need to think differently about development."
Gail Wilensky, Senior Fellow at Project HOPE, an international health education foundation. Previously she directed the Medicare and Medicaid programmes in the United States and also chaired two commissions that advise the United States Congress on Medicare: "What this report makes clear is that improving health and health outcomes and reducing avoidable health differences---goals of all countries-- involves far more than just improving the health care system. Basic living conditions, employment, early childhood education, treatment of women and poverty all impact on health outcomes and incorporating their effects on health outcomes needs to become an important part of public policymaking. This is as true for wealthy countries like the United States as it is for many of the emerging countries of the world, where large numbers of people live on less than $2 per day."
For more information or interviews, please contact:
Sharad Agarwal
Communications Officer
WHO, Geneva
Tel.: +41 22 791 1905
Mob.: +41 79 621 5286
Email: agarwals@who.int
Felicity Porritt
Head, Communications
CSDH, UCL Secretariat
London
Mob.: +44 773 941 9219
Email: felicity.porritt@mac.com
on a "grand scale"
reports WHO's Commission
World Health Organization (WHO)
28 August 2008
Press release
[To download the report, click here]
GENEVA -- A child born in a Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 kilometres away. A girl in Lesotho is likely to live 42 years less than
another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17 400; in Afghanistan, the odds are 1 in 8. Biology does not explain any of this. Instead, the differences between - and within - countries result from the social environment where people are born, live, grow, work and age.These "social determinants of health" have been the focus of a three-year investigation by an eminent group of policy makers, academics, former heads of state and former ministers of health. Together, they comprise the World Health Organization's Commission on the Social Determinants of Health. Today, the Commission presents its findings to the WHO Director-General Dr Margaret Chan.
"(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible," the Commissioners write in Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. "Social injustice is killing people on a grand scale."
"Health inequity really is a matter of life and death," said Dr Chan today while welcoming the Report and congratulating the Commission. "But health systems will not naturally gravitate towards equity. Unprecedented leadership is needed that compels all actors, including those beyond the health sector, to examine their impact on health. Primary health care, which integrates health in all of government's policies, is the best framework for doing so."
Sir Michael Marmot, Commission Chair said: "Central to the Commission's recommendations is creating the conditions for people to be empowered, to have freedom to lead flourishing lives. Nowhere is lack of empowerment more obvious than in the plight of women in many parts of the world. Health suffers as a result. Following our recommendations would dramatically improve the health and life chances of billions of people."
Inequities within countries
Health inequities -- unfair, unjust and avoidable causes of ill health -- have long been measured between countries but the Commission documents "health gradients" within countries as well. For example:
* Life expectancy for Indigenous Australian males is shorter by 17 years than all other Australian males.
* Maternal mortality is 3--4 times higher among the poor compared to the rich in Indonesia. The difference in adult mortality between least and most deprived neighbourhoods in the UK is more than 2.5 times.
* Child mortality in the slums of Nairobi is 2.5 times higher than in other parts of the city. A baby born to a Bolivian mother with no education has 10% chance of dying, while one born to a woman with at least secondary education has a 0.4% chance.
* In the United States, 886 202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalized. (This contrasts to 176 633 lives saved in the US by medical advances in the same period.)
* In Uganda the death rate of children under 5 years in the richest fifth of households is 106 per 1000 live births but in the poorest fifth of households in Uganda it is even worse -- 192 deaths per 1000 live births -- that is nearly a fifth of all babies born alive to the poorest households destined to die before they reach their fifth birthday. Set this against an average death rate for under fives in high income countries of 7 deaths per 1000.
The Commission found evidence that demonstrates in general the poor are worse off than those less deprived, but they also found that the less deprived are in turn worse than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere -- not just in developing countries, but all countries, including the richest. The slope may be more or less steep in different countries, but the phenomenon is universal.
Wealth is not necessarily a determinant
Economic growth is raising incomes in many countries but increasing national wealth alone does not necessarily increase national health. Without equitable distribution of benefits, national growth can even exacerbate inequities.
While there has been enormous increase in global wealth, technology and living standards in recent years, the key question is how it is used for fair distribution of services and institution-building especially in low-income countries. In 1980, the richest countries with 10% of the population had a gross national income 60 times that of the poorest countries with 10% of the world's population. After 25 years of globalization, this difference increased to 122, reports the Commission. Worse, in the last 15 years, the poorest quintile in many low-income countries have shown a declining share in national consumption.
Wealth alone does not have to determine the health of a nation's population. Some low-income countries such as Cuba, Costa Rica, China, state of Kerala in India and Sri Lanka have achieved levels of good health despite relatively low national incomes. But, the Commission points out, wealth can be wisely used. Nordic countries, for example, have followed policies that encouraged equality of benefits and services, full employment, gender equity and low levels of social exclusion. This, said the Commission, is an outstanding example of what needs to be done everywhere.
Solutions from beyond the health sector
Much of the work to redress health inequities lies beyond the health sector. According to the Commission's report, "Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods." Consequently, the health sector -- globally and nationally -- needs to focus attention on addressing the root causes of inequities in health.
"We rely too much on medical interventions as a way of increasing life expectancy" explained Sir Michael. "A more effective way of increasing life expectancy and improving health would be for every government policy and programme to be assessed for its impact on health and health equity; to make health and health equity a marker for government performance."
Recommendations
Based on this compelling evidence, the Commission makes three overarching recommendations to tackle the "corrosive effects of inequality of life chances":
* Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age.
* Tackle the inequitable distribution of power, money and resources -- the structural drivers of those conditions -- globally, nationally and locally.
* Measure and understand the problem and assess the impact of action.
Recommendations for daily living
Improving daily living conditions begins at the start of life. The Commission recommends that countries set up an interagency mechanism to ensure effective collaboration and coherent policy between all sectors for early childhood development, and aim to provide early childhood services to all of their young citizens. Investing in early childhood development provides one of the best ways to reduce health inequities. Evidence shows that investment in the education of women pays for itself many times over.
Billions of people live without adequate shelter and clean water. The Commission's report pays particular attention to the increasing numbers of people who live in urban slums, and the impact of urban governance on health. The Commission joins other voices in calling for a renewed effort to ensure water, sanitation and electricity for all, as well as better urban planning to address the epidemic of chronic disease.
Health systems also have an important role to play. While the Commission report shows how the health sector can not reduce health inequities on its own, providing universal coverage and ensuring a focus on equity throughout health systems are important steps.
The report also highlights how over 100 million people are impoverished due to paying for health care -- a key contributor to health inequity. The Commission thus calls for health systems to be based on principles of equity, disease prevention and health promotion with universal coverage, based on primary health care.
Distribution of resources
Enacting the recommendations of the Commission to improve daily living conditions will also require tackling the inequitable distribution of resources. This requires far-reaching and systematic action.
The report foregrounds a range of recommendations aimed at ensuring fair financing, corporate social responsibility, gender equity and better governance. These include using health equity as an indicator of government performance and overall social development, the widespread use of health equity impact assessments, ensuring that rich countries honour their commitment to provide 0.7% of their GNP as aid, strengthening legislation to prohibit discrimination by gender and improving the capacity for all groups in society to participate in policy-making with space for civil society to work unencumbered to promote and protect political and social rights. At the global level, the Commission recommends that health equity should be a core development goal and that a social determinants of health framework should be used to monitor progress.
The Commission also highlights how implementing any of the above recommendations requires measurement of the existing problem of health inequity (where in many countries adequate data does not exist) and then monitoring the impact on health equity of the proposed interventions. To do this will require firstly investing in basic vital registration systems which have seen limited progress in the last thirty years. There is also a great need for training of policy-makers, health workers and workers in other sectors to understand the need for and how to act on the social determinants of health.
While more research is needed, enough is known for policy makers to initiate action. The feasibility of action is indicated in the change that is already occurring. Egypt has shown a remarkable drop in child mortality from 235 to 33 per 1000 in 30 years. Greece and Portugal reduced their child mortality from 50 per 1000 births to levels nearly as low as Japan, Sweden, and Iceland. Cuba achieved more than 99% coverage of its child development services in 2000. But trends showing improved health are not foreordained. In fact, without attention health can decline rapidly.
Is this feasible?
The Commission has already inspired and supported action in many parts of the world. Brazil, Canada, Chile, Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the UK have become 'country partners' on the basis of their commitment to make progress on the social determinants of health equity and are already developing policies across governments to tackle them. These examples show that change is possible through political will. There is a long way to go, but the direction is set, say the Commissioners, the path clear.
WHO will now make the report available to Member States which will determine how the health agency is to respond.
Comments from the Commissioners
Fran Baum, Head of Department and Professor of Public Health at Flinders University, Foundation Director of the South Australian Community Health Research Unit and Co-Chair of the Global Coordinating Council of the People's Health Movement: "It is wonderful to have global endorsement of the Australian Closing the Gap campaign from the CSDH established by the WHO. The CSDH sets Closing the Gap as a goal for the whole world and produces the evidence on how health inequities are a reflection of the way we organize society and distribute power and resources. The good news from the CSDH for Australia is that it provides plenty of ideas on how to set an agenda that will tackle the underlying determinants of health and create a healthier Australia for all of us"
Monique Begin, Professor at the School of Management, University of Ottawa, Canada, twice-appointed Minister of National Health and Welfare and the first woman from Quebec elected to the House of Commons: "Canada likes to brag that for seven years in a row the United Nations voted us "the best country in the world in which to live". Do all Canadians share equally in that great quality of life? No they don't. The truth is that our country is so wealthy that it manages to mask the reality of food banks in our cities, of unacceptable housing (1 in 5), of young Inuit adults very high suicide rates. This report is a wake up call for action towards truly living up to our reputation."
Giovanni Berlinguer, Member of the European Parliament, member of the International Bioethics Committee of UNESCO (2001--2007) and rapporteur of the project Universal Declaration on Bioethics: "A fairer world will be a healthier world. A health service and medical interventions are just one of the factors that influence population health. The growth of inequalities and the phenomena of increased injustice in health is present in low and middle income countries as well as across Europe. It would be a crime not to take every action possible to reduce them."
Mirai Chatterjee, Coordinator of Social Security for India's Self-Employed Women's Association, a trade union of over 900 000 self-employed women and recently appointed to the National Advisory Council and the National Commission for the Unorganised Sector: "The report suggests avenues for action from the local to national and global levels. It has been eagerly awaited by policy-makers, health officials, grassroot activists and their community-based organizations. Much of the research and evidence is of particular relevance to the South-East Asian region, where too many people struggle daily for justice and equity in health. The report will inspire the region to act and develop new policies and programmes."
Yan Guo, Professor of Public Health and Vice-President of the Peking University Health Science Centre, Vice-Chairman of the Chinese Rural Health Association and Vice-Director of the China Academy of Health Policy: "A man should not be concerned with whether he has enough possessions but whether possessions have been equally distributed", this is a time-honored teaching in China. Constructing a harmonious society is our shared aspiration, and equity, including health equity, composes the prerequisite for a harmonious development. Eliminating determinants that are adverse to health under the efforts from all of the society, promoting social justice, and advancing human health are our shared goals. Let's join our hands in this grand course!"
Kiyoshi Kurokawa, Professor at the National Graduate Institute for Policy Studies, Tokyo, Member of the Science and Technology Policy Committee of the Cabinet Office, formerly President of the Science Council of Japan and the Pacific Science Association: "The WHO Commission addresses one of the major issues of our global world - health inequity. The report's recommendations will be perceived, utilized and implemented as a major policy agenda at national and global levels. The issue will increase in importance as the general public become more engaged via civil society movements and multi-stakeholder involvement."
Alireza Marandi, Professor of Pediatrics at Shaheed Beheshti University, Islamic Republic of Iran, former two-term Minister of Health and Medical Education, former Deputy Minister and Advisor to the Minister and recently elected to be a member of the Iranian Parliament: "According to the Islamic ideology, social justice became a priority, when the Islamic revolution materialized in Iran. Establishing a solid Primary Health Care network in our country, not only improved our health statistics, but it was an excellent vehicle to move towards health equity. Now through the final report of the CSDH and implementing its recommendations we need to move much faster in our own country toward health equity."
Pascoal Mocumbi, High Representative of the European and Developing Countries Clinical Trials Partnership, former Prime Minister of the Republic of Mozambique, former head of the Ministry of Foreign Affairs and the Ministry of Health: "The Commission on Social Determinants of Health report will help African leaders adapt their national development strategies to address the challenges to health. These are derived from the current systemic changes taking place in the global economy that affects heavily on the poorest segments of Africa's population."
Amartya Sen, Lamont University Professor and Professor of Economics and Philosophy at Harvard University, awarded the Nobel Prize in Economics in 1998: "The primary object of development - for any country and for the world as a whole - is the elimination of 'unfreedoms' that reduce and impoverish the lives of people. Central to human deprivation is the failure of the capability to live long and healthy lives. This is much more than a medical problem. It relates to handicaps that have deep social roots. Under Michael Marmot's leadership, this WHO Commission has concentrated on the badly neglected causal linkages that have to be adequately understood and remedied. A fuller understanding is also a call for action."
David Satcher, Director of the Center of Excellence on Health Disparities and the Satcher Health Leadership Institute Initiative, formerly the United States Surgeon General and Assistant Secretary for Health and also Director of the Centers for Disease Control and Prevention: "The United States of America spends more on health care than any other country in the world, yet it ranks 41st in terms of life expectancy. New Orleans and its experience with Hurricane Katrina illustrate why we need to target social determinants of health (SDH) --- including housing, education, working and learning conditions, and whether people are exposed to toxins---better than any place I can think of right now. By targeting the SDH, we can rapidly move towards closing the gap that unfairly and avoidably separates the health status of groups of different socio-economic status, social exclusion experience, and educational background."
Anna Tibaijuka, Executive Director of UN-HABITAT and founding Chairperson of the independent Tanzanian National Women's Council: "Health delivery is not possible for people living in squalor, in dehumanizing pathetic conditions prevailing in the ever growing slum settlements of cities and towns in developing countries. Investment in basic services such as water and education will always remain constrained if not wasted unless accompanied by requisite investment in decent housing with basic sanitation."
Denny Vagero", Professor of Medical Sociology, Director of CHESS (Centre for Health Equity Studies) in Sweden, member of the Royal Swedish Academy of Sciences and of its Standing Committee on Health: "Countries of the world are presently growing apart in health terms. This is very worrying. In many countries in the world social differences in health are also growing, and this is true in Europe. We have been one-sidedly focused on economic growth, disregarding negative consequences for health and climate. We need to think differently about development."
Gail Wilensky, Senior Fellow at Project HOPE, an international health education foundation. Previously she directed the Medicare and Medicaid programmes in the United States and also chaired two commissions that advise the United States Congress on Medicare: "What this report makes clear is that improving health and health outcomes and reducing avoidable health differences---goals of all countries-- involves far more than just improving the health care system. Basic living conditions, employment, early childhood education, treatment of women and poverty all impact on health outcomes and incorporating their effects on health outcomes needs to become an important part of public policymaking. This is as true for wealthy countries like the United States as it is for many of the emerging countries of the world, where large numbers of people live on less than $2 per day."
For more information or interviews, please contact:
Sharad Agarwal
Communications Officer
WHO, Geneva
Tel.: +41 22 791 1905
Mob.: +41 79 621 5286
Email: agarwals@who.int
Felicity Porritt
Head, Communications
CSDH, UCL Secretariat
London
Mob.: +44 773 941 9219
Email: felicity.porritt@mac.com
Berlin Call to Action
Global Partners in Action:
NGO Forum on Sexual and Reproductive Health and Development
Berlin Call to Action
(The ‘Berlin Call to Action is the outcome document from the Berlin NGO forum appealing to governments, UN agencies, Donors, Parliamentarians, NGOs, Businesses, Religious communities to take the necessary steps to improve access to comprehensive sexual and reproductive health and rights. Organizers plan to push the Berlin Call to Action at the 2009 International Parliamentarians' Conference on the Implementation of the ICPD Programme of Action in Addis Ababa, Ethiopia, at the end of October.)
Berlin Call to Action: Now is the time for donors and government leaders at all levels to accelerate implementation of the International Conference on Population and Development (ICPD) Programme of Action (PoA) as fundamental to achieving equality and equity, human rights and social and economic development.
Leaders of non-governmental organisations (NGOs) from more than 130 countries have come together in Berlin to demand that the international community reinforce and strengthen their commitment to the vision of the ICPD PoA, and in particular, sexual and reproductive health and rights.
As urgent as the ICPD agenda was in 1994, it is even more so today as countries, communities, and individuals seek effective responses to financial, political, humanitarian and environmental crises, climate change, insufficient health resources, continuing high maternal mortality and morbidity and the spread of HIV, and inequality in ensuring human rights. It is important to recognize the social determinants of health and are responsible for a major part of health inequities between and within countries. Access to sexual and reproductive health and rights information and services is essential to addressing these issues. The ICPD created a visionary global consensus which confirmed that the best way to improve global health and population policies, support sustainable development, advance human rights and help end poverty is to:
* Invest in health and rights for women and young people
* Provide comprehensive sexual and reproductive health information, services and supplies for all people
* Eradicate discrimination against girls and ensure access to all levels of education
* Advance gender equality and equity and empower girls and women
ICPD’s core principles and priority actions have repeatedly been affirmed by governments as having links to other aspects of development, such as in the 21st session of the UN General Assembly in 1999, the UN Millennium Declaration in 2000 and Millennium Development Goals (MDGs), the World Summit Outcome in 2005, the inclusion of universal access to reproductive health as a target in the MDGs, in the 2009 resolution of the UN Commission on Population and Development and in recommendations issued by the UN Human Rights treaty monitoring bodies.
With five years left to implement the ICPD PoA and achieve the MDGs, which are integrally linked, we call on local, national and international decision-makers to join with non-governmental organisations (NGOs) to establish and implement concrete, practical, and fully funded actions for ensuring sexual and reproductive health and rights.
We urge the following actions to be taken immediately:
I. Guarantee that sexual and reproductive rights, as human rights, are fully recognized and fulfilled. Reform laws and policies to protect and promote sexual and reproductive rights, which are central to achieving the highest attainable level of health. Repeal restrictive and punitive laws and policies which deny access to information and services for sexual and reproductive health and rights, as well as those which criminalize the transmission of HIV and abortion. These laws and policies should at the minimum comply with international human rights standards, treaties and conventions. These rights enable free and informed decisions over marriage, pregnancy, childbirth, contraception, sexuality, sexual orientation, pleasure and livelihood. Eradicate sexual and reproductive coercion, stigma, discrimination, harmful traditional practices and gender-based violence, particularly against women and girls.
II. Invest in comprehensive sexual and reproductive health (SRH) information, supplies and services as a priority in health system strengthening. We are deeply concerned with the consequences of unsafe abortion and maternal mortality, and as a result call for governments to address these as public health and human rights issues. Ensure equitable and affordable access for contraception, safe and legal abortion, skilled maternity and newborn care, including access and referral to pregnancy and delivery complications; prevention, diagnosis, treatment and care of HIV and AIDS and all other sexually transmitted infections, including in humanitarian crisis. All of these services must be available and fully funded throughout the health system, particularly in the public sector and at the primary health care level as well as taking into consideration the important role that NGOs play in providing complementary health services. Provide these services for all, ensuring quality, gender and age-sensitive healthcare and non-discrimination for low income and other marginalised groups. Service providers need to be non-judgmental and respect diversity. Support innovation, including the development of new technologies and service models, and access to scientific progress. We call upon governments to include objectives and indicators in the national health planning and budgeting process that ensure positive sexual and reproductive health and rights outcomes.
III. Ensure the sexual and reproductive rights of adolescents and young people. Empower young people to make informed decisions about their life and livelihood in an environment that removes all barriers to accessing the full range of sexual and reproductive health information and services. Guarantee confidentiality and eliminate parental and spousal consent and age restrictions. Expand and allocate the resources needed to deliver effective, continuous, gender sensitive and youth-friendly services and evidence-based, timely, and comprehensive sexuality education. Acknowledge and respect the diversity of young people and collect age and gender disaggregated data.
IV. Create and implement formal mechanisms for meaningful civil society participation in programs, policy and budget decisions, monitoring and evaluation. Provide ongoing opportunities, especially for women and young people, to be full partners in the policy dialogue and decision-making processes. Increase funding and ensure autonomy for non-governmental organisations (NGOs), especially women’s organisations to expand and strengthen their work to inform, influence and advocate for sexual and reproductive health and rights. Repeal repressive laws regulating NGOs and enact and implement legislation that protects and facilitates their actions. Recognize and protect sexual and reproductive health and rights advocates as human rights defenders and foster meaningful leadership among women, young people and? groups of people living in situations? increasing their vulnerability.
V. Ensure that national governments and donors allocate sufficient resources and budgets that meet the needs of all people’s sexual and reproductive health and rights. Particularly in times of economic crisis, we strongly urge all donors to meet their commitments to overseas assistance and provide full funding that is predictable and long-term. Ensure funding mechanisms include sexual and reproductive health and rights policies and services. Establish and implement concrete, practical, and fully funded actions for ensuring sexual and reproductive health and rights. Strengthen and harmonise people-centered, economically and environmentally sustainable policies. Prioritise sexual and reproductive health and rights as a critical component of economic and social justice, health and development.
We ask you to adopt the following principles in taking action:
* Equity and equality. The ICPD PoA and MDGs cannot be achieved without equity and equality,? therefore actions must always be designed and monitored to foster equity, participation and representation
* Inclusiveness and transparency. All stakeholders, including the NG0s making this statement, will work in partnership to ensure that priority actions are taken and have an impact.
* Accountability and sustainability. All stakeholders—policymakers, donors and civil society—are committed to achieving the ICPD PoA and to ensure sexual and reproductive health and rights.
* Democratic processes and policies free from fundamentalisms and other doctrines that restrict human rights.
We, the NGOs participating in the Global Partners in Action NGO Forum urge governments to reaffirm their commitment to the ICPD PoA and as NGOs, we will promote this Berlin Call to Action in our own countries and communities. We will work in cooperation with governments, bilateral and multilateral agencies and policymakers and other sectors of the social movements? to ensure its timely implementation and hold governments accountable for the full realisation of the PoA.
Human beings cannot live in dignity without the full implementation of the ICPD PoA. We demand that all governments fulfill the commitments made to their own people and the international community at Cairo in 1994. As NGOs, we work daily to uphold the right to health and commit ourselves to this Call to Action and its dissemination among policymakers and stakeholders who are committed to shape the future. It is a matter of human rights, democracy, and equality for all. This mandate does not end in Berlin. We must intensify our efforts.
Ishdeep Kohli-CNS
NGO Forum on Sexual and Reproductive Health and Development
Berlin Call to Action
(The ‘Berlin Call to Action is the outcome document from the Berlin NGO forum appealing to governments, UN agencies, Donors, Parliamentarians, NGOs, Businesses, Religious communities to take the necessary steps to improve access to comprehensive sexual and reproductive health and rights. Organizers plan to push the Berlin Call to Action at the 2009 International Parliamentarians' Conference on the Implementation of the ICPD Programme of Action in Addis Ababa, Ethiopia, at the end of October.)
Berlin Call to Action: Now is the time for donors and government leaders at all levels to accelerate implementation of the International Conference on Population and Development (ICPD) Programme of Action (PoA) as fundamental to achieving equality and equity, human rights and social and economic development.
Leaders of non-governmental organisations (NGOs) from more than 130 countries have come together in Berlin to demand that the international community reinforce and strengthen their commitment to the vision of the ICPD PoA, and in particular, sexual and reproductive health and rights.
As urgent as the ICPD agenda was in 1994, it is even more so today as countries, communities, and individuals seek effective responses to financial, political, humanitarian and environmental crises, climate change, insufficient health resources, continuing high maternal mortality and morbidity and the spread of HIV, and inequality in ensuring human rights. It is important to recognize the social determinants of health and are responsible for a major part of health inequities between and within countries. Access to sexual and reproductive health and rights information and services is essential to addressing these issues. The ICPD created a visionary global consensus which confirmed that the best way to improve global health and population policies, support sustainable development, advance human rights and help end poverty is to:
* Invest in health and rights for women and young people
* Provide comprehensive sexual and reproductive health information, services and supplies for all people
* Eradicate discrimination against girls and ensure access to all levels of education
* Advance gender equality and equity and empower girls and women
ICPD’s core principles and priority actions have repeatedly been affirmed by governments as having links to other aspects of development, such as in the 21st session of the UN General Assembly in 1999, the UN Millennium Declaration in 2000 and Millennium Development Goals (MDGs), the World Summit Outcome in 2005, the inclusion of universal access to reproductive health as a target in the MDGs, in the 2009 resolution of the UN Commission on Population and Development and in recommendations issued by the UN Human Rights treaty monitoring bodies.
With five years left to implement the ICPD PoA and achieve the MDGs, which are integrally linked, we call on local, national and international decision-makers to join with non-governmental organisations (NGOs) to establish and implement concrete, practical, and fully funded actions for ensuring sexual and reproductive health and rights.
We urge the following actions to be taken immediately:
I. Guarantee that sexual and reproductive rights, as human rights, are fully recognized and fulfilled. Reform laws and policies to protect and promote sexual and reproductive rights, which are central to achieving the highest attainable level of health. Repeal restrictive and punitive laws and policies which deny access to information and services for sexual and reproductive health and rights, as well as those which criminalize the transmission of HIV and abortion. These laws and policies should at the minimum comply with international human rights standards, treaties and conventions. These rights enable free and informed decisions over marriage, pregnancy, childbirth, contraception, sexuality, sexual orientation, pleasure and livelihood. Eradicate sexual and reproductive coercion, stigma, discrimination, harmful traditional practices and gender-based violence, particularly against women and girls.
II. Invest in comprehensive sexual and reproductive health (SRH) information, supplies and services as a priority in health system strengthening. We are deeply concerned with the consequences of unsafe abortion and maternal mortality, and as a result call for governments to address these as public health and human rights issues. Ensure equitable and affordable access for contraception, safe and legal abortion, skilled maternity and newborn care, including access and referral to pregnancy and delivery complications; prevention, diagnosis, treatment and care of HIV and AIDS and all other sexually transmitted infections, including in humanitarian crisis. All of these services must be available and fully funded throughout the health system, particularly in the public sector and at the primary health care level as well as taking into consideration the important role that NGOs play in providing complementary health services. Provide these services for all, ensuring quality, gender and age-sensitive healthcare and non-discrimination for low income and other marginalised groups. Service providers need to be non-judgmental and respect diversity. Support innovation, including the development of new technologies and service models, and access to scientific progress. We call upon governments to include objectives and indicators in the national health planning and budgeting process that ensure positive sexual and reproductive health and rights outcomes.
III. Ensure the sexual and reproductive rights of adolescents and young people. Empower young people to make informed decisions about their life and livelihood in an environment that removes all barriers to accessing the full range of sexual and reproductive health information and services. Guarantee confidentiality and eliminate parental and spousal consent and age restrictions. Expand and allocate the resources needed to deliver effective, continuous, gender sensitive and youth-friendly services and evidence-based, timely, and comprehensive sexuality education. Acknowledge and respect the diversity of young people and collect age and gender disaggregated data.
IV. Create and implement formal mechanisms for meaningful civil society participation in programs, policy and budget decisions, monitoring and evaluation. Provide ongoing opportunities, especially for women and young people, to be full partners in the policy dialogue and decision-making processes. Increase funding and ensure autonomy for non-governmental organisations (NGOs), especially women’s organisations to expand and strengthen their work to inform, influence and advocate for sexual and reproductive health and rights. Repeal repressive laws regulating NGOs and enact and implement legislation that protects and facilitates their actions. Recognize and protect sexual and reproductive health and rights advocates as human rights defenders and foster meaningful leadership among women, young people and? groups of people living in situations? increasing their vulnerability.
V. Ensure that national governments and donors allocate sufficient resources and budgets that meet the needs of all people’s sexual and reproductive health and rights. Particularly in times of economic crisis, we strongly urge all donors to meet their commitments to overseas assistance and provide full funding that is predictable and long-term. Ensure funding mechanisms include sexual and reproductive health and rights policies and services. Establish and implement concrete, practical, and fully funded actions for ensuring sexual and reproductive health and rights. Strengthen and harmonise people-centered, economically and environmentally sustainable policies. Prioritise sexual and reproductive health and rights as a critical component of economic and social justice, health and development.
We ask you to adopt the following principles in taking action:
* Equity and equality. The ICPD PoA and MDGs cannot be achieved without equity and equality,? therefore actions must always be designed and monitored to foster equity, participation and representation
* Inclusiveness and transparency. All stakeholders, including the NG0s making this statement, will work in partnership to ensure that priority actions are taken and have an impact.
* Accountability and sustainability. All stakeholders—policymakers, donors and civil society—are committed to achieving the ICPD PoA and to ensure sexual and reproductive health and rights.
* Democratic processes and policies free from fundamentalisms and other doctrines that restrict human rights.
We, the NGOs participating in the Global Partners in Action NGO Forum urge governments to reaffirm their commitment to the ICPD PoA and as NGOs, we will promote this Berlin Call to Action in our own countries and communities. We will work in cooperation with governments, bilateral and multilateral agencies and policymakers and other sectors of the social movements? to ensure its timely implementation and hold governments accountable for the full realisation of the PoA.
Human beings cannot live in dignity without the full implementation of the ICPD PoA. We demand that all governments fulfill the commitments made to their own people and the international community at Cairo in 1994. As NGOs, we work daily to uphold the right to health and commit ourselves to this Call to Action and its dissemination among policymakers and stakeholders who are committed to shape the future. It is a matter of human rights, democracy, and equality for all. This mandate does not end in Berlin. We must intensify our efforts.
Ishdeep Kohli-CNS
NGO Forum on Sexual and Reproductive Health and Development
Global Partners in Action: NGO Forum on Sexual and Reproductive Health and Development, Invest in Health, Rights and the Future is taking place in Berlin, Germany, 2-4 September. The Forum provides a venue where non-governmental organizations and other partners convene, exchange experiences and discuss strategies that have worked in making a difference. Special emphasis is being placed in involving young people to ensure that the ICPD vision of participatory development is owned by coming generations and made relevant to our rapidly changing world. The conference is co-hosted by the United Nations Population Fund (UNFPA) and the Federal Ministry for Economic Cooperation and Development (BMZ).
Civil society played a central role in the birth of the Cairo Programme of Action and civil society still has a crucial role to play as a developer of ideas, an implementing force and an advocate for all stakeholders. Heidemarie Wieczorek-Zeul, Member of the German Bundestag and German Federal Minister for Economic Cooperation and Development in her opening address mentioned that the German government and she personally have always seen the implementation of the Cairo Programme of Action and the achievement of the 5th Millennium Development Goal – universal access to sexual and reproductive health services and lowering maternal mortality – as issues of prime importance. Between 1995 and 2007, more than 1 billion US dollars were provided under bilateral German development cooperation for measures in the field of family planning and reproductive health including HIV/AIDS control. She said, “We are pursuing an approach based on universal human rights that rejects any form of discrimination or violence: promoting gender equality and women’s empowerment thus become the key to poverty reduction, economic growth and social development”.
Minister Wieczorek-Zeul further stressed, “Particularly in these times of economic and financial crisis, it is important that we pay special attention to the rights of women, the health sector and social protection. I call on both the governments in our partner countries and the donor community in equal measure to continue their implementation of our shared commitments.” She has launched the “Berlin Clarion Call: The Spirit of Cairo Lives On” the focus being realizing women’s rights. Every form of violence against women is absolutely unacceptable. There must be a universal access to health services without discrimination which includes modern methods of family planning, affordable drugs, HIV/AIDS prevention, treatment and care for people living with HIV and safe methods of abortion in line with human rights.
Ms Thoraya Ahmed Obaid, UNFPA Executive Director stressed three areas that require priority attention. The first is improving maternal health, within the broad framework of the right to sexual and reproductive health, expanding access to family planning, and strengthening health systems. Progress is underway in countries and the momentum to achieve MDG5 has to be continued; this is prerequisite to the empowerment of women. The second priority is advancing the right to sexual and reproductive health of young people. Youth leadership should be fully supported, and there is urgent need to address continuing high teen birthrates and sexually transmitted infections, including HIV. The third is ending discrimination and violence against girls and women and impunity.
There is urgent need to focus on enforcement, implementation and building public awareness, with men as partners for equality. Ms Obaid highlighted, “Universal access to reproductive health is now part of the Millennium Development Goals, as a target under MDG 5 to improve maternal health, which paves the way for greater progress. Stronger action is being taken to link policies and programmes for HIV and AIDS with sexual and reproductive health, which will magnify the impact of these interventions. And gender and reproductive health are now addressed more than ever before in humanitarian response benefiting displaced persons and refugees.”
Helen Clark, Administrator United Nations Development Programme UNDP in her opening remarks stated, “I believe women have the right to make their own decisions about whether or when to have children, how many to have, and with whom, and then to receive support and care to give birth safely. Women’s sexual and reproductive health will also benefit from better education, reduced poverty and hunger, and from the progress we make in reducing the spread and prevalence of HIV and other diseases.”
UNDP’s mandate is to promote gender perspectives in development. The HIV/AIDS response pays special attention to addressing the particular vulnerability of women and girls, and to tackling the effects the epidemic has on their lives. In the areas of crisis prevention and early recovery, UNDP works to address justice and security for women and violence against women. UNDP works along with other partners to implement Security Council Resolution 1325, promoting women's contributions to conflict resolution and building sustainable peace. Pursuant to the Security Council’s strongly worded resolution 1820, UNDP also plays a role in finding solutions to the scourge of sexual and gender-based violence in conflict and post conflict areas. UNDP’s partnership with civil society is very important for this work, needs to strengthen further.
All actors in development, regardless of their specific mandates, need to work closely together, across governments, NGOs, the private sector, foundations, and multilateral agencies to support universal access to reproductive health.
Ishdeep Kohli-CNS
Civil society played a central role in the birth of the Cairo Programme of Action and civil society still has a crucial role to play as a developer of ideas, an implementing force and an advocate for all stakeholders. Heidemarie Wieczorek-Zeul, Member of the German Bundestag and German Federal Minister for Economic Cooperation and Development in her opening address mentioned that the German government and she personally have always seen the implementation of the Cairo Programme of Action and the achievement of the 5th Millennium Development Goal – universal access to sexual and reproductive health services and lowering maternal mortality – as issues of prime importance. Between 1995 and 2007, more than 1 billion US dollars were provided under bilateral German development cooperation for measures in the field of family planning and reproductive health including HIV/AIDS control. She said, “We are pursuing an approach based on universal human rights that rejects any form of discrimination or violence: promoting gender equality and women’s empowerment thus become the key to poverty reduction, economic growth and social development”.
Minister Wieczorek-Zeul further stressed, “Particularly in these times of economic and financial crisis, it is important that we pay special attention to the rights of women, the health sector and social protection. I call on both the governments in our partner countries and the donor community in equal measure to continue their implementation of our shared commitments.” She has launched the “Berlin Clarion Call: The Spirit of Cairo Lives On” the focus being realizing women’s rights. Every form of violence against women is absolutely unacceptable. There must be a universal access to health services without discrimination which includes modern methods of family planning, affordable drugs, HIV/AIDS prevention, treatment and care for people living with HIV and safe methods of abortion in line with human rights.
Ms Thoraya Ahmed Obaid, UNFPA Executive Director stressed three areas that require priority attention. The first is improving maternal health, within the broad framework of the right to sexual and reproductive health, expanding access to family planning, and strengthening health systems. Progress is underway in countries and the momentum to achieve MDG5 has to be continued; this is prerequisite to the empowerment of women. The second priority is advancing the right to sexual and reproductive health of young people. Youth leadership should be fully supported, and there is urgent need to address continuing high teen birthrates and sexually transmitted infections, including HIV. The third is ending discrimination and violence against girls and women and impunity.
There is urgent need to focus on enforcement, implementation and building public awareness, with men as partners for equality. Ms Obaid highlighted, “Universal access to reproductive health is now part of the Millennium Development Goals, as a target under MDG 5 to improve maternal health, which paves the way for greater progress. Stronger action is being taken to link policies and programmes for HIV and AIDS with sexual and reproductive health, which will magnify the impact of these interventions. And gender and reproductive health are now addressed more than ever before in humanitarian response benefiting displaced persons and refugees.”
Helen Clark, Administrator United Nations Development Programme UNDP in her opening remarks stated, “I believe women have the right to make their own decisions about whether or when to have children, how many to have, and with whom, and then to receive support and care to give birth safely. Women’s sexual and reproductive health will also benefit from better education, reduced poverty and hunger, and from the progress we make in reducing the spread and prevalence of HIV and other diseases.”
UNDP’s mandate is to promote gender perspectives in development. The HIV/AIDS response pays special attention to addressing the particular vulnerability of women and girls, and to tackling the effects the epidemic has on their lives. In the areas of crisis prevention and early recovery, UNDP works to address justice and security for women and violence against women. UNDP works along with other partners to implement Security Council Resolution 1325, promoting women's contributions to conflict resolution and building sustainable peace. Pursuant to the Security Council’s strongly worded resolution 1820, UNDP also plays a role in finding solutions to the scourge of sexual and gender-based violence in conflict and post conflict areas. UNDP’s partnership with civil society is very important for this work, needs to strengthen further.
All actors in development, regardless of their specific mandates, need to work closely together, across governments, NGOs, the private sector, foundations, and multilateral agencies to support universal access to reproductive health.
Ishdeep Kohli-CNS
Female Condoms: Saving Lives Now
Global Partners in Action: NGO Forum for Sexual and Reproductive Health and Development Berlin, Germany is being held in recognition of the fifteen year anniversary of the International Conference on Population and Development (ICPD). At the pre-conference satellite session ‘Female Condom Programming: breaking down the barriers’ hosted by Universal Access to Female Condom (UAFC) Joint Programme and World Population Foundation different prejudices were discussed with the audience while showing the different female condom models. Because many people judge the female condom without ever seeing, let alone using one, participants were given demonstration about the female condom.
The female condom is a proven HIV and pregnancy prevention method. But in 2007, only 26 million female condoms were distributed worldwide, just one for every 100 women in Asia, Latin American and Africa between the ages of 15 and 49. Numerous studies have indicated that female condom effectiveness is comparable to male condoms in preventing HIV and unintended pregnancy.
Myths, misconceptions and biases against the female condom have hindered international investment in and expanded access to this method, resulting in a high cost-per-unit price. To lower the price of the female condom, we need governments and donor agencies to make bulk purchases and to invest in the programs that can make this method more widely accessible.
Female condoms are available now. This means that we can immediately begin increasing people’s choices, and reducing the numbers of HIV infections, unintended pregnancies and related adverse outcomes of unprotected sex right away. Female condoms can be inserted independently and well in advance of intercourse by a woman seeking to protect herself from infection and unintended pregnancy. They can reduce the rate of HIV transmission among women having sex with an infected partner by more than 90 percent; are at least as effective in reducing other sexually transmitted infections as are male condoms; and can be used to avoid unintended pregnancy.
Analysis of studies from 40 countries show that acceptability rates for female condoms range between 37 and 93 percent of potential users; thus female condoms have high rates of acceptability. Studies show that access to female condoms increases the rate of use of both male and female condoms, increasing the rate of protected sex overall.
Recent cost analyses of the female condom show that increased access to female condoms can lead to dramatic savings in both lives and in health care costs in diverse country settings. Education on partner communication and condom negotiation provided by female condom training programs increases the ability of women and men to discuss effective HIV prevention strategies and take steps to better protect themselves.
National governments, bilateral aid agencies, and international donors can drive down the price of the female condom and make it affordable by making bulk purchases of this method, as is traditionally done with virtually every reproductive and sexual health technology, including male condoms.
Increasing access to and effective use of all currently available technologies such as the female condom, male condom and other sexual and reproductive health technologies is essential to enabling people to realize their basic human rights to health; to health information; to informed choices in health care; and to the benefits of scientific progress. Making female condoms available is part of the obligations by states to ensure the progressive realization of these rights and is critically important to improving public health.
Women and men everywhere need more prevention options right now. The time has come to remove barriers that have denied women and men access to the female condom. The time has come to demand prevention now. Prevention Now! is a global campaign led by advocates throughout the world working to prevent the spread of HIV, reduce unintended pregnancy, and advance the sexual and reproductive health and rights of all people worldwide. The main goal of the campaign is to ensure that governments and donor agencies provide the funds needed to dramatically increase access to female condoms and other existing HIV prevention options for women and men now.
Ishdeep Kohli-CNS
The female condom is a proven HIV and pregnancy prevention method. But in 2007, only 26 million female condoms were distributed worldwide, just one for every 100 women in Asia, Latin American and Africa between the ages of 15 and 49. Numerous studies have indicated that female condom effectiveness is comparable to male condoms in preventing HIV and unintended pregnancy.
Myths, misconceptions and biases against the female condom have hindered international investment in and expanded access to this method, resulting in a high cost-per-unit price. To lower the price of the female condom, we need governments and donor agencies to make bulk purchases and to invest in the programs that can make this method more widely accessible.
Female condoms are available now. This means that we can immediately begin increasing people’s choices, and reducing the numbers of HIV infections, unintended pregnancies and related adverse outcomes of unprotected sex right away. Female condoms can be inserted independently and well in advance of intercourse by a woman seeking to protect herself from infection and unintended pregnancy. They can reduce the rate of HIV transmission among women having sex with an infected partner by more than 90 percent; are at least as effective in reducing other sexually transmitted infections as are male condoms; and can be used to avoid unintended pregnancy.
Analysis of studies from 40 countries show that acceptability rates for female condoms range between 37 and 93 percent of potential users; thus female condoms have high rates of acceptability. Studies show that access to female condoms increases the rate of use of both male and female condoms, increasing the rate of protected sex overall.
Recent cost analyses of the female condom show that increased access to female condoms can lead to dramatic savings in both lives and in health care costs in diverse country settings. Education on partner communication and condom negotiation provided by female condom training programs increases the ability of women and men to discuss effective HIV prevention strategies and take steps to better protect themselves.
National governments, bilateral aid agencies, and international donors can drive down the price of the female condom and make it affordable by making bulk purchases of this method, as is traditionally done with virtually every reproductive and sexual health technology, including male condoms.
Increasing access to and effective use of all currently available technologies such as the female condom, male condom and other sexual and reproductive health technologies is essential to enabling people to realize their basic human rights to health; to health information; to informed choices in health care; and to the benefits of scientific progress. Making female condoms available is part of the obligations by states to ensure the progressive realization of these rights and is critically important to improving public health.
Women and men everywhere need more prevention options right now. The time has come to remove barriers that have denied women and men access to the female condom. The time has come to demand prevention now. Prevention Now! is a global campaign led by advocates throughout the world working to prevent the spread of HIV, reduce unintended pregnancy, and advance the sexual and reproductive health and rights of all people worldwide. The main goal of the campaign is to ensure that governments and donor agencies provide the funds needed to dramatically increase access to female condoms and other existing HIV prevention options for women and men now.
Ishdeep Kohli-CNS
Promoting linkages and synergies for sexual reproductive health rights and HIV/AIDS
The recent commitment by the international community to intensify linkages between SRHR and HIV/AIDS at the policy and programme levels builds upon the Glion Call to Action (2004) and the New York Call to Commitment (2004). These have expressed the concern that too many policies programmes and initiatives addressing either SRHR of HIV/AIDS have failed to exploit potential linkages; as a result, global efforts have been less effective than would otherwise have been the case.
The United Nations General Assembly Special Session on HIV/AIDS (UNGASS 2001 and 2006) emphasized that investment in sexual and reproductive health is a major foundation for HIV/AIDS prevention and treatment. The incorporation of SRHR into national strategies as a prerequisite for attaining the MDGs expressed a commitment to achieving universal access to reproductive health by 2015, as a new target under MDG 5 and to promoting gender equality and ending discrimination against women.
The call for joint policies and programming for SRHR and HIV/AIDS, particularly in the light of these commitments to universal access to (comprehensive HIV/AIDS services by 2010 and to reproductive health by 2015), recognizes that such access can only be achieved through strengthened health systems. Sexual and reproductive health services (SRH) include family planning, maternal and infant care, prevention and management of STI and the prevention of gender based violence. HIV/AIDS services involve prevention measures as well as treatment, care and support. Several main areas of linkage arise between the two, such as improving condom supplies, integrating HIV counselling, testing and care into SRH services especially for maternal health and PMTCT, and integrating SRH information and services into HIV/AIDS programmes.
The International Conference on Population and Development (ICPD) in Cairo in 1994, established the concept of comprehensive sexual and reproductive health and rights (SRHR). However, due to the dramatic development of the AIDS pandemic the targeted interventions that addressed the disease overlooked the natural linkages between HIV/AIDS and SRHR.
The changing aid environment and new aid modalities present opportunities for stronger operational linkages between various programmes. Thus intensive efforts with a full range of partners, including civil society and affected populations, at national, bilateral and multilateral levels are needed to promote the development of comprehensive health sector response to SRHR and HIV/AIDS. These are all part of the commitment to universal access. German development cooperation is committed to the integration of measures for HIV/AIDS and SRHR in its health and development efforts, which are guided by cross-cutting principles of rights-based, gender sensitive and multi-sectoral approach.
Ishdeep Kohli-CNS
The United Nations General Assembly Special Session on HIV/AIDS (UNGASS 2001 and 2006) emphasized that investment in sexual and reproductive health is a major foundation for HIV/AIDS prevention and treatment. The incorporation of SRHR into national strategies as a prerequisite for attaining the MDGs expressed a commitment to achieving universal access to reproductive health by 2015, as a new target under MDG 5 and to promoting gender equality and ending discrimination against women.
The call for joint policies and programming for SRHR and HIV/AIDS, particularly in the light of these commitments to universal access to (comprehensive HIV/AIDS services by 2010 and to reproductive health by 2015), recognizes that such access can only be achieved through strengthened health systems. Sexual and reproductive health services (SRH) include family planning, maternal and infant care, prevention and management of STI and the prevention of gender based violence. HIV/AIDS services involve prevention measures as well as treatment, care and support. Several main areas of linkage arise between the two, such as improving condom supplies, integrating HIV counselling, testing and care into SRH services especially for maternal health and PMTCT, and integrating SRH information and services into HIV/AIDS programmes.
The International Conference on Population and Development (ICPD) in Cairo in 1994, established the concept of comprehensive sexual and reproductive health and rights (SRHR). However, due to the dramatic development of the AIDS pandemic the targeted interventions that addressed the disease overlooked the natural linkages between HIV/AIDS and SRHR.
The changing aid environment and new aid modalities present opportunities for stronger operational linkages between various programmes. Thus intensive efforts with a full range of partners, including civil society and affected populations, at national, bilateral and multilateral levels are needed to promote the development of comprehensive health sector response to SRHR and HIV/AIDS. These are all part of the commitment to universal access. German development cooperation is committed to the integration of measures for HIV/AIDS and SRHR in its health and development efforts, which are guided by cross-cutting principles of rights-based, gender sensitive and multi-sectoral approach.
Ishdeep Kohli-CNS
Survey done by Lucknow University students on tobacco control issues in Lucknow
Survey done by Lucknow University students on tobacco control issues in Lucknow
Acknowledgement: -
We express our sincere gratitude to Professor Dr Rama Kant, Head, Department of General Surgery, Chhatrapati Shahu Ji Maharaj Medical University (CSMMU, upgraded King George's Medical College - KGMC) and Chairman, Tobacco Cessation Clinic at CSMMU supported by World Health Organization (WHO), for his extensive invaluable guidance to make our internship an enormous learning experience. We are also thankful to Mr Abhishek Misra and Mr Ritesh Arya who gave their precious time for data collection. We feel short of words to thank the young legendary tobacco control advocate, public health crusader and prolific writer Mr Amit Dwivedi for his unflinching support, guidance and mentorship. We are also thankful to all the 763 respondents who have given their precious time to talk to us and make this effort successful.
Background
Tobacco is the most preventable cause of death in the world today. This year, tobacco is estimated to kill more than five million people – more than tuberculosis, HIV/AIDS and malaria combined. By 2030, the death toll due to this deadly substance is likely to exceed eight millions a year. Unless urgent action is taken, tobacco could kill one billion people during this century. Although tobacco deaths rarely make headlines, tobacco kills one person every six seconds.
Policies
In India, tobacco kills more than one million (10 lakhs) people annually. To control tobacco usage and reduce the occurrence of life-threatening diseases, disabilities and deaths caused by tobacco use, the Government of India brought into effect one of the most comprehensive tobacco control policy – The Cigarette and Other Tobacco Products Act 2003. Since then, different rulings and processes have been giving shape to enforce the various provisions of this Act. India has also signed ( and the Indian parliament has ratified) the first global corporate accountability and public health tobacco treaty – the Framework Convention on Tobacco Control (FCTC) on 5 th February 2005. Despite existing tobacco control policies, not only the number of juvenile and young tobacco users continues to rise unabated, but so have the diseases, disabilities and deaths attributed to tobacco use, upped considerably. Clearly, enforcing the public health policies is an enormous challenge confronting India and other countries of the world.
Issues
According to the World Health Organization (WHO), tobacco is the only legal consumer product that can harm everyone exposed to it- and it kills up to half of those who use it . Yet, tobacco use is common throughout the world due to low prices, aggressive/ widespread marketing, lack of awareness about its dangers, and inconsistent public policies against its use. Most of tobacco’s damage to health does not become evident until years or even decades after the onset of its use. So, while tobacco use is rising globally, the epidemic of tobacco- related diseases and deaths has just begun.
The way forward
But we can change the future. The tobacco epidemic is devastating –but preventable. The fight against tobacco must be engaged forcefully and quickly- with no less urgency than battles against life-threatening infectious diseases. We can halt the tobacco epidemic and move towards a tobacco free world – but we must act now.
The Survey
Objectives
- To validate the national tobacco use statistics in India at Lucknow city level
- To find out the awareness level about existing key tobacco control policies in India
- To find out the community perceptions of the proven-cost-effective tobacco control interventions
- To disseminate the survey findings through different channels including media so as to inform the different stakeholders in tobacco control at national level.
METHOD
- Designing the questionnaire
o In a brainstorming session involving clinicians, researchers, statisticians, tobacco control advocates with substantial experience, we drafted the open-ended, unloaded, non-suggestive and objective questions in easy-to-read and understand Hindi language, so that respondents feel comfortable in opting for any given choice without any bias or prompt.
o The 15 questions (see annexure for the questionnaire) were broadly categorized in 4 categories:
- Personal information of respondents
- One section only for those respondents who were tobacco users on their tobacco use history
- One section to validate the key finding of the Bidi Monograph released by the Ministry of Health & Family Welfare, Government of India, in May 2008
- One section to evaluate the perceived effectiveness of key tobacco control policies and interventions being enforced in India.
o Every question had a set number of multiple choices which were coded (see questionnaire for data coding)- Data sheeto We used Microsoft Excel sheet and its formula to enter and analyze the data (see the data sheet attached in the annexure)
- Data collection
o We formed a team of data collectors or surveyors which included both men and women
o Lead surveyors were:
- Alok Kumar Dwivedi
- Sarika Tripathi
- Survey Briefing for surveyors
o Introduce yourself to the respondents and tell him/her about this survey.
o Take permission of the respondents before asking any question.
o Ask every question in an easy and informal manner so that respondents feel comfortable to opt for any given option without hesitation.
o Don’t react if a respondent is not responding to your question or feeling uncomfortable.
o Sample of respondents should not be biased towards a particular age group, educational status and/or sex .
o A respondent should be free to quit the survey any time.
o Show your questionnaire sheet to the respondents for their information.
- Data entry and analysis
o Data was entered by Alok Kumar Dwivedi and Sarika Tripathi as per the data coding and data entry excel sheet and formula-based software self-developed by them
o After data entry was completed, data was analyzed (see the output below) on different parameters
Survey Results
Out of the 763 respondents, 70 per cent were male and 30 per cent were female. According to a World Health Organization study of 2008, about 14.1% of the Indian teenagers are tobacco users---this percentage being 17.3 amongst males and 9.7 amongst females.
Tobacco consumption amongst adult males and females in India is respectively 57 per cent and 3.1 per cent. According to National Family Health Survey (NFHS), 2006, most tobacco users belong to the age group 18-24 years.
Maximum survey-respondents were in the age group of 30-50 years (44%), followed by the respondents in the age group of 18-30 years (39%). 11 per cent respondents were above 50 years of age and the least number of respondents were in the age group of 0-18 years (6%).
Age of respondents
Several data indicates that tobacco use is prevalent in people from different education backgrounds including those who don’t have any formal education. In this survey, most respondents were graduates (41%) followed by the remaining three categories without any significant difference: post-graduates (29%), undergraduates (28.10%) and those who had no formal education (31%).
The survey data revealed that 57% of respondents had never consumed any form of tobacco, and 43% of the respondents were tobacco users. The survey data revealed that 44% of the respondents were using tobacco for the last 0-5 years, and 43% of the respondents were using tobacco for the last 5-10 years. 12% survey-respondents were using tobacco for last 15-20 years while 1% had consumed tobacco for 20 or more years.
Traditional forms of tobacco chewing such as paan now appear to be mainly an indulgence of the older generation; the younger generation is taking up newer forms of tobacco use such as, tobacco toothpaste, gutkha, and cigarette. Gutkha is a very common form of chewing tobacco. Our study revealed that 39 per cent of the respondents consumed gutkha, 32 per cent said that they smoked cigarette, 10 per cent of the respondents were bidi smokers, while 19 per cent of the respondents said that they had consumed all forms of tobacco products.
A World Health Organization (WHO) study reviewed 440 bollywood films released between 1991 and 2002 and, shockingly, found that tobacco consumption, mainly in the form of smoking, was shown in nearly three out of four movies. Tobacco use by the lead actors in movies can be directly related with youth’s initiation into smoking as a symbol of fashion and style. 36 per cent of the survey-respondents said that they began tobacco due to all the three factors that is stress, peer pressure and seeing film-actors smoking in movies. 30 per cent of the respondents said that they began using tobacco because of stress.
The results of the Global Youth Tobacco Survey, supported by the WHO and the Centres for Disease Control and Prevention (CDC), conducted in India during the years 2000-2004, revealed that over 68.5% of students who smoked wanted to stop whereas 71.4% had already tried to stop smoking during the past year. All over India, 84.6% of cigarette smoking students had received help or advice to stop smoking from family members, community members, health personnel or friends. In the survey conducted by us in Lucknow, the data also revealed that 69 per cent of the survey-respondents had attempted to quit tobacco use, while 31 per cent said that they had never tried to quit their tobacco habit.
The different forms of tobacco often do not include the same warning labels, taxes and other restrictions which are placed on cigarettes. Also gutkha, bidis and many other local forms of tobacco are manufactured and marketed in an unorganized sector to a considerable extent – making it further difficult to regulate these tobacco products. But is bidi more harmful or cigarettes? 49 percent of the survey-respondents were of the view that both cigarette and bidi are equally harmful while 30 percent said that bidi is more harmful than cigarette and 20 percent said that cigarette is more harmful than bidi. According to the bidi monograph released by the Ministry of Health and Family Welfare, Government of India in May 2008, bidis are, at least, as harmful as cigarettes.
Countries of comparable status to India, like Brazil, Thailand, Singapore, Hong Kong, Uruguay, Venezuela and a host of developed countries have devoted more than 50% of tobacco-pack space to picture-based tobacco warnings, many of them gorier than the proposed Indian pictures. The survey revealed that 52 per cent of the respondents felt that the pictorial warnings on tobacco packs will help raise awareness about tobacco-related hazards, while 45 per cent said that these pictorial tobacco warnings will have no effect in raising awareness. Since pictorial tobacco-warnings are yet to be implemented in India, these responses were based on, and reflect upon the perceptions and not actual field-testing data. Around the world, pictorial warnings on tobacco packs have significantly contributed to raise awareness, deter tobacco users and encourage them to quit tobacco use.
Pictorial warnings have proved to be highly effective in reducing the percentage of tobacco usage in countries like Canada, Australia, Belgium, Thailand, Brazil and the European Union where the tobacco usage has dropped, on an average, by 1% per annum post-implementation. The survey done in Lucknow also revealed that 37 per cent of the respondents felt that the pictorial tobacco warnings will encourage people to quit tobacco use, while 56 per cent said that pictorial warnings on tobacco packs will not motivate people to quit tobacco.
A WHO study revealed that the passive smoking is associated with ischemic heart disease (IHD), with a 30% excess risk of IHD in non-smokers whose spouses smoke compared with non-smokers whose spouses do not smoke. Non-smokers exposed to secondhand-smoke had a 25% excess risk of CHD (Coronary Heart Disease) compared to non-smokers not exposed to smoke in India. This survey revealed that an overwhelming majority of 73 per cent of the respondents wanted a complete ban on smoking in both public and private places.
A public interest litigation (PIL) was filed before the High Court of Kerala by a woman who complained of problems caused by exposure to tobacco smoke from co-passengers during frequent travel by bus. In response to this petition, the High Court delivered a judgment which stated that a public health law to eliminate exposure to second hand smoke is long overdue. The court held that the policy makers should pursue all the strategies that would help accomplish this goal. Upholding this judgment and recognizing the delay of the legislature in enacting a national law, the Supreme Court of India in November 2001 stepped in to ban smoking in public places such as schools, libraries, railway waiting rooms and public transport throughout the country. In a recent statement, Dr Anbumani Ramadoss, Union Health and Family Welfare minister, Government of India, said that from 2 October 2008 smoking will be completely banned in all public and private places. Regarding this declaration of Dr Ramadoss , 71 per cent of the survey-respondents felt that this ban will not be effectively implemented, and 19 per cent of the respondents felt that it could be implemented effectively.
Tobacco cessation services need to be scaled up drastically (and rapidly) to assist people to quit tobacco use successfully. This is going to complement other tobacco control interventions. This is also in line with the Framework Convention of Tobacco Control (FCTC). With the establishment of the National Tobacco Control Cell as part of the Government of India and World Health Organization (WHO) initiative on tobacco control in India, it was felt that tobacco cessation services have to be developed to help tobacco users in India give up their habit. In the survey conducted in Lucknow, 13% of the survey-respondents were aware of some proper tobacco cessation counsellng facility, while 57% of the survey-respondents weren’t aware of any such facility.
The Ministry of Health and Family Welfare, Government of India, has started Tobacco Cessation Clinics on a pilot basis in 13 centers. In 2002, the WHO supported the setting up of Tobacco Cessation Clinics (TCCs) in diverse settings (cancer treatment centers, psychiatric centers, medical colleges and non governmental organizations) to help people stop tobacco use. Lucknow’s Tobacco Cessation clinic was one such centre that WHO helped develop and expand.In the survey conducted in Lucknow, a stupendous majority of 96 per cent of the survey-respondents said that there should be a tobacco cessation clinic in all districts hospitals and primary health centres of the state. This clearly indicates the pressing demand for such tobacco cessation clinics, as perceived by the survey-respondents in the communities they come from.
Contacts:
Alok Kumar Dwivedi
Sarika Tripathi
Department of Public Health
Lucknow University
Berlin Clarion Call: Universal Access to Sexual and Reproductive Health
Heidemarie Wieczorek-Zeul, Germany Minister for Economic Cooperation and Development, issued a ten point call for new investment and political commitment on behalf of women and girls worldwide. Fifteen years after the International Conference on Population and Development in Cairo, the United Nations Population Fund (UNFPA) and the Federal Ministry for Economic Cooperation and Development (BMZ) together with non-governmental organizations from over 120 countries are meeting in Berlin from 2nd to 4th September, 2009, to take stock of what has been achieved so far and to seek answers to new challenges such as climate change and the current financial and economic crisis.
‘Berlin Clarion Call’ was presented by Minister Heidemarie Wieczorek-Zeul to the representatives of governments from both North and South, and also to the representatives of the United Nations, the World Bank, regional development banks, religious communities, parliamentarians, non-governmental organizations, business and trade unions. She said, “The call is for the realization of women’s human rights as being a key to making sustainable progress on population development and health care. Determined action must be taken to combat all forms of violence against women, particularly female genital mutilation and rape.”
The minister stressed that universal access to sexual and reproductive health information and services need to be realized by 2015 at the latest. This also means making available modern methods of family planning and options for safe abortion. Linkages between strategies, programmes and services in the field of HIV/AIDS and sexual and reproductive health must be promoted. Universal access to measures for the prevention of HIV and AIDS and to treatment and care for people living with HIV must be realized in line with the goals of the Universal Access Initiative.
The call supports equal access to using health services regardless of age, gender, origin and ethnicity, religious conviction, disability, economic and social status or sexual orientation. Partnerships have to be strengthened with civil society in the provision of health services, education and information, particularly to the poorest and most vulnerable and marginalized. The Global Consensus for Maternal and Newborn Health should be supported. Political and financial engagement in the field of infant and maternal health should be intensified to achieve the Millennium Development Goals. Millennium Development Goals need to be further developed beyond 2015 and linked more with human rights.
Ishdeep Kohli-CNS
‘Berlin Clarion Call’ was presented by Minister Heidemarie Wieczorek-Zeul to the representatives of governments from both North and South, and also to the representatives of the United Nations, the World Bank, regional development banks, religious communities, parliamentarians, non-governmental organizations, business and trade unions. She said, “The call is for the realization of women’s human rights as being a key to making sustainable progress on population development and health care. Determined action must be taken to combat all forms of violence against women, particularly female genital mutilation and rape.”
The minister stressed that universal access to sexual and reproductive health information and services need to be realized by 2015 at the latest. This also means making available modern methods of family planning and options for safe abortion. Linkages between strategies, programmes and services in the field of HIV/AIDS and sexual and reproductive health must be promoted. Universal access to measures for the prevention of HIV and AIDS and to treatment and care for people living with HIV must be realized in line with the goals of the Universal Access Initiative.
The call supports equal access to using health services regardless of age, gender, origin and ethnicity, religious conviction, disability, economic and social status or sexual orientation. Partnerships have to be strengthened with civil society in the provision of health services, education and information, particularly to the poorest and most vulnerable and marginalized. The Global Consensus for Maternal and Newborn Health should be supported. Political and financial engagement in the field of infant and maternal health should be intensified to achieve the Millennium Development Goals. Millennium Development Goals need to be further developed beyond 2015 and linked more with human rights.
Ishdeep Kohli-CNS
Whither India ? - Dr Sandeep Pandey
Whither India ?
Dr Sandeep Pandey
The mainstream freedom movement of this country definitely had a vision for an egalitarian society. A society in which each family w
ould be able to earn their livelihood with dignity and accord the same respect to every other member of the society that they would expect for themselves. People would be able to live in an atmosphere free from fear. There would be mutual respect for diversity of ideas. India would lead the world towards disarmament and peace and would help establish a just and humane global order.
The development policies adopted by the Nehru's government, completely ignoring the principles of Hind Swaraj put forward by Mahatma Gandhi, later further aggravated by the economic policies of liberalization, privatization and globalization have resulted in dual development stream in this country. A small minority of the society which possesses a purchasing power can afford the latest fruit of modern technological development available in the global market. The industrialists are allowed unhindered to produce material items for the consumption of this class and this class is allowed to consume things unbounded. Just like the American society nobody cares a damn about global warming or any such thing coming in their way of a global lifestyle. On the other hand for the vast majority of poor, devoid of the magical purchasing power - which doesn't accrue from one's capability alone - the country's parliament has passed a National Rural Employment Guarantee Act which bars machines from being used in work offered to them for the fear of causing a threat to the employment of the poor. In spite of Prime Minister's advice in a CII meeting the CEOs resist the idea of placing a ceiling on their salaries whereas the poor earns a maximum wage of what is described as minimum daily wage. So, obviously there are two sets of policies. One which allows unlimited growth and unbridled indulgence. The other which tends to restrict.
This is not just limited to the field of economy. It extends to all other areas of human life. The elite of the country resist the idea of common school system ever since the Kothari Commission gave a recommendation in its favour in the mid '60s. Even the child of a government school teacher goes to a nearby private school. Same is the case with health care system, access to electricity, potable water, transportation, communication, etc. We have a system offering better services to the rich and another for the rest where people are asked to make do with subhuman conditions. A good example would be people who can pay a higher amount can travel in reserved coaches of the railways and those who cannot afford it are relegated to animal like travel in the general unreserved coaches.
As if things were not bad enough. The shining India now aspires to be a military power, in the august company of the country which is the single biggest threat to the sovereignty of various nations around the world. More people have probably died in India pre-maturely because of disease, poverty and debt related suicides than would die because of dropping of a nuclear weapon by an enemy country. Through a stupid deal on nuclear energy, which has been rejected as an option for producing electricity by most of the developed nations, we're entering into a strategic tie-up with the US which will make it more difficult for us to resist exploitation by their MNCs of our natural resources and the market, will create more enemies for us in our neighbourhood and unnecessarily involve us in wars which the US will fight in this region and elsewhere. Already, our Prime Minister appears to be committed to fulfilling promises made to the US President at the cost of ignoring the priorities of people of this country. This is a serious departure from our policy of non-alignment and self-reliance. From being a leader is pursuing the agenda of global peace until as late as 1995 in the International Court of Justice, we've now slipped down to being a military ally of the US in making.
It is not a coincidence that the terrorist incidents in this country have seen a rise since we decided unilaterally to join the US 's war against terror in 2001. After the demolition of Babri Masjid, the first major terrorist incident which marked the arrival of right wing politics India, there was a lull until the mysterious attack on India parliament just before the passage of POTA Act. Since then there have been a series of incidents which have engulfed this country in an unknown fear. As we raise more brute power to crush the problem of terrorism, or for that matter naxalism, the cycles of violence continue to grow. The government policy of acting with vengeance, instead of trying to solve the problems politically through dialogue, ends up in targeting innocent individuals like Syed Abdul Rehman Geelani and Binayak Sen. Our response to a Irom Sharmila who has been fasting for eight years now to demand repeal of the draconian Armed Forces Special Powers Act is to charge her with attempt to suicide and jail her in the hospital ward in Imphal. The Indian state doesn't know how to deal with its people except for a small elite segment loyal to it for its own vested interest. Farmers and labourers fighting to save their lands from corporate take over, for example in the name of SEZs, are labeled as naxalites.
It is quite clear that majority of India doesn't know what it means to
be 'independent.' It lives as a second rate citizen of this country, denied the fruits of modern development or of the basic human rights, working hard day and night to make two ends meet. The police, military, nuclear weapons, intelligence agencies, laws of the land and increasingly the development juggernaut do not instill a sense of security in her, rather they appear as ominous threat to their very existence.
(Author has won the 2002 Ramon Magsaysay Award in the Emergent Leadership category for work towards empowering the poorest of the poor and lending the underprivileged in India a voice- from education to grassroots democracy to peace to promoting local ownership of resources)
Dr Sandeep Pandey
The mainstream freedom movement of this country definitely had a vision for an egalitarian society. A society in which each family w
ould be able to earn their livelihood with dignity and accord the same respect to every other member of the society that they would expect for themselves. People would be able to live in an atmosphere free from fear. There would be mutual respect for diversity of ideas. India would lead the world towards disarmament and peace and would help establish a just and humane global order.The development policies adopted by the Nehru's government, completely ignoring the principles of Hind Swaraj put forward by Mahatma Gandhi, later further aggravated by the economic policies of liberalization, privatization and globalization have resulted in dual development stream in this country. A small minority of the society which possesses a purchasing power can afford the latest fruit of modern technological development available in the global market. The industrialists are allowed unhindered to produce material items for the consumption of this class and this class is allowed to consume things unbounded. Just like the American society nobody cares a damn about global warming or any such thing coming in their way of a global lifestyle. On the other hand for the vast majority of poor, devoid of the magical purchasing power - which doesn't accrue from one's capability alone - the country's parliament has passed a National Rural Employment Guarantee Act which bars machines from being used in work offered to them for the fear of causing a threat to the employment of the poor. In spite of Prime Minister's advice in a CII meeting the CEOs resist the idea of placing a ceiling on their salaries whereas the poor earns a maximum wage of what is described as minimum daily wage. So, obviously there are two sets of policies. One which allows unlimited growth and unbridled indulgence. The other which tends to restrict.
This is not just limited to the field of economy. It extends to all other areas of human life. The elite of the country resist the idea of common school system ever since the Kothari Commission gave a recommendation in its favour in the mid '60s. Even the child of a government school teacher goes to a nearby private school. Same is the case with health care system, access to electricity, potable water, transportation, communication, etc. We have a system offering better services to the rich and another for the rest where people are asked to make do with subhuman conditions. A good example would be people who can pay a higher amount can travel in reserved coaches of the railways and those who cannot afford it are relegated to animal like travel in the general unreserved coaches.
As if things were not bad enough. The shining India now aspires to be a military power, in the august company of the country which is the single biggest threat to the sovereignty of various nations around the world. More people have probably died in India pre-maturely because of disease, poverty and debt related suicides than would die because of dropping of a nuclear weapon by an enemy country. Through a stupid deal on nuclear energy, which has been rejected as an option for producing electricity by most of the developed nations, we're entering into a strategic tie-up with the US which will make it more difficult for us to resist exploitation by their MNCs of our natural resources and the market, will create more enemies for us in our neighbourhood and unnecessarily involve us in wars which the US will fight in this region and elsewhere. Already, our Prime Minister appears to be committed to fulfilling promises made to the US President at the cost of ignoring the priorities of people of this country. This is a serious departure from our policy of non-alignment and self-reliance. From being a leader is pursuing the agenda of global peace until as late as 1995 in the International Court of Justice, we've now slipped down to being a military ally of the US in making.
It is not a coincidence that the terrorist incidents in this country have seen a rise since we decided unilaterally to join the US 's war against terror in 2001. After the demolition of Babri Masjid, the first major terrorist incident which marked the arrival of right wing politics India, there was a lull until the mysterious attack on India parliament just before the passage of POTA Act. Since then there have been a series of incidents which have engulfed this country in an unknown fear. As we raise more brute power to crush the problem of terrorism, or for that matter naxalism, the cycles of violence continue to grow. The government policy of acting with vengeance, instead of trying to solve the problems politically through dialogue, ends up in targeting innocent individuals like Syed Abdul Rehman Geelani and Binayak Sen. Our response to a Irom Sharmila who has been fasting for eight years now to demand repeal of the draconian Armed Forces Special Powers Act is to charge her with attempt to suicide and jail her in the hospital ward in Imphal. The Indian state doesn't know how to deal with its people except for a small elite segment loyal to it for its own vested interest. Farmers and labourers fighting to save their lands from corporate take over, for example in the name of SEZs, are labeled as naxalites.
It is quite clear that majority of India doesn't know what it means to
be 'independent.' It lives as a second rate citizen of this country, denied the fruits of modern development or of the basic human rights, working hard day and night to make two ends meet. The police, military, nuclear weapons, intelligence agencies, laws of the land and increasingly the development juggernaut do not instill a sense of security in her, rather they appear as ominous threat to their very existence. Dr Sandeep Pandey
(Author has won the 2002 Ramon Magsaysay Award in the Emergent Leadership category for work towards empowering the poorest of the poor and lending the underprivileged in India a voice- from education to grassroots democracy to peace to promoting local ownership of resources)