| SAPLER Population Trust | |
| Splendidly Alive People Within Limited Environmental Resources | |
Part XI: Problem Areas
This section covers Catholics, abortion and AIDS.
Strict Catholics do not have problems with teenage pregnancies and AIDS. If they make strenuous efforts to make the rhythm method work they can become an asset, as they did in Mauritius.
The Catholic community worldwide has been in turmoil over birth control for decades. Some people leave the Catholic church altogether because of this issue. Most urban people stay in the church and also practice birth control.
Italy has the lowest birth rate in the world. Florence, the city of great Catholic art and architecture, is said to be the city with the lowest birth rate in Italy.
In South America the rate of illegal abortion is said to be the highest in the world. Women are now using a method which involves taking a pharmaceutical product which induces bleeding, and then going to the hospital for the process to be completed.
The Philippines is one country in SE Asia which has not managed to limit its population growth, largely due to its Catholicism. Now they have a Protestant president who has introduced a family planning programme. Nevertheless there has been a recent visit from the Pope and he was still greeted by the people in a worshipful way.
Of the three homelands we visited only Kangwane was wary of family planning programmes. We were either told, "This is a very Catholic area," or "This is a very tribal area where the women are afraid of the chiefs."
The chief minister of Kangwane, Enos Mabuza, is an ardent environmentalist. But he managed to write the introduction to The Green Pages (1991/92) without once mentioning population or family planning.
At Jane Furze Hospital in Lebowa there is a Catholic nurse who is also married to a Catholic. They are both practising Catholics who go to church every Sunday. However, after they had had five children, the husband said to his wife, "This is enough." She agreed and was sterilised. She has never regretted it.
The Catholics have a rural outreach programme called "DELTA". This programme has had outstanding success in mobilising rural women to do things for themselves. The principle they work on is to ask people what they want, and then help them achieve this.
We were told the following story, by an Anglican rural worker.
A group of women were very poor and demoralised. They were visited by people from Delta and asked what they would most like.
They replied, "A graveyard for the children who die."
They were helped to carry out this project, in the course of which they became organized and co-operative.
They were asked what they wanted next.
They replied, "A clinic." This is where the story ends.
We do not know whether Catholics in SA are encouraging the rhythm method. In Mauritius they accepted the concept of family planning and the two-child family and they achieved it by relying on the rhythm method.
We heard about Catholic hospital in SA where the nuns do not condone birth control, but where black nurses give it anyway for humanitarian reasons.
The Cairo Conference was not about the problem of world over-population and what to do about it.
The United Nations produced a document which listed all the things which "should" be done in a perfect world. This document was then debated at the United Nations forum. The page in Part IX on "Sexual Reproductive Health" is taken from the final document.
Most of the debate was taken up with finding a way to rearrange the words of the document so that they would be acceptable to those countries which did not accept abortion. This was finally achieved by saying that abortion would be allowed in all countries except in those countries where it was not legal.
SAPLER was given the right to attend this conference but not to debate the issues.
There was another population conference at Cairo, and this was the one I mostly attended. This was the NGO conference, held in a different building.
The range of meetings at this conference was vast. At any one time one could attend meetings on anything from "Family Planning in Kenya" to "Women's Rights" to "The Environment".
The people attending the NGO conference stayed in a different hotel from the official delegates, and I got to know some of them. They were largely black women and Afrikaans women who had liaised during the final apartheid years in an effort to build bridges. They were mostly religious and included Catholics.
The women were middle-aged to elderly with a sprinkling of young people.
The overwhelming impression I got from them was of a horror at the declining values of our time. Legalising abortion seemed to them to be the ultimate indication of decadence.
On the bus going to the airport on the last night a young black woman came to the front and conducted a song which went:
"Down with abortion, up with the Muslims,
Down with abortion, up with the Muslims."
Most women joined in.
The SAPLER trustees support abortion on request. However, we accept that some of our members do not agree with this position.
An early SAPLER supporter, Archbishop Tutu, who fully understands the problems of over-population, said recently on "Microphone-In" that he would leave the abortion problem up to "the woman and her doctor".
No one at SAPLER wants to see abortion used as a method of limiting population growth. One of the additional advantages of making really excellent family planning services properly available in SA is that the incidence of abortion would drop dramatically.
The Abortion Rights Action Group (ARAG)
This group was started in the early 1970s to examine the law concerning abortion.
They have now submitted their recommendations to the Select Commission on Abortion. This commission is led by Dr Nkomo and will consider changes in the present legislation.
ARAG recommends:
1. That the present law be replaced by new legislation and not just amended.
2. That abortion be allowed in the first trimester of pregnancy on the request of the woman without anyone else's consent. (The first trimester is the first 12 weeks.)
3. That abortion in the second trimester (12 to 24 weeks) be the decision of the pregnant woman and one doctor.
ARAG believes that no spousal consent should be required for abortion.
For under-18s there should be counselling, but abortion should not be refused thereafter.
After consulting some gynaecologists, ARAG believes that all general practitioners should be allowed to do abortions. They also feel that other health personnel, including nurses, should be allowed to do abortions after training and certification.
Will AIDS Limit the Population?
Anyone reading Business Day of 7 March 1995 might justifiably think that a population limitation campaign is misplaced.
The article states, "Dr Xuma states that] there are now more than 8 million known HIV cases in SA, compared with 1,2 million in 1990."
Since the number is also said to be doubling every year this would mean:
1996 16 million
1997 32 million
1998 64 million
That is more than the entire SA population.
The AIDS expert, Dr Clive Evian told me than the known HIV cases are 60 000, and the possible HIV cases are 1 million.
He believes that the total number of people who will die of AIDS will be about 10 million. This will be over a period of 20 years to 2020.
The AIDS Disaster
AIDS will not limit the population to any great extent. The more AIDS takes over the health services the less attention will be given to family planning. There will also probably be a natural tendency to want to replace AIDS deaths with new children.
The predicted population size, excluding migration, has for some time been said to be 80 million by 2020. This is if nothing more dramatic is done to limit population growth.
If AIDS deaths brings this down to 70 million, we are still left with an unwinnable situation in terms of improving health and well-being in this country.
Positive Aspects of the AIDS Epidemic
The one positive aspect of AIDS is that it is waking people up to the importance of sexuality education and safer sex practices.
Educated people are now more likely to abstain, to be monogamous, to limit their number of partners or to use condoms. This is not a group which has been having large families, so the effect on population growth is unlikely to be great.
While abstention among teenagers, as in the True Love Waits movement, is desirable, it may lead to earlier marriage and therefore having children sooner - leading to an increase in population.
As the following article by Dr Clive Evian shows, it is those most devastated by apartheid and subsequent rapid urbanisation who are likely to be most affected by the epidemic.
The information from Mitchell Warren shows that an attempt is being made to reach the most vulnerable men.
Mitchell Warren advocates the ABC principle:
A = Abstain
B = Be faithful
C = Condoms
STD Prevention, Diagnosis and Cure
AIDS is very largely associated with the existence of other sexually-transmitted diseases. It is therefore thought that STD prevention, diagnosis and cure should be widely available.
A report from the Centre for Health Policy (Dept of Community Health, SAIMR, Box 1038, Jhb 2000) by Helen Schneider, goes into this in detail.
One of the suggestions is that family planning clinics become more involved in STD work.
Page 59: "The potential roles of fp clinics in STD care include: detecting and treating symptomatic infections in women; screening programmes to detect and treat asymptomatic infections; treatment of male sexual contacts of women with STDs; and opening the service to all men."
The trouble is that this recommendation comes at a time when there will be less money for such services in the major urban areas now that the budget is spread over the former homelands.
Family planning nurses at busy clinics expressed dismay at having further duties. This same report states on page 48 that "The process within a fp clinic resembles a production line where mass processing rather than individual problem solving is the norm."
Since only just over 50% of fertile women in the old RSA were said to be reached (1992/3), it is not desirable to reduce this still further by increasing the work of each FP nurse.
FP clinics can perhaps have a separate person who deals with STDs, as well as videos and posters to alert people.
Our Winterveld nompilos are informed about STDs, know the symptoms which can be easily detected, and recommend check-ups as part of the whole outreach. Those people whom they take for sterilisations would automatically be checked for STDs.
Mobilising the country for mass prevention campaigns probably remains the best technique of all.
Cervical Cancer
Cervical cancer is now thought to be caused by a virus and therefore likely to be associated with having other STDs. It is also particularly likely to occur in teenagers because of more vulnerable cervixes.
EnviroFeature
The socio-economic determinants of the AIDS epidemic in South Africa A cycle of poverty
Dr Clive Evian, Head, Johannesburg City AIDS Programme,
Community AIDS Centre, P 0 Box 1477, Johannesburg 2000
AIDS has become the predominant health problem of the nineties and will likely dominate the health
and social agendas into the early part of the next century. As the epidemic evolves, one of its most striking features is its profound relationship to poverty. For it is those who are most afflicted by poverty who in turn are most affected by HIV and AIDS. It is thus not surprising that the fastest growing epidemics of AIDS are in Africa, South America and parts of Asia.
It is imperative therefore to understand the links between poverty and AIDS. A better understanding will help minimize negative attitudes and lead the way to developing more appropriate and more global intervention strategies.
Poverty and AIDS:
1. Migration:
There are now few communities who are able to survive outside of a cash-based economy. In poor communities migration is a common practice (South Africa has 3,5 million migrant workers). These people leave their families, loved ones, familiarities, friends, comforts, traditions and cultures - essentially all the factors that contribute to making people feel alive, human and part of a community.
These are the very forces that cement a community, and which contribute to the prevention of epidemics of sexually transmitted diseases (STDs). This is because after leaving home it is common to struggle in other ways there is competition for scarce opportunities and resources; the environment is hostile, alienating and depressing.
The migrant worker thus moves from a situation where he is a somebody to a place where he is a nobody in a nowhere place. In South Africa single sex hostels often provide this form of accommodation meeting a very urgent need, but falling far short of providing a satisfactory environment for normal human habitation.
Sex is a basic human need which can provide rapid short-lived escape from an otherwise mundane and hostile environment. The loosening of personal and community sexual constraints is a common consequence of this process, resulting in indiscriminate and frequent multi-partner sexual practices. It is therefore of little surprise that STDs are so rampant among people who have become displaced from their usual and normal family, traditional and cultural life.
2. Commercial sex:
For women in poor circumstances and in migrant situations sex becomes a commodity which can be sold or exchanged for jobs, food, or other favours.
Gender inequalities are often more acute, more focused and obvious in patriarchal communities. This is especially so when the communities have been further stressed by community and family disruption and instability. Even in stable communities women have little meaningful control over their sex lives and much less in disrupted communities which are wide open to exploitation and abuse. The need to sell sex further exacerbates their already powerless and vulnerable situation.
There is enormous potential for the elite to exploit the poor masses and sexual exploitation flourishes in these circumstances. Therefore in poor communities it is not only the poor who succumb to AIDS but the wealthy and the rich as well.
3. Poor health care:
In poor conditions people have less access to health care, thus in the context of HIV transmission, less access to either the detection and treatment of sexually transmitted diseases or the availability of condoms and health information. STDs are known to be a major co-factor aiding the transmission of HIV, and poor genital health promotes the transmission of HIV and other STDs.
4. Poor education:
Even when people in low socio-economic circumstances do get health care or access to mass media, their poor educational experiences and illiteracy make it difficult for them to gain a clear understanding and appreciation of the seriousness of the silent nature of the HIV infection, the many complexities about AIDS and its transmission, and the relevance of this information for their own lives.
5. Limited leisure and recreation:
The situation is further compounded by the fact that there are very few opportunities for leisure and entertainment. Sex, frequently combined with alcohol, is often used as a substitute - to gain at least a fleeting sense of pleasure, comfort, intimacy and even belonging.
6. Crime and violence:
The trends of urban violence, crime, unrest and uncertainty in South Africa promote a fatalism and despondency which are extremely detrimental to any AIDS prevention effort. Expecting an individual to take initiatives to prevent an infection today which will remain silent and only cause ill health in 7-10 years' time is possibly expecting too much. The day-to-day struggle together with the prevalence of violence and crime mitigate against such initiatives.
AIDS causes poverty:AIDS in turn also promotes poverty. Job and income loss, rejection, discrimination and stigmatisation and finally W health and death all contribute to an individual's and a family's misfortune, and to the overall cycle of poverty.
The many links between poverty and Aids, combined with the biological features and determinants of the epidemic (such as the long silent, clinically latent yet infectious nature of HIV infection), the paralysis of the body's immune system and the prevention of any natural or herd immunity, the vertical perinatal transmission, and the association of HIV infection with other STDs, highlight the extreme complexity and malignant nature of the epidemic.
Concluding comments:It is of little surprise therefore that preventive efforts are making no discernable impact on the pandemic and are unlikely to in the foreseeable future. Inevitably we face an epidemic with devastating and tragic consequences.
South Africa has been one of the last countries in Africa to be affected by the HIV/AIDS epidemic. However the legacies of apartheid and its devastating impact on normal cultural, traditional and family life of especially black South Africans and its ultimate contribution to the cycle of poverty, together with an industrial economic base which promotes migrancy, mobility and exploitation, ensure that South Africa will be no exception and will face a massive and devastating AIDS epidemic.
Any initiative to combat the epidemic needs ultimately to be directed at stabilising community and family life, and attempting to remove the forces which drive people into vulnerable situations. (The material included here has been extracted from a paper delivered to the STD Congress, 1992.) We're growing confidently into the future
Society for Family HealthPopulation Services International/Southern Africa
1994 will be remembered for many things in South Africa, and, while President Mandela's inauguration on May is the most significant event, the year also marked extraordinary growth for condom in South Africa.
'The Society for Family Health (SFH), South African non-governmental organisation, and population Services International (PSI), its U.S. based partner, made tremendous strides in expanding their innovative and targeted social marketing initiative to increase knowledge and use of condoms based on its two principle strategies; broad-based and diverse distribution through traditional and non-traditional outlets, and a mass media motivation campaign to create and sustain demand for condoms among sexuality-active South Africans.
Through social marketing , SFH has increased the accessibility of condoms and led the way to de-stigmatise condoms and create an environment for behaviours to change.
Building on the success of its KwaZulu/Natal pilot project which began in 1992, in 1994 SFH expanded condom social marketing for AIDS prevention to the Greater Johannesburg area, the Western Area mining communities and to Lesotho. SFH's programme is the only condom social marketing programme in South Africa.
During 1994, SFH
Social - Marketing in South Africa
SFH uses social marketing-- a proven and cost effective public health intervention -- to promote safer sexual behaviour and to distribute a condom designed to appeal most to those who are poor and to individuals that practice high risk behaviours.
The socially marketed condom brand, LOVERS PLUS, was developed through extensive focus group research with the Medical Research Council and is affordable, accessible and attractive. The project is effective; demand for and use of LOVERS PLUS is increasing.
SFH's social marketing activities in South Africa are an integral part of PSI's Southern African AIDS Prevention Initiative. With economic linkages and majority work patterns throughout the region, HIV knows no borders. PSI now has a synergistic regional AIDS prevention programme in South Africa, Lesotho, Botswana, Zambia, Malawi and Mozambique.
These social marketing projects distribute essential health products to lower income people by marketing through the existing commercial infrastructure. in South Africa, SFH distributes LOVERS PLUS condoms at a subsidised price of R1 for a pack of three.
This price is low enough to be affordable but allows for the individual to make a personal investments which is more likely to lead to actual use. The price structure also includes typical retailer and wholesaler trade margins.
Local traders are thus given an opportunity to make a profit which acts as an incentive to distribute and promote the product. The social marketed brand is available in a much wider range of outlets than commercial or public sector condoms.
In addition, a key element of this successful social marketing activity is an innovative communications strategy to educate customers, create demand for condoms, de-stigmatise their usage and motivate behaviour change.
This approach uses mass media as a motivational and informational tool by integrating powerful messages within appealing and entertaining formats which translate the knowledge of actual needs, hopes and values into viable behavioural options.
LOVERS PLUS Distribution
During 1994, distribution of LOVERS PLUS expanded significantly. The project. is now distributing over 100,000 condoms per month, and, during December 1994, SFH distributed its two millionth condom since the start of the project on World AIDS Day 1992.
Since the beginning of the project, SFH has opened over 900 outlets in KwaZulu/Natal for condom distribution. Since May of 1994, the project has also opened over 500 outlets in the Johannesburg area, the wider Gauteng Province and in the Western Areas mining communities.
As the number of outlets grows, condoms are increasingly available when and where they are needed. In addition, as LOVERS PLUS are visible in so many new types of outlets, condoms become a much more "normal" part of life.
SFH works with various regional wholesalers to distribute LOVERS PLUS. More importantly, SFH's sales/educators aggressively open new outlets by motivating retailers with one-on-one communication, innovative marketing and promotional events to simultaneously create consumer demand.
The attached sales report charts SFH's growth over the past year. It shows that 60% of LOVERS PLUS condoms are distributed in the non-traditional outlets that had not previously sold condoms -- petrol stations, spaza shops, shebeens, muti shops, motels and brothels, hawkers, bottle stores and butcheries. In the Hillbrow section of Johannesburg and near the mines, commercial sex workers are also distributing LOVERS PLUS condoms to their clients and their peers
The chart also shows that 60% condoms were re-orders, meaning that the majority of outlets are selling LOVERS PLUS condoms on an on-going basis, implying that people within the given communities are, in fact, using condoms.
In August, SFH and PSI launched a companion project in Lesotho, from where over 40% of South Africa's mine workers come. The project ensures that mine workers and their sexual partners can get the same educational messages through the same media as well as LOVERS PLUS condoms in the mines, in the communities around the mines and in the home communities in Lesotho. The project is currently distributing about 20,000 LOVERS PLUS condoms per month in Lesotho.
Education, Promotion and Advertising
While it is crucial to make condoms available when and where needed, SFH has also focused on developing an innovative communication campaign that both promotes the LOVERS PLUS brand and paves the way for open discussion of condoms and safer sex.
The project currently uses a wide variety of approaches to de-stigmatise condoms and encourage correct and consistent condom use. SFH"s strategy integrates face-to-face communication, promotional materials and mass media to provide brand-specific messages as well as generic safer sex messages.
Face-to-face communication helps to personalize the risk of HIV infection and provide very targeted messages. Activities currently include:
Promotional materials and events aim to popularise condom use and educate about safer sexual practices. Activities currently include:
Mass media communication presents messages sensitively, information and entertainingly. The media is chosen to reach the largest number of sexuality active people in the target communities. Activities currently include:
New Initiatives in 1995
In addition to strengthening its current distribution system in KwaZulu/Natal, Gauteng and the North West and increasing advertising, promotional and communication activities in these areas, SFH plans the following activities during 1995;